Giving priority to medical tourists over Israelis, operating on those tourists in the morning while the doctors are on the public payroll, financial irregularities in the management of medical tourism agents, are among the findings of an official report from the audit unit in the accountant general’s division of the Finance Ministry in Israel. The report covers five large state-owned hospitals during 2013 and the first quarter of 2014. Health corporations are the bodies that run the additional operations at the hospitals in the afternoons after services to the public have ended, and this includes medical tourism. The five hospitals: Sheba Medical Center at Tel Hashomer; Ichilov Hospital in Tel Aviv; Rambam Medical Center in Haifa; Assaf Harofeh Hospital in Tzrifin; and Wolfson Medical Center in Holon. The revenue of these five hospitals from medical tourism in 2013 was 347 million shekels, states the report. The report estimates that by including other large private hospitals such as the two Hadassah medical centers and Shaare Zedek Medical Center in Jerusalem, as well as Assouta Medical Center in Tel Aviv, the total revenue of the medical tourism market in Israel in 2013 is more than 600 million shekels (£102 million). Of the five hospitals, Ichilov took in by far the most money at 155.4 million shekels, with Sheba earning 129 million shekels. The rest earned much smaller sums. The accountant general’s report was presented to the health ministry’s German Committee which is studying potential reforms in the health care system. The committee is scheduled to vote soon on its recommendations. The report is scathing about the way hospitals tried to hide what they are earning from medical tourism: ’Hospitals did not fully cooperate even after the intervention of the director general of the Health Ministry and his order to cooperate with the audit team. Hospitals either refused to provide documents outright or provided some, but refused to allow them to be removed from the hospital or photocopied — something which made it difficult to conduct the work of the audit.” All five hospitals are state owned and state run. The audit says that medical tourists are given priority over Israelis — at the latter’s expense. This violates ministry regulations that ban giving such tourists priority in making appointments, as well as requiring that such appointments for the tourists do not lengthen waiting times for Israeli patients. In practice, the medical tourists go through a separate procedure and wait much less time and in most cases receive appointments on the dates they ask for. The agency studied the question by examining the patients’ files — and found that medical tourists had priority in all the hospitals, and often wait only a few days, while Israelis can wait months. In cases in which the waiting time for Israelis is unreasonable according to the National Health Law, medical tourism should be stopped, says the report. Hospitals are reluctant to talk about medical tourism but when they do, the big defence is that money earned goes to improve health care for the public. The report could not conform this and as the Health Ministry has no supervision over the use of the funds it is not clear where the money goes. Regulations state that medical tourists must be charged the standard rates for Israelis, and are not allowed to choose their doctors in return for payment. In practice neither rule is followed. At Wolfson and Assaf Harofeh, payments to doctors were the result of negotiations between management and the doctors, and in almost all cases the payments were much higher than what is allowed. The health ministry now bans the practice of charging medical tourists higher rates. The audit recommends banning medical tourism agents from being able to approach doctors directly and suggests that they should have to work through the hospital medical tourism departments. The report also found that doctors were being paid for medical tourism procedures at the same time that they were being paid for being on duty in the morning hours on their regular jobs providing services in the public health care system. Other hospital facilities such as laboratories and imaging departments also worked for medical tourism clients during the hours they were supposed to be doing public work only. The report highlights that medical tourism agents are completely unregulated, as are their fees, and there is no transparency. There are no tenders or rules, and no price lists; and in some cases these agents get free offices inside the hospitals and often present themselves as being representatives of the hospitals. Another problem is that in a number of cases the hospitals have been stuck with bad debts as the tourists leave the country owing money that often cannot be collected.Overall the report is an indictment of how medical tourism agencies and state hospitals can misuse medical tourism, with strong suggestions that agents and doctors get most of the financial benefit.

The Philippines could attract more medical tourists if it could reduce the cost of air travel, improve air links, cut airport fees, build a transport infrastructure, improve tourist safety and security, deal with consumer concerns about the quality of healthcare, market better, and decide what niche it can target. So says the latest official report on medical tourism. Bearing in mind that the government has had initiatives, research groups, marketing forums and a bewildering history of official organisations since as long ago as 2004, a report that brings up the same answers as previous ones goes a long way to explain why inbound medical tourism has a long way to go in the Philippines. A key part of the problem is that politicians have long been proclaiming the Philippines as a top Asian medical and health wellness destination; but, believing their own rhetoric that they have done little to promote medical tourism. The report points out that the country could claim to be a leader if it had a million medical tourists, two million health and wellness tourists and 200,000 healthcare seeking retirees. The reality is that numbers are very much below these, and that the local medical tourism industry lacks direction. The harshest comments raise issues about standards of healthcare: “Poor health outcomes, combined with poor regulatory mechanisms, and uncoordinated government effort, contribute to the country’s low competitiveness.” Will this wake-up call make any difference? Or will the country continue to talk a lot about medical tourism but with no effective action plan? The report from the Asian Institute of Management says that medical tourism can only become a viable growth strategy in the Philippines if a progressive health system; developed physical infrastructure and stable political environment are present. For years, the government has been promoting the country as a medical tourism destination. The AIM study lists several challenges to achieve this goal. The first is the high cost of travel to the Philippines because of the lack of direct flights to and from target markets in North America, Europe and Northeast Asia. High airfares and numerous airport fees not implemented elsewhere also increase the cost of travel to the country. The second challenge is the lack of transport infrastructure. This deters medical travelers used to trains, buses and other organized systems of transportation. Further investments in airports, highways and organized transportation systems are needed to solve this problem. The third challenge involves security and safety concerns. Worries about peace and order force prospective medical tourists to choose other destinations. Poor health outcomes, combined with poor regulatory mechanisms, and uncoordinated government effort, contribute to the country’s low competitiveness against its competitors. Also, with the brain drain of doctors and nurses migrating to greener pastures, those who are left are new graduates working to gain experience. The fourth challenge is the development of a market niche. The various groups involved with promoting medical tourism are engaged in yet more talks about how to solve the problems and promote the country.

Perfect Profiles used to send UK patients to Hungary and Poland for treatment. The excellent standard of dental care, along with the low costs, meant it was the most cost-effective option for people looking to save money on UK dental prices. But with the price of UK dental implants now starting at £1,500, instead of sending patients to dentists overseas, the company has decided to bring the overseas dentists to their clinics in Luton and Wolverhampton. The company argues that the advantages are obvious: the same low cost, high quality implants, but without the expense and inconvenience of travelling abroad. For people with missing teeth, dental implants can be a good solution. It admits that the same quality implants can be had in Hungary or Poland for £400, a third less than UK dental prices. But it argues that it is rarely a one-off procedure. Customers might need to go back to see the overseas dentist 2 or 3 times over a few months. So, once you have factored in the cost of several flights, hotels, food and time off work, the savings are no longer there. If people take good care of implants they can last a lifetime. But the crown attached to the implant will wear and need replacement within 3 to 10 years. UK dentists can be reluctant to treat work carried out by another dentist, especially if treatment outside the UK uses different procedures and materials. Perfect Profiles have two locations for dental patients near Luton in Bedfordshire, and Wolverhampton in the West Midlands. These offer easy access by car and public transport. So it is attracting customers from all over England and Wales. Luton Airport offers easy access and connections for patients from Scotland and Ireland.

A medical tourism conference aiming to launch Taiwan’s plans for medical tourism badly backfired when health professionals protesting that the plans are a profit making exercise ignoring staff shortages and high medical care costs, interrupted the opening ceremony while chanting slogans and holding cardboard signs that read: “Health is not for sale.” Members of healthcare reform groups protested outside the Taipei International Convention Center against the government’s plan to set up profit-making international medical centres in the proposed free economic pilot zones. The World Medical Tourism Congress in Taipei sought to discuss healthcare and showcase Taiwan’s development in medical services. As well as the zones, plans include five international medical service liaison centres at Taiwan’s major airports, all part of a master plan to make Taiwan’s medical services an international brand. Several healthcare reform groups panned the government’s medical tourism plan, saying it was a ploy for favouring big corporations by allowing them to set up profit-making medical centers in the proposed free economic pilot zones. Protest groups from the Doctors’ Working Conditions Reform Task Force, the Taiwan Radical Nurses Union, the Taiwan Healthcare Reform Foundation, Covenants Watch, the Taiwan Association for Victims of Occupational Injuries and the Black Island National Youth Front staged a protest. Ellery Huang of the Doctors’ Working Conditions Reform Task Force explains, “The congress may be branded as an academic seminar, but it is a platform for the Ministry of Health and Welfare to spread its propaganda on international medical centres and the free economic pilot zones.” The protestors argue that the country’s National Health Insurance programme is heavily in debt and healthcare professionals face adverse conditions at work, so medical tourism is a luxury that the country cannot afford. Ellery Huang adds, “We demand that the ministry work to identify the root causes of the nation’s collapsing healthcare system and stop promoting something that seeks only to satisfy the needs of big corporations and overseas patients. We also urge the ministry to invest more resources to improve the employment environment of frontline medical personnel and stop attempting to lure the country’s talent into the for-profit medical centers in the planned pilot zones.” According to the government plan, the proposed international medical centres will primarily provide physical examination services and cosmetic surgery, which will not be covered by National Health Insurance and must be paid by patients out of their own pockets. Taiwanese doctors will be allowed to take on part-time jobs at the centres and work a maximum of 20 hours per week. Chao Meng-chieh of Taiwan Healthcare Reform Foundation highlights major problems in the government’s plan to set up the centers. - A severe shortage of healthcare personnel and the establishment of the centres will only aggravate the problem. - The ministry’s relaxation of hospital regulations for the centers will only make under-the-table irregularities even harder to detect. For many years the main argument against promoting medical tourism came from academic research, but in the last few weeks we have seen governments planning laws to restrict it in Israel and Nigeria and now this unprecedented protest from health professionals at a global medical tourism conference.

Israel plans major reforms of the country’s healthcare system that will ban private healthcare in most state hospitals and seek to use profits from medical tourism to boost the healthcare of Israeli citizens. Health Minister Yael German presented the long-awaited German Committee to Strengthen the Public Health System report in late June that could implement the most important reform to the healthcare system for 25 years. Some changes will be immediate and some implemented gradually in the next few years. The Treasury will inject NIS 1 billion into improvement in healthcare and additional manpower. All private medical services in hospitals owned by the government and Clalit Health Services will stop completely, except in a few selected Jerusalem medical centres. People will have a choice of being referred by their health fund to three hospitals rather than one, with the aim of shorter queues for treatment and operations and higher-quality care. New websites will increase public information and choice about healthcare. Senior doctors in government and Clalit hospitals will be encouraged to become full timers instead of only working mornings and then working the afternoon at private clinics. So they will be paid more by the government in return for treating patients and performing surgery in public hospitals after their regular shifts end. Profits from medical tourism will go toward improving the treatment and services for Israeli residents, but the committee that wrote and publicized the report have yet to explain how this would happen. For the first time, health budgets will be linked to a demographic index, meaning they will get bigger as the population grows and ages. Israelis who want additional health insurance beyond the basic policy guaranteed to every resident by National Health Insurance will be able to pick and choose among layers of benefits from health funds supplementary health insurance. Most people will not need private medical insurance, the report contends, as queues for procedures and consultations will be reduced. The plans for the general hospital being built in Ashdod by Assuta Medical Centers, whose contract includes a significant percentage of medical procedures carried out as private medical services, will be amended so there will now be no private treatment there. The committee that wrote the report includes representatives from the Health Ministry, the Finance Ministry, hospitals, the Israel Medical Association, universities and from the general public. A new authority will be set up to run the government owned hospitals. This will give the state more control over hospitals that have been running independently and often ignoring requests or instructions from the health ministry. Israelis will be able to compare online the various public and private health-insurance policies available, and choose the ones they want. A host of reforms aims to offer alternatives to hospital care and using health professionals more efficiently. The aim is to strengthen healthcare in the community and connections with the hospitals, keep senior doctors in the hospitals and provide more public funding. Assuta Medical Centers are building the Ashdod hospital, and have protested that the plans to retrospectively stop them offering private care is illegal and breaks the contract. With senior doctors unable to work privately in the afternoons, this will have an impact on medical tourism. What the eventual impact on medical tourism of the proposals is unclear. The report emphasizes that the health ministry wants to regulate medical tourism but exactly how it will do that, and whether it even has the power to regulate private clinics without new laws is debatable.

Almost 200 million Europeans already have the European Health Insurance Card (EHIC), according to the latest figures from the European Commission. This represents more than half of the insured population in the EU. The number of EHIC holders is steadily increasing, with 8 million more citizens carrying it in 2013 compared to the previous year (+4%). The EHIC allows people to get necessary treatment when travelling within the European Union, Switzerland, Liechtenstein, Norway and Iceland. The EHIC, available free of charge, confirms that a person is entitled to receive medical treatment that becomes necessary on a temporary stay abroad from the host country’s public healthcare system on the same terms and at the same cost as nationals of that country. Hospitals that provide public health services are obliged to recognise the EHIC. In the vast majority of cases, patients presenting the EHIC receive the necessary healthcare and are reimbursed without any problems. However, there have been cases of refusals, in general due to a lack of awareness on the part of healthcare providers. Therefore both the European Commission and the member countries must continue to raise awareness on how the card works, both among health practitioners and citizens. In case the EHIC is not accepted, patients should contact the relevant health authority in the country they are visiting. The emergency contact numbers are easily accessible via the EHIC application for smart phones and tablets. In case of further refusal, patients should request support from their home country’s health authorities. Finally, if they still encounter problems, they should contact the European Commission, which can investigate the claims and raise the issue with the authorities of the country concerned. The Commission investigates such cases and when necessary, infringement procedures will be opened against any countries not applying EU law on the use of the EHIC. The EHIC cannot be used to cover planned medical treatment in another country. The huge amount of travel within Europe and the millions who get treatment while in another country, go some way to explaining why country and hospital figures of international patients are often several multiples of actual medical tourists-the two get confused, sometimes accidentally, sometimes not.

The crisis in Iraq is reducing numbers of medical tourists to India from Iraq, Iran and Syria. Some Delhi hospitals get between 25% and 35% of their medical tourists from the region, as they seek cardiology, spinal injuries and oncology. War has virtually destroyed the healthcare sector in Iraq and Syria, so patients with money have been traveling to India and other countries to get treatment. While Iran has much better health facilities than the other two, those needing specialist care still have to look abroad. Director of international business at the Rockland group of hospitals, Sunil Kapur, says, “There has been a dramatic drop in patients from Iraq, Syria and Iran. Where we would get five to eight patients every day, we are now getting one patient a week.” Anil Vinayak at Max Healthcare agrees, “We expect a drop in patients traveling from Iraq, if the situation does not improve soon. Patients are facing difficulty in getting flight tickets. Also, there are problems in getting a travel visa.” Hospitals that attract patients where the state pays for them have seen their business collapse from the region. Artemis Hospital had substantial numbers paid for by the Iraqi government, and at least for the time being, that business has fallen off. Several Indian hospitals were used to sending doctors to these countries to offer consultations to potential patients and act as medical tourism ambassadors. But visa restrictions and security concerns in the region have forced them to stop sending Indian doctors to any of these countries. Fortis hospital confirms that consultations of doctors in the region stopped from the first week of June.

While Kenya is building more hospitals and some healthcare professionals are making bold claims about the number of medical tourists they may in future attract from other African states, the reality is that thousands of Kenyans go overseas for treatment. Some of the common ailments that have driven Kenyans out of for specialised treatments include cardiac conditions, kidney diseases, neurosurgery and cancer. Most go to India and South Africa with a few to Europe and the USA. The real concern for the local healthcare sector and the government is that valuable foreign currency is flowing out to other countries to pay for healthcare. Kenya Commercial Bank plans to offer loans to patients who want to undergo kidney transplant and dialysis at a Kenyan public hospital in an attempt to reduce capital flight that banks estimate to be up to Sh10 billion. Local healthcare professionals and government officials are working on a draft medical tourism strategy to reduce the increasing number of Kenyans going out of the country to get treatment. The longer-term aim is to provide facilities to attract patients to go to Kenya for treatment.