At this year’s Nigeria Medical Association annual conference, experts traced the causes of medical tourism and proffered solutions towards reversing the trend, reports MOSES EMORINKEN
YEARLY, Nigeria loses far more than $1 billion to medical tourism. To better appreciate this figure, $1 billion is equivalent to about N359 billion, which is more than the N340.46 billion allocated to the entire health sector last year. About 60 per cent of over $1 billion lost to medical tourism is spent on specialised areas like oncology, nephrology, orthopaedics and cardiology.
Medical tourism and how to reverse it was one of the major discussions at this year’s Nigeria Medical Association (NMA) conference, with the theme: “Patient-Centered care.”
According to experts, medical tourism is when people in one country travel to another country to receive medical, dental and surgical care while at the same time receiving equal to or greater care than they would have in their country. This is said to be happening because of affordability, better access to care or a higher level of quality of care.
Around the globe, medical tourism has contributed greatly to the growth and development of health care systems. However, while the visited nations (usually more developed) have been the better for it because of the economic value it brings to their balance sheet, the reverse is the case for less developed countries like Nigeria. Besides the cost of hospital care and the bill from the country that is rendering the service, there is also the cost of travel of the person and perhaps a companion, cost of hotel, feeding and visa.
Why medical tourism persists
Medical professionals conclude that the massive exodus of patients trooping to other countries for medical care and treatment is as a result of lack of confidence in the competence, integrity and most importantly the confidentiality in health facilities. Dilapidated infrastructure, obsolete machines, and the worst of all, the absence of a culture of patient-centered care, are part of the factors that continue to fuel the crisis of medical tourism.
According to Prof. Samuel Ohaegbulam, founder, Memfys Hospital, the primarily reason for medical tourism is the loss of confidence in the medical services in the country. He blamed erratic power supply (patients fear that power could be cut off in the middle of surgical operation that could cost them dear life), insufficient and unreliable water supply, shameful infrastructure, and inadequate modern facilities – diagnostics and therapeutics for the crisis.
“The starting point is to improve our facilities and the quality of care in our hospitals. If you have all the equipment in the world and the quality of care is not good, you can’t achieve much. Provision of water and electricity is mandatory. We must also upgrade the medical services in Nigeria and invest heavily on medical equipment.
“We must emphasise on adequate and proper training of the medical and paramedical staff. We need to make our services affordable because if we put our services so high and the patients weigh the cost of treatment somewhere in Nigeria and the cost of getting the same treatment in another country and see that there is no much difference, they will rather travel for medical services. Our cost of treatment must be affordable and competitive,” he advised.
At the conference, the Minister of Health, Prof. Osagie Ehanire, who represented President Muhammadu Buhari, also fingered loss of confidence in the hospitals as one of the major reasons for medical tourism. “The patient is at the centre of all healthcare activities and there is no greater measure of the quality of healthcare anywhere than the priority accorded the patient at every level of treatment, at all times. It is no longer just enough for the patient to be assured accurate diagnosis and treatment for his ailment, he expects and must be accorded full confidentiality and due respect so that patient experience is improved. It does not cost too much money to repair that. All we need is a mindset change. There is no doubt that the loss of confidence in our hospitals is the father of medical tourism. There is also no doubt that our health system is in need of review and reforms,” he said.
For the Deputy Governor, Rivers states, Dr. Ibalibo Banigo, who was represented by the Chief Medical Director of Rivers State Teaching Hospital, Dr. Friday Aaron, when medical tourism began, it was to go to places where health care was cheaper. However, people now travel to where healthcare services are more expensive.
“Poor attitudes of health care workers is one of the reasons people seek treatment abroad. We need to build capacities of human resources for health. Doctors must train themselves and not just look only to government for training. Even though government is able to provide infrastructure, the question is: do we have enough people to utilise them well? In training, it is not only doctors that are involved; we need to carry along other healthcare workers. We also need a regional congregation of skills and work together as doctors,” Banigo said.
Medical tourism as elite problem
Medical experts say people who occupy public offices, be they in the legislative, judiciary and executive arms, seem to derive joy in their frequency of medical tourism. Reason: they mostly go for treatment and routine checkups, even when not necessary, especially when there are hospitals and specialists in the country that can handle their cases. Critics lampoon politicians and government officials, saying political elite do this especially since funding for those trips are not from their private pockets but from government coffers.
According to Dr. Osahon Enabulele, former NMA president and President, Commonwealth Medical Association, the crisis persists because there is a lack of political commitment and sincerity on the part of the ruling elite. “The major problem we have is a lack of political commitment. When you talk about the affordability and quality of services, everything at the end of the day is tied to political commitment and governance. When we talk about reversing medical tourism, it is not all about stopping our people from going, but we are also looking at how we can make foreigners come to our country.
“We found out that in 2012 that over 60 per cent of those who go out were going out for frivolous reasons and most of them were political office holders, and that was why we supported clause 46 in the National Health Act, which has helped to restrict foreign medical tourism by political and public office holders. That was why I challenged the President of Nigeria in 2016 when he travelled out for medical treatment, which was in violation of that law. The question now is – are we as citizens ready to take government to account even in observing those provisions?
“If changes must be done, it needs to start from our public office holders. As they say, charity begins at home. No one is against medical tourism, but about preventing those that are not necessary. Capital flight through waste on medical tourism by government officials should stop. They should only go out if it is absolutely necessary,” Enabulele said.
How touting fuels medical tourism
According to Dr. Jimmy Arigbabuwo, president, the Healthcare Providers Association of Nigeria (HCPAN), some medical doctors have turned touting into their major profession. By this, he meant some doctors are in the business of referring patients to hospitals abroad for care with the sole intention of getting commissions for such referrals.
“I am sorry to say, but some of our colleges are touts. They tout for Indian, American and many other journeys and get percentages (commissions) from the destination and some have turned that to their full time jobs and do not even have clinics that they run. When they tell you what they earn in a month, a consultant neurosurgeon cannot get that amount in a month. So, if we part with $1 billion in a year, which is very close to 2018 Nigerian budget, therefore, we really need to discourage this.
“If there is a case that ought to be referred and we know we are not able; it definitely should be referred to the person nearest to that discipline who can then write the referral letter. Another trend is that of non-governmental organisations (NGOs) referring patients abroad for treatment instead of first looking inwards to see if there are competences and specialists in that area of care in the country. In fact, Indians have NGOs in Nigeria that refer patients to them,” Arigbabuwo said.
Prof. Ohaegbulam corroborated this, saying the primary motives for referring patients are for selfish interests; financial gain by some doctors who refer patients to get commission for the referral and commission to agents/companies who recruit patients and estacode allowances to patients or their accompanying persons if they are in the public services. According to Aaron, in states where there is no medical board, it is a free-for-all affair, as anybody can refer anybody anywhere.
“In fact, we have patients referring other patients abroad. It is big business because these people come from India and visit our hospitals to shop for medical tourists. In fact, there is a hospital in Rivers State that all they do is advertise for Indian hospitals.
“For a patient to be referred, he or she has to pass through processes and centers who can handle such cases locally before they are referred abroad. We should therefore work with the government to ensure that such things are stopped; proper policies are put in place, and every state should have a medical board. Travelling abroad must be approved by the medical board,” Aaron said.
How medical tourism in IVF
was reversed
Dr. Jaf Momoh, the Chief Medical Director, National Hospital, Abuja, shared his experience on how Nigeria reversed medical tourism in fertility medicine. “In 1995/96 when I was in the UK, I worked directly under the secretary for the Human Fertility and Reproductive Authority; the authority responsible for regulating In-vitro fertilisation (IVF). At this time IVF had just turned 10 years and the government announced that they were in a dilemma and wanted to destroy embryos because the law said you cannot keep embryos for more than 10 years.
“But the law did not recognise the fact that you have to take permission from the owners of the embryos that they have frozen for 10 years. So, they published the list of the owners of these embryos and where they come from without publishing the names of the people so that they become aware. The first country on the list was Saudi Arabia, followed by the middle east countries, followed by Nigeria. This was as at 1995.
“What sent people abroad then was those who could afford it. There was no IVF available in Africa, so they had to go to UK which was the center of excellence for IVF. Ten years later, they were looking for the Nigerians to destroy these embryos. We eventually started IVF in the National Hospital. There are also a lot of IVF in private practice now, but the story about National Hospital’s IVF is that it has remained uninterrupted for 13 years, and we have produced more than 800 babies. It is also done at subsidised rates compared to the private sector. We have reversed medical tourism in IVF.
“So, if you want to reverse medical tourism, you have to face squarely the challenges. We need to ensure that services are available and personnel are properly trained. Then people will patronise you. There are those who can afford medical tourism that you cannot stop from going. But for those who know that the services are available and excellent, they will patronise you.”
From the perspective of the President of the Association of Nigerian Physicians in the Americas, (ANPA), Dr. Charmaine Emelife, “Reverse medical tourism using IVF as an example has been successful. I don’t see as much people coming to the US any longer for IVF or anything that has to do with having babies. It is indeed true that many of the doctors they have as the forefront of the hospitals in the US and the UK are Nigerians; we are the ones holding up the healthcare in those countries. So it makes absolutely no sense that we sit over there and be told that the Indians and Vietnamese are coming to our country to come and do healthcare or medical tourism – it is absurd. We have shown that we can definitely do something with IVF.”
One of the core policy objectives of the present administration in the health sector is to increase access to care services through the revitalisation of the state’s primary health system; this we are committed to and this we will achieve