Seminar on International Trade in Health Services and TRIPS and Public Health 22 MARCH 2014

1. Seminar on International Trade in Health Services and TRIPS and Public Health 22 MARCH 2014 10:00 – 11:30 IBNOU SINA CONFERENCE HALL- FAIR GROUNDS CASABLANCA, KINDGOM OF MOROCCO

2. "Sea Sand Scalpel and Safari : Medical Tourism the new face of International Trade in Health Services" By Carolyne Tumuhimbise Trade Adviser- AUC Tumuhimbisec@africa-union.org

3. Scope of Presentation  Examples of Health Services exports  Modes of Supply of Health Services: Focusing on Consumption Abroad  Trend in Health Services exports  Examples of Health Tourism Exports in Africa  Challenges with Health services exports  Condition for Successful health services exports  Opportunities for developing Countries

4. Examples of health Services  Health Services include hospital services (i.e. health services delivered under the supervision of doctors ),  deliveries and related services, nursing services, paramedic services, ambulance services and residential health facilities other than hospitals),  other human health services (i.e morphological or chemical pathology, bacteriology, virology immunology etc) social services and  medical and dental services, veterinary services and the services provided by nurses, midwives etc. are grouped separately under “professional services”. Under W120

5. What do we mean by "international Trade in Health Services?"  The WTO General Agreement on Services (GATS)- multilateral legal framework for international trade in nearly every type of service.  It also defines 4 modes under which services can be traded i.e. Cross border Supply (Mode1), Consumption Abroad (Mode 2), Commercial Presence (Mode 3) and Movement of natural Persons (Mode 4)

6. Mode I ( Cross Border Supply)  Shipment of laboratory samples, diagnosis, and clinical consultation via traditional mail channels, as well as electronic delivery of health services, such as diagnosis, second opinions, and consultations.  Benefits: can enable health care providers to cater to remote and underserved segments of the population; help alleviate human resource constraints; enable more cost-effective surveillance of diseases; improve the quality of diagnosis and treatment; and help upgrade skills through interactive electronic means.

7. Mode II ( Consumption Abroad) "Medical Tourism" "Sea - Sand -Scalpel and Safari"  This creates the most potential for developement for developing countries.  "Patients without borders" a medical traveler as anyone who travels across international borders for the purpose of receiving medical care.  USD 20-24bn and Approx. 8m patients spending an average of USD 3,000-5,000 per visit, including all medically-related costs, cross-border and local transport, inpatient stay and accommodations. Source "Patients without Borders" 2013

8. Mode III Commercial Presence Establishment of hospitals, clinics, diagnostic and treatment centres, and nursing homes. Corporate hospitals in developing countries are also establishing commercial presence overseas. For example AAR Services based in Kenya with branches in Uganda and Tanzania, Life Health care (formerly Afrox) in South Africa with operations in Botswana and UK

9. Mode IV(Movement of Natural Persons) The movement of health personnel, including physicians, specialists, nurses, paramedics, midwives, technicians, consultants, trainers, health management personnel, and other professionals. The biggest arguement agaisnt this mode of export has been that brain drain feeds the health systems of the North with skilled professionals doesnt contribute to the consolidation or development of a productive export sector at the national level. Such brain drain rather saps national capacity.

10. Most medical export services cover specialised expertise like:  Cosmetic surgery  Dentistry (general, restorative, cosmetic)  Cardiovascular (transplants)  Orthopedics (joint and spine; sports medicine)  Cancer (often high-acuity or last resort)  Reproductive (fertility, women's health)  Weight loss (LAP-BAND, gastric bypass)  Scans, tests, health screenings and second opinion Body Contouring/reconstruction

11. Trends in Trade in International Health Services M.II Traditionally international health services have been south to North, seeking treatment in developed countries where more qualified staff and moreefficient structures provided healthcare that was unavailable in theirhome countries.  In 2011, medical tourism contributed to 9% of the world’s gross domestic product (GDP) of US$ 6 trillion. (CNN Travel 22 March 2013)  International trade in health services share in the world market for tourism services rose from 1.2% in 1997 to 1.5% in 2010 (AfDB 2013)  In 2010, the apparent market share of the South reached 54%, while that of the North was 46% ( AfDB - Economic Brief 2013)

12. Health Services Exports in Africa: Medical Tourism countries in Africa include; South Africa, Tunisia, Egypt, Morocco and Lybia  Tourism in Africa is comprised of Tourists from north and south for example Africans comprised 2,196,000 medical visitors to South Africa. They constituted nearly 80% of all medical tourists to South Africa  African medical tourists mainly target Asia - India in 2012 generated over N 40.94 billion (US$ 260 million) from Nigeria’s medical tourists alone (International Medical Travel Journal 2013)  Surgery in South Africa costs roughly a third of surgeries performed the United Kingdom (UK). For example, a facelift in Britain costs about GBP 9,000 (US$ 13,953), while the same services in South Africa costs about ZAR 53,276 (US$ 5,428).(20) In South Africa luxury hotel fees and tourist activities, such as a post-op safari, are included in the price.  The Medical Tourism Association (MTA) of South Africa promotes the industry and represents its value chain. This helps ensure that services in the industry are consistent, standardised, and integrated.

13. Africa cont.... It costs $3500-4000 for knee replacement surgery in Tunisia and $40,000 in USA, $16000-17000-UK, $7500-9000 in France.  Tunisia, 84%of foreign patients came from neighbouring countries in 2003 (70%in 2007); (AfDB 2013)  an estimate of approximately 37,000 jobs generated directly by healthcare exports in Tunisia, including close to 20,000 in subsistence and accommodation services, close to 10,000 medical jobs (physicians, nurses) and approximately 8,000 hospital support staff jobs  Popular services in Egypt’s medical tourism industry include cosmetic surgery and dental work, in part due to the country’s flourishing film industry and celebrity aesthetics. Source Discover Medical Tourism)

14. Challenges with Medical services Exports  Medical Dualism- Countries like South African have managed to have a booming medical tourism and still provide public health access  diversion of medical resources towards the treatment of foreigners to the detriment ofnational patients.  Brain drain  Incentives to invest in exporting medical services can be geared towards public health care  Barriers like regulations and standards

15. Factors that Create Health Servicess Exports:  Government and private sector investment in healthcare infrastructure  Demonstrable commitment to international accreditation, quality assurance, and transparency of outcomes  International patient flow  Potential for cost savings on medical procedures  Political transparency and social stability  Excellent tourism infrastructure  Sustained reputation for clinical excellence  History of healthcare innovation and achievement  Successful adoption of best practices and state-of-the-art medical technology  Availability of internationally-trained, experienced medical staff

16. Potential for international health Services Exports  Huge number of Africans and Arabs leaving the continent indicate is an opportunity for both African and Arab countries to provide those services. But there is need for a balance between the direction towards health services exports and public health care provision

17. Shukran