Using the high-end health market for regional integration in Africa
By Seye Abimbola
The global medical tourism market has been estimated at US $10.5 billion in 2012 and is projected to grow to US $32.5 billion by 2019. While there are uncertainties about the total number of medical tourists globally (as distinct from spa and wellness tourists), increasingly more Africans leave the continent in search of health care, and more tourists visit African countries to receive health care.
Nigeria is perhaps Africa’s leading country of outbound medical tourists. In 2012, 47% of Nigerians who visited India did so for health reasons. With about 18,000 Indian visas issued to Nigerians for medical purposes in 2012, Nigerians spent $260 million to access health care in India. In the three years before 2012, this number had increased by a factor of three. Trips to India account for only half of the annual cost of medical tourism from Nigeria. Other middle-class Nigerians go to the Middle East while the richest Nigerians go to Western Europe and the United States.
South Africa is Africa’s market leader in providing medical tourism services. In the five years from 2006 to 2010, more than 2.5 million medical tourists visited South Africa, out of which less than 10% were from high-income countries and more than 85% from other African countries, mostly from neighbouring Lesotho, Swaziland, Mozambique and Zimbabwe. Like outbound tourists from Nigeria, visitors to South Africa tend to be middle-class or wealthy Africans. The other major medical tourism markets in Africa are in Egypt and Tunisia where people from the United States, Middle East and Europe access services at prices which are 60-70% lower than nearby European countries. South Africa has the added attraction of visits to the spa and safari parks while in the country for treatment.
So why are more Nigerians not going to South Africa, a fellow African country? Why have Nigeria and other African countries not established similar medical tourism markets as in India and South Africa? People increasingly travel to countries like India and South Africa because the cost of high-end health services is much less there compared to Europe and the United States. The overall cost of surgical procedures such as hip replacement or heart-valve replacement in India or South Africa can be as low as one-third to one-tenth of the cost in the United States or Western Europe.
Faster delivery of services is another attraction of the South Africa market as compared to say the United States or Europe where patients can be subjected to long waiting periods. This is a major factor in why Westerners increasingly look “south” for health care, presenting a big opportunity for Africa. However, medical tourism to South Africa from African countries outside southern Africa is limited because air travel between African countries is relatively costly. There may also be difficulties in obtaining visas and finding reasonably priced hotels. In addition, compared to South Africa, Indian providers actively market their medical tourism industry. Countries desiring to attract more health tourists have to address these issues.
Health services in Africa remain weak and progress towards achieving the health-related MDGs is slow. Africa has the highest maternal mortality rate in the world, and remains the region with the highest global burden of under-five deaths. A few African countries are doing well, with Ethiopia, Malawi, Rwanda and eight others on track to reduce child mortality by two thirds by 2015. African countries also have very low numbers of health workers per population. For example, there are 58 health providers per 100,000 people in Malawi, 34 in Mozambique, 468 in South Africa, 1,147 in the United States and 1,552 in the United Kingdom.
In addition to a manpower shortage, the required infrastructure and medical equipment to treat conditions that often get referred abroad are not available in many African countries. There is little confidence in the domestic health system, even when the system can properly handle the condition. This is made worse by low public spending on health care and infrastructure in many African countries. For example, by 2011, only Rwanda and South Africa had met the 2001 Abuja Declaration in which African governments agreed to allocate at least 15% of their annual budgets to the health sector. In comparison, Nigeria allocated only 5.7% of the 2014 national budget to the health sector.
Two key factors explain this poor supply of high skills, infrastructure and equipment. First is the low or complete lack of health insurance coverage in much of Africa, as the majority of the population live on less than a dollar a day and are not be able to afford health insurance. This results in high out-of-pocket expenditure on health care, low demand for health care services, and a lack of economies of scale for high quality hospital services.
The second factor is that weak health system governance, particularly in terms of regulation, which results in low-quality public and private health services in many African countries. Insufficient investment in infrastructure and training of health care professionals results in poor maintenance and irregular upgrades of equipment and infrastructure, lack of supervision of health providers and a weak, sometimes non-existent legal framework for medical malpractice.
While medical tourism will continue as people shop around for prices and countries vie to improve their offering, solving the health system challenges in Africa will likely reduce the amount spent on medical tourism, which in Nigeria is about 20% of the annual government health budget. In turn, savings from medical tourism can be used to finance or subsidise health insurance for the poor.
To do this, a few countries in Africa with the capacity to grow a viable high-end health market for medical tourism will create the enabling environment to attract private health care providers as in South Africa. For example, Indian investors are setting up high-end medical facilities in Nigeria to generate inbound and reduce outbound medical tourism. Rwanda has started to attract investors to its new medical tourism industry. These countries can become regional hubs for specific disease categories: Nigeria in West Africa and Rwanda in East Africa. To facilitate this regional integration of high-end health services, a regional health insurance scheme targeted at Africa’s middle class can be designed to cover such expenses.
The initial challenge will include building confidence in these new service providers, using intensive marketing efforts, similar to how India promotes its medical tourism industry. Beyond marketing, there is a need for an effective regulatory framework that involves regular international certifications, and a legal framework that allows for continent-wide protection of patients and practitioners in case of malpractice claims. The governments of these countries will also have to provide economic incentives to investors in order to create a favourable environment for doing high-end business in the health sector.
Having regional high-end health markets will not only foster regional integration and trade, it will also create jobs. Most importantly, it will save individuals a lot of expenses. Where they are public sector providers, such markets will also generate revenue for national health systems, which can be used to support basic primary health care services especially for the poor. There is a similar model in India, where the Arvind Eye Hospital provides high-end services, attracting patients from all over the world who pay the market price for their surgeries, with the profit then used to subsidise or fund free services for the poor. In this two-way system, regional high-end health market will not only promote regional trade, it may also help finance universal health coverage at least for primary health care in some African countries.
Seye Abimbola is a medical doctor and PhD candidate in health systems and policy at the School of Public Health, University of Sydney, Australia. He studies the governance of primary health care in low- and middle-income countries.