health and wellness report may 2006

H&W Market in the Caribbean 5/22/2006 1

A Roadmap for the Development of the

Caribbean Health and Wellness Market Sector

Report

The arguments and conclusions in this paper are solely those of the author and do not

reflect the views and opinions of the Inter-American Development Bank (IDB)

IDB

May 2006

Dr. Leroy Miller

13111 Moran Ct

Gaithersburg, MD 20878

Tel: 301-990-8514

Cell: 240-355-4874

Fax: 240-597-0794

Email: [email protected]

mailto:[email protected]


Table of Contents

1. EXECUTIVE SUMMARY ..................................................................................................................................... 3

2. MEDICAL TOURISM .......................................................................................................................................... 12

GLOBAL HEALTHCARE EXPENDITURES INCREASING .............................................................................12

MEDICAL TOURISM OFFERS PATIENTS INTERNATIONAL CHOICES .........................................................13

DRIVERS OF DEMAND FOR BRITISH, CANADIAN AND U.S. MEDICAL TOURISM .....................................17

MEDICAL TOURISM - CARIBBEAN COMPETITIVE ASSESSMENT AND RECOMMENDATIONS ....................25

3. ENTRY STRATEGY: WORLD-CLASS HEALTHCARE EDUCATION IN THE CARIBBEAN ..................... 28

GLOBAL DEMAND AND MIGRATION OF MEDICAL PERSONNEL ..............................................................29

LIMITATIONS OF EXISTING INTERNATIONAL HEALTHCARE EDUCATION ...............................................37

CATALYZING THE CARIBBEAN MARKET FOR HEALTH AND WELLNESS EDUCATION .............................43

4. DEVELOPING MAGNETS FOR HEALTH AND WELLNESS EMPLOYMENT............................................. 47

ALTERNATIVE HEALTH AND WELLNESS – BUILDING THE CARIBBEAN BRAND .....................................48

ELDERCARE– SERVING THE DIASPORA, HIGH-END RETIREES AND THE PEOPLE OF THE CARIBBEAN ....54

TELEHEALTH – LEVERAGING UNIQUE CARIBBEAN ADVANTAGES.........................................................64

5. MARKET OPPORTUNITY AND ROADMAP REVIEW – PRIVATE INVESTMENT AND THE PUBLIC

INTEREST ..................................................................................................................................................................... 68

MARKET OPPORTUNITY REVIEW ...........................................................................................................68

ROADMAP REVIEW - NEXT STEPS ..........................................................................................................70

APPENDIX..................................................................................................................................................................... 72

EMPLOYMENT STATISTICS .....................................................................................................................73

DRAFT PROPOSAL FOR A GLOBAL STUDENT LOAN FUND FOR HEALTHCARE EDUCATION IN THE

ENGLISH-SPEAKING CARIBBEAN ...........................................................................................................77

HEALTHCARE MIGRATION .....................................................................................................................81

TOURISM INDUSTRY STATISTICS ...........................................................................................................83

BIBLIOGRAPHY ........................................................................................................................................................... 88

SOURCES CONSULTED ...........................................................................................................................89

MEETINGS AND INTERVIEWS ...............................................................................................................112


1. Executive Summary

The English-speaking Caribbean1 faces an array of challenges in the realization of

―sustainable economic growth and the reduction of poverty and inequality‖.2 Confronted

with global competition and reductions in subsidies and protection, manufacturing and

agriculture accelerate their historical shrinkage as value-added sectors. While primary

production benefits some countries, the mining and petroleum industries have not been a

significant source of job growth in the Caribbean. A lack of career opportunities leads to

migration of a high percentage of graduates of tertiary education3, and a concern of ―no

future‖ for those remaining with limited education. High crime rates – and the perception

of insecurity – undermine economic investment. High indebtedness of many IDB

member countries limits public investment.

Mirroring global trends, the service sector has been a bright spot as the motor for job

growth in the Caribbean. As a sector of the service economy, tourism has become a major

source of employment and economic development for much of the Caribbean. The

tourism sector has immense significance for The Bahamas, Barbados, Jamaica, and

considerable potential for Trinidad & Tobago, and Guyana. According to the World

Travel & Tourism Council (WTTC), in the Caribbean as a whole, tourism generated

1 The countries which are the focus of this report include the borrowing member countries of the IDB in the

English-speaking Caribbean: The Bahamas, Barbados, Guyana, Jamaica, Trinidad & Tobago 2 Mandate of the Inter-American Development Bank is to support the IDB‘s borrowing member countries

in the attainment of these goals. See IDB website at www.iadb.org 3 An Inter-American Dialogue and World Bank report noted for example that ―an estimated 76 percent of

Jamaicans with a college education live in the United States.‖ Michelle Lapointe, ―Diasporas in Caribbean

Development,‖ Report of the Inter-American Dialogue and the World Bank, August 2004, at:

http://www.thedialogue.org/publications/country_studies/caribbean/diasporas.pdf



nearly 2.5 million tourism-related jobs (15.5% of total employment) and $28.4 billion in

gross domestic product in 2004. By 2014, it is expected that tourism-related jobs will

account for over 3.2 million jobs and $58.5 billion in GDP.4

Yet job and economic growth in Caribbean tourism may not be sufficient to power

overall economic development. Tourism projections for the countries of the English-

speaking Caribbean may not match expectations, or alternatively, may lead to an

economic monoculture that could be overly dependent on one sector5. While cruise ship

tourism has experienced dramatic growth6, expenditure per passenger is considerably

below stay-over tourism, which has been growing slowly during the 2000 to 2005 time

frame. A continuation of the recent trend towards more frequent hurricanes in the

Caribbean could further undermine the predictability of tourism revenue. Lower cost

destinations in the Caribbean, including the Dominican Republic and Cuba, are gaining

market share. This trend would only accelerate if the U.S. embargo on Cuba were lifted.

Moreover, further growth in mass tourism and cruise ship passenger arrivals, if realized,

could undermine the environmental sustainability of the tourism industry especially on

the smaller islands.

4 Source: World Travel & Tourism Council, ―The Caribbean: The Impact of Travel & Tourism on Jobs and

the Economy,‖ London: World Travel & Tourism Council, 2004, at:

http://www.caribbeanhotels.org/WTTC_Caribbean_Report.pdf 5 See tables in Appendix extracted from the World Travel & Tourism Council study for tourism statistics

and projections for Bahamas, Barbados, Jamaica and Trinidad and Tobago. 6 ―Island Traffic Jam‖, Wall Street Journal, February 25-26, 2006.

http://www.caribbeanhotels.org/WTTC_Caribbean_Report.pdf


Additional market opportunities must be explored: health and wellness products and

services, i.e. the health and wellness sector,7 has been identified as a growing global

opportunity with relevance for the Caribbean8. As the world population ages and more

disposable income is directed towards health expenditures, the health and wellness

market is becoming a major driver of economic and social development. Health and

wellness products and services may represent a strategic area of economic development

with the potential for the medium and long-term expansion of high value-added

employment in The Bahamas, Barbados, Guyana, Jamaica and Trinidad and Tobago.

What are the strategic market opportunities and how can multilateral agencies,

governments and the private sector facilitate the development of the health and wellness

market in these five countries of the English-speaking Caribbean? While this sector is

currently in an emergent stage of development in that region, this report delineates a

strategic plan of action to facilitate private sector led expansion in order to catalyze the

health and wellness sector as a substantial contributor to economic growth, social

development, and high value-added job creation. The plan of action is contingent upon

leadership, coordination and support by multilateral agencies to maximize the

development effect of a public-private partnership for the health and wellness sector in

7 The term originally designated in the project description of ―Healthcare Tourism‖ has been replaced with

―Health & Wellness Products and Services‖ to capture the full breadth of the opportunities explored in this

paper. Healthcare Tourism is found to be more generally synonymous with ―Medical Tourism‖ or the

market for people travelling outside their home country for medical procedures which may be of higher

quality and lower cost than in their home country. The Health and Wellness Sector encompasses not only

medical tourism (Medical Treatment Services), but other market segments of the health and wellness sector

as well: Wellness Services, Rehabilitation Services, Eldercare, but also Telehealth Services, Alternative

Health Services and Herbal Products, and Healthcare and Wellness Education and Training Facilities. 8 Compare: Caribbean Country Management Unit, ―A Time to Choose, Caribbean Development in the 21

st

Century,‖ World Bank, Report No. 31725-LAC, April 26, 2005 pp. 108-118; Anthony Gonzales, Logan

Brenzel, Jennifer Sancho, ―Health Tourism and Related Services: Caribbean Development and

International Trade,‖ Regional Negotiating Machinery, August 31, 2001.


the Caribbean. The premise of this approach is that future economic development in an

increasingly globalized economy is based upon unique differentiation and specialization

in knowledge centered enterprises which address markets with high long-term demand.

Moreover, human development is predicated on expanding access to high quality

education opportunities which enable the individual to make life decisions on the basis of

an expanded palette of choices.

The primary barrier to the development of the health and wellness market in the

Caribbean is the paucity of trained healthcare professionals in the Caribbean. The vortex

of world-wide demand for health and wellness personnel is accelerating the historical

process of brain drain. Yet such demand also creates the single greatest opportunity for

private sector investment in the Caribbean health and wellness sector: the creation of

world-class health and wellness education and training institutions in the Caribbean

designed to enroll a globally sourced reservoir of learners. The countries of the Caribbean

would benefit from such private investment through inflow of capital for the construction

and operation of healthcare education facilities, the attraction of qualified health and

wellness educators and medical staff from the Caribbean, the U.K. and North America,

the spending by healthcare ―tourism‖ visitors (i.e. students and staff), the economic

multiplier effect of the concentration of tertiary knowledge-based research and

development, and the potential for an increase in the totally available labor pool of

qualified healthcare professionals in the Caribbean.


Multilateral agencies can play a key role in catalyzing and financing private sector

investment in health and wellness education services. Financing could support and

supplement the initial capital financing requirements of private sector investors in

healthcare education enterprises. In addition, a creative form of a new Caribbean

healthcare education student loan corporation, jointly financed by the multilateral

agencies and private investors, could be explored as a long term instrument for student

tuition and the operation of healthcare education facilities.

While the available pool of qualified health and wellness professionals is being

developed through the expansion of education and training facilities in the Caribbean,

small scale private sector projects should be encouraged to create high value employment

magnets for the retention of Caribbean healthcare professionals, returning Diaspora

medical professionals, international healthcare personnel, graduates of the public

healthcare education system and the eventual graduates of new healthcare education

facilities. Emphasis should be placed initially on small scale projects with high market

potential in alternative health and wellness products and services, telehealth, eldercare,

and, to a limited extent, in medical tourism in order to minimize a disruptive crowding

out effect of staff available to the fragile public health sector. Multilateral agencies could

play a critical role in supporting and supplementing the financing of selected small scale

health and wellness private sector businesses and in supporting the creation of a SMB

Health and Wellness internet-based marketing cooperative to build branding and

accreditation awareness in Caribbean target markets.


A primary role is recommended for multilateral institutions to facilitate private sector led

development of the Caribbean health and wellness market. By establishing the market

framework conditions for the regional development of the health and wellness market as

outlined above, multilateral initiatives create the impetus for the governments of the

Caribbean to improve national competitiveness through government support of

legislation, regulatory and infrastructure modernization, including: streamlining of

medical licensing procedures and visa requirements for international healthcare

practitioners in the Caribbean; incentives and business climate improvement for private

investment in health and wellness; revision of visa requirements for international students

to facilitate enrollment in public and private healthcare education institutions in the

Caribbean; establishment of globally recognized accreditation standards for Caribbean

health and wellness professionals and institutions; continued modernization and

privatization of telecom services to enable international telehealth competitiveness and

online healthcare education; and continuing efforts to reduce crime as an impediment to

private investment.

In Chapter Two of this report (Medical Tourism), the context, nature and scope of

medical tourism is assessed. World-wide demand for healthcare is shown to be robust and

significant. Global demographic and socio-economic drivers form the basis for long-term

expansion of healthcare services. Yet medical tourism itself is shown to be a limited and

highly competitive market, especially without international portability of health insurance

benefits. In the medical tourism segment, the English-speaking Caribbean is confronted

with substantial barriers to entry. It is recommended that multilateral agencies and


Caribbean governments not focus on encouraging private investment in this market

segment as an market entry strategy.

Chapter Three (Healthcare Education) elaborates a plan of action in addressing the

biggest opportunity in the health and wellness sector: the creation of world-class

healthcare education facilities in the Caribbean. The Caribbean has singular natural

advantages in the healthcare education market including proximity, cultural and linguistic

affinity to the world‘s largest healthcare markets, potential cost advantages in the

operation of healthcare education facilities, and a strong venue for the attraction of a

global student body. Multilateral agencies can play a unique role in catalyzing the private

sector led development of the tertiary healthcare education market in the Caribbean.

In Chapter Four (Developing Magnets) three additional segments of the health and

wellness sector are proposed for market development in tandem with the development of

the healthcare education market: eldercare, alternative health and wellness products and

services, and telehealth. Eldercare for returning Diaspora and remittance funded

retirement living for relatives of the Diaspora is shown to be a market opportunity for

small and medium sized businesses in the Caribbean. At the high-end of the market,

eldercare facilities could be created as senior vacation and respite environments for short-

term and medium-term stayovers in the Caribbean in co-marketing agreements with

eldercare specialists in North America and the U.K.. The rapidly growing and

internationally branded spa industry in the Caribbean should be supported by the creation

of accredited private sector spa schools as part of the healthcare education initiative.


Existing alternative health and wellness services could be expanded and Caribbean-

branded through targetted cooperative marketing aggregators. Building on that

momentum, alternative Caribbean-branded health and wellness products which draw on

the rich biodiversity and cultural healing heritage of the Caribbean could be further

developed. Finally, telehealth applications, especially telephonic nursing, is shown to

have considerable employment potential in the Caribbean if high quality educational

facilities have produced sufficient numbers of skilled graduates.

In the final chapter (Roadmap for Development), market opportunities are compared and

a roadmap for the development of the health and wellness sector is delineated. The

creation of world-class healthcare education facilities is recommended as an entry

strategy in order to lay the foundation for the expansion of the Caribbean health and

wellness market. Nascent markets particularly in alternative health, eldercare and

telehealth, are excellent adjunct markets for the creation of magnets for private sector

employment in the Caribbean. A catalytic role for multilateral agencies is seen, especially

in supporting development of an internationally enforceable student loan fund for

healthcare education in the Caribbean which would be accessible to a global sourced

student body. Recommendations are made concerning Bank facilitation of private sector

investment in all four market segments.

In addition to a survey of relevant primary and secondary literature on global health and

wellness markets, statistical data and studies from the World Bank, PAHO, and

UNESCO, as well as member governments, the Caribbean Tourism Organization, World


Travel & Tourism Council and the Association of Caribbean States were used extensively

in the development of the study. Research has included a review of existing project

documentation, discussions with IDB staff, extensive internet research, review of relevant

market research and healthcare research databases including Dialog, Lexis/Nexis,

Profound, Proquest, Investext, Mindbranch, marketresearch.com,

researchandmarkets.com, Global Information, Datamonitor, Euromonitor, Packaged

Facts and other sources. The consultant attended the ―Caribbean Diaspora Experts

Meeting‖ hosted by the UN ICT Task Force and Ambassador Eugene Pursoo of Medgar

Evers College/CUNY in New York City, and the ―Caribbean Health Tourism & Spa

Symposium‖ organized by Positive Tourism Ltd. in Kingston, Jamaica. Over 200 phone

and onsite interviews with government and civil society representatives, and private

sector investors in North America, the U.K., The Bahamas, Barbados, Guyana, Jamaica

and Trinidad and Tobago were completed during the course of the project.


2. Medical Tourism

Driven by the aging of the population and other factors, healthcare expenditures9 in most

OECD countries are growing faster than gross domestic product (GDP). International

medical tourism10

seeks to profit from the growing demand for health and wellness

services by offering direct access to high quality medical procedures at a lower cost than

is available in the patient‘s home country. With few exceptions, private medical facilities

in the English-speaking Caribbean generally lack accredited highest-quality or branded

medical services, or substantial price differentiation to compete effectively in medical

tourism.

Global Healthcare Expenditures Increasing

Although ―healthy ageing‖ may mitigate some of the worldwide increase in health

spending, a steadily ageing population, new technologies, and the tendency of health

expenditures to rise with increasing wealth will continue to exert upward pressure on

healthcare spending.11

As people grow older they spend more on healthcare. Average

9 Healthcare expenditures are generally defined as costs relating to inpatient and outpatient medical

procedures, therapies, pharmaceuticals and occupancy of medically related facilities including hospitals and

nursing homes, and other free-standing facilities. 10

International medical tourism which draws upper class clientele from around the world to high-quality

branded facilities in North America and Europe for medical care at premium prices is substantial, but not

considered in the context of this study. But anecdotal evidence gathered during interviews and site visits in

the Caribbean indicates that there is there is a greater flow of upper-class medical tourists from the

Caribbean to North America and the U.K. than any inflow of medical tourists to the Caribbean. In addition,

there is evidence that many in the Caribbean upper middle class may be seeking medical treatment in Cuba

which offers a variety of high-quality, low cost medical procedures, especially in ophthalmology. 11

OECD Economics Department, ―Projecting OECD health and long-term care expenditures: what are the

main drivers?‖, OECD Economics Department Working Papers N. 477, 2006. See also Keiko Honjo,


health expenditures are relatively high for young children, costs then decline for younger

age groups and then rise steadily and quadruple after 65 years of age and increase to six

to nine times average expenditures as people move into older age groups.12

In the U.S., Canada and the U.K., the three primary markets for the English-speaking

Caribbean,13

current healthcare spending is nearly US$2.3 trillion and growing. U.S.

healthcare spending will increase by about 7.2% annually from over US$2 trillion and

16.2% of GDP in 2005 to reach about $4 trillion or 20% of U.S. GDP in 2015 14

. In the

U.K., health spending is currently £92 billion (~US$156 billion), and could rise from

current 6% of GDP to about 14% of GDP between 2007 and 2050.15

Canadian

healthcare expenditures reached $142 (cdn) (~US$142 billion) in 2005 or 10.4% of GDP

and are growing at nearly 8% annually.16

Medical Tourism Offers Patients International Choices

One approach to accessing the demand generated by the U.S., U.K. and Canadian

healthcare markets is through medical tourism. Countries including Thailand, India17

,

―Long-Term Health Care Costs: Will They Make the Budget Sick?‖ in: ―United Kingdom, Selected

Issues,‖ IMF February 16, 2006. 12

OECD Health Database, 2005 13

The United States, Canada and the U.K. are the primary international markets for the English-speaking

Caribbean, especially in tourism. 14

Christine Borger et al, ― Health Spending Projections Through 2015: Changes on the Horizon‖, Health

Affairs, February 22, 2006, at: www.healthaffairs.org 15

Keiko Honjo, ―Long-Term Health Care Costs: Will They Make the Budget Sick?‖ in: ―United Kingdom,

Selected Issues,‖ IMF February 16, 2006; Department of Health, ―Departmental Report 2005,‖ U.K.

Department of Health, June 2005. In 2005 in the U.K. public health care spending was about £82 billion and

private spending approximately £10.5 billion. King‘s Fund, ―NHS Funding,‖ April 1, 2005, available

online: http://www.kingsfund.org.uk/news/briefings/nhs_funding.html. 16

Canadian Institute for Health Information, ―National Health Expenditure Trends 1975-2005‖. Ottawa:

CIHI, 2005. 17

Ganapati Mudur, ―Hospitals in India woo foreign patients,‖ British Medical Journal. (International

edition). London: Jun 5, 2004.Vol.328, Iss. 7452; pg. 1338. According to Ganapati Mudur: ―Large

http://www.healthaffairs.org/


Cuba18

, Lithuania, Hungary, Turkey, Israel, Jordan, Malaysia, South Africa and Costa

Rica have launched medical tourism campaigns aimed at international patients who are

seeking high quality, low cost medical care.

Source: CBC News Online, June 18, 2004

Thailand and India are current medical tourism market leaders in a global market

estimated at approximately $1 billion annually with North American and U.K. patients

comprising less than 10% of spending 19

. In Thailand, the number of international

patients at Bumrungrad Hospital has increased from 50,000 in 1996 to 350,000 in 2005.

India‘s Apollo Group of hospitals is particularly visible as destination for medical

procedures. Approximately 40,000 foreign patients were treated in Apollo hospitals in

hospitals in Mumbia, Chennai, and New Delhi are marketing themselves as centers capable of delivering

world class medical services at low cost.‖ 18

Fred Charatan, ―Foreigners flock to Cuba for medical care‖ British Medical Journal. (International

edition). London: May 19, 2001.Vol.322, Iss. 7296; pg. 1198 See also, for example: ―Walcott: Barbados

plans to take up Cuba‘s free eye care offer‖, The Barbados Advocate, December 13, 2005, at:

http://www.barbadosadvocate.com/NewViewNewsleft.cfm?Record=23704 19

International Business Strategies estimate.


200420

out of an estimated overall 150,000 such patients who came to India in 200421

. An

oft cited McKinsey report projects $1.1 billion to $2.2 billion in annual revenue in India

by 201222

, and the Minister of State for Tourism for India expects 1 million medical

tourists by 201023

. The number of medical tourists visiting Cuba was estimated at about

3500 in 2000 with $20 million in expenditures24

.

Table 1: Selected Examples of Medical Tourism Market Size

Country Number of Medical Tourists Number of European and

N. American Med Tourists

Revenues from Medical

Tourism

Thailand 350,000 (2004) (Bumrungrad) 70,000 (2004)

(Bumrungrad)

2005: $350 million

India 150,000 (2004)

Projections of 1 million+ (2012)

~10% 2005: $330 million (est)

$1.1 b to $2.1b by 2012

Malaysia 100,000 (2001) < 10% $103 million (2001)

Singapore 150,000 (2001) 80% from Indonesia and

Malaysia

Target of 1 million

foreign patients by 2012

Cuba 3500 (2000) 350 (Est. ) $20 million

Sources: Economist, British Medical Journal, Medical Devices & Surgical Technology Week, Company

websites, Advertising Age, Tourism Review International, Bloomberg, IBS estimates.

Costs of typical surgeries in Indian and Thai hospitals are often estimated at 50% to 80%

below the equivalent prices in U.S. hospitals so that even with airfare and stayover

expenses medical tourism can be price competitive with European and North American

facilities25

.

20

Profile: India becoming the hot spot for medical tourism; Weekend All Things Considered. Washington,

D.C.: Mar 26, 2005. pg. 1. Statistics are quoted from Bumrungrad Hospital CEO Curtis Schroeder. 21

Medical tourism' on rise Jim Landers. Advertising Age. (Midwest region edition). Chicago: Nov 21,

2005.Vol.76, Iss. 47; pg. 14, 1 pgs. Cites estimate by the Confederation of Indian Industries. 22

―Business: Get well away; Medical tourism to India‖, The Economist. London: Oct 9, 2004.Vol.373, Iss.

8396; pg. 76 23

'Medical tourism to attract 1 million visitors by 2010' , The Hindu Business Line: December 15, 2005 at:

http://www.ibef.org/artdisplay.aspx?cat_id=163&art_id=8826 24

Fred Charatan, ―Foreigners flock to Cuba for medical care,‖ British Medical Journal. (International

edition). London: May 19, 2001.Vol.322, Iss. 7296; pg. 1198. 80% of international patients are from Latin

America and the Caribbean and spend $20million annually in medical tourism related expenditures. 25

A smart shopper would beware of some of the cost calculations which are approximated in the literature.

According to an article in Health Affairs (―How Health Insurance Inhibits Trade in Health Care,‖

March/April 2006: ―an inpatient knee surgery, roughly 400,000 of which are performed annually in the


Table 2: Comparative Price List – Surgeries in the U.S. and in India

Surgery US ($) India ($)

Bone Marrow Transplant 400,000 30,000

Liver Transplant 500,000 40,000

Open Heart Surgery (CABG) 50,000 4,400

Neuro surgery $29,000 8000

Knee Surgery 16,000 4,500

Source: IBEF (India Brand Equity Foundation) Research

Quality of care is evidenced by increasing efforts to gain international accreditation and

document operating statistics, and current anecdotal positive press coverage on patient

experiences. Bumrungrad Hospital in Thailand, which is the largest international private

clinic in Asia, is accredited through the Joint Commission on International Accreditation

(JCIA). 850,000 patients are treated annually26

by 500 doctors, most with international

training27

. Although international accreditation and independent quality assessment is a

goal in India, some Indian hospitals are seeking to publish their own quality measures.

According to operating statistics disclosed by the Escorts Heart Institute, an Indian

hospital specializing in cardiac surgery, Escorts had a death rate for coronary bypass

patients of 0.8% as compared to the 1999 death rate at New York-Presbyterian Hospital

of 2.35%.28

United States, costs more than $10,000 there but less than $2,000, including travel, at the best hospitals in

Hungary and India.‖ It would appear that travel costs alone to anywhere in the world from North America

or the U.K. and staying for 7-10 days would be greater than $2000 excluding any companions or actual

medical treatment. 26

Press Release, ―Bumrungrad Hospital, Bangkok, Thailand,‖ available online at:

http://www.hospital2000.com/english/customer_bh.asp 27

Vacation, Adventure And Surgery?, CBS News, Sept. 4, 2005 28

―Surgeries, Side Trips for 'Medical Tourists' Affordable Care at India's Private Hospitals Draws Growing

Number of Foreigners‖ , Washington Post, October 21, 2004.


The vast majority of the medical tourism patients are regional and probably less than 10%

are from North America or Europe. Of the 850,000 patients treated at Bumrungrad,

approximately 70,000 or 8% are from Europe (40,000) and the U.S. (30,000). Despite

anecdotal examples highlighted in the press29

, of the 150,000 medical tourists estimated

to travel to India each year, probably less than 10% are of North American or U.K.

origin. India seeks to focus marketing efforts on Diaspora Indians returning home for

short stays. According to Sita World Travel, a leading Indian travel company, the main

demand for medical tourism in India will come from the non-resident Indians30

. Several

medical tourism intermediaries have sought to present international consumers with lists

of prequalified healthcare facilities.31

Drivers of Demand for British, Canadian and U.S. Medical Tourism

Waiting lists in Canadian and British public health systems, and the uninsured market in

the U.S. are seen as drivers for medical tourism. While healthcare systems in the U.K.

and Canada provide universal access to quality healthcare services, insufficient supply

can lead to long waiting times for elective surgeries in the British and Canadian health

systems. In the U.S., which lacks universal access to healthcare, there are nearly 46

29

―Indian Hospitals Lure Foreigners With $6,700 Heart Surgery,‖ Bloomberg.com, January 27, 2005, at:

http://quote.bloomberg.com/apps/news?pid=nifea&&sid=a8vosisrgmd0 30

―Sita Enters Healthcare Tourism Segment‖, Express Travel & Tourism, September 2003. at:

http://www.expresstravelandtourism.com/200309/tradebytes02.shtml 31

―Healthcare Access: MedRetreat offers worldwide options for medical tourism,‖ Medical Devices &

Surgical Technology Week. Atlanta: Dec 25, 2005. pg. 222; see also IndUShealth, www.indushealth.com ;

―Patients go to India - Raleigh company promotes cost-savings at modern New Delhi hospitals,‖ News &

Observer, Dec 13, 2005; and Medical Tourism India at: http://www.medicaltourismindia.com/index.html

http://www.expresstravelandtourism.com/200309/tradebytes02.shtml

http://www.indushealth.com/

http://www.medicaltourismindia.com/index.html


million Americans without health coverage, including 8 million children32

. It is argued

that long waiting lists in the U.K. and Canada may increase the number of British and

Canadian patients who are willing to seek medical surgeries abroad in countries which

offer high quality, low-cost services with limited or no waiting period. While formal

waiting lists may not be as much of an issue in the decentralized and competitive U.S.

healthcare system, access to healthcare services is impeded by the high number of

medically uninsured, who may seek treatment outside of the U.S. at a lower cost.

In Canada, wait times between visiting a general practitioner and treatment by a specialist

are currently near peak levels of about 18 weeks33

. These delays are comprised of the 8.3

week median wait between referral by GP and appointment with a specialist, and the

additional wait times averaging 9.4 weeks between the specialist‘s decision that treatment

is required and actual treatment. Wait times from specialist appointment to treatment can

vary significantly by specialty as seen in the chart below.

32

―Income, Poverty, and Health Insurance Coverage in the United States: 2004,‖ U.S. Census Bureau,

August 2005. See also: Catherine Hoffman et al, ―Health Insurance Coverage in America, 2004 Data

Update,‖ Kaiser Commission on Medicaid and the Uninsured, November 2005. See also: Robert Wood

Johnson Foundation, at: http://covertheuninsured.org/ . The 65 and older demographic group - which has

the highest per capita health care expenditures - are covered by Medicare. The majority of Americans under

the age of 65 have access to health insurance through their employer and many low income Americans are

covered by Medicaid or the State Children‘s Health Insurance Program. 33

―Waiting Times are the Second Longest Canadians Have Experienced; Little Relief in Spite of Increased

Health Care Spending,‖ ; and Nadeem Esmail, Michael Walker, ―Waiting Your Turn: Hospital Waiting

Lists in Canada,‖

http://covertheuninsured.org/


Graph 1: Median Wait by Specialty in 2005 in Canada: Weeks Waited from Referral by

GP to Treatment

Source: Fraser Institute, 2005

While the total average Canadian wait time is 18 weeks, the difference between median

actual wait and median clinically reasonable wait by specialty is most pronounced in

plastic surgery, orthopedic surgery and ophthalmology suggesting that these two areas

have the most market potential for Canadian medical tourism.34

34

Canadian Institute for Health Information (CIHI), ―Waiting for Health Care in Canada: What We Know

and What We Don‘t Know‖, March 7, 2006 available at:

http://www.cihi.ca/cihiweb/dispPage.jsp?cw_page=media_07mar2006_e



Graph 2: Median Actual Wait Versus Median Clinically Reasonable Wait by Specialty

for Canada: Weeks Waited from Appointment with Specialist to Treatment in 2005

Source: Fraser Institute, 2005

Of the 1.5 million adults who had non-acute surgery in Canada in 2005, about 50%

waited for 30 days or less. Only 10% of patients waited for six months or more.

According to a CIHI survey, 162,000 patients experienced difficulty in getting non-

emergency surgery in 2005.

As the Canadian healthcare system is built on a single payer monopoly and prohibits

privately funded purchases of core services including a vast array of hospital and

physician services35

, the alternative to waiting times for core services is to go abroad for

treatment if the patient is capable or willing to assume the cost of such surgery. Yet even

for a non-core service which is privately available in Canada - cataract surgery – only

35

Nadeem Esmail and Michael Walker, ― How Good is Canadian Health Care? 2005 Report,‖ Vancouver:

The Fraser Institute, 2005


63% were aware of locally available private services in Canada, and only 7% were

willing to pay $2,000 to have cataract extraction performed within one month in a private

facility in order to avoid the waiting list for free public services. Only 1.7% of the

participants in the survey actually did jump the queue and paid for private surgery.36

The U.K. has made significant improvements in reducing treatment wait times in the

public healthcare system and has plans in place to reduce GP referral to treatment wait

time to a maximum of 18 weeks by 2008. Maximum waiting times for inpatient

procedures were expected to fall to 6 months by the end of 200537

. Inpatient lists have

declined to 843,923 in 2004 with less than 62,000 waiting more than 6 months38

. Wait

times continue to trend lower. For those patients with the ability to pay and an

unwillingness to wait, private health services are available in the U.K. and abroad39

.

Waiting times for elective surgery have tended to be less pronounced in the U.S. than in

the U.K. or Canada and have therefore not been highlighted as a driver for U.S. residents

seeking medical care abroad:

36

Gerard Anderson et al, ―Willingness to Pay to Shorten Waiting Time for Cataract Surgery,‖ Health

Affairs, September/October 1997. 37

Foreword by the Secretary of State, ―Department of Health: Departmental Report 2005,‖ U.K.

Department of Health, June 21, 2005, at:

http://www.dh.gov.uk/PublicationsAndStatistics/Publications/AnnualReports/DHAnnualReportsArticle/fs/e

n?CONTENT_ID=4113725&chk=1krOlR 38

King‘ Fund, ―NHS Waiting Times‖, April 1, 2005 available at:

http://www.kingsfund.org.uk/news/briefings/nhs_waiting.html 39

J. Moorhead, ―Sun, Sea, Sand, and Surgery,‖ Guardian (London), 11May 2004. According to this article,

in 2003 an estimated 50,000 British medical tourists traveled to Thailand, South Africa, India, and Cuba for

a variety of check-ups, treatments and operations.

http://www.dh.gov.uk/PublicationsAndStatistics/Publications/AnnualReports/DHAnnualReportsArticle/fs/en?CONTENT_ID=4113725&chk=1krOlR

http://www.dh.gov.uk/PublicationsAndStatistics/Publications/AnnualReports/DHAnnualReportsArticle/fs/en?CONTENT_ID=4113725&chk=1krOlR

http://www.kingsfund.org.uk/news/briefings/nhs_waiting.html


Table 3: Waiting Times for Elective Surgery During the Past Year, 2001 in the U.S., U.K.

and Canada Canada U.K. U.S.

Waited less than 1 month 37% 38% 63%

Waited 1 to less than 4 months 36% 24% 32%

Waited 4 months or more 27% 38% 5%

Note: Waiting time as reported by patients needing elective surgery.

Source: Blendon et al, ―Inequities in Health Care: A Five-Country Comparison,‖ Health Affairs, May/June

2002

For the U.S., the search for affordable healthcare by the 45.5 million uninsured is

considered the critical driver for medical tourism40

. The number of uninsured in the

United States has increased steadily over the past five years.

Graph 3: Number of Nonelderly Uninsured in the U.S., 2000 - 2004

Source: Holahan and Cook, ―Changes In Economic Conditions And Health Insurance Coverage, 2000-

2004,‖ Health Affairs Web Exclusive, November 1, 2005.

Yet, some very basic issues diminish the uninsured in the U.S. as a potential market for

medical tourism. The uninsured are concentrated in the 19 to 34 year old age group which

typically has the lowest per capita healthcare expenditures. Secondly, the uninsured are

most prevalent in lower income households. Less than 20% of the uninsured belong to a

household unit with an annual income of more than $75,000, a level of income which

40

―Medical Tourism Growing Worldwide,‖ University of Delaware, July 25, 2005, at:

http://www.udel.edu/PR/UDaily/2005/mar/tourism072505.html

http://www.udel.edu/PR/UDaily/2005/mar/tourism072505.html


could possibly support frugal international travel and extensive medical expenditures.

And thirdly, persons without health insurance are much less likely to visit a medical

provider – even if they believe that they need medical assistance41

.

As age and the likelihood of significant healthcare expenditures increases, the percentage

of the age group that is uninsured decreases. Medicare provides (nearly) universal

coverage for persons 65 years and older so very few people in that age group are

uninsured.

Table 4: Number of Uninsured in the U.S. by Age in 2004

Age Group

Uninsured

(in thousands)

% of

Uninsured

% of Age Group

Uninsured

under 18 years 8,269 18.0% 11.2%

18-24 Years 8,772 19.1% 31.4%

25-34 Years 10,177 22.2% 25.9%

35-44 Years 8,110 17.7% 18.7%

45-64 Years 10,196 22.3% 14.3%

65 Years + 297 0.6% 0.8%

Source: U.S. Census, IBS calculations

As household income increases, the percentage of the household income (HHI) group

that is uninsured decreases. Approximately 8 million uninsured persons are in households

with $75,000 in HHI.

Table 5: Number of Uninsured in the U.S. by Household Income (HHI) in 2004

HHI

Uninsured

(in thousands) % of Uninsured

% of HHI

Group

Uninsured

Less than $25,000 15,102 33.0% 24.3%

$25,000 to $49,999 14,784 32.3% 20.0%

$50,000 to $74,999 7,842 17.1% 13.3%

$75,000 or more 8,092 17.7% 8.4%

Source: U.S. Census, IBS calculations

41

Jack Hadley and Peter J. Cunningham, ―Perception, Reality and Health Insurance,‖ Center for Studying

Health System Change, Issue Brief 100, October 2005.


Given the age distribution of the uninsured, it is likely that less than 5% or 400,000 of the

U.S. uninsured with HHI of $75,000 or more would need elective surgery each year.

In summary, the current potential for medical tourists from the U.S., U.K. and Canada is

quite small. If we define the available pool of potential medical tourists in those countries

as patients experiencing difficulty in accessing non-emergency surgery due to waiting

lists or lack of insurance, we can see that this is not a large market in and of itself. Yet

further constraints (Barrier Multiplier) are also apparent: lack of income or financial

resources to self-finance international travel for self and companions, and medical

expenses; lack of awareness of international medical resources; unwillingness or inability

to travel especially while ill; and quality concerns and lack of internationally recognized

certification of medical tourist facilities.

Table 6: Number of Potential Medical Tourists in Canada, U.K. and U.S.

Country

of Origin

Number of Patients with Difficult

Access to Elective Surgery ( on

waiting lists or uninsured needing

surgery)

Barrier

Multiplier

Number of Potential

Medical Tourists for

Elective Surgery

Canada 750,000 10% 75,000

U.K. 800,000 10% 80,000

U.S. 400,000 10% 40,000

Total 1,950,000 10% 195,000 Source: International Business Strategies estimates.

A much broader market is potentially available for medical tourism if health insurance

were unlimited in its portability42

. Should Canadian and British public healthcare

42

Aaditya Mattoo and Randeep Rathindran, ―How Health Insurance Inhibits Trade In Health Care,‖ Health

Affairs, March/April 2006.


systems, and U.S. public and private payers, choose to reimburse patients for elective

surgeries abroad, more significant growth in medical tourism may occur.

Medical Tourism - Caribbean Competitive Assessment and Recommendations

Medical tourism is not recommended as a point of strategic entry into the health and

wellness sector for the Caribbean. Not only is the U.K. and North American medical

tourism market relatively small, the Caribbean has no significant competitive advantages

in a fiercely competitive global market. The relatively high cost structure of the

Caribbean which has forced even casual Caribbean tourism into higher end markets,

makes competition with low cost Thai and Indian medical tourism very challenging. In

addition, given the demands on scarce healthcare human resources which the expansion

of medical tourism could entail if it were successful, neither the Caribbean governments

nor multilateral agencies should make expansion of this market segment a priority at this

time.

However, small niche markets in medical services could be explored and possibly

expanded. For example, a timeshare model43

for visiting physicians44

from the U.K. and

43

The timeshare industry product to be one of the fastest growing segments of the global travel and tourism

sector with a CAGR of over 17.5% over the past 22 years. See: World Travel & Tourism Council, ―The

Caribbean: The Impact of Travel & Tourism on Jobs and the Economy,‖ London: World Travel & Tourism

Council, 2004, p. 66. 44

In discussions with Jasmin Garraway, Director of the Association of Caribbean States, and Ian Ho-A-Shu

of the IDB country office in Port of Spain, Trinidad we developed a model called ―Dr. Time Share‖ which

would consist of a clinic designed by the physician investors, a physician villa and a patient villa. In

addition to a Caribbean physician who would coordinate and follow-up on patient care on a year around

basis, the physician investors would bring their patients with them from their practices in Europe and in

North America, thereby overcoming some of the principle barriers to medical tourism. As part of the

agreement with the host government, the physicians would be required to provide pro bono treatment for a

certain number of country residents per year.


North America could be further developed and could build upon the existing model being

practiced on a limited basis at Mobay Hope Medical Centre in Jamaica45

. Targetted

marketing to returning Diaspora and their families prior to and during home visits could

provide supplemental revenue for private medical and dental practices in the Caribbean.

Cutting edge, non-FDA approved medical services for high-end clients, such as cancer

treatments or stem cell therapy, while small markets, could be expanded. Yet, such

treatments would require additional imported technologies and may have ethical

implications which could be incongruent with Caribbean societal norms and could be

risky for destination image management. Nonetheless, Caribbean governments should

continue to encourage - or at least not discourage – private development of medical

facilities.

The availability of access to high quality private medical facilities for eventual treatment

of acute episodes has a positive destination effect for stayover tourists. Although such

facilities are unlikely to be profitable, they are immensely important for the reputation

and attractiveness of the destination. A common concern of long and even short stay-over

guests in the Caribbean is what might be termed the ―what if I get hit on the head by a

golf ball‖ syndrome. Immediate treatment for acute cases is considered by many high end

tourists to be essential and Medivac services are not considered a substitute. Jamaica and

The Bahamas are fortunate to have skilled and extensive private medical facilities in

several of their primary tourist areas as these provide, at the very least, a psychological

cushion for an ageing tourist base who want to have immediate attention in acute cases.

In Barbados and in the Bahamas, several investors are considering development of

45

Site visit and interview at Mobay Hope Medical Centre, Mrs. Judy Farmer, Administrator


additional facilities.46

Specialized exercise facilities for visitors with heart conditions

offered by the Heart Foundation of Barbados or dialysis services are additional examples

of destination supporting medical facilities47

. In addition to the destination effect for

tourism, such facilities such be encouraged and supported as a basis for expansion of the

nascent eldercare market in the Caribbean.

In the recent World Bank study it is argued that there is ―excess capacity‖ available in the

Caribbean for ―medical treatment and surgery to health visitors on a larger scale‖. As an

indicator of excess capacity the study explains that ―significant areas of the Eric

Williams Medical Services Complex (EWMSC) at Mount Hope remain empty, and only

about 30 percent of capacity is utilized‖48

. Yet half empty buildings are not an indicator

of latent supply. Skilled human resources are at the core of a successful competitive

position, and as we shall see in the next chapter, the Caribbean is struggling to retain its

highly skilled and respected medical personnel in the face of a global vortex of demand

for healthcare specialists.

46

Several investment groups have sought to buy St Joseph‘s Hospital in Barbados to develop a high-quality

private medical facility. The St. Joseph‘s Hospital has remained vacant and abandoned since its purchase

from the Vatican in 1987. Another part time resident of Barbados is planning on building a new private

clinic in Barbados even if it means continuing subsidies of $35 million per year. Extensive studies

undertaken by the investor have shown that such a private clinic could not be profitable in Barbados. 47

Site visit and interview with: Adrian Randall, CEO, The Heart Foundation of Barbados. 48

See section below on global demand for health care professionals. Compare: Caribbean Country

Management Unit, ―A Time to Choose, Caribbean Development in the 21st Century,‖ World Bank, Report

No. 31725-LAC, April 26, 2005, p. 116.


3. Entry Strategy: World-Class Healthcare Education in the Caribbean

Given rapidly growing global expenditures for healthcare services49

it is not surprising

that global demand for medical personnel is increasing as well. Moreover, current and

projected demand for healthcare professionals far exceeds the supply of qualified

healthcare personnel. While most medical professions are experiencing high demand,

trained nurses are in especially short supply. With high wages and high demand, Canada,

the U.K. and the U.S. are among the countries which have been magnets for the global

migration of healthcare personnel. Healthcare education institutions have sought to

increase output of healthcare personnel but have not been able to keep up with domestic

and international demand for qualified graduates. While private sector investment has

made private healthcare education a focus of investment in the smaller islands of the

Caribbean and in India, serious concerns about the effects of training physicians and

nurses ―for export‖ have been raised. However, world-class healthcare education

facilities in the Bahamas, Barbados, Guyana, Jamaica, and Trinidad and Tobago could

provide the catalyst for high-value economic development of the health and wellness

sector in the Caribbean. By supporting the establishment of an enforceable and globally

accessible student loan fund for study at accredited healthcare education facilities in the

Caribbean, multilateral agencies could use their unique position as catalysts of

development to expand this market in a way that serves the people of the Caribbean.

49

See Section above, ―Global Health Care Expenditures Increasing‖


Global Demand and Migration of Medical Personnel

There is a global shortage of qualified healthcare personnel. Increasing demand for

healthcare personnel and a lack of sufficient output of existing healthcare education

facilities combine to create the ―perfect storm‖50

: a widening gap between demand and

supply.

Projected job growth in the United States reflects this demand. By 2014, nearly 80% of

all employment will be in service industries and within that sector ―educational

services, health care and social assistance, and professional and business services

represent the industry sectors with the fastest projected employment growth.‖51

Almost

one quarter of all new jobs created in the United States between 2004 and 2014 will be in

healthcare and social assistance related employment. By 2014 there will be 18.5 million

jobs in healthcare and social assistance, and 3.7 million jobs in educational services.

Healthcare/social services and educational services will have increased from nearly 10%

of all U.S. jobs in 1994 to 13.4% by 2014. The home healthcare service sub-segment

which includes such in-home services as nursing and physical therapy, will be the fastest

growing U.S. employer by 2014. By comparison, leisure and hospitality employment –

while still dynamic - will have grown at a relatively leisurely rate of 1.6% from 2004 to

2014, just ahead of the overall 1.2% average annual rate of change, and at a slower rate

than the preceding period between 1994 and 2004.

50

See for example the title of a recent book review in Health Affairs: S. Robert Hernandez, ―The Perfect

Storm: Nursing in Twenty-First-Century America,‖ Health Affairs, September/October 2005. 51

Jay M. Berman, ―Employment outlook: 2004–14, Industry Output and Employment Projections to 2014,‖

U.S. Bureau of Labor Statistics, Monthly Labor Review, November 2005.


Table 7: U.S. Employment in Selected Industry Sectors, 1994, 2004, 2014

Industry

sector

Thousands of jobs Change Percent distribution Average annual

rate of change

1994 2004 2014 1994–

2004

2004–

2014 1994 2004 2014

1994–

2004

2004–

2014 Professional

and business

services

12,173.9 16,413.7 20,979.9 4,239.8 4,566.2 9.4 11.3 12.8 3.0 2.5

Educational services

1,894.8 2,766.4 3,664.5 871.6 898.1 1.5 1.9 2.2 3.9 2.9

Health care

and social assistance

10,911.9 14,187.2 18,482.1 3,275.3 4,294.9 8.4 9.7 11.2 2.7 2.7

Leisure and

hospitality 10,099.8 12,479.1 14,693.8 2,379.3 2,214.7 7.8 8.6 8.9 2.1 1.6

Total for all BLS

Industry

Sectors

129,245.9 145,612.3 164,539.9 16,366.4 18,927.6 100.0 100.0 100.0 1.2 1.2

Source: Monthly Labor Review, U.S. Bureau of Labor Statistics, November 2005

However, given such projections of demand for skilled healthcare personnel, there is

concern that there may be insufficient supply to fill those positions. One area of particular

concern is the supply of registered nurses52

. Skilled nurses are in high demand and low

supply. In 2000, there were 1.89 million registered nurses in the U.S. while demand was

estimated at 2 million for a shortfall of 110,000 or 6%. In 2006 there is an expected

shortage of 8% or nearly 200,000 nurses. By 2014 the shortage is projected to reach 18%

and grow to 29% or 800,000 nurses by 2020.53

52

Nurses are projected to be the occupation with the second largest job growth in the U.S. for the period

2004 to 2014. See Appendix (―Healthcare Employment by Occupation, 2004 and Projected 2014‖) for

detailed statistics on projected occupational growth from 2004 to 2014 in the U.S. . 53

―Projected Supply, Demand, and Shortages of Registered Nurses: 2000-2020,‖ U.S. Dept of Health and

Human Services: National Center for Health Workforce Analysis, July 2002.


Graph 4: U.S. National Supply and Demand Projections for FTE Registered Nurses:

2000 to 2020

Source: U.S. Dept of Health and Human Services, Bureau of Health Professions, July 2002

Unsatisfied demand for qualified healthcare personnel is not limited to the U.S. and other

OECD countries54

. Africa, Asia55

, Latin America56

are all experiencing extreme

shortages in qualified healthcare personnel.

Graph 5: Health Workers Density By Region

Source: December 2004 WHO report: Addressing Africa‘s Health Workforce, cited in: ―Efforts under way

to stem ‗brain drain‘ of doctors and nurses‖, Bulletin of the World Health Organization, February 2005,

available at: http://www.who.int/bulletin/volumes/82/8/en/

54

Steven Simoens and Jeremy Hurst, ―The Supply of Physician Services in OECD Countries,‖ OECD

HEALTH WORKING PAPERS, 21, Jan 16, 2006. 55

Martha Ann Overland, ―A Nursing Crisis in the Philippines‖ The Chronicle of Higher Education.

Washington: Jan 7, 2005.Vol.51, Iss. 18; pg. A.46 56

―Nursing Shortage Threatens Health Care‖, Newsletter of the Pan American Health Organization,

September 2005, at: http://www.paho.org/english/dd/pin/ptoday18_sep05.htm.

http://www.who.int/bulletin/volumes/82/8/en/


The current shortage of Caribbean nurses - a 29% vacancy rate - is at the level predicted

for the U.S. in 2020. Trinidad and Tobago have the highest percentage of vacancies at

53% 57

and are currently recruiting healthcare personnel from India and the Philippines.58

Table 8: Vacancy Levels for Registered Nurses in the Caribbean

Country # of Registered Nurses Posts # of Vacancies % Vacancies

Antigua 320 56 18%

Barbados 930 192 21%

Dominica 177 11 6%

Grenada 432 16 4%

Guyana 667 245 37%

Jamaica 2457 568 23%

St. Kitts 192 50 26%

St. Lucia 409 18 4%

St. Vincent 216 34 16%

Trinidad and Tobago 2125 1132 53%

Total 7925 2322 29%

Source: Jamaican Ministry of Health59

Africa, Asia and Latin America are essential sources of healthcare personnel for OECD

countries. There are nearly 60,000 Indian physicians practicing in the U.S., the U.K.,

Canada and Australia, equivalent to 10% of the physicians in India60

. Approximately

90,000 nurses in the United States, i.e., 4% of the employed nurses in the U.S., are

foreign trained. If the U.S. were to double that percentage it would come closer to the 8%

of foreign trained nurses in the U.K. and the 6% in Canada. Such an increase would

undoubtedly cause further demand for recruitment of nurses worldwide, and from the

Caribbean. In turn, the U.S. also continues recruiting healthcare personnel from Canada,

57

Source: Judith Smith Richards, Director, Human Resource Management & Development in the Ministry

of Health, Jamaica, ―Managed Migration of Nurses‖, at:

http://www.observatoriorh.org/Toronto/presentaciones.html 58

Interviews in Trinidad and Tobago. 59

Ibid, Richards, Ministry of Health, Jamaica 60

Fitzhugh Mullan, ―Doctors For TheWorld: Indian Physician Emigration‖, Health Affairs, March/April

2006.

http://www.observatoriorh.org/Toronto/presentaciones.html


the U.K. and Australia which adds further momentum to recruitment from non-OECD

countries. Even an additional 100,000 nurses in current supply would not even come

close to satisfying demand.61

For the U.K. almost half of all new nurses admitted to the U.K. register have been from

international sources. The apparent reversal of the trend in 2002/2003 is probably an

aberration.62

Graph 6: International and U.K. sources as a % of total new nurses admitted to the U.K.

Register, 1989/90 - 2002/2003 (Initial Registrations)

Source: DFID

In many islands of the Caribbean, healthcare recruiters advertise in local media and set up

monthly job fairs in local hotels to seek qualified applicants for healthcare positions,

especially trained nurses, in North America, Europe and the Middle East.63

If, in an effort

to prevent the loss of healthcare professionals in the Caribbean, these job fairs were

prohibited, job seekers would only need to turn to Google: the term ―nursing jobs‖ yields

over 69 million relevant results64

. In the following table it becomes apparent that

61

Linda Aiken et al, ―Trends in International Nurse Migration,‖ Health Affairs, May/June 2004. 62

James Buchan et al, ―International Recruitment of Health Workers to the U.K.: A Report for DFID‖,

London: DDFID Health Systems Resource Centre, February 2004, at:

http://www.dfidhealthrc.org/Shared/publications/reports/int_rec/int-rec-main.pdf 63

Site visits in the Caribbean. 64

www.google.com

http://www.dfidhealthrc.org/Shared/publications/reports/int_rec/int-rec-main.pdf

http://www.google.com/


hospital administrators in the U.K., Canada and the U.S., and in New Zealand and

Australia as well, are actively recruiting nurses internationally, and are willing to offer

bonuses and tuition assistance to attract and retain nurses.

Table 9: Hospital Executives' Views On The Health Care Systems Of Five Countries,

2003

Source: Blendon, ―Confronting Competing Demands To Improve Quality‖, Health Affairs, May/June

2004.


The shortage of healthcare professionals is not limited to the supply of nurses. PAHO

statistics show serious deficiencies in the numbers of physicians, dentists and nurses in

the Caribbean. The charts below indicate that with few exceptions, North American ratios

of healthcare professionals per 10,000 inhabitants far exceed the levels available to serve

the needs of the people of the Caribbean.

Source: PAHO

Physicians in Last Available Year

(Ratio per 10,000 Inhabitants)

22.5

18.916.7

13.7

8.5 7.5

2.6

0

5

10

15

20

25

U.S

.

Can

ad

a

Bah

am

as

Barb

ad

os

Jam

aic

a

Tri

nid

ad

an

d T

ob

ag

o

Gu

yan

a


Source: PAHO

Source: PAHO

Nurses by Country in Last Available Year


78.573.4

23.8

51.2

16.5

28.7

8.6

0102030405060708090

U.S

.

Ca

na

da

Ba

ha

ma

s

Ba

rba

do

s

Ja

ma

ica

Tri

nid

ad

an

d T

ob

ag

o

Gu

ya

na

Dentists in Last Available Year


5.45.7

2.51.9

0.8 0.90.4

0

1

2

3

4

5

6U

.S.

Can

ad

a

Bah

am

as

Barb

ad

os

Jam

aic

a

Tri

nid

ad

an

d

To

bag

o

Gu

yan

a


Yet demand for health and wellness professionals is not limited to traditional healthcare

occupations. The spa industry, for example, is also in desperate need of qualified spa

professionals65

.

In summary, global demand for healthcare, and health and wellness workers is immense,

apparently insatiable and the basis for a good and stable business model.

Limitations of Existing International Healthcare Education

There are currently three models of offshore healthcare education which produce

graduates for export66

. Type 1 includes private schools which educate primarily domestic

students for export and include schools in India and the Philippines (Type 1). The second

type consists of private schools which specialize in training North Americans and

Europeans for return to their home countries. They are primarily located in member

countries of the Organization of Eastern Caribbean States (OECS)) and to a lesser extent,

are located in other non-OECD countries as well67

. The third type consists of public

universities world-wide which do not necessarily intend to export graduates. Such

publicly financed colleges and universities (in the Caribbean and worldwide) provide

training for domestic students who remain in country or move abroad after graduation.

65

An anecdotal indication of the demand for spa professionals is well placed on the opening screen of

Steiner Leisure, a leader in the spa industry: ―Attention job seekers: Interviews for Spa jobs onboard cruise

ships are taking place in California and Illinois in May 2006. Email [email protected] for details. Steiner

Leisure has two divisions: Spas, and Steiner Education. Steiner recently purchased a seven school chain of

spa schools headquartered in Utah for $28 million. As a result, Steiner Education Group will control ―a

total of 14 schools in eight states with approximately three thousand students once the Utah College deal

closes.‖ See: ―College of Massage Therapy to be Sold,‖ ksl.com, January 30th

, 2006, at:

http://www.ksl.com/?nid=148&sid=156684 66

Healthcare schools which by design or inadvertently produce healthcare graduates for export. 67

Compare international schools on the lively ValueMD forum at: http://www.valuemd.com/index.php

http://www.ksl.com/?nid=148&sid=156684

http://www.valuemd.com/index.php


Through their exports of qualified graduates, these public schools essentially subsidize

healthcare in the U.S., Canada, the UK and other countries which can attract migrant

workforces.

India is the leading source of international medical graduates (IMGs) for physicians

practicing in the United States followed by the Philippines and Mexico. Grenada (ranked

7) and Dominica (ranked 15) are two leading locations in the OECS (Type 2) which are

training primarily North Americans for return to the U.S. The remainder come mostly

from Type 3 public institutions which are unintentionally financing healthcare migration

flows to the United States.


Table 10: Top 20 Countries Where IMGs Practicing in the U.S. Received Medical

Training Rank Source Country % of IMGs

in the U.S.

Number of IMGs

in the U.S.

1 India 24.0% 44,585

2 Philippines 10.6% 19,656

3 Mexico 6.7% 12,448

4 Pakistan 5.7% 10,689

5 Dominican Republic 3.8% 7,147

6 Russia 2.9% 5,343

7 Grenada 2.8% 5,196

8 Egypt 2.6% 4,884

9 Italy 2.5% 4,755

10 South Korea 2.5% 4,676

11 China 2.4% 4,523

12 Iran 2.3% 4,355

13 Spain 2.3% 4,332

14 Germany 2.3% 4,269

15 Dominica 2.1% 4,050

16 Syria 1.8% 3,491

17 Israel 1.6% 3,098

18 Colombia 1.6% 3,095

19 England 1.6% 3,071

20 Lebanon 1.5% 2,871

Total IMG population

in United States

23.3% 185,234

Source: 2005 AMA Membership Fact Book, at: http://www.ama-assn.org/ama/pub/category/1550.html

Note: The above list ranks the top 20 countries where the largest numbers of U.S. physicians have been

trained. These data do not represent citizenship or ethnic origin; they only represent the location of the

medical school where the U.S. practicing physician obtained their medical degree.

In India, where 24,000 students are admitted to public and private medical schools

annually, 42% of those students are enrolled in private, for profit medical schools. At the

time of admission, students at private institutions are charged a $40,000 to $50,000

entrance fee followed by tuition payments of $3,000 to $6,000 per year. Admission is

based on ability to pay and academic achievement. There are government requirements

that a certain number of seats be allotted to merit candidates. Although private schools in

India do not ―explicitly educate for emigration,‖ the rationale for development of more

private schools is the ―continued high interest in immigration.‖68

Indian trained

68


2006, page 385, at www.healthaffairs.org.

http://www.ama-assn.org/ama/pub/category/1550.html


physicians represent 10.9% of the U.K. physician workforce69

, and 6.8% of the 650,000

physicians in the U.S. physician70

. Currently there are approximately 1,200 Indian

physicians who enter the U.S. Residency system each year.71

Yet the export of healthcare professionals is not limited to physicians. High world-wide

demand for nurses has led to a rapid increase in the number and output of private nursing

schools in the Philippines, and has enabled increased nurse immigration. However, rapid

expansion and high demand have led to a decline in the quality of nursing schools in the

Philippines as large numbers of healthcare educators have joined the exodus. Whereas 10

years ago 80% of students passed the national board examinations, currently ―less than

half pass.‖ And the impact on healthcare in the Philippines is immense: 15,000 nurses

leave annually while the Philippines is only producing 5,300 nurses per year.72

Private for profit healthcare schools in the OECS have grown rapidly since the 1970s

and have expanded from medical school offerings to the recent opening of an associate

degree nursing school program in St. Kitts.73

Such programs allow students, primarily

from North America, to complete their initial basic health science and clinical courses in

an OECS country, and then go on to complete coursework and clinical practicums or

69


2006, page 386, at www.healthaffairs.org. 70

Calculations from statistics on the AMA website. See: http://www.ama-

assn.org/ama/pub/category/2670.html and http://www.ama-assn.org/ama/pub/category/1550.html . 71


2006, page 386, at www.healthaffairs.org.

72 Martha Ann Overland, ―A Nursing Crisis in the Philippines,‖ The Chronicle of Higher Education, Jan7,

2005, at: http://chronicle.com/weekly/v51/i18/18a04601.htm . 73

See for example: Robert Ross International University of Nursing, St. Kitts, at: http://www.iuon.org/ .

While the OECS medical schools are the oldest and have provided the most physicians to the U.S., medical

schools in Philippines are also recruiting North American students. See Philippine Medical Schools, at:

http://www.valuemd.com/asian-medical-schools/26196-philippine-medical-schools.html .




http://chronicle.com/weekly/v51/i18/18a04601.htm

http://www.iuon.org/


residency at affiliated institutions in the United States. A major advantage for these

healthcare schools is that U.S. students can qualify for federal and private students loan

financed through Sallie Mae and other loan programs in the United States. Maintaining

student access to U.S. Stafford loans is an issue of considerable concern to the OECS

healthcare school community.74

The third type of offshore healthcare schools are public colleges and universities which

train domestic graduates for healthcare careers with the intention of fulfilling in country

demand. Jamaica, Guyana, Barbados, Trinidad and Tobago and the Bahamas belong to

this group. Yet many of the graduates migrate to the job markets of the north which are

experiencing high demand. Guyana is perhaps the most extreme example with two-thirds

of each medical school class from the University of Guyana leaving almost immediately

upon graduation.75

The University of the West Indies as well as the community colleges

of the region also experience significant out-migration of their graduating healthcare

classes.76

The newly announced University of Western Jamaica, which will be supported

with US$15 million from Jamaican government funds, will have nursing and especially

geriatric nursing among its course offerings ―to fulfil domestic requirements‖ as well as

providing training ―for those who wish to pursue their professions overseas‖.77

74

See discussion on ValueMD at: http://www.valuemd.com/main-foreign-medical-schools-forum/52334-

offshore-schools-may-lose-federal-loans.html 75

Interviews in Guyana. 76

Interviews in Jamaica, Barbados and Trinidad and Tobago. 77

―University to be Established in St. James,‖ Office of the Prime Minister, Jamaica, March 29,2006, at:

http://www.jis.gov.jm/officePM/html/20060328T130000-

0500_8431_JIS_UNIVERSITY_TO_BE_ESTABLISHED_IN_ST__JAMES.asp

http://www.valuemd.com/main-foreign-medical-schools-forum/52334-offshore-schools-may-lose-federal-loans.html

http://www.valuemd.com/main-foreign-medical-schools-forum/52334-offshore-schools-may-lose-federal-loans.html

http://www.jis.gov.jm/officePM/html/20060328T130000-0500_8431_JIS_UNIVERSITY_TO_BE_ESTABLISHED_IN_ST__JAMES.asp

http://www.jis.gov.jm/officePM/html/20060328T130000-0500_8431_JIS_UNIVERSITY_TO_BE_ESTABLISHED_IN_ST__JAMES.asp


All three models are fufilling global demand for skilled healthcare professionals, but have

significant limitations. Willingly or unwillingly, all three types of institutions are training

for export and are not producing enough graduates who will remain in country and satisfy

domestic demand for healthcare services. No mechanism is in place to assure adequate

domestic supply. In addition, given the dimensions of global demand, even private

education institutions are confronted with staffing shortages, further inhibiting supply.

Moreover, public and institutions are often undercapitalized, straining their capacity to

maintain or achieve accreditation standards.

And demand for health and wellness education is not limited to traditional medical and

healthcare education in colleges and universities for terminal degrees. Immediate

opportunities also exist in the growing short-term healthcare seminar market including

courses for medical Continuing Education Courses (CEUs - Continuing Education Units),

alternative health and wellness seminars based upon Caribbean techniques, and also short

term courses in tropical medicine, and intensive graduate level courses in selected topics

such as geriatric nursing and other courses in advanced specialties. Accredited and high-

quality spa schools in the Caribbean are also a significant market opportunity.


Catalyzing the Caribbean Market for Health and Wellness Education

The catalyzation of the health and wellness education market in the Caribbean through an

innovative public private partnership (PPP) is an important opportunity for multilateral

agencies to align the Caribbean with global market demand for health and wellness

professionals. The key element that is missing is a student loan fund for tertiary health

education in the Caribbean that is enforceable across borders78

. Such an initiative would

catalyze private investment and even public investment in health and wellness education

facilities, increase the availability of health professionals and healthcare services for the

people of the Caribbean, and unfold new life choices for an expanded pool of tertiary

level graduates.

It is recommended that multilateral agencies finance such a cross border student loan

fund and engage a large global private sector loan administrator to process loan

applications and ensure timely repayment of student loans internationally. Student loans

would be available to any student from any country in the world who is enrolled in any,

public or private, accredited health and wellness education institution in the Caribbean.

Repayment terms could be structured to reflect individual choices of employment

location after graduation and provide self-funding of the capital pool after initial funding

by multilateral agencies. Students who remained in the Caribbean and were employed in

the health and wellness sector could be offered no interest loans with bonus reductions of

78

See Appendix for a more detailed draft of the mechanics of the cross-border student loan fund.


the principle for each year of employment in the Caribbean. Conceivably, special terms

could also be offered to students who become employed in low income countries outside

of the Caribbean, such as countries of Africa, which are experiencing an extreme paucity

of health professionals. Students who choose employment in OECD countries would be

charged above market rates on an accelerated loan repayment schedule in order to

subsidize terms for graduates remaining in the Caribbean. Thus, in essence, the student

loan pool could be self-funding once the initial capital was supplied by a multi-lateral

development bank. Loan terms for migrants to high demand markets would be set at

levels which would replenish the fund and contribute to the support of professionals who

remained to serve in the Caribbean and other high need geographic areas.

Similar to the historical expansion of access to tertiary education that has been powered

to a significant degree by the availability of student loans in the United States79

, greater

availability of educational financing could support the evolution of knowledge-based

industries in the Caribbean. However, as a high growth ‗sector oriented fund,‘ the

exclusive focus on tertiary health and wellness education financing could allow the fund

to forgo government subsidies required by the U.S. loan system, and instead use private

sector demand to limit risk and assure replenishment of the loan pool.

Availability of student loans from such a cross-border fund need not be limited to

participants in traditional healthcare education such as nursing or medical students, but

79

Sandy Baum et al, ―College on Credit: How Borrowers Perceive their Education Debt,‖ National Student

Loan Survey, Final Report, February 6, 2003, at: http://www.nelliemae.com/library/nasls_2002.pdf . Of

students borrowing to pay for higher education, ―Over 70% continue to agree that student loans were very

or extremely important in allowing them access to education after high school.‖

http://www.nelliemae.com/library/nasls_2002.pdf


could be made available to students in any high growth health and wellness segment,

including spa therapists and alternative health specialists. Based on global market

demand, periodic adjustments could be made to include tuition availability for new

health professions, and the phasing out of funding for healthcare training in segments

with declining demand.

A concerted effort must be made to attract qualified staff from around the world to serve

in the emergence of world-class institutions in the Caribbean. The healthcare skills and

expertise of returning Diaspora as well as existing health and wellness professionals in

the Caribbean will be a key element in the realization of the goal of creating high quality

health and wellness education institutions.

As in the U.S., the creation of privately administered student loans80

would attract new

investors seeking an exceptional rate of return for investment in private education

institutions. Privately owned healthcare schools currently operating in the OECS, with

proper accreditation, could be encouraged to expand the scope and geographic reach of

their operations to include global student sourcing and operations in the larger countries

of the Caribbean. Through such a cross-border loan program Caribbean health education

institutions would no longer be limited to enrolling North American students who have

access to U.S. federal student loan programs. Public colleges and universities in the

Caribbean providing health and wellness curricula would benefit as well as new sources

80

See for example the explosion of for profit private education institutions in the U.S. that was made

possible by widely available federal and private student loan programs (Sallie Mae for example).


of tuition and student enrollments would enable them expand their enrollment capacities

and justify public recapitalization.


4. Developing Magnets for Health and Wellness Employment

While building healthcare education is the major opportunity for economic development,

three additional market segments in the health and wellness sector should be explored

and supported as magnets for employment in the Caribbean as the output of qualified

healthcare personnel is expanded. Alternative health and wellness products and services

have proven to be a market segment with strong global demand. This segment exhibits

superior prospects for long-term market growth with high value-added potential. In

addition, eldercare is a significant market segment for the Caribbean. Special focus

should be placed on returning Diaspora who wish to retire in the Caribbean, and on

remittance supported living arrangements for family members of the Diaspora who have

remained in the region. Telehealth applications such as telephonic nursing, and remote

patient monitoring and support have potential for growth as well. What is needed to

sustain growth in all of these market segments is a sufficient supply of skilled health and

wellness professionals which can be developed through the expanded output of health

education and training institutions in the Caribbean.

It is important to keep in mind that development of these segments must be undertaken in

tandem with the expansion of the output of health and wellness education facilities.

Paradoxically, if the private sector were to be successful in rapidly expanding

employment, public healthcare facilities may face even greater challenges in retaining

staff and filling open positions due to the paucity of skilled healthcare human resources in


the Caribbean. In addition, growth in these segments would be impaired without an

expansion of the supply of qualified Caribbean health and wellness professionals.

Alternative Health and Wellness – Building the Caribbean Brand

The global market for alternative health and wellness products and services continues to

grow dynamically81

. Caribbean branded and developed alternative health and wellness

products and services are the area with perhaps the greatest medium and long-term

opportunity for the Caribbean to increase multi-sector employment, not only in health

and wellness tourism,82

but also in herbal agriculture, research and development in

pharmaceutical and herbal remedies, the bottled water industry, and holistic and

alternative therapies. As these segments are not dependent upon healthcare insurance

reimbursement, and are not as price sensitive as medical tourism, they are much more

attractive for development within the current demand structure.

In a recent Health Affairs article, the most recent estimates of U.S. market size for

complementary and alternative medicine (CAM) are cited:

―…in 1991, one-third of respondents spent about $14 billion - $10.5 billion out of

pocket—for these therapies. When the survey was repeated in 1997, all of the numbers

were much larger: 42 percent of respondents had spent $21 billion—$12 billion out of

pocket. These expenditures exceeded the amount spent on all U.S. hospitalizations. And,

81

Compare citations at the U.S. National Institutes of Health:

http://www.nlm.nih.gov/medlineplus/alternativemedicine.html 82

In a recent IDB funded review of the Barbados tourism sector, nearly over 85% of U.K. Tour Operators

noted ―health and wellness‖ as one of the top three potential areas with the most growth potential in the

next 5 to 10 years for Barbados tourism.

http://www.nlm.nih.gov/medlineplus/alternativemedicine.html


as before, Americans were visiting CAM practitioners more frequently than primary care

physicians.‖83

$5 billion of the out-of pocket spending was on herbal products alone in 1997. In an NIH

study in 2004, 74.6% of U.S. adults reported having used CAM:

Source: U.S. National Institutes of Health, CAM Survey, 2004

And practices used are services which are already showing strong development in the

Caribbean:

83

Mary Ruggie, ―Mainstreaming Complementary Therapies: New Directions In Health Care,‖ Health

Affairs, July/August 2005.


Natural products used are indicative of an herbal base which has a strong competitive

edge in the Caribbean:

The key however, is not simply to engage in commodity priced and unbranded

participation in the health and wellness market. For example, the margin on Caribbean-

branded high quality ginger could be significantly higher than commodity ginger


products. Food companies in northern markets have recognized the attractiveness of the

―Jamaican Ginger‖ brand and have expropriated its use in their marketing:

Illustration 1: Biscuit Wrapper in Australia

Source: Professor Robert J. Lancashire, Department of Chemistry, University of West Indies, at:

http://wwwchem.uwimona.edu.jm:1104/lectures/ginger.html

Unfortunately, this strong Caribbean-based brand has been allowed to ―lapse‖. While

Jamaica was formerly one of the top three producers in the world with 2 million

kilograms of ―the finest ginger in the world‖ in 1953, by 1995 Jamaica was producing

less than 0.4 million kilos annually84

. Note that in the graph above ―Top 10 Natural

Products‖ that ginger supplements are ranked 9th

.

And ginger is but one of many potential health and wellness products and services85

which the Caribbean could brand, perhaps uniquely, on the basis of the region‘s immense

biodiversity and traditional knowledge of healing86

. Unique opportunities exist in the

Caribbean that have not been fully developed. In addition to herbal remedies and the

84

Professor Robert J. Lancashire, ―Jamaican Ginger‖, Department of Chemistry, University of West Indies,

at: http://wwwchem.uwimona.edu.jm:1104/lectures/ginger.html 85

Discussions and numerous publications: Dr. Henry Lowe, Eden Gardens, Jamaica; Dr. Tony Vendryes,

Vendryes Wellness Centre, and Dr. L.D. Whyte, Lifestyle Transformation Centre, Jamaica. 86

Compare: Bill Rogers, ―Shantos from Guyana‖, Calypso song which details the herbal remedies available

in Guyana.




potential for pharmaceutical bio-prospecting87

, the role of water in alternative healing in

the Caribbean could be especially powerful: ―Black Water‖ in Guyana, mineral springs in

Jamaica, the healing and salt ponds of the Bahamas, the special uses of seaweed, and the

composition of Caribbean sea water for use in thellasotherapy are all under explored

strengths of a potentially very powerful market differentiation.88

Bottled water89

exports,

if well-positioned and marketed90

could open up an additional health and wellness sub-

segment of the health and wellness sector.

Illustration 2: “Black Water” at the Emerald Tower Resort in Guyana

Source: Photo by author, January 2006

87

In a site visit and interview with Ajay Baksh of Conservation International in Guyana, Mr. Baksh

highlighted the extraordinary biodiversity of Guyana and its potential, if properly regulated, for

pharmaceutical and biotech prospecting in Guyana. He also recommended the Calypso song in the previous

footnote. Compare the potential for bioprospecting in a recent IDB article: Roger Hamilton,

Bioprospecting, with no apologies,‖ IDBAmerica, April 3, 2006, at:

http://www.iadb.org/idbamerica/index.cfm?thisid=2705 88

Discussions with Eric J. Light, of the Strawberry Hill Group, and Hannelore Leavy, Founder &

Executive Director of the International Medical Spa Association at the ―Caribbean Health Tourism & Spa

Symposium 2006,‖ and all of the participants in Kingston, Jamaica, February 12-13, 2006, organized by

Theo and Sharon of Positive Tourism Limited at: www.positivetourism.com. 89

See for example: Blue Mountain Spring Water, Ocho Rios, Jamaica. Website unavailable. 90

Compare marketing of Hawaiian ―Mahalo Deep Sea Water‖ at: http://www.hawaiideepseawater.com

http://www.iadb.org/idbamerica/index.cfm?thisid=2705

http://www.positivetourism.com/

http://www.hawaiideepseawater.com/


Yet while larger, globally branded wellness services, especially in the Caribbean spa

industry, have experienced considerable growth and expansion, the nascent health and

wellness market in the English-speaking Caribbean has not yet reached its potential as a

sub-segment of the health and wellness sector. Holistic and alternative treatments already

offered by small and medium sized businesses in the Caribbean have the potential for

strong growth if they could improve their market visibility. Skilled and creative

entrepreneurs in the Caribbean have built viable health and wellness businesses, but a

lack of internationally recognized branding, well-funded marketing and sales capability,

and inadequate access to capital have limited their ability to expand and add new

employees.

This is a key area for a strong role for multilateral agencies. By opening multilateral

investment to Caribbean entrepreneurs in this segment, supply could be better aligned

with demand. This goal could be accomplished through the creation of a micro-loan

program for small businesses with well-founded business plans. In addition, by funding a

project to support the efforts of marketing co-operatives in the Caribbean, fee-based

alternative health and wellness membership organizations could improve the

international visibility of small and medium sized operators. This effort could be further

strengthened by a standards and certification study of existing alternative health and

wellness services and companies in the Caribbean. Key assistance could also be provided

by the multilateral agencies in funding a study to research and publish an ―Encyclopedia

of Traditional Caribbean Herbal Remedies‖ and a market study of such herbs which

could serve as the platform for the expansion of organic herbal farming in the Caribbean.


Eldercare– Serving the Diaspora, High-End Retirees and the People of the Caribbean

There are large numbers of Caribbean-born populations residing in the U.S., Canada and

the U.K.. In the U.S. alone, over 16 million people, or 9.5 % of the foreign-born

population in the United States, were from the Caribbean in the year 2000. Four of the

five large English-speaking countries of the Caribbean have significant numbers of

residents living in the United States.

Table 7: Caribbean Diaspora in the U.S.

Place of Birth

and Resident in

the U.S. (2000)

Ancestry and

Living in the U.S.

(2000)

Country

Population

(2005 est)

Jamaica 553,827 716,513 2,731,832

Guyana n/a 162,425 765,283

Trinidad & Tobago 197,398 164,738 1,088,644

Barbados 52,172 n/a 279,254

The Bahamas n/a n/a 301,790

Source: U.S. Census

Already, Jamaica has seen the market opportunity in retirement and assisted living for

returning Diaspora and has launched an intensive public private initiative under the new

prime minister to develop facilities for this market segment.91

Although it cannot be

expected that the entire Diaspora will return home, this market does offer significant

potential. While assisted living or nursing home facilities in the U.S. may cost between

91

―Lifestyle Villages Project to get Underway Soon,‖ Office of the Prime Minister, Jamaica, March

29,2006, at: http://www.jis.gov.jm/officePM/html/20060328T130000-

0500_8430_JIS_LIFESTYLE_VILLAGES_PROJECT_TO_GET_UNDERWAY_SOON.asp

http://www.jis.gov.jm/officePM/html/20060328T130000-0500_8430_JIS_LIFESTYLE_VILLAGES_PROJECT_TO_GET_UNDERWAY_SOON.asp

http://www.jis.gov.jm/officePM/html/20060328T130000-0500_8430_JIS_LIFESTYLE_VILLAGES_PROJECT_TO_GET_UNDERWAY_SOON.asp


$4,500 and $8,000 per month, such arrangements can be priced below $1,000 per month

in Jamaica.92

In addition to demand from the Diaspora, these Caribbean countries will also experience

a historical shift of their population pyramids within the next 20 years further increasing

the domestic demand for eldercare for the island populations. As one study notes:

―The speed of demographic aging in Latin America and the Caribbean will be

unprecedented. The time it will take a typical country in Latin America and the

Caribbean to attain a substantial fraction of people above age 60, say around 15 percent,

from current levels of around 8 percent is less than two fifths the length of time it took

the U.S., and between one fifth and two fifths of the time it took an average Western

European country to attain similar levels. The annualized rate of increase of the

population older than 60 is approaching values as high as .045 implying doubling times

of the order of 5 years for the next three to five decades. Barring unexpected

demographic upheavals we should expect that for the next three to five decades the speed

of aging in the region will continue on a singularly fast course, a result of the momentum

of demographic force set in motion long ago.‖93

92

Site Visit and interview with Nurse Devon, Kingston, Jamaica 93

Aging and Health Status of Elderly in Latin America and the Caribbean Alberto Palloni

Mary McEniry CDE Working Paper No. 2004-09 October 2004


The following graphs illustrate the speed of that transition.

Graph 8: Population Pyramid for the Bahamas, Barbados, Guyana, Jamaica and

Trinidad and Tobago, 2000 and 2025


Locally, traditional community and family-based care may disintegrate in the Caribbean

as the young migrate and the sheer numbers of the Caribbean old increase. Yet, many of

the Diaspora families still feel strong ties to their home countries and families and have

contributed to their support through immense remittance flows94

. While many families

seek to bring their elderly relatives to live with them in North America and the U.K., this

is not always an option given visa constraints and the desire of the elderly to remain in

their communities.

However, community-based, small scale facilities in the Caribbean could meet the

growing need of the Diaspora to care for their relatives at home in the Caribbean. Small,

particularly home-based businesses, and medium sized businesses in the Caribbean could

be organized to provide shopping and cooking for the elderly, home visits and eventual

integration into small scale community homes and assisted living facilities. If such

services were accredited and well-staffed with skilled eldercare professionals, remittances

could be funneled into revenue for such businesses. As will be discussed later under

telehealth opportunities, the quality of these eldercare offerings could be further enhanced

if they were equipped with VOIP and teleconferencing capabilities which would enable

the Diaspora to monitor the care of their relatives, and open up the possibility of remote

care supervision and physician ―visits‖.

94

Michelle Lapointe, ―Diasporas in Caribbean Development,‖ Report of the Inter-American Dialogue and

the World Bank, August 2004, at:

http://www.thedialogue.org/publications/country_studies/caribbean/diasporas.pdf. According to the report,

remittances to six Caribbean countries - Jamaica, the Dominican Republic, Haiti, Cuba, Trinidad and

Tobago, and Guyana - totaled over $6 billion in 2003.



In the graphic below, the requirement for skilled healthcare personnel increases with

eldercare intensity. Thus, creation of attractive eldercare offerings in the Caribbean also

depends upon a significant upgrade in the available pool of qualified professionals.

Source: ―The Impact of the Aging Population on the Health Workforce in the United States,‖ National

Center for Health Workforce Analysis, December 2005

In the United States, nearly 20% of the population will be over 65 years of age by 2025,

and yet as a result of immigration into the United States, the population pyramid will still

not be as dramatically skewed between older and younger as in many of the English-

speaking Caribbean countries. Nonetheless, the entire eldercare industry in the United

States is expected to experience dramatic growth over the next twenty years, and skilled

eldercare professionals in the U.S. will be in short supply as well.


While the vast majority of elderly prefer to receive services at home or in a home-like

setting in their community, a large number of active retirees from North America and the

U.K. is seeking to buy retirement properties in Central America. Mexico and Costa Rica

have attracted a significant number of such retirees who are seeking a low cost setting for

their active retirement95

. Yet given the high cost of living and high real estate prices in

the English-speaking Caribbean, the North American and U.K. retiree market will

remain, similar to medical tourism, a relatively uncompetitive area for the Bahamas,

Barbados, Jamaica and Trinidad and Tobago. In areas of those countries and in Guyana

which are price attractive, high crime rates and perceived high crime rates, exposure to

95

―Retiring Americans, Go south, old man,‖ Economist.com, November 24, 2005. Includes estimate of

250,000 U.S. Americans of non-Mexican ethnicity who have moved to Mexico alone.


hurricanes or flooding, and lack of high quality private medical facilities limit the appeal

for the budget-minded North American and U.K. retirees.

Yet, baby boomers as they retire will seek active retirement opportunities and control

significant disposable income. Already the 50+ age market buys ―80% of all luxury

travel.‖96

While hotels were not previously designed for mobility impaired travelers, this

segment will increase. As one hotelier in Jamaica put it, ―We used to have one

wheelchair available for our guests and now we have five, and we will have to buy

more.‖97

Innovative co-marketing agreements with North American and U.K. eldercare

companies could address the segment of respite and assisted tourism for upper-middle to

upper segment eldercare travel to the Caribbean. Investment in assisted living hotels and

medium stay facilities, even if constructed in non-premium (i.e. not necessarily beach

front) locations, and if staffed with qualified eldercare professionals, could fill a growing

need of families who are presently caring for elderly relatives in North America and the

U.K. to come to the Caribbean for vacations and extended stays, thus reducing the strain

on family caregivers.

The high-end segment of retirement communities in the Caribbean also offers

opportunities yet with significant limitations. For example, a high-end retirement

community in Barbados which is currently planned is constrained by the lack of high-

96

―Industry Facts: Travel and Leisure.‖ Mature Market Group (MMG), part of J. Walter Thompson

Worldwide, At: http://www.jwtmmg.com/knowhow/pdf/travelandleisure.pdf 97

Site Visit and interview, Hotelier in Jamaica.

http://www.jwtmmg.com/knowhow/pdf/travelandleisure.pdf


quality private healthcare facilities and private medical staff in Barbados. Another

planned high end retirement development in the Bahamas is considering overcoming a

similar constraint. Both groups of investors are planning to construct private medical

facilities to address that need. In addition, particularly in the smaller and more densely

populated islands, in Barbados and Tobago for example, local populations are concerned

that high-end retirement and villa tourism will lead to the acquisition of more and more

real estate in competition with the resident population. The advantage of this segment of

the eldercare market is that it is highly employment intensive and could create high-value

employment because of the requirement for skilled healthcare personnel and facilities.

The downside is that the villa segment is real estate intensive and can crowd out the

residents of small, densely populated islands such as Barbados.

Overall, the eldercare segment of the health and wellness sector will provide growing

employment opportunities and could draw significant private investment, if the need for

qualified healthcare personnel is met.


Telehealth – Leveraging Unique Caribbean Advantages

The traditional approach to telemedicine, defined as ―rapid access to shared and remote

medical expertise by means of telecommunications and information technologies, no

matter where the patient or relevant information is located,‖98

is typically based upon the

offer of medical services to geographic areas which are underserved by medical care.

Current market size for such telemedicine applications in the U.S. is estimated at $350

million per year.99

From this perspective, the same market barriers that apply to

Caribbean medical tourism may also apply to the provision of traditional telemedicine

from the Caribbean to Northern markets.

However, if the Caribbean were to continue its efforts to modernize and privatize

telecommunications infrastructure, and add to the pool of qualified healthcare

professionals through increasing output of tertiary healthcare institutions in the

Caribbean, substantial market opportunities could emerge in applications such as

telephonic disease management, and in remote monitoring and contact with eldercare

clients.

In the area of telephonic nursing, which currently has greater than a $1 billion market size

in the U.S., leading disease management outsourcing companies including American

Healthways, Health Dialog, Matria, and Life Masters, in house programs at health

98

EU Healthcare Telematics Programme 99

David Brantley et al, ―Innovation, Demand and Investment in Telehealth,‖ U.S. Department of

Commerce, Office of Technology Policy, February 2004, p. 58, at:

http://www.technology.gov/reports/TechPolicy/Telehealth/2004Report.pdf



insurance companies, pharmaceutical benefit management companies, and

pharmaceutical companies are currently serving a wide and growing market of both

public and private payers100

. Such disease management companies are potentially

impaired in their growth through the impending and current shortage of qualified nurses

in the United States. Disease management companies tend to put their call centers in

geographic areas with a high density of qualified nurses, such as the Baltimore-

Washington area in the U.S..101

Potential areas for expansion within North America are

becoming less available and open an opportunity for the English-speaking Caribbean to

enter the out-sourcing market.

The British National Health Service runs the largest telephone healthcare service in the

world.102

Fielding 6.5 million calls a year, the center acts as triage and health information

service for patients accessing public health services in the U.K. As the nursing shortage

in the U.K. grows, outsourcing of nursing call center functions may also be a market

opportunity for the Caribbean.

The English-speaking Caribbean has linguistic, cultural and proximity advantages which

would ease market entry. The graphic below illustrates the proposed model of

outsourcing to the Caribbean.

100

See for example the corporate membership roster of the Disease Management Association of America,

at: http://www.dmaa.org/corporate_roster.html 101

Interview 102

―UK: Health Hotline a model patient,‖ AAP General News Wire. Sydney: Feb 3, 2006. pg. 1.

http://www.dmaa.org/corporate_roster.html


17

Telehealth Services Telehealth Services

Telephonic Nursing ExampleTelephonic Nursing Example

Caribbean-Based

Telephonic Nursing Center

(200 nurses with Headsets,

Broadband Computers

and VOIP)

Outbound

Calls

Patients in North

America with Chronic

Conditions (Diabetes,

Hypertension, CHF,

COPD… )

PAYORS

Health Insurance Companies, Medicare and Medicaid

(in order to avoid the high cost of hospitalizations)

Disease Management Companies

Who Pays for this?

Caribbean Patients with Chronic

Conditions (Diabetes,

Hypertension, CHF, COPD… )

Mortality Rate from Diabetes Mellitus

in Last Available Year (per 100,000 pop)

94.5

70.0

57.5

36.632.9

25.2 23.7

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

Tri

nid

ad

an

d

To

bag

o

Barb

ad

os

Jam

aic

a

Bah

am

as

Gu

yan

a

U.S

.

Can

ad

a


In addition to telephonic nursing applications in disease management, whole new areas of

remote monitoring and companionship may be emerging. Given technical advances in

remote monitoring of patients, it is possible if human resource constraints in the

Caribbean are effectively addressed, to offer mobility impaired seniors and their

caregivers in the United States, Canada and the U.K. the option of a ―teleconferenced

companion‖ in the Caribbean with whom they could remain in contact while in-place

caregivers are offered a respite. In retirement homes, assisted living facilities, hospitals

and nursing homes in the U.S., the Caribbean ―teleconferenced companion‖ could offer

remote monitoring and companionship for patients in understaffed North American and

UK facilities, and alert staff in critical situations.

The ―world is flat‖103

and getting flatter all the time. With the unique linguistic and

cultural advantages of the Caribbean and continued advances in telecommunications

technology, telehealth applications will become a major competitive opportunity for the

Caribbean to create economic value in a segment with stable and sustainable future

potential and employment, promotion of gender equality, improvement of health and

wellness of the Caribbean, and with little or no environmental impact – if expanded

access to tertiary education in accredited healthcare institutions in the Caribbean is

achieved.

103

Thomas L. Friedman, ―The World is Flat,‖ Farrar, Straus and Giroux, April 2005.

H&W Market in the Caribbean 5/22/2006

68

5. Market Opportunity and Roadmap Review – Private Investment and

the Public Interest

The health and wellness sector in the English-speaking Caribbean offers singular

opportunities for the economic development of the region in a way the promotes equality

and the liberation that ensues from education. Yet these benefits and the development of

the sector will be difficult to achieve without a new public private partnership. An

integrated plan of development with both public and private sector engagement is

necessary to catalyze the development of the health and wellness sector in the Caribbean.

Market Opportunity Review

The health and wellness education market offers the most complete array of positive

attributes of all of the compared segments: market size is large and growing; clear

competitive advantages including proximity, cultural and linguistic characteristics; the

potential for significant expansion of high-value added employment; equality of access to

tertiary education and employment; a substantial increase in the quality of health and

wellness for the people of the Caribbean; and sustainability which could only be impaired

by further automation of healthcare services and a decline in the demand for healthcare

professionals. Alternative health and wellness is ranked second primarily because of

smaller market size when compared to healthcare education. Eldercare promotes equality,

the health and wellness of an aging Caribbean population and ranks high on sustainability

based on demographic trends but declines in attractiveness due to smaller market size,

more limited employment opportunities and lack of competitiveness with other regional

offerings in Central and North America. Teleheath services, while offering substantial


69

future potential, are severely limited by the lack of qualified health and wellness

professionals required for short term market entry. Medical tourism ranks last in

attractiveness primarily because of small market size and lack of competitiveness.

The table below provides a summary of Caribbean market opportunities in the health and

wellness sector from both a public and private perspective:

Table 11: Opportunity Assessment for Health and Wellness Tourism in the Caribbean

Ran

k

Mark

et S

ize

Com

pet

itiv

enes

s

Em

plo

ym

ent

Eq

uali

ty

H&

W o

f C

ari

bb

ean

Su

stain

ab

ilit

y

Over

all

Sco

re

1 Health and Wellness Education 5 5 5 5 5 4 29

2 Alternative Health and Wellness 3 4 4 5 4 4 24

3 Eldercare 2 3 3 5 5 5 23

4 Telehealth Services 2 3 2 4 3 3 17

5 Medical Tourism 1 1 1 1 1 1 6

Scale: 1 is poor and 5 is excellent


70

Roadmap Review - Next Steps

Beginning with the catalyzation of world-class health educational facilities in the

Caribbean, the foundation is laid for the expansion of magnets of employment in

eldercare, telehealth and alternative health and wellness.

Table 12: Summary of Next Steps for Development of H&W Sector in the Caribbean

Market Segment Goal

Next Steps for Private

Sector, Governmental

Entities and Multilateral

Institutions

Health and Wellness Education Enable expansion of private and

public tertiary education offerings

in health and wellness education

Technical feasibility study of

cross-border student loan fund

for H&W education in the

Caribbean; upon launch of

fund, co-financing of private

and public investment in

H&W education institutions

through multilateral lending

institutions

Alternative Health and Wellness Catalyze growth in SMB in

alternative health and wellness

Marketing Cooperative;

Encyclopedia of herbal

remedies; Standards and

accreditation; Micro-loan fund

for SMB through multilateral

lending institutions

Retirement and Assisted Living Support growth of retirement and

assisted living facilities

Evaluate sustainability of

projects for possible

participation by multilateral

lending institutions

Telehealth Services Facilitate telehealth services in the

medium term

Support private investment

when a critical mass of

qualified health and wellness

staff is available

Medical Tourism Support growth of destination

enhancing private medical

facilities; niche products in

medical tourism

Consideration of financially

sustainable project proposals

by multilateral lending

institutions

If required, multilateral financing should be used to support individual private investment

projects in healthcare education, eldercare, telehealth and alternative health and wellness.


71

Particular emphasis should be given to small and medium sized Caribbean enterprises

which may lack access to capital. In the alternative health and wellness segment relevant

multi-lateral agencies should support the creation of a cooperative marketing company in

the Caribbean to enhance the visibility of small and medium sized enterprises.

The governments of the English-speaking Caribbean can increase their competitive

attractiveness by easing visa requirements for healthcare practitioners and prospective

students, continuing improvement of the general business climate, adopting globally

recognized healthcare education accreditation and standards, accelerating

telecommunications privatization and modernization, and reducing crime as a major

impediment to private investment.

The essential catalyst however, and one that only a multilateral development investment

bank can provide, is the facilitation of a new cross-border student loan fund for students

of public and private health and wellness education institutions in the Caribbean. This is

the key spark which is needed to fuel the fire of market growth. New health and wellness

schools could be encouraged in the spa industry and in other areas of health and wellness.

Public healthcare colleges and universities in the Caribbean would gain access to a new

source of tuition funding which could fuel their expansion. Existing healthcare schools in

the Caribbean, now concentrated in the OECS, may be encouraged to expand to the larger

islands of the English-speaking Caribbean. And new investors in the growing healthcare

education market could be encouraged to enter the Caribbean market.


72

Appendix


73

Employment Statistics


74

U.S. Healthcare Employment by Occupation, 2004 and Projected 2014

Source: Daniel E. Hecker, ―Employment Outlook: 2004–14 - Occupational Employment Projections to

2014,‖ U.S. Bureau of Labor Statistics, Monthly Labor Review, November 2005.


75




76




77

Draft Proposal for a Global Student Loan Fund for Healthcare Education in the English-

Speaking Caribbean


78

Draft Proposal for a Global Student Loan Fund for Healthcare Education in the

English-Speaking Caribbean

Goal

Create a market-based student loan fund to support tertiary education in private or public

healthcare colleges and universities in the English-speaking Caribbean countries 104

. Such

a fund would be capitalized with private sector equity and with debt from multilateral

lending agencies using a debt/equity ratio to be determined.

Purpose

To catalyze private and public sector investment in world-class healthcare education

facilities in the Caribbean to meet the dramatic increase in regional and global demand

for qualified healthcare personnel.

Rationale

The catalyzation of the health and wellness education market in the Caribbean through an

innovative public private partnership (PPP) is an important opportunity for multilateral

agencies to assist in the alignment of the Caribbean with global market demand for health

and wellness professionals. The key element that is missing is a student loan fund for

tertiary health education in the Caribbean that is enforceable across borders. Such an

initiative would catalyze private investment and even public investment in health and

wellness education facilities, increase the availability of health professionals and

healthcare services for the people of the Caribbean, and unfold new life choices for an

expanded pool of tertiary level graduates.

As in the U.S., the creation of privately administered student loans would attract new

investors seeking an exceptional rate of return for investment in private education

institutions. Privately owned healthcare schools currently operating in the OECS, with

proper accreditation, could be encouraged to expand the scope and geographic reach of

their operations to include global student sourcing and operations in the larger countries

of the English-speaking Caribbean. Through such a cross-border loan program

Caribbean health education institutions would no longer be limited to enrolling North

American students who have access to U.S. federal student loan programs. Public

colleges and universities in the Caribbean providing health and wellness curricula would

benefit as well as new sources of tuition and student enrollments would enable them

expand their enrollment capacities and justify public recapitalization.

Similar to the historical expansion of access to tertiary education that has been powered

to a significant degree by the availability of student loans in the United States , greater

availability of educational financing could support the evolution of knowledge-based

industries in the Caribbean. However, as a high growth ‗sector oriented fund,‘ the

104

Bahamas, Barbados, Jamaica, Guyana, , Trinidad & Tobago


79

exclusive focus on tertiary health and wellness education financing could allow the fund

to forgo government subsidies required by the U.S. loan system, and instead use private

sector demand to limit risk and assure replenishment of the loan pool.

Availability of student loans from such a cross-border fund need not be limited to

participants in traditional healthcare education such as nursing or medical students, but

could be made available to students in any high growth health and wellness segment,

including spa therapists and alternative health specialists. Based on global market

demand, periodic adjustments could be made to include tuition availability for new

health professions, and the phasing out of funding for healthcare training in segments

with declining demand.

Key Parties

There are four primary parties who would be involved in funding and administering the

student loan fund: multilateral agencies may consider providing initial technical

assistance funding for the design of a private sector equity fund and subsequently

provide senior debt funding to the fund; a fund manager which would raise the required

private sector equity and subsequently invest the equity and the debt in student loans; an

international administrator of the loan program; and the private and public sector

educational institutions in the Caribbean who would receive funds for students enrolled in

their programs.

In order to maximize the benefit for the Caribbean, a multilateral lending agency would

be the primary contributor to the debt funding of the student loan pool and thereby

influence the policy guidelines and terms of the student loan program through its debt

covenants. The design of the fund‘s policies and guidelines would correspond with the

developmental objectives of the multilateral lending agency.

Fund Size

An initial fund of $60 million to support 1,000 students per year for two years.

Fund Structure

Repayment terms of the student loans could be structured to reflect individual choices of

employment location after graduation and provide self-funding of the capital pool after

initial equity funding and debt funding by a multilateral lending agency. Students who

remained in the Caribbean and were employed in the health and wellness sector could be

offered no interest loans with bonus reductions of the principle for each year of

employment in the Caribbean (although the interest rate on the debt facility from the

multilateral agency to the fund would not be subsidized). Conceivably, special terms

could also be offered to students who become employed in low income countries outside


80

of the Caribbean which are experiencing an extreme paucity of health professionals.

Students who choose employment in OECD countries and other countries which import

healthcare professionals would be charged above market rates by the fund, on an

accelerated loan repayment schedule in order to subsidize terms for graduates remaining

in the Caribbean. Thus, in essence, the student loan pool could be self-funding once the

initial capital was supplied by private equity and debt from the multilateral agency. Loan

terms for migrants to high demand markets would be set at levels which would replenish

the fund and contribute to the support of professionals who remained to serve in the

Caribbean and other high need geographic areas.


81

Healthcare Migration


82

Table 13: Registered Nurse (RN)-To-Population Ratios Among Major Host And Source

Countries For Foreign Nurses

Source: Linda H. Aiken et al, ―Trends in International Nurse Migration,‖ Health Affairs, May/June 2004


Tourism Industry Statistics


84

BAHAMAS 1999 2000 2001 2002 2003E 2004E 2014P

Travel & Tourism - US$ mn Personal Travel & Tourism 616.48 612.18 640.11 655.19 689.53 745.97 1,427.94

Business Travel & Tourism 106.43 89.94 91.28 81.58 86.99 97.76 189.94

Gov‟t Expenditures - Individual 22.58 24.24 25.64 26.97 28.76 30.61 56.75

Visitor Exports 1,597.80 1,829.30 1,681.90 1,507.10 1,613.40 1,884.40 4,490.02

Travel & Tourism Consumption 2,343.29 2,555.66 2,438.93 2,270.84 2,418.68 2,758.73 6,164.64

Gov‟t Expenditures - Collective 51.92 55.36 58.85 61.90 65.96 70.15 130.02

Capital Investment 538.23 581.73 632.78 667.86 709.70 752.80 1,357.80

Exports (Non-Visitor) 23.47 21.22 18.55 27.68 29.36 31.40 59.78

Travel & Tourism Demand 2,956.91 3,213.98 3,149.11 3,028.29 3,223.71 3,613.07 7,712.24

T&T Industry GDP 838.34 920.66 884.26 801.67 858.54 990.45 2,296.32

T&T Economy GDP 2,431.41 2,645.57 2,623.74 2,473.15 2,644.02 2,986.82 6,555.23

T&T Industry Employment („000) 38.77 40.28 39.26 35.30 37.57 42.08 67.28

T&T Economy Employment („000) 101.71 105.03 104.57 96.48 102.56 113.29 174.70

Travel & Tourism Accounts as % of National Accounts

Personal Travel & Tourism 21.24 19.82 19.60 19.13 18.97 19.37 20.80

Gov‟t Expenditures 13.58 13.64 13.69 13.74 13.79 13.85 14.40

Capital Investment 63.05 64.04 65.88 66.32 66.39 66.47 67.26

Exports 73.99 64.57 67.17 63.37 63.52 65.48 69.05

Imports 19.03 17.85 19.43 18.41 18.24 18.76 21.94

T&T Industry GDP 18.51 19.11 18.38 16.19 16.90 18.56 24.14

T&T Economy GDP 53.70 54.91 54.55 49.95 52.05 55.96 68.91

T&T Industry Employment 25.92 26.75 25.74 22.67 23.66 25.98 33.79

T&T Economy Employment 68.00 69.77 68.55 61.96 64.59 69.93 87.75

Travel & Tourism Real Growth (per annum except 2014 = 10-year annualized) Personal Travel & Tourism 5.74 -2.48 2.54 0.14 3.49 5.54 4.11

Business Travel & Tourism 21.59 -17.01 -0.47 -12.57 4.85 9.64 4.28



Visitor Exports 14.08 12.43 -9.84 -12.34 5.27 13.95 6.45

Other Exports 133.66 -11.20 -14.29 46.02 4.31 4.31 4.05

Travel & Tourism Demand 10.88 6.74 -3.92 -5.92 4.68 9.34 5.26

T&T Industry GDP 13.81 7.84 -5.81 -11.31 5.31 12.55 6.15

T&T Economy GDP 12.29 6.85 -2.75 -7.78 5.13 10.21 5.56

T&T Industry Employment 10.84 3.89 -2.51 -10.09 6.42 12.02 4.83

T&T Economy Employment 9.87 3.27 -0.44 -7.74 6.29 10.46 4.45

Source: World Travel & Tourism Council, “The Caribbean: The Impact of Travel & Tourism on Jobs and the Economy,” London: World Travel & Tourism Council, 2004, at: http://www.caribbeanhotels.org/WTTC_Caribbean_Report.pdf



85

BARBADOS 1999 2000 2001 2002 2003E 2004E 2014P

Travel & Tourism - US$ mn Personal Travel & Tourism 169.01 177.87 187.93 184.92 187.64 204.00 377.03



Visitor Exports 686.50 721.50 696.30 670.94 699.43 843.21 1,687.78

Travel & Tourism Consumption 938.76 990.24 974.88 939.62 971.38 1,139.04 2,244.79





T&T Industry GDP 344.78 363.35 354.70 341.07 353.06 420.26 843.87

T&T Economy GDP 1,121.65 1,187.93 1,188.64 1,174.27 1,218.94 1,391.87 2,731.97



Travel & Tourism Accounts as % of National Accounts

Personal Travel & Tourism 10.79 11.06 11.07 10.52 10.60 11.00 11.21



Exports 53.21 53.21 51.79 51.96 51.66 54.23 53.23

Imports 13.34 13.50 14.37 13.89 13.54 13.94 15.19

T&T Industry GDP 13.85 13.76 12.79 13.81 13.86 15.75 18.30

T&T Economy GDP 45.05 44.97 42.87 47.55 47.86 52.18 59.26



Travel & Tourism Real Growth (per annum except 2014 = 10-year annualized)

Personal Travel & Tourism 2.34 6.31 2.14 -1.77 -0.03 6.18 3.76

Business Travel & Tourism -1.46 10.28 -5.92 -10.38 -1.07 8.35 4.55

Gov‟t Expenditures 10.40 9.70 2.31 -1.83 -0.70 2.60 3.97


Visitor Exports -6.77 6.16 -6.71 -3.81 2.70 17.74 4.60

Other Exports 18.87 56.19 -19.02 3.43 3.50 8.34 4.61

Travel & Tourism Demand -1.68 7.00 -3.03 -1.47 2.20 10.69 4.24

T&T Industry GDP -5.10 6.45 -5.63 -4.01 1.98 16.26 4.63

T&T Economy GDP -1.76 6.98 -3.28 -1.38 2.27 11.52 4.38

T&T Industry Employment -3.48 1.45 -4.96 10.41 2.67 16.50 3.63

T&T Economy Employment -1.00 1.82 -3.21 12.67 2.89 12.93 3.45




86

JAMAICA 1999 2000 2001 2002 2003E 2004E 2014P




Visitor Exports 1.49 1.58 1.49 1.48 1.59 1.87 4.23

Travel & Tourism Consumption 2.09 2.17 2.08 2.09 2.18 2.49 5.40




Travel & Tourism Demand 2.85 3.01 3.05 2.97 2.98 3.30 6.85

T&T Industry GDP 0.75 0.78 0.72 0.73 0.76 0.87 1.95

T&T Economy GDP 2.37 2.47 2.45 2.39 2.38 2.65 5.63



Travel & Tourism Accounts as % of National Accounts Personal Travel & Tourism 7.17 6.63 6.33 7.27 7.88 8.42 8.82



Exports 43.89 43.97 43.59 45.02 46.04 47.87 51.61

Imports 11.95 12.18 12.97 12.02 11.91 12.13 12.71

T&T Industry GDP 10.01 10.08 9.31 9.04 10.29 11.82 14.85

T&T Economy GDP 31.43 32.08 31.48 29.70 32.45 35.95 42.90



Travel & Tourism Real Growth (per annum except 2014 = 10-year annualized) Personal Travel & Tourism 7.93 -5.66 -1.54 11.34 11.05 8.76 2.64

Business Travel & Tourism 5.11 3.83 -1.36 -16.12 2.56 7.78 3.03

Gov‟t Expenditures -3.52 -0.89 -2.98 15.46 1.75 1.73 2.55

Capital Investment 3.69 13.84 21.82 -16.23 1.79 2.10 2.36

Visitor Exports 6.52 4.34 -4.50 -2.51 20.42 18.48 4.82

Other Exports 15.23 -27.47 -27.23 15.49 19.24 12.23 2.44

Travel & Tourism Demand 5.37 4.17 1.80 -4.22 12.48 12.05 3.88

T&T Industry GDP 5.40 1.32 -5.99 -1.48 16.42 16.66 4.68

T&T Economy GDP 4.56 2.74 -0.17 -4.22 11.66 12.55 4.13

T&T Industry Employment 6.95 3.04 -6.66 -1.47 15.64 16.56 3.87

T&T Economy Employment 6.14 4.40 -1.23 -4.05 11.19 12.70 3.37




87

TRINIDAD AND TOBAGO 1999 2000 2001 2002 2003E 2004E 2014P




Visitor Exports 364.70 371.20 361.20 337.20 350.43 407.66 859.48

Travel & Tourism Consumption 755.17 815.86 807.99 830.95 867.23 976.22 1,922.84





T&T Industry GDP 213.74 187.77 220.09 208.53 215.77 244.71 435.47

T&T Economy GDP 851.50 925.63 939.01 981.35 1,033.26 1,147.50 2,115.54



Travel & Tourism Accounts as % of National Accounts Personal Travel & Tourism 6.76 7.44 7.34 6.86 6.90 7.11 8.25



Exports 17.28 15.07 13.69 13.20 12.84 13.16 12.33

Imports 13.38 18.46 11.63 13.89 13.78 13.97 13.85

T&T Industry GDP 3.15 2.34 2.50 2.22 2.17 2.30 2.50

T&T Economy GDP 12.53 11.54 10.68 10.46 10.37 10.78 12.13



Travel & Tourism Real Growth (per annum except 2014 = 10-year annualized)

Personal Travel & Tourism 7.43 8.53 -1.73 8.47 1.95 6.63 4.68

Business Travel & Tourism 20.25 -10.91 -13.02 -1.21 1.52 9.51 4.05

Gov‟t Expenditures -9.06 -7.20 24.79 4.32 3.81 3.82 3.48

Capital Investment 25.10 41.96 -41.84 43.11 4.03 4.00 4.52

Visitor Exports -1.36 -7.88 -6.79 -10.13 1.19 13.25 5.80

Other Exports 61.35 49.69 -17.75 4.01 5.83 6.49 6.52

Travel & Tourism Demand 15.20 16.01 -16.78 7.90 3.15 7.48 5.27

T&T Industry GDP -7.85 -20.49 12.28 -8.80 0.75 10.41 4.02

T&T Economy GDP 4.56 -1.61 -2.83 0.60 2.52 8.11 4.38

T&T Industry Employment -11.08 -23.05 9.99 -9.20 -0.60 8.29 2.86

T&T Economy Employment -1.25 -7.74 -2.81 -1.27 0.89 6.35 3.16




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Meetings and Interviews

Bahamas

A. Davis Taxi Cab Service

Dr. Anthony Regis UWI Bahamas

Dr. Baldwin Carey Ministry of Health

Dr. Barry Rassin Doctors Hospital

Bruno Pletscher Banca Del Gottardo

Charles L. Storr C.L Storr's Taxi Cab Service

Dr. Constantine D. Tseretopoulos Bahamas Heart Institute

Dr. Conville S. Brown The Bahamas Heart Center

D.Rahming Taxi Cab Service

Elma I. Garraway Ministry of Health

Geneva Cooper Ministry of Tourism

Dr. Glen Beneby Ministry of Health

Hon. J. Oswald Ingraham J.P Speaker of Hon. House of Assembly

Jorge Torres IDB Country Office

Ambassador Joshua Sears Embassy of The Bahamas

Khaalis E. Rolle Bahamas Ferries

Merceline Dahl-Regis Ministry of Health

Michael E. Turner Ministry of Health

Nalini Bethel Ministry of Tourism

Paul Major

Ramon Adderley British Colonial Hilton

Dr. Reynaldo H. Guina Physician

Richard J. McCombe Rotary International

Shirley E. Curtis The College of the Bahamas

Van & Gerry Oldham

Youlanda D. Deveaux Mandara Spa


113

Barbados

Adrian Gale Harris Holdings Limited

Adrian Randall The Heart Foundation of Barbados Inc

Allyson G. Forte Ministry of Tourism

Andrew Cox Ministry of Tourism

Dr. Andrew LeR Forde Dermatologist

Antoinette Forte Williams Ministry of Health

Arley Sobers Caribbean Tourism Organization

Bruce M.Juba Inter-American Development Bank

Dr. C.V. Alert The Wellness Clinic

Carlton Airport Taxi

Sir Charles Williams C.O. Williams Construction

Cheryl Weekes Barbados Community College

Darcy Boyce Barbados Tourism Investment Inc.

David Bulbulia Embassy of Barbados

David Hutchinson Pangroove Events

David Sargeant D and T Building Services

Donna Forde Embassy of Barbados

Eleen Taxi Cab Service

Eric R.Mapp Sandy Lane

Dr. Gladstone A. Best Barbados Community College

Gwendolyn E. Medford Barbados Community College

Professor Henry Fraser UWI

Dr. Hudson Husbands Barbados Tourism Authority

Ian Coombs Kenya Safari Tours

Kamal B. Clarke Home Realty Ltd

Laurence Telson Inter-American Development Bank

Linda Griffith-Bowen Ocean View Nursing Services

Linda Griffith-Bowen Ocean View Nursing Services

D.M.D Lon McIntosh Clarke Aesthetic Dental

Luther Miller Caribbean Tourism Organization

Michael Springer Taxi Cab Service

Muhammad Nassar Barbados Small Business Association

Natalie Rochester Caribbean Regional Negotiating Machinery

Peter C. Frank Peter C. Frank

Reginald White Tours & Taxi Service

Ricardo Blenman S.B.I Distribution Inc.

Richard Taxi Cab Service

Selwyn M. Ferdinand Queen Elizabeth Hospital

Steve Andrews Soothing Touch

Stuart Layne Barbados Tourism Authority

Vincent Vanderpool-Wallace Caribbean Tourism Organization

Dr. Winston A.Crookendale General Surgeon and Plastic Surgeon


114

Caribbean

Desmond Brunton Caribbean Development Bank

Ronald Allen Caribbean Tourism Organization

Denmark

Poul-Erik Holst BWSC

Germany

Oltmann G. Siemens The World Bank Group

Guyana

Ajay Baksh Conservation International

Ambassador Bayney Karran Embassy of Guyana

Dr. Carl Hanoman University of Guyana

Catherine Cholmondeley Hughes VideoMega Productions

Dr. Chin- See Medical Arts Centre Limited

Capt. Gerry Gouveia Roraima Airways

Indira Anandjit Tourism Authority

Jaiwattie (Navita) Anganu IDB Country Office

Dr. Leslie S. Ramsammy M.P Minister of Health

Manzoor Nadir M.P Minister of Tourism, Industry & Commerce

Marco Carlo Nicola Inter-American Development Bank

Maureen Paul Tourism & Hospitality Association

Pascal Mongeau Le Meridien Pegasus

Ramesh Ghir Cheddi Jagan International Airport Corporation

Sergio Varas Olea IDB Country Office

Dr. T.O.A Joseph Orthopaedic Surgeon

Winnie Harper Mitchell Clinic Medical Practice


115

IDB

Alicia Ritchie Inter-American Development Bank

Dr. Camille Gaskin-Reyes Inter-American Development Bank

Charles Skeete Inter-American Development Bank

Christian Gomez Inter-American Development Bank

Desmond Thomas Inter-American Development Bank

Dora Currea Inter-American Development Bank

Gustavo Romero IIC

Jerry Butler Inter-American Development Bank

John Beckham IDB/Inter-American Investment Corp

Kathryn Hewlett-Jobes IIC/MIF

Michael Jacobs Inter-American Development Bank

Michael McLeod Inter-American Development Bank

Peter Stevenson IDB/Private Sector Department

Dr. Richard Fletcher Inter-American Development Bank

Dr. Sandra Henry Inter-American Development Bank

Tomas Engler Inter-American Development Bank

Winsome Leslie MIF

Xavier Comas Inter-American Development Bank

Jamaica

A.Miller Taxi Cab Service

Alfred Gill Jr International Consortium of Caribbean Professionals

Aloun Ndombet-Assamba Minister of Industry & Tourism

Dr. Arusha Campbell-Chambers Dermatology Solutions

Aubyn Hill National Investment Bank Jamaica

Bill Poinsett Nuttall Hospital

Carol Straw JAMPRO

Carolyn E. Hayle The University of the West Indies

Carrole A. M. Guntley Ministry of Industry & Tourism

Cebert "butty" Blackellar JUTA Tours

Cheddy Parchment Breezes Runaway Bay

Claudia C. Barnes Ministry of Foreign Affairs

Clive Gordon Clive's Transport Service

Courtney A. Kazembe Kazembe & Associates

Darien Googlar JUTA

Davon. E. Wilks Nightingale Nursing Home

Dr. Deanna Ashley Ministry of Health

Denzil Wilks Ministry of Tourism

Dr. Donovan Whyte Jamaica All Natural Ltd

Douglas Levermore National Investment Bank Jamaica

Elaine R. Chambers C Rowe & Associates Company Ltd


116

Fabian G. Brown St.Joseph's Hospital

Galba Bright Galba Bright & Associates

Garfield "Gary" Watt Welcome to Jamaica

Gaudia Chevannes-Aquart Nirvana Day Spa

Dr. Gerald White International Consortitium of Caribbean Professionals

Ambassador Gordon Shirley Embassy of Jamaica

Dr. Henry Lowe Blue Cross of Jamaica/Eden Gardens

Hugh Wint Runaway Bay HEART Hotel & Training Institute

Jackie Lewis Jackies on the Reef

James JUTA Tours

Hon. John J. Issa SuperClubs

Hon. John Junor Minister of Health

John. A. Junor MP Minister of Health

Jonathan Surtees Strawberry Hill Group

Joy Wheeler Ministry of Foreign Affairs & Foreign Trade

Judith Farmer MoBay Hope Medical Center

Kevin Hendrickson The Courtleigh Hotel & Suites

Kevin Levee Hedonism III

Kirk Kennedy JAMPRO

Dr. L.D. Whyte Jamaica All Natural LTD

Lincoln Price Caribbean Regional Negotiating Machinery

Marilyn Cornelius Breezes Montego Bay

Megan J.A Deane National Investment Bank Jamaica Ltd

Melvin Smith JAMPRO

Oscar E. Spencer Inter-American Development Bank

Patricia Francis JAMPRO

Paula Surtees Strawberry Hill Hotel & Spa

Hon.Dr. Richard L. Bernal OJ Caribbean Regional Negotiating Machinery

Richard Whitfield Half Moon Medical Complex

Sacha Vaccianna The Private Sector Organisation of Jamaica

Sharon Chambers Positive Tourism

T. McKenzie JUTA Tours

Theo Chambers Positive Tourism

Dr. Tony Vendryes Vendryes Wellness Centre

Dr. Wayne Robinson National Investment Bank Jamaica

William Poinsett Nuttall Hospital

Winsome Bel Navis New Lifestyle

Dr. Winston Davidson National Telemedicine Project

Winston Morgan The Stress Management Center


117

Trinidad and Tobago

Aldington Spencer Tobago Secretary of Health

Andrea Yearwood Ministry of Health

Anselm Richards Policy Research & Development Institute Tobago

House of Assembly

Carlos B. Dillon Mount Irvine Bay Hotel and Golf Club

Charlotte Whitbread CCI

Collin Bissessar Eric Williams Med Center

Duane Kenny Blue Waters Inn

Errol Gift Taxi Cab Service

Fitzroy Quamina Tobago Rain Forest Tours

Harry Bruce Office of the Secretary for Health and Social Services

Ian Ho-A-Shu Inter-American Development Bank

James R.Hepple Tourism Development Company Limited

Jasmin A. Garraway Association of Caribbean States

Mackisack Logie Embassy of Trinidad & Tobago

Ambassador Marina Valere Embassy of Trinidad & Tobago

Merna Riley Des-Vignes Tobago Regional Health Authority

Newton George N.G Nature Tours

Dr. Tsoiafatt-Angus The Omada Center

William Robinson IDB Country Office

UK

Alan Morail

Rosa Davis

US

Alexander Markowits Spring Hills

Ali Akghar Regency, Inc

Dr. Alicia Georges CUNY/Lehman College

Allan Martindale Caribbean Media Enterprise

Alston Meade Jamphil

Amal Devani Kidd & Company

Andrea Stephens Creative Management

Dr. Andrew Barrer Healthcare Services/ Harvard Medical

Andrew Stern Dahlberg

Ann Lin Johns Hopkins Medicine

Chandradath Singh The Trinity Management Group

Cheryl Blackwell Bryson Duane Morris LLP

Dr. Claude Scott South Eleuthera Project


118

David Bythewood, Esq. South Eleuthera Project

Dr. David Chess Enhanced Care Initiatives

Elaine Chambers Healthy Alternative Jamaica Ltd.

Dr. Enrique Riggs South Eleuthera Project

Eric Light Strawberry Hill Group

Professor Eugene Pursoo Medgar Evers College of CUNY

Francis Turner South Eleuthera Project

Gary Allen Saratoga Associates

Dr. George Alleyne PAHO and UWI

H. L. Alberola, JD, KM Order of Malta

Halim Majeed Medgar Evers College

Hannelore Leavy Int. Med Spa Assn

Dr. Harold Mignott University of Pennsylvania Health System

Heba Ali Johns Hopkins Medicine

Dr. Jacqueline Watson Health Concepts

Janet Madden Embassy of jamaica

Jean-Jacques Pascal

Jennifer Schultz Kidd & Company

John Kemp Powers, Pyles, Sutter & Verville

Dr. John Killen NIH

Jonathan E. Kroehler Sallie Mae

Jonathan Nelson South Eleuthera Project

Joseph Rosenberg Global Student Loan Corp

Judy Saita Strategic Alchemy

Karen Roberts OPIC

Kurt Schneiber Citibank

Lelei LeLaulu Counterpart

Lincoln Marshall George Washington University

Logan Brenzel The World Bank

Dr. Louis Camilien South Eleuthera Project

Dr. Lucille Perez South Eleuthera Project

Luis Sierra Strother Enterprises, Inc.

Lynn Ross Sallie Mae

Manuel Candamo Inter-American Foundation

Marion Godfinger John D. & Catherine T. MacArthur Foundation

Mark Shaver Johns Hopkins Medicine

Mark Stuckart OPIC

Matthew Moore Calvert Fund

Meredith Rosenberg Global Student Loan Corp

Michael Jackson Strother Enterprises, Inc.

Michael Paull Lehman College

Mujahid Bakht American Business & Consulting Group

Natasha Strother Strother Enterprises, Inc.

Neil Dick Saratoga Associates

Ngozi Moses Brooklyn Perinatal Network, Inc


119

Nigel Haynes

Oksana Carlson Johns Hopkins Medicine

Dr. Ophnell Cumberbatch

Paul Kurnit Kurnit Communications

Peter Ballinger OPIC

Peter Tynan Dahlberg

Dr. Reginald Manning South Eleuthera Project

Richard Rakowski Kidd & Company

Robert Dillworth The Trinity Management Group, LLC

Robert Farmer Third Planet

Dr. Ron Chase South Eleuthera Project

Sharon McLean Creative Management

Trevor Gunn Medtronic/Georgetown

Wanda Fischer Wellness Escape

Whitney MacEachern Citibank

health and wellness report may 2006

Documents