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Changing the narrative during and post COVID-19 for Nigerian international health travellers

International health travel must not be confused with having an unplanned surgery in a foreign country due to an unexpected illness or injury. International health travel as medical tourism means intentionally going to another country for medical care.

In all its definitions, it can be agreed that medical tourism occurs when one travels outside his/her place of residence in search of health or medical care for whatever reason. It could either be inter-state in a country or from one country to another.

In recent times, medical tourism has been considered as a worldwide multibillion-dollar phenomenon that is expected to grow considerably in the next decade. Be it for general wellbeing, cosmetic surgery or life-saving procedures, people are expected to traverse from developing countries to developed countries to access health care mainly driven by various factors such as affordability, easy access, quality and sometimes just a simple getaway.

Patients from these developed countries such as United States, United Kingdom and Europe who seek health care in less developed countries such as India and China are more interested in low cost healthcare and no waiting period.

As it has been widely reported, the cost of healthcare in the US is the most evident key factor that encourages US citizens to seek health care outside the country. This has inevitably proven that medical tourism is the norm for cutting and lowering costs which has continued to excessively soar.

In this part of the world, Nigeria, the case is different. A multitude of reasons conspire to push patients out of the country for health care. Nigerian authorities have stated that the country is losing more than $1 billion annually to medical tourism as tens of thousands of Nigerians travel abroad in search of the best treatment.

Whether it is cost (financial and non-financial), access (physical and skilled workforce) to quality of care, there is an unspoken increasing preference to travel overseas for health care at the slightest opportunity or just for the pleasure of it.

Many Nigerians are known to have a GP abroad who tends to their every need, even to a negligible cough. Just before the COVID-19 pandemic, a friend had informed me of his travel plans, solely for his annual medical check-up. Another friend also stated that after he was diagnosed of hernia and was scheduled for surgery in Nigeria, he opted to fly out to see his GP for a second opinion.

These and many more are clear reasons that attribute to the loss of over $1billion in medical tourism in Nigeria; while International Medical Travel Journal and Global Medical Travel and Tourism estimates that inbound medical tourism generates a whopping $3.5 billion of revenue for the USA.

During the recent commissioning of a Federal Medical Center in the Northern part of Nigeria, the Medical Director identified the following as common challenges faced in running the facility – ‘lack of an X-ray machine, scarcity of potable water, shortage of consultants and indiscipline amongst staff’. I dare to say that these challenges can be ameliorated.

Although it has been argued that in a perfect world, people should need not travel in search of medical care, either way, both antagonists and protagonists of medical tourism can agree that the international health travel is a thing of choice and people should not be forced into making those choices. It is worthy to note that a major factor responsible to this choice is the ease of travel. Our increasingly globalized world has made international travel faster, cheaper, and more accessible.

Even though the financial implication to travel abroad is a bit high priced, families and friends usually rally round the patients to offset cost of procedures in foreign lands. Some people who can afford the travels may even see it as a tourism opportunity to explore the foreign lands and recuperate after their procedure – using one airline ticket to kill two birds.

COVID-19 has devastatingly affected several medical travel destinations, making countries to look inward in correcting the deficiencies that promote undue seeking of medical treatments abroad and thus reducing the high number of billions lost annually over the past decades.

Since the lockdown and travel restrictions, Nigerians at home have been forced to patronize the health sector in its present condition. With the light beamed on the industry, health care professionals have had to standup to the challenge in their different capacities.

While we hear stories of people visiting hospitals in the country for the same reasons they would have travelled abroad – cosmetic surgery, brain surgery, broken arms, sprained ankles, heart attacks and other medical emergencies, there is no available data to compare the country’s health indices in the past five months before the lockdown and travel restrictions.

However, the industry recorded some technological advancements especially around Telehealth, knowledge sharing through remote medical applications with other health experts outside the country and digital subscription for health insurance.

As simple as these may seem, they are progress made in pushing the industry in the right direction, which is part of the solution for the common reasons why Nigerians readily travel abroad for healthcare. If the health industry and consumers of care can hold each other accountable, seeking health care abroad would drastically reduce over time.

Over 99 countries recorded confirmed cases of COVID-19 leading to governments banning flights to certain countries as well as restricting travelers from affected regions and changing visa requirements. These restrictions and virus fears have greatly impacted the travel industry negatively.

Countries, businesses, and healthcare providers cannot just fold their arms and wait for things to get back to normal. The Nigerian government in reaction released 100-billion-naira health intervention fund through the CBN leading to opened opportunities for new leadership, collaboration, growth, and infrastructural development in the industry.

Reducing the outflow of undue international health travel and limiting capital flights may be influenced on how much our country was affected by the pandemic, what the government did or did not do, and the post-COVID-19 view of risk by the potential medical travellers in the next few years.

Following the relaxation of lockdowns, many countries have started relaxing the travel restrictions. Airlines are seen resuming international travels and many people are looking to commence travelling amidst the strict biosecurity measures, international travel guidelines and territorial restrictions.

Will people still want to fly long distances? Travel will get more expensive, inconveniencing in terms of time zones, connections for long flights, etc., pre-travel preparations, requirements, and longer lines in the airport for screening, reduced inflight movements will be quite discomforting and post-travel quarantine.

WHO still warns that sick travelers and persons at risk including elderly travelers and people with chronic diseases or underlying health conditions, should delay or avoid travelling internationally to and from areas with community transmission.

It is reported that COVID-19 appears to be deadlier than seasonal influenza, but far less deadly than SARS, MERS or Ebola, with a death rate average of 3.5% that could drop to 1%. However, there is still much we do not know about this disease. Many medical travelers fall into the high-risk categories and so are mostly at risk.

The risk of severe disease gradually increases with age starting from around 40 years. It is important that adults in this age range protect themselves and in turn protect others that may be more vulnerable. According to the World Economic Forum (WEF), “Pandemics top national risk-management frameworks in many countries and each outbreak of a potentially dangerous infection prompts authorities to ask a rational set of questions”.

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Countries must then strike a fine balance between protecting health, preventing economic and social disruption, and respecting human rights. The American CDC is the first to openly admit that the effects of the pandemic could last into 2021, and if this is the case, the fall out effect of international medical travel could be significant.

Consumers of health care and potential medical travellers in Nigeria needs to be encouraged to use available health providers in the country from 2021 going forward as well as to encourage both new and existing customers to pool funds in the industry which would lead to hospitals and clinics having more income and customers locally.

Not planning now for the future may be a major catastrophic and tactical mistake and this is where health insurance comes into play. Health insurance guarantees peace of mind that one can access medical care when you are at home. This significantly takes care of issues of access and affordability of health care while reducing undue seeking of health care abroad.

International health insurance will serve individuals who have real health needs abroad especially regarding cases that cannot be managed in the evolving and growing health sector in the meantime. Identifying this category of people and market will help in protecting individuals from the cost of both travel and unsustainable purchase of health care abroad.

Hospitals, clinics, and health maintenance organizations (HMO) may be able to use modern marketing techniques to help encourage new and returning customers. But they can only do so if the customers feel safe and putting patients experience as top priority.

Patients on the other hand must see themselves as consumers of health with a sound knowledge of what they are looking for in health care, local or abroad. According to Price Waterhouse Coopers (2016) report, 60% of the over $1 billion dollars spent on medical tourism by Nigeria are based on four key specialties namely: oncology, orthopaedics, nephrology, and cardiology.

This figure may have increased given that the medical tourism business has witnessed a boost in the last 3 years. With COVID – 19 in 2020, cases that fall into these specialties have been forced to stay back and seek health in the country.

The question then is, how can we sustain this or at least reduce the preference for health care abroad significantly? Since the pledge by African Union countries (at a conference in Nigeria’s capital – Abuja) to set a target of allocating at least 15% of their annual budgets to improve the health sector within their borders, Nigeria is yet to meet that budgetary allocation.

In 2018, our health budget is approximately 4% of the 2018 proposed national budget and these allocations to the health sector continue to decline. This leaves a huge deficit in government spending on health and it is no wonder that public spending has failed to address abnormalities in the sector.

Nigeria has relied on donor funds for years and unfortunately, these funds are also steadily drying up. A key element of the budgetary allocation for health that is greatly challenged is the 1 percent of the Consolidated Revenue Fund amounting to N51.22 billion which has been earmarked for the Basic Health Care Provision Fund.

Meanwhile, Capital flight due to international health travel is five times more than this much-needed allocation. As the Managing Director and Chief Executive Officer of a Healthcare organization, I have had the opportunity to interact with businesses and industry leaders outside the health sector.

Evidently, to successfully impact and improve any institution, irrespective of the size, – leadership plays a major role. The health industry needs its sector players to tackle and promote that which is obtainable within the country instead of seeking international health travel.

Such quick wins will support the pooling of funds into the industry, optimize the opportunity that COVID-19 presented and remedy the general perception of the industry which is sadly very poor. For many potential health travellers, access to skilled workforce is pertinent.

While funds can tackle the pervasive lack of infrastructure, the industry players and private sector can bridge the gap in lack of human resources of health workers compared to their global counterparts through Professional development.

This will help leaders to retool themselves across the sector. They must be able to communicate openly, listen to people and operate in a more fluid environment. Health care teams must be nurtured and provided with relevant training to carry out their roles for the good of the patient.

In as much as brain drain continues to pose a challenge for the sector, the World Health Organization classifies Nigeria among the 44 percent of nations that have less than one percent 10 of physicians-per-1,000 population as of 2010.

It is reported that the number of Nigerian trained doctors practising in the United States and the United Kingdom stood at 2,392 and 1,529, respectively. Industry leaders must create professional development programs that will reattract exchange of knowledge with other global counterparts and offer certification opportunities for continuous skill and personal growth to limit this brain drain.

This will be aligned with better rewards and incentives for professionals who build skill and capacity for growth and in-turn attract more consumers to their facility. The technical/academic expertise of a health professional must be matched with professional expertise which comes from developing various capacities needed to adapt to the many more dramatic changes forecasted in the healthcare space.

Incidentally, it has been reported that some of the best doctors in the world who have made remarkable contributions in the field of medicine come from Nigeria (Akande, 2015). Healthcare leaders can invest in the same leadership capabilities at home and especially now that the Coronavirus pandemic has challenged how sectors operate in different economies.

Remote global healthcare developmental programs are a great resource for developing new learnings. For facilities, accreditation will help not only to improve the standards of hospitals and clinics but will offer safety, comfort, and better patient experience.

This confidence can be even stronger if accreditation is followed by affiliation with reputable hospitals or health care systems in industrialized countries. Once healthcare providers are accredited and become a part of international referral networks, they can be appropriately rated for risks which provide a sense of safety for patients.

For those travelling abroad for healthcare who are concerned with quality, there are two major components of the service quality in the health care sector described as technical or mechanical quality. This is at the core of a patients’ diagnostic algorithm and could be serviceable or functional quality which is measured by the service offered in the healthcare centres (such as the services of staffs, nurses and, most importantly, the doctors towards the patient and their assistants).

In recent years, the Nigerian health system has experienced numerous strike actions involving doctors, nurses and allied healthcare workers coupled with the negative attitude of health professionals to patients and medical negligence among health professionals.

These in turn unfortunately encouraged medical tourism outside the country. This negative attitude influences the service quality which is a vital part in the preference of consumers of health in seeking care abroad. Industry leaders must hold themselves accountable and empower consumers of care with patients experience as top priority.

Affordability also influences the decision to travel abroad mostly for those travelling from developed to less developed or developing countries. Health care is cheaper in developing countries. However, due to the poverty rate, this affordability can be said to be relative.

Dynamic initiatives to offer health insurance even at the lowest level of the social strata including public health programs that support detection of diseases at the early stages to prevent huge financial loses when treating complicated cases is key.

When trying to save lives, families have had to go to any extent selling their lands to seek care abroad. The richer social class are forced to spend significant amount of their life savings. Paying huge sums of money has no direct correlation with quality of care.

Health insurance helps to provide the affordability within the community. It is reported that the primary reason that clinics and hospitals in the developing countries can lower their prices is directly related to the nation’s economic status.

Explaining further, the direct correlation with per capita gross domestic product of the country is observed, which is a proxy for income levels. Consequently, surgery prices are from 30% to 70% lower in developing countries when compared to the US.

Globally it was a manufacturing economy before now; in present times it is a service, information, and creative economy. Daily, we are confronted with new and possible ideas to help drive the health sector. Some of the ideas are coming from other sectors and will need a platform for collaboration.

We need leadership with broad functional orientation to promote intersectoral collaboration, explore opportunities, make other sectors real partners and stakeholders to drive the flow of revenue and resources and bridge infrastructure gap.

Partnerships are crucial for sector growth especially in a technology advanced world as we are today, of which the health sector yearns greatly for it. Other targeted collaborations can help ensure that unnecessary barriers are removed or relaxed to alleviate pressure posed on vulnerable groups like the retirees for health care.

These group fall into the risk group who have had to make the difficult choice to leave home in search of health care abroad or spend their entire retirement benefit when seeking health care. Can the Nigeria health sector boast of leveraging on advancements in the face of COVID-19?

Many healthcare professionals may not understand how simple technology or refined processes can bridge existing gaps and infuse growth in our sector or adopt evolving healthcare trends. For example, Telehealth offers a revolutionary approach to better patient care and global access from home for people who seek better care or improved hospital visitations when necessary by simplifying and improving processing/visit times where practical.

It is therefore a sector leadership essential to lead discussions on new ideas and partnerships for the industry to redirect the over $1 billion naira lost through undue international health travel and grow the industry especially as the present government is bogged with competing needs from different sectors in the face of limited resources and the COVID-19 pandemic.
Dorothy Jeff-Nnamani, a medical doctor who runs Novo Health Africa.

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