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Tue 11 Sep 2007 04:00 AM

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Have sickness, will travel...

Health tourism looks set to be one of the most fiercely contested medical markets, and ME is gearing up for battle.

When it comes to the regularly-aired topic of medical tourism, the Middle East couldn't be accused of being shy. As one of the first regions to usher its residents abroad for care, local governments are savvy in the ways of sun and surgery. But, as high-profile projects such as Dubai Healthcare City (DHCC) show, times are changing. Now the Middle East wants its patients - and their profits - back.

Dr Muhadditha Al Hashimi, CEO of DHCC, is in no doubt about her centre's remit. "We want Dubai to become a medical hub as much as it is a tourist destination," she says, frankly. "Usually anyone with the smallest health problem gets the next flight out."

I have an ethical problem with insurance companies encouraging their patients to go abroad because they collect their premiums in dirhams and then send them abroad to get the operation done on the cheap.

But PR firms tasked with publicising the Middle East as a healthcare hub face an embarrassing dilemma; namely, how to market the region as a world leader when its own inhabitants are prepared to fly thousands of miles to receive the same service elsewhere.

A report by the Abu Dhabi Chamber of commerce and Industry (ADCCI) optimistically maintains the United Arab Emirates will pocket AED 7 billion annually in medical tourism profits by 2010. The projected growth rate, an enviable 15% per year, seems feasible when balanced against the current scale of investment in the country's healthcare system.

But industry analysts are questioning whether ADCCI's sums add up, as healthcare providers in the Subcontinent and South East Asia continue to report growing numbers of patients from the Middle East. If patients are beginning to choose healthcare closer to home, it has yet to register on their radar.

It's the economy, stupid

Analysts suggest that the primary driver behind medical tourism is economic. If a patient can't afford adequate care in their own region, logic dictates they travel to a country where they can. The situation in the UAE, however, is more intricate.

While the cost of surgery is an issue, the high number of expatriates living and working in the region means that cultural and familial factors nudge the decision of where to receive complex medical treatment.

Dr Andre Wessels, medical director for Welcare Hospital, Dubai, notes that, for residents from India and Pakistan, a large hunk of the UAE's demographic, family is often the greatest influence on the decision to travel abroad.

"When the patient requires cardiac surgery, many of them feel more comfortable going to their countries of origin as they normally have very good support systems there," he says.

"If the patient needs a bypass or a valve replacement we say ‘we can do it for you here without a problem', [but] they speak with their family and there is a lot of pressure to have it done in their country of origin."

Family pressure, adds Wessel, is compounded by the willingness of insurance companies to fund the least expensive means of treatment. Health insurance policies rarely dictate that a claimant must travel to a certain country in order to be treated, but companies often encourage the idea in order to keep costs down. This combination of factors means regional care providers can find themselves fighting a losing battle.

"I have an ethical problem with insurance companies encouraging their patients to go abroad, because they collect their premiums in dirhams and then send them abroad to get the operation done on the cheap," Wessel states. "But you can't argue that point with an insurance company as they are in business, it is an economic decision."

For expatriate residents without health insurance, the cost of serious care is usually beyond their budget. Destinations such as India then become a necessity, not a choice.

The readiness of GCC governments to fund overseas treatment for nationals, however, places Arab patients at the other end of the scale. Yet the irony for those looking to raise the profile of healthcare in the Middle East, is that they still have plenty of marketing work to be done with patients in their own backyard.

How can the Middle East expect to attract patients to a region that its own population would rather avoid? In some ways, the Middle East is its own worst enemy when it comes to its reputation for healthcare. Dr Prem Kumar, general manager of Raffles Hospital in Singapore is often surprised that Arab patients will travel all the way to his hospital just for a general check-up.

"I ask patients from the Middle East, ‘Why do you come here for a health screen? It is a simple thing that can be done in your country?' Then you realise that even for things like health screening, which has a large imagery and laboratory component, trust is very important. Lots of people are coming because they don't trust the simple laboratory results."
Crisis of confidence

Cases like this must frustrate the many, competent physicians working in the Middle East. But it seems that this lack of confidence is ingrained in the Middle Eastern psyche and evidently extends all the way to the region's leaders.

The government of the UAE may be investing in healthcare in the hope of boosting revenue from medical tourism, but continues to spend over US$2 billion every year on sending nationals abroad to receive treatment.

This arrangement makes it difficult for healthcare facilities in the region as the volume of patients is too low to attract and hold on to top-level clinical staff. Governments are caught in a catch-22 situation. To improve the standard of healthcare in the region, they must stop providing citizens with plane tickets.

There is no reason why patients should go elsewhere; our results are the same. We’re not any worse than anywhere else.

Dr Steven Tucker is the medical director of The West Clinic in Singapore, which has a large base of Middle Eastern clients. With patient numbers continuing to climb, Tucker believes lifting the standard, and reputation, of healthcare in the Middle East will not be a simple task.

"The initiatives by Sheikh Maktoum with Dubai Healthcare City and DuBiotech are all aimed at reducing the export of medical revenue out of the Middle East to North America, North Europe and South East Asia," he says. "The question that remains unanswered is what will the Middle East initiatives bring in a period of five to 10 years?

"As of today, I don't see a change in this pattern."

The main challenge, adds Tucker, will be finding the personnel to man these initiatives. "Dubai is great at building buildings, the next step will be staffing these facilities to the standard that nationals are accustomed to receiving abroad," he claims. "That is truly the task that they have at hand."

A clinical decision

Recruiting top-class surgeons is set to become harder over the next few years as the region's cost of living continues to rise. Even with adequate financial incentives, medical professionals considering a move to the Middle East have to consider what implications relocation may have to their clinical reputation. It is an accepted truth among the medical community that top clinical outcomes are best achieved through a high volume of procedures.

The more regularly a physician performs a procedure, the better their chances of success are. If low patient volumes mean physicians risk the skills they worked for years to develop, no amount of short-term financial gain will compensate.

It is a problem that Singapore had to overcome before they could develop as a medical tourism destination, says Dr Jason Yap, director of healthcare services for Singapore Tourism Board.

"If I want to set up a top healthcare facility, then the question is whether I have the critical mass of patients to support my doctors? If I don't, my doctors are just not going to be very good."

What must further frustrate the top professionals in the region is that there is not necessarily a link between their clinical outcomes and their reputation. If a hospital in Saudi Arabia is achieving the same level of success rates as a hospital in San Francisco, it is likely that the American clinic will be held in higher regard.

"Some people still perceive the facilities here to be substandard and prefer to go to other countries for what they perceive to be greater expertise," admits Wessels.

"We publish our statistics and we benchmark them against the United States and the United Kingdom - there is an international database to see if you are up to standard or not and we are; we are right up there.

"There is no reason why patients should go elsewhere; our results are the same. We're not any worse than anywhere else."

Achieving parity with top medical facilities is only half the battle for healthcare providers in the Middle East. In order to stop the flow of patients travelling abroad for treatment, top names in the region have to develop reputations that can compete with the established names worldwide.

In the case of Dubai Healthcare City, the free zone has confronted this problem by ‘buying in' big brand names, such as Mayo Clinic and Harvard. By riding on the coat-tails of established centres, DHCC hopes to lure patients through ready-made reputations.

To a certain extent, and for a certain level of patient, where you go to receive your medical treatment is still a statement of your wealth and importance. A healthcare provider is as much a status symbol as it is an informed decision.

Medical provision is increasingly becoming a global market and the competition for patients is formidable. If the Middle East is ever going to become the primary provider of healthcare to its own discerning patients, never mind its own governments, it is going to have to prove itself a world leader.

The Facts: MT’s guide to a global industry• At any one time, between 150 and 200 UAE nationals are receiving medical care abroad.

• In 2001, the number of Saudi nationals travelling to the US for treatment topped 56,000.

• Escorts Heart Institute and Research Center in Delhi and Faridabad, India, performs nearly 15,000 cardiac surgeries every year. The reported mortality rate among patients during surgery is 0.8% - less than half that reported by many major hospitals in the United States.

• The medical tourism market is currently valued at $20 billion annually. These numbers are expected to double by 2010.

• By 2012, the medical tourism market in Asia is expected to be worth $4.4 billion, with1.3 million tourist arrivals per annum to five key locations - Thailand, India, Singapore, South Korea and Malaysia.

•In 2006, over 410,000 international patients travelled to Singapore. Accompanying them on their visits were a further 89,000 persons.

Another 56,000 people received healthcare incidentally on visits for other purposes. In total, some 555,000 international visitors to Singapore in 2006 were involved in some aspect of medical travel.

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