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Page 1: International trade in healthcareweb90.opencloud.dssdi.ugm.ac.id/wp-content/uploads/sites/...African doctors working abroad* Country Total doctors in home country Doctors working in

International trade in healthcare

Yodi Mahendradhata

Page 2: International trade in healthcareweb90.opencloud.dssdi.ugm.ac.id/wp-content/uploads/sites/...African doctors working abroad* Country Total doctors in home country Doctors working in

International trades in services

Cross-border trade

Consumption abroad

Commercial presence

Natural presence

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8 success factors for medical tourism

Competitive price

Tourist appeal

Market economicsDeveloped political

and legal institutions

Local R &DHuman capital

Confluence of western and traditional medicine

Developed physical infrastructure

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International trades in services

Cross-border trade

Consumption abroad

Commercial presence

Natural presence

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US$ 4 billion industry

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Teleradiology

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Telepathology

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Teleconsultation

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Telepharmacy

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Cross border revenue (US$ million)

Service 2000 2005

Customer-interaction center 60 2250

Medical transcription 28 800

Financial and accounting services 50 375

Medical billing and collection 3 75

Medical claims processing 13 30

Pre-press and digital pre-media 45 200

Geographic information system - 50

Distance learning 60 150

Human resources services - 115

Litigation support services 3 27

TOTAL 264 4072

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International trades in services

Cross-border trade

Consumption abroad

Commercial presence

Natural presence

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Foreign investment in healthcare

Country Situation

India • No caps on direct foreign investment• 90% German ownership of 200-bed hospital in

New Delhi• 100% ownership of orthopedic clinic in Mumbai

• All providers must be registered by councils

Malaysia Foreign share <30%

Thailand Foreign share <50%

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Foreign investment in healthcare in Indonesia?

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President Regulation No.36/2010, Investment Negative List

Pharmaceutical industry Maximum 75% foreign shareholding

Hospital management and health assistance services (health aid and patient evacuation in emergency situations); Specialist/sub-specialist hospital service (200 beds); Health care providers (mental rehabilitation, specialist medical, dental,laboratory and medical clinics)

Maximum 67% foreign shareholding

Calibration testing, health and medical equipment rental, maintenance and repair services; Acupuncture and nursing services (outside Medan and Surabaya)

Maximum 49% foreign shareholding

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President Regulation No.36/2010, Investment Negative List

Nursing services in Medan and Surabaya Maximum 51% foreign shareholding

Pharmaceutical drug producer and wholesaler

Requires a special license from the Minister of Health

Traditional medicine producer and business industry; Pharmaceutical including raw material, wholesaler, and drug store/pharmacy; Health care providers (hospitals, health research center, health service facility, ambulance,etc.); Health professionals (e.g. specialist doctor, etc.)

Requires 100% domestic capital

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Foreign investment in Indonesian hospitals 1993-1999

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Foreign Investment in healthcare

Parkway Holding (Singapore)

Malaysia

Others

Pantai Holding (Malaysia)

Singapore

Other

* Source: Leng CH (2010)

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International trades in services

Cross-border trade

Consumption abroad

Commercial presence

Natural presence

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Doctors and nurses trained abroad working in OECD countries*

Countries Doctor trained abroad Nurses trained abroad

Number Percentage Number Percentage

Australia 11,122 21 NA NA

Canada 13,620 23 19,061 6

Finland 1,003 9 140 0

France 11,269 6 NA NA

Germany 17,318 6 26,284 3

Ireland NA NA 8,758 14

New Zealand 2,832 34 10,616 21

Portugal 1,258 4 NA NA

UK 69,813 33 65,000 10

USA 213,331 27 99,456 5

*Source: WHO (2006)

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The cost of training one doctor in Australia =

AU$280,000

The cost of recruiting a foreign doctor to

Australia = AU$30,000

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Percentage of doctor trained working in OECD countries (Docquier & Bhargava, 2006)

Malaysia

12.8%

Philippines

9.7%

Singapore

10.2%

Thailand

3.3%

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African doctors working abroad*Country Total doctors in

home countryDoctors working in 8 OECD countries

Number Percentage

Angola 881 168 19

Cameroon 3,124 109 3

Ethiopia 1,936 335 17

Ghana 3,240 926 29

Mozambique 514 22 4

Nigeria 34,923 4,261 12

South Africa 32,973 12,136 37

Uganda 1,918 316 16

Tanzania 822 46 6

Zimbabwe 2,086 237 11

Total 82,417 18,556 23

*Source: WHO (2006)

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Countries with critical shortage of health workforce (doctors, nurses, midwives)

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Global distribution of health workforce (doctors, nurses, midwives) shortage*

WHO Region Number of countries In countries with shortage

Total With shortage

Total stock Shortage Percentage increase required

Africa 46 36 590,198 817,992 139

Americas 35 5 93,603 37,886 40

South-East Asia

11 6 2,332,054 1,164,001 50

Europe 52 0 NA NA NA

Eastern Mediterranean

21 7 312,613 306,031 98

WesternPacific

27 3 27,260 32,560 119

TOTAL 192 57 3,355,728 2,358,470 70

*Source: WHO (2006)

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There are 5 times more Indian neurosurgeons in

USA than in India

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Passing rates of Indonesia nurses

Year Country Number of applied nurses

Number of nurses passed

Passing rate (%)

1996 United Emirate Arab (UEA)

120 11 9.1

1997 UEA 123 17 13.8

1998 UEAThe Netherlands

600300

14360

23.820.0

1999 UEA 300 50 16.6

2000 UEAKuwait

315726

6241

19.028.9

2001 Kuwait 768 210 27.3

2002 KuwaitUK

75419

2414

32.121.1

2003 - - - -

2004 Saudi Arabia 120 58 48.3

2005 Saudi Arabia 179 107 59.7

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Each migrating African professional

costs the country US$ 184,000

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Why African health workers migrate?*

*Source: WHO (2006)

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Proportion of foreign* doctors in Malaysia in 2005**

Medical officers

Local

Foreign

Specialists

Local

Foreign

*Origins: India, Myanmar, Pakistan, Indonesia, Bangladesh, Sri Lanka and Egypt**Source:: Leng CH (2010)

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Proportion of foreign doctors among all doctors registered in Singapore in 2008*

Local

Foreign

* Source:: Leng CH (2010)

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Where would cardiac surgeons prefer to work?

MOPH (National Chest Hospital)

Teaching hospitals (Chulalongkornand Siriraj)

International hospital (Bangkok General hospital)

Annual number of heart surgery 900 800-1200 200-250

Number of active cardiac surgeon

4-5 8-9 7

Year work load per surgeon 200 100-134 28-35

Total monthly income (Baht) < 100.000 (regsalary plus incentive per case (7200 Baht)

200.000 (regsalary and other incentives)

400.000 (40.000-60.000 Baht per surgery)

* Exchange rate: US$ 1 = 38 Baht

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Risks of medical tourism?

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Health workforce migration

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The impact of Thai medical tourism

• Extra 100 000 patients seeking treatment in Thailand

• Internal brain drain of up to 700 doctors

• Exacerbated shortages of medical professionals, especially in the public sector and in rural areas.

• Recruitment of 10,000 doctors to keep up with needs and demand

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Pros vs cons of medical tourism

Pros Cons

Doctors who would migrate incentivized to stay

Doctors lured away from public facilities and remote areas

Advanced technology and equipments available to local patients

Only accessible to those who can afford -> widen gap

More revenues Accrued to foreign/private investors

Resource allocation diversion

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Quality of healthcare abroad

• Insufficient management of complications and lack of post-operative care (Terzi et al 2008)

• Problems with continuity of care (Birch et al 2004)

• Post-discharge experience (Boffin et al 2005)

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Complications post cosmetic tourism*

Operation undertaken

0 5 10 15

Breast surgery

Abdominoplasty

Facial rejuvenation

Liposuction

Type of complication

0 2 4 6 8

Dehiscence/…

Poor cosmesis

Implant rupture

Contracture

Bowel perforation

Nerve palsy

*Ref: Miyagi et al 2011

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Plastic surgery abroad websites

• 37% - no information on adverstised procedures

• 10% - mentioned possibility of complications

• 4% - mentioned aftercare and follow up form post-op complications

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Medical tourism websites

• 11.9% - mentioned risk of procedures

• 21.5% - mentioned possibility of complications

• 35% - mentioned post-op complications

• 9.8% - legal recourse

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Average medical practice payout (US$)*

0

50000

100000

150000

200000

250000

300000

350000

Thailand Mexico USA

Mill

ion

USD

*Cortez 2012

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Womb for rent?

Surrogacy in US: $70.000

Surrogacy in India: $12.000

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Major risks of medical tourism

Patient safetyCross-border

spread of diseases

Donor & surrogate

safety

Public health system impacts

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Addressing medical tourism risks

Increase patient safety

Improve Disease surveillance &

control

Promote ethical practices

Protect domestic public health

system

Develop better data

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International trades in services

Cross-border trade

Consumption abroad

Commercial presence

Natural presence