Medical Tourism and Investment Options in Nigeria Healthcare System: Roles of NMA and other Stakeholders

1. Medical Tourism and Investment Options in Nigeria Healthcare System: Roles of NMA and other Stakeholders Presentation By TundeKolajo Management Consultant/Trainer, Health Solutions Provider and Medical Tourism Operator

2. OUTLINE • Definition and Description of Medical Tourism • The Nigerian Perspectives • Predisposing Factors • Common Destinations • The India Preference • Options for Stakeholders • The Role of NMA • Anno Domini? • Conclusions

3. About Medical Tourism • Medical tourism (also called medical travel, or health tourism) could be defined as patient movement from highly developed nations to less developed areas of the world for medical care by bypassing services offered in their own communities. Medical tourism has also come to embrace the more traditional model of international medical travel where patients generally journey from less developed nations to major medical centers in highly developed countries for medical treatment that is unavailable in their own communities.

4. Services typically sought by travellers include elective procedures (cancer treatment) as well as complex specialized surgeries such as joint replacement (knee/hip), cardiac surgery, dental surgery, brain surgery and cosmetic surgeries. Individuals with rare genetic disorders may travel to another country where treatment of these conditions is better understood. However, virtually every type of health care, including psychiatry, alternative treatments, convalescent care and even burial services are available.

5. The typical process is as follows: the person seeking medical treatment abroad contacts a medical tourism provider. The provider usually requires the patient to provide a medical report, including the nature of ailment, local doctor’s opinion, medical history, and diagnosis, and may request additional information. Certified physicians or consultants then advise on the medical treatment. The approximate expenditure, choice of hospitals and tourist destinations, and duration of stay, etc., is discussed. After signing consent bonds and agreements, the patient is given recommendation letters for a medical visa, to be procured from the concerned embassy. The patient travels to the destination country, where the medical tourism provider assigns a case executive, who takes care of the patient's accommodation, treatment and any other form of care. Once the treatment is done, the patient can remain in the tourist destination or return home.

6. The Nigerian Experience There is no gainsaying that the Nigeria healthcare delivery system is critically “sick”! Indeed, improvement in healthcare services across the country is of major concern, as Federal Medical Centres and teaching hospitals remain ill-equipped, under-staffed and under-funded. The increased burden of preventable diseases such as polio, malaria, cholera and heart- related diseases that have now over-stretched Nigeria’s healthcare facilities, and lack of improvement in medical services is forcing more and more Nigerians, who can afford it, to seek better healthcare services abroad. 

7. According to a 2012 BGL report on Nigeria healthcare system, infrastructure decay, brain drain, incessant workers’ strikes and low investment in the sector characterise healthcare services in Nigeria. Collectively, all tiers of the healthcare system have suffered. In 2011, national spending on teaching hospitals and federal medical centres was estimated at N204 billion, approximately 79% of the government’s health expenditure. However, only N20.25 billion (10 percent of total hospital expenditure) was allotted to capital expenditure in spite of insufficient medical equipment.

8. Predisposing Factors • Factors that have led to the increasing popularity of medical travel include the high cost of health care, long wait times for certain procedures, the ease and affordability of international travel, and improvements in both technology and standards of care in many countries. The avoidance of waiting times is the leading factor for medical tourism from the UK, whereas in the US, the main reason is cheaper prices abroad. In 2009, there were 60,000 patients going for treatment abroad in the UK.

9. Many surgery procedures performed in medical tourism destinations cost a fraction of the price they do in the First World. For example a liver transplant that cost $300,000 USD in America cost about $91,000 USD in Taiwan. A large draw to medical travel is convenience and speed. Countries that operate public health-care systems are often so taxed that it can take considerable time to get non-urgent medical care. Using Canada as an example, an estimated 782,936 Canadians spent time on medical waiting lists in 2005, waiting an average of 9.4 weeks. Canada has set waiting-time benchmarks, e. g. 26 weeks for a hip replacement and 16 weeks for cataract surgery, for non-urgent medical procedures.

10. . Factors that drive demand for medical services abroad in First World countries include: large populations, comparatively high wealth, the high expense of health care or lack of health care options locally, and increasingly high expectations of their populations with respect to health care. Another strong factor is the cheaper cost of treatment in some countries abroad in comparison with others:

11. For example, Medical tourism for knee/hip replacements has emerged as one of the more widely accepted procedures because of the lower cost and minimal difficulties associated with the traveling to/from the surgery. Colombia provides a knee replacement for about $5,000 USD, including all associated fees, such as FDA-approved prosthetics and hospital stay-over expenses against the up to 35,000 USD it may cost in the US!

12. The cost of surgery in India, Thailand or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost $200,000 or more in the US, for example, goes for $10,000 in India--and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the US costs $500 in India, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth $3,700 in the US is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the US runs about $1,250 in South Africa.

13. Target Destinations • Popular medical travel worldwide destinations include: Argentina, Brunei, Cuba, Colombia, Costa Rica, Hong Kong, Hungary, India, Jordan, Lithuania, Malaysia, The Philippines, Singapore, South Africa, Thailand, and recently, Saudi Arabia, UAE, South Korea, Tunisia, Ukraine, and New Zealand • Popular cosmetic surgery travel destinations include: Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Mexico, Turkey,andUkraine. In South America, countries such as Argentina, Bolivia, Brazil and Colombia lead on plastic surgery medical skills relying on their experienced plastic surgeons. In Bolivia and Colombia, plastic surgery has also become quite common. Colombia also provides advanced care in cardiovascular and transplant surgery

14. In Europe Belgium, Poland, Slovakia, and Ukraine are also breaking into the business. South Africa is taking the term "medical tourism" very literally by promoting their "medical safaris". A specialized subset of medical tourism is reproductive tourism and reproductive outsourcing,[which is the practice of traveling abroad to undergo in-vitro fertilization, surrogate pregnancy and other assisted reproductive technology treatments including freezing embryos for retro-production. India leads here as with other areas.

15. Focus on India • Without any prejudice, India seems to be emerging as the ultimate destination for global health tourists. It is the most attended across the globe for specialized medical treatment abroad with over 20,000 patients monthly across the globe. • Over 750 Nigerians travel to India hospitals monthly from a list of about 2,400 Africans. • An average monthly of 7,000 patients are recorded for Middle East/Far East countries.

16. More and more people across the globe are eschewing expensive treatments or long waits at hospitals at home for the benefits offered by cheaper countries like India, Thailand, Philippines and Singapore. Comparatively, India is still cheaper than its other Asian neighbors. For instance,heart valve replacement surgery for US$10,000 in Thailand, $12,500 in Singapore and US$200,000 in the US can be carried out in India for $8,000. According to the American Medical Association data, as against a charge of $5,000 for a spinal fusion in India, a patient will pay $62,000 in the US, $9,000 in Singapore and $7,000 in Thailand.

17. Ironically, despite India's abysmal spend of 4.9 % of its GDP on healthcare -- as compared to America's 15.3%, Switzerland's 11.3% or France's 11.1% – the country is well poised to become a frontrunner in the global medical tourism market. An exponential 27% annual growth has been projected by the consultancy firm of Deloitte from 2004. This is ascribed to increasing demand as India is regarded as a value-for-money destination for health care because they produce over 30,000 new doctors each year combined with a diverse genetic pool for drug testing!

18. It is estimated that nearly 75% of health care services and investments in India are now provided by the private sector. Coupled with this is the fact that India has perhaps one of the largest pharmaceutical industries in the world which is not only self-sufficient in drug production but also exports them to over 180 countries at a fraction of the price of US pharmaceuticals.

19. Investment Options for Stakeholders • Stakeholders include: • Federal Government, State Governments, • Local Governments, Private Hospitals and Clinics, Medical Doctors/NMA, Patients, Medical Tourism Providers, NGOs, Private Investors, etc.

20. In a report, the Federal Ministry of Health alluded to the fact that, the human development indices for Nigeria were among the worst in the world. Nigeria shoulders 10 %of the global disease burden and is making slow progress towards achieving the 2015 target for the MDGs on healthcare.Instructively, healthcare delivery indices in Nigeria have largely remained below country targets and internationally-set benchmarks due to weaknesses inherent in the system. Hence the government is convinced that a purposeful reform of the National healthcare delivery is necessary. The government, thus, initiated a process that led to the development of the National Strategic Health Development plan 2011-2015(NSHIP), which was developed in 2010.

21. However, the national strategic plan, which hopes to strengthen the national health system and to vastly improve the health status of Nigerians, estimates that a total amount of N3.99 trillion (US$26.6 billion) would be required to reposition the Nigerian health system over the next six years. But that has not taken off 2 years hence. That already puts the plan on a shaky start and has cast doubts on it ability deliver as intended just like the previous years. Just the same, the National Health Insurance Scheme (NHIS) conceived to provide medical coverage for users under the scheme has only have 5 million enrolled. The NHIS has equally remained primarily an urban thing, a clear departure from its objective, which was to make primary healthcare accessible and affordable for all Nigerians. Experts say the lack of clear policy direction in healthcare delivery has hindered its expected progress.

22. The implication of the fore-going is that if the turn around impact of the Federal Government being the most critical amongst stakeholders is not happening for now, the reality imposed on all stakeholders as a result is the need to gainfully explore to mutually beneficial advantage the precarious situation of our healthcare system. The challenge to both doctors and patients first of all is to agree not to suffer avoidable casualties in the face of inadequate diagnostic and treatment technology and hence be united in seeking alternative options within reach, outside the country: medical value travel while still valuable. The cooperation of both parties in increasing health chances of the patients is critical in getting the best that medical tourism can offer.

23. The opportunity provided for operators of health tourism is obvious. The cooperation of Medical Tourism Providers and Medical Doctors and Patients ought to be more systematic and professional. Operators should target more systematic and pertinent information to Doctors who owe their patients the moral duty of making themselves more accessible to such information as well as realistically consider them and act timely with the best interest of their needy patients in mind. Tour Operators on their part must be a lot more organized and professional in creating useful linkages for Docs , patients and relatives of patients with a view to making the process of accessing the intended medical value seamless and stress free as well as minimize the risks to give good value for their fees.

24. The more common risks involved in medical tourism include: + The risks of being swindled of your money altogether over the internet, dealing with faceless individuals. + Falling into incompetent hands/ill-equipped Hospitals + The risks of delay in visa procurement + Getting adequate attention in a foreign land and unfamiliar hospitals. + Difficult logistics and financial exploitation as a result of lack of familiarity with the foreign environment and lack of personal touch from an agent. + Adequate follow up on return to base. +

25. While waiting for the mighty Federal Government to set tangible direction with tangible spend in the right direction, State Govts, Local Govts and Private Investors including NGOs may explore investment in key health infrastructure with good returns over medium term to short term time range. Well equipped Laboratories, Diagnostic centres, major investment in well equipped hospitals will always be tremendous assets with top of the range socio economic rating for a very long time to come. NGOs may attract good funding for proposals in this direction as contribution to improving on the worrisome healthcare aggregate capacity in Nigeria

26. Healthcare stakeholders regular fora: seminars, workshops, conferences, etc organized to discuss way forward on specific solution issues will be of tremendous value for pertinent policymaking, public orientation, and moulding stakeholders disposition for the benefit of all. We must all agree to make the best of the bad situation.

27. THANK YOU FOR YOUR TIME!

28. TUNDE KOLAJO BPharm,MPSN,MBA,MNIM,MNIMN,FCBA Consultant/Trainer, GNL Business Management Solutions CEO, GNL Health Solutions Simplified 10, KofoPopoola Close, Old Ife Rd, Ibadan 08033218228 www.godzbiznig.comhealthsolutions@godzbiznig.com