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

1. 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 Gwenaël Dhaene Senior Adviser / French international health and social protection agency Workshop on rejuvenating tourism - innovation and sustainability Belgrade – 7th September 2009

2. IT IS ALL ABOUT CAREHealth 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 HEARTHProfessionals 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 Context – Fuel for thoughts

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

4. 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 ensureyour 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 impactcan 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 ? GVFMIf 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 ? Rationale – what are the stakes ?

5. Health systems in a nutshell

6. 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 What’s 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 ! Health systems critical components

7. 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/climbing, 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) Tourist clinical needs: an infinite variety of situations… Whatever happens… 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

8. 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 Professionals? Effective follow up mechanisms to sort out severe health situations: long-stay hospitalisation, repatriation

9. 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 ? Resources are critical

10. 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

11. 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? Reliable care network

12. Medical tourism: a new business model (my doctor is good for you !) • What is medical tourismmedical 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 patient’s 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

13. 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 prevent…tourism. 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

14. Driving factors (cont’d) 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

15. Pros and Cons

16. 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.) Infrastructures / services needed

17. 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 • Isn’t that what they call… Global Health ? Source : N. Tatu – La roulette hongroise, Budapest

18. 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

19. 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 individual…that 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 Cross cutting issues

20. 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 » ?

21. Range of issues (cont’d) • 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 ?

22. 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 Co-ordination – institutional asset

23. 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: isn’t that how we all came to meet through this excellent workshop initiative ?

24. 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@gipspsi.orgW www.gipspsi.org Thank you very much for your attention