HEALTH ASPECTS RELATING TO TOURISM Health and tourism: matching a multidimensional care provision de

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HEALTH ASPECTS RELATING TO
TOURISMHealth and tourism matching a
multidimensional care provision demand.  How can
the system cope with an incoming flow of new
healthcare beneficiaries
French international health and social protection
agency
Workshop on rejuvenating tourism - innovation and
sustainability Belgrade 7th September 2009

• Gwenaël Dhaene
• Senior Adviser / French international health and
  social protection agency

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Context Fuel for thoughts

• IT IS ALL ABOUT CARE Health and tourism are
  mainly entwinned when it comes to harnessing the
  well being of the entire population (inc.
  Foreigners, and tourists amongst them) and the
  availability of sufficient accessible and quality
  health resources (whether medical/care resources
  or infrastructures, equipments and
  transportation)
• HAPPY CUSTOMERS ? When it comes to health, it is
  quite seldom that one talks about a customer
  approach. Health care and customer service are
  somewhat different. However, medical tourism is
  booming. Whether the result of globalisation and
  the taking of of new consumerist beahaviours, or
  a planned strategy at country level, many
  individuals now cross borders in order to get
  healthcare that meets their demands
• HEAVEN ON HEARTH Professionals of the tourism
  branch more frequently come across health
  considerations when promoting a country/specific
  zone assets. Water resources of exceptional
  quality/properties, healthy montaign spots with
  pure air and excellent organic food to name only
  a few this last aspect will not be gone through
  during the course of this presentation

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Contents

• Rationale
• Health systems in a nutshell
• Addressing specific needs (handling the tourist
  community)
• Medical tourism a new business model
• Cross-cutting issues

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Rationale what are the stakes ?

• How to handle a tourist population ? What does
  it take in terms of public health organisation
  and capacities. How to strengthen the network of
  care accordingly? From a tourist industry
  perspective, what level of reliability can
  reasonably be expected from a health system ?
• How do you ensure your whole health system
  responds to this new strain without drawbacks,
  shortages or failures? This not from a tourist
  standpoint only. How do you juggle with a whole
  range of health situations that combines the
  response to the health needs of the populations
  topped up by new needs from an incoming flow of
  foreign population with potentially different
  expectations ?
• What impact can a health system hold on the
  tourism, leisure and entertainment industry ?
  How can a reliable health system help promoting a
  safe and relaxing environment for the benefit of
  the whole industry ?
• GVFM If tourists are coming with a specific aim
  of getting good value for money health services,
  what does that imply from a political,
  institutional and community perpsective ?

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Health systems in a nutshell
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Health systems critical components

• Get the money ! Components of a health system
  rely on health financing mechanisms. Whether
  budget based or supported by social security
  schemes (social contribution based), insurance
  schemes (market insurance, non-for-profit mutual
  funds) and out of pocket payments from
  households. Mixing these financial flows is a
  common trend to many systems
• Do you need anyone? A health system is
  underpinned by a variety of clinical and
  non-clinical profile professionals operating the
  health services. Doctors, nurses and health
  managers are but a few of the many resources
  needed to address the needs of a population
• Whats in the bag Infrastructures (strategically
  implemented throughout the territory to
  accordingly address the needs of the population)
  equipments and transportation, liaison and
  references systems, health information systems,
  drugs, consumables, ancillary services.this is a
  whole sector of activity !

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Whatever happens

• Tourist clinical needs an infinite variety of
  situations

• PHC foreigners will at first require specific
  attention to a variety of pathologies GPs and
  health centres can address (flu, upset stomachs,
  small injuries resulting from walks/sports/climbin
  g, severe sunburns)
• 2ary care from otitis to eye trouble and
  relatively benign traumas outpatients or
  ambulatory consultations will clear most
  situations
• 3ary care include traumas (transport/sport/serious
  injuries and traumas/infections/severe
  illnesses)
• An average population usually requires care that
  rather focus on infectious diseases and
  traumatology. However, planning for chronic
  diseases care has to be thought through. Other
  risks may occur (e.g. deliveries, mental health
  situations)

toothache
snake bites
Broken limb
Falls (multi Traumas)
hayfever
Chronic disease
Road accident
Home sickness
Cardio Vascular diseases
Avian flu Swine flu
Sore eyes
transplants
Ethylic comas
Sun burns
accidents
Panic attacks
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Addressing specific needs (handling the tourist
population)
Availability of appropriate ressources (both HR
and facilities) close to tourist sites
Ministry of Health Policy making and System
organisation
Adapted care (taking into account cultural,
linguistic, psychological factors relevant to a
foreign population)
Operational reimbursment mechanisms and
co-ordination with social security and mutual /
private insurance schemes
What partnership With the tourism Sector Professio
nals?
Effective follow up mechanisms to sort out severe
health situations long-stay hospitalisation,
repatriation
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Resources are critical

• HR shortage is one of the most sensible issues at
  global level (with a massive shortage)
• Chances are clinical and perhaps non-clinical
  staff as well are not available. What if you put
  more strain on an already overstretched system ?
  How does it cope?
• Resources are not enough. Tourists can be
  demanding and high maintenance, customer is king
  as the saying goes.
• What about excellent resources ? Proficiency in
  foreign languages, variety of medical
  specialisations, range of ancillary services
  designed to meet different standards ?
• Think outside the medical box Doctors are not
  enough. Do you have to ensure biomedical
  engineers and technical staff as well are
  committed to ensure the facility is run according
  to its mission statement ?

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Health financing, social security and insurance
schemes in the loop
MOH The Ministry of Health keep an overall power
of organisation, planning, supervision of the
health system. It can also help and fund healh
services and infrastructures (e.g. public health
laboratories) What steps could be taken on to
empower any scaling up of the health services ?
HIF What contractualisation process with medical
resources how fast is the reimbursment
process Is the reimbursment rate/speed deterring
so that medical staff morale can be impaired
? Could this lead to an availability of medical
resources for customers with the means to pay ?
Social security schemes Do the reimbursment
mechanisms work well ? Are they run smoothly so
that they comply with EU or non EU Regulations ?
What drawbacks have been identified ? What
shortfalls need to be tackled ?
Private insurances Private insurance are likely
to help build care network that meets their
standards. This impacts on the Preference
option medical resources can place for these kind
of schemes. This could also be an opportunity to
reflect on care standards and work towards
contractualisation instruments for better care
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Reliable care network

• This requires sensible health planning and
  organisation (involving institutional
  stakeholders, public and private operators at
  both health and economics/trade/tourism level)
• This also enables to develop referring
  practionners capacities (language competences,
  accreditation, contracting with social
  security/private insurance schemes)
• This empowers the setting up of a network of
  health facilities based on their medical
  expertise and supported by a reliable medical
  transportation service.
• Ancillary services, flexible accomodation also
  need to be looked at what non clinical services?

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Medical tourism a new business model (my doctor
is good for you !)

• What is medical tourism medical tourism (the
  expression has been coined by the tourism
  industry themselves) is the abroad lookout for
  available quality services that are
  cost-effective and less expensive while offering
  a similar level of safety to the patient
• How can medical tourism become an opportunity ?
  Apart from the savings aspect from the patients
  perspective, medical tourism is a growing part of
  the global health market, with countries taking
  on and favouring this activity as a part of their
  national industry
• Are there any risks ? The impact of this inflow
  of new inpatients has to be carefully assessed so
  as to ensure compliance of this activity with the
  public health objectives fixed priced for
  medical care for the insured population
  availability of resources that could tend to
  favour international clients (for cashflow
  reasons) incentive to migrate to other
  countries with more attractive remunerations

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Driving factors what triggers medical tourism ?

• 1 Good value for money the driving force
  behind it lies in the aim to save money on
  medical costs and hospitalisation costs. It
  allows patients to access to quality care and
  equipments that are not well reimbursed or not
  reimbursed at all by their own insurance and/or
  social security scheme.
• 2 No queuing ! Medical tourism can be seen as a
  shortcut to benefiting from care that demand to
  wait (inconvenient waiting list system) or are
  not considered as emergencies in the patients
  national health system
• 3 Quality care Countries that develop medical
  tourism as a part of their national health
  industry keep a narrow focus on the quality of
  care. This is a trade image and an absolute
  condition to the development of these activities,
  ever since no legal action is actually feasible.
  Patients satisfaction is mandatory
• 4 Easy going Medical tourism does not
  preventtourism. This is also an opportunity to
  recover in a relaxing and friendly environment
  and often a good way to start and find out more
  about another culture and heritage

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Driving factors (contd)

• 5 Insurance Coverage EC rules enforce the right
  for any European citizen to benefit from care
  anywhere within the EU. This provides just one
  example of international regulation empowering
  medical tourism in a sense. Meanwhile, it should
  be stressed that patients have to check the
  reimbursements conditions with their social
  security/insurance system beforehand
• 6 Level of services Medical equipments, care,
  surgeries are often state of the art in countries
  where a (usually private) offer for medical
  tourism is mushrooming. Given the level of
  comfort of the ancillary services and
  accommodation and the often bargain price of the
  travel, this is a burden of incentives for
  patients to wrap the deal
• 7 Package Deals Intermediaries (tourism
  industry professionals) act as go betweens to
  facilitate these vacations. These intermediaries
  can play a crucial role in tending to the
  patient/tourist and offering a deal that
  encompasses airport transfers, hotels, and a
  whole range of extras

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Pros and Cons
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Infrastructures / services needed

• Upscale in equipment and level of services
• This requires a layer approach to a range of
  medical acts/care and/or economic and spending
  profiles of patients
• Private insurance companies might be potential
  partners interested in developing new cutting
  edge medical facilities where patients could be
  addressed when staying in the country
• Liaison with external services have to be thought
  through (labs, medical transportation, etc.)

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Budapest, a tourist magnet

• A bridge too far ? Dental prothesis can go up to
  20K in France while invoiced 8K in Hungary.
• Give the price range, travel and accomodation are
  not an issue
• Quality of equipments and availability of medical
  staff also attract patients/customers
• Low-costs companies are getting in and looking
  for a slice of the cake
• Isnt that what they call Global Health ?
• Source N. Tatu La roulette hongroise, Budapest

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A political and a community option

• Health tends to be seen as a public good. A
  market based approach of health needs a consensus
  to be reached prior to the mushrooming of medical
  tourism facilities
• People keep a close watch on the availability of
  their health systems for the prime and core
  missions. A potential strain on the available
  resources could send the wrong signal
• Co-existence of varied populations beware
  potential cultural shocks. If tourists expect
  luxury services and facilities it might be tricky
  to fully address their demands on the one hand
  but also to confront this apparent luxury to a
  population whose living standards is much lower
  on the other hand

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Cross cutting issues

• At any rate, when health comes into the picture
  some basic key questions have to be addressed
• A number of considerations have to be borne in
  mind, since health is a basic component of the
  personal and social well-being of any
  individualthat includes tourists
• Health is a complex background environment for a
  lot of different activities amongst which tourism
  activities. Their interaction has to be thought
  through

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Range of issues

• Mobility impaired persons and access to
  infrastructures and sites?
• Addressing different kinds/layers of tourist
  according to their needs and expectations is it
  acceptable in the same facilities ?
• Carry on liaising with MoH to further adapt
  (tailor?) the health facilities and services to
  the tourism plants and gathering points
• Curricula strengthening, continuous training
  involving tourism staff in the provision of a
  basic health safety net. Where are the
   appointed persons  ?

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Range of issues (contd)

• Going further where are the reference
  GP/Hospitals ?
• What platform of overall cross cutting
  policies/decision making process help share
  perspectives and ensure policy coherence
• Communications, information and warning are they
  sufficiently obvious ? Are your tourist
  population aware ? How do you tackle risky
  /unpredictable behaviours in sensible situations
  ?

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Co-ordination institutional asset

• Whether through flexible co-ordination and
  liaison mechanisms or through a dedicated unit,
  constant communication flows between major
  stakeholders is critical
• No time need be wasted to sort out the prominence
  of health over tourism and its economic weight or
  vice versa. These are common opportunities to put
  together
• Once combined, aligned public policies can only
  improve the quality of the tourism services
  backgrounds while allowing the preservation of
  accessible and available care for the entire
  population

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EC Role EC Rules

• Ec compliance and rules can apply in many areas
  such as food control and quality to care
  standards and recommendations. Following the
  guidelines of DG SanCo (health and consumers)
  helps implementing safe procedures for more
  effective health systems
• It can also provides coordination mechanisms
  when it comes to the payment of care provided
  outside the beneficiaries residence country
  (e.g. european health insurance card)
• It leads to harmonisation and sharing of
  experience isnt that how we all came to meet
  through this excellent workshop initiative ?

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Gwenaël DhaeneConseiller/Senior AdviserGIP
Santé Protection Sociale InternationaleFrench
international health and social
protectionAddress 76- Boulevard Haussmann
F75008 ParisT 33 (0)1 5530 1706F 33 (0)1 5530
1712E gdhaene_at_gipspsi.orgW www.gipspsi.org

• Thank you very much for your attention