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

Business Day (Nigeria) - - INSIGHT - DOROTHY JEFF- NNAMANI

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 life­sav­ing 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 trav­el­ers 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”. 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 trav­el­ers 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, or­tho­pe­dics, 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 for 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 trav­el­ers, 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 train­ings 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 physi­ciansper-1,000 pop­u­la­tion as of 2010. It is re­ported that the num­ber of Nigerian trained doc­tors prac­tic­ing 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 an 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 pro­vides 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 cen­ters (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 Healthafri­ca.

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