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Patients
without borders: Medical tourism and medical migration in southern
Africa - Policy Series 57
Southern
African Research Centre
April
02, 2012
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Executive
Summary
Medical tourism
has become a major focus of research and policy interest in the
Global South in recent years. Much of the discussion focuses on
the motives and impact of Europeans and North Americans who travel
to developing countries for lower-cost medical and health care.
One recent overview of the global medical tourism industry identified
three major hubs (Thailand, India and Singapore) and three minor
hubs (Costa Rica, Hungary and South Africa) for North-South medical
tourists. Medical tourism operators, facilitators and service providers
generally advertise South Africa as a cosmetic tourism destination.
The most popular procedures for European medical tourists are hip
replacements, rhinoplasty, breast augmentation, liposuction, facelifts
and tummy tucks. In other words, South Africa is seen as an archetypal
medical tourism destination, combining a medical (elective) procedure
with related travel and tourism activity. This paper first reviews
the operation of the private sector industry in South Africa and
the role of medical facilitators in particular. It shows that the
industry is premised on a highly romanticised and stylised image
of South Africa which stresses the quality of the country's private
healthcare system and its numerous tourist attractions.
The paper shows
that cosmetic surgery is only one small segment of medical tourism
to South Africa. A great deal of medical tourism to South Africa
is not from the North at all, but from other African countries.
The number of medical migrants to South Africa increased from 327,000
in 2006 to over 500,000 in 2009. Around 4.5% of total entries were
for medical treatment which, became relatively more important over
time (rising from 3.9% in 2006 to 5.0% in 2010). The Global North
generated a total of 281,000 medical travellers over this time period
while the Global South was the source of over 2 million The South
African case therefore offers an important opportunity to examine
the dynamics of South-South and intra-African travel for medical
treatment. Just as South-South migration has generally been ignored,
there is a danger that the same will happen to South-South medical
tourism. This is unfortunate as South-South medical migration is
growing rapidly and challenges conventional notions of medical tourism.
This paper aims to reinstate intra-African medical tourism and migration
as an important topic worthy of further research and policy attention.
South-South
movement to South Africa for medical treatment is far more significant,
numerically and financially, than North-South movement. Two major
forms of South-South medical migration (or medical travel) to South
Africa from the rest of Africa are identified. The first is the
growth in medical travel from East and West Africa to South Africa.
These travellers spend more in South Africa than any other traveller
(including those from the North) and are generally middle-class
Africans seeking specialist diagnosis and treatment. The second,
making up over 80% of the total medical travel flow to South Africa,
are formal and informal movements from countries neighbouring South
Africa (especially Lesotho, Swaziland, Mozambique and Zimbabwe).
Very little is known about this movement beyond the basic dimensions
of the flow.
Public health
systems in countries neighbouring South Africa are in a state of
crisis, under-resourced, understaffed and overburdened. The problem
is exacerbated by the ongoing brain drain of doctors and nurses
to South Africa and overseas. The countries neighbouring South Africa
have much worse patient to doctor and nurse ratios than South Africa
or the recommended WHO minimum. Southern Africa is also the epicentre
of the global HIV and AIDS pandemic, which has increased the burden
of disease on health systems by increasing the demand for treatment
and palliative care, imposing heavier workloads on health care workers,
reducing the workforce by infecting health care workers and imposing
psychological stress on health workers who have to administer palliative
care, leading to low morale, burn-out and absenteeism.
The general
lack of access to medical diagnosis and treatment in SADC has led
to a growing temporary movement of people across borders to seek
help at South African institutions in border towns and in the major
cities. These movements are both formal (institutional) and informal
(individual) in nature. In some cases, patients go to South Africa
for procedures that are not offered in their own countries. In others,
patients are referred by doctors and hospitals to South African
facilities. But the majority of the movement is motivated by lack
of access to basic healthcare at home. An analysis of exit
survey data reveals the following about the movement:
- The proportion
of medical travelers from neighbouring states as a proportion
of total entries was around 6% in 2010. However, there is considerable
country variation with medical travellers amounting to 17% of
total entrants from Mozambique and 12% of those from Angola. The
proportion for most countries neighbouring South Africa is much
lower: Botswana (4%), Lesotho (4%), Zimbabwe (3%) and Swaziland
(2%). This is because cross-border traffic with these countries
is so large that medical travel is relatively insignificant as
a proportion of the whole.
- The actual
number of medical travellers is currently 300-350,000 per annum.
Lesotho is the source of the greatest numbers (140,000), followed
by Botswana (55,000), Swaziland (47,000), Mozambique (38,000)
and Zimbabwe (17,000). The flow has been increasing fastest from
Mozambique: from 8,000 in 2003 to 147,000 in 2008.
- The average
length of stay for medical tourists from Europe is 8 nights. The
average length of stay for medical travellers from countries neighbouring
South Africa, on the other hand, is lower than 4 nights and as
low as 1 night in the case of Botswana and Lesotho. This is consistent
with a pattern of short-term cross-border movement to access routine
medical services or treatment in South African towns close to
the border between the countries.
- The total
annual spend by medical travellers in South Africa amounts to
over R1.5 billion. Of this, over 90% is generated by South-South
medical travellers from the rest of Africa, powerfully illustrating
the overall economic importance of this form of medical travel.
The high demand
and large informal flow of patients from countries neighbouring
South Africa has prompted the South African government to try and
formalize arrangements for medical travel to its public hospitals
and clinics through inter-country agreements. South Africa has entered
into bilateral health agreements with eighteen African countries.
Bilateral agreements can be seen as an effort to formalise and manage
these movements and obtain payment from governments for the cost
of treating non-residents. Some SADC governments have set up special
funding mechanisms (such as the Phalala Fund in Swaziland) to pay
the medical costs of patients who go to South Africa for approved
treatment. However, these special funds have been plagued by corruption
on both sides of the border to the detriment of patients. Medical
tourism and South-South medical travel are areas that require much
additional research and policy formulation. SAMP has recently embarked
on a major research project on South-South medical travel to examine
the following issues:
- Drivers
of Cross-Border Medical Migration. The reasons for the growth
of medical travel to South Africa require investigation. Possible
"push" factors include the crisis of detailed public
health care systems in most SADC countries; lack of access of
patients to diagnosis, drugs and care; inequitable distribution
of health care resources that disadvantage rural populations;
growth in the burden of disease and care accompanying the HIV
and TB pandemics; lack of access to ART for PLHIV; and the comparative
costs of treatment at home versus in South Africa. Possible "pull"
factors include South Africa's better-resourced and staffed
public health system; the existence of world-class medical facilities
in the private system for those who can afford to pay; easier
access to diagnosis, treatment and care; and greater ART coverage
and accessibility.
- Health Seeking
Behaviour by Medical Migrants. Beyond aggregate statistical information
on the numbers involved, their length of stay in South Africa
and their expenditure patterns, little is known about the medical
reasons why residents of neighbouring countries seek treatment
and care in South Africa and the ways in which they seek to access
medical treatment in South Africa. What kinds of medical conditions
prompt people to cross borders for treatment? Have HIV and AIDS
and TB played a role in inducing more people to cross borders
and, if so, what do they hope to achieve by going to South Africa?
What role does the quest for maternal and child health play in
prompting migration? Do people cross borders in order to access
ART and how is their treatment regime affected by the fact that
they have to travel regularly to access the drugs? Do medical
migrants tend to go to hospitals and clinics in border towns or
do they go to the larger centres? How do they decide which clinics
and hospitals to attend and how do they actually get to these
centres? What kinds of follow-up do they receive and, in particular,
do they continue on prescribed drug regimens after leaving South
Africa? This could be a crucial issue in the context of the emergence
of drug-resistant strains of TB and other conditions.
- Treatment
of Medical Migrants in South Africa. There is considerable evidence
that migrants living in South Africa are regularly denied their
constitutional right to medical treatment and care by personnel
at hospitals and clinics. Studies of foreign residents of South
Africa have clearly demonstrated the difficulties faced in getting
medical attention from the public health system. Clearly, given
the scale of the movement involved, medical migrants are somehow
able to access treatment or they would not come. The fundamental
question, then, is whether the barriers to access and human rights
violations experienced by foreign residents are also experienced
by medical migrants and what strategies they adopt to try and
overcome these barriers. Are patients denied access to clinics
and hospitals on the grounds of origin, citizenship and language?
How are they treated by South African health workers and physicians?
Do they receive the same kinds of care as South African patients?
What kinds of payments are they asked to make for treatment? What
happens to them if admission is considered medically advisable?
Are they admitted and under what conditions or are they sent home?
- Policy Responses
to Medical Migration. The 1999 SADC Health Protocol has amongst
its objectives "to facilitate the establishment of a mechanism
for the referral of patients for tertiary care" and "to
coordinate regional efforts on epidemic preparedness, mapping,
prevention, control and where possible the eradication of communicable
and non-communicable diseases." Bilateral agreements can
be seen as an effort to formalise these movements and obtain payment
for the cost of treating non-residents who cannot afford to pay
for expensive, specialised medical treatments in South Africa.
Recent press reports from Botswana and Swaziland suggest that
these agreements are not functioning well, to the detriment of
patient care. For example, 500 Swazi cancer patients undergoing
chemotherapy were recently sent home because the Swazi government
had not paid their hospital bills. A critical analysis is needed
of the functioning of the bilateral agreements and the extent
to which they facilitate or obstruct the rights of patients.
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