Can medical tourism be responsible?

The islands of St. Kitts and Nevis (population 50,000) is the mother colony of the British Caribbean islands. In the early 17th century the native population was exterminated by French and British settlers and they developed the islands with tobacco plantations and then sugar (Thomas Jefferson’s great-great grandfather owned a sugar estate). For a while the islands are said to have been the richest place on the planet: Today most of the population is poor, heavily dependent on remittances from family members working overseas. The Irish were the first workers, being transported there as a result of Cromwellian land clearances (they were the original ‘red necks’). The Irish proved too troublesome and sided with the French, and so the islands’ long and difficult history with the West African slave trade began: Slave plantations whose wretched conditions eventually inspired the William Wilberforce’s emancipation movement.

Today St Kitts and Nevis have been autonomous since 1967. On St. Kitts, sugar production began falling in the1960s and was abandoned altogether on Nevis because of rising production costs and declining prices. Long-standing quotas with Britain and the United States sustained minimal profitability on St Kitts a while longer, but by the mid-1970s the sugar industry could no longer operate profitably, and its operations were assumed by the government.  Following the 2005 harvest the sugar industry was closed after decades of losses of 3-4% of GDP annually. The islands are today the third most heavily indebted nation in the world: The debt burden is equivalent to roughly 185% of GDP, largely attributable to public enterprise losses.

The European Union’s sugar compensation package is helping to explore how the economy can be revived and how large tracts of former sugar production land might best be made available for other uses. Tourism is one development avenue being actively explored and there are extensive inward investment areas awaiting a new wave of settlers. St Kitts has one large hotel, a Hilton and Nevis had a Four Seasons, closed following hurricane damage. Large areas have been made available for second homes and a passport scheme encourages the rich to settle. Smaller ‘Plantation Inns’ make attractive use of old colonial buildings, but their economic viability is marginal. At Basseterre a tax free cruise liner port as a special economic zone, but profits are largely expatriated. This situation has led some commentators to point out that the relations between the West and developing counties are really no different to what they were at the height of colonialism, except that the number of ‘colonists’ has increased dramatically.

“Tourism is simply a continuation of one-commodity dependency inherited from colonial rule.  Foreign sun-seekers replace bananas; Hiltons replace sugar” Cynthia Enloe,  Professor of International Development, Clark University.

 

While the tourism industry may indeed foster dependency, medical tourism (big business in the Caribbean) can perhaps be an exception: The foreign capital and technology transferred do not need to be exclusively for the use of the investing nation, if strong health policies are put in place. And the islands’ health services badly need investment. Secondly, medical tourism can perhaps be a means of product development that can help the islands escape from the cycle of low product quality, low expenditure, low incomes and low re-investment that much of its tourism product currently exudes.

 

Medical tourism requires high quality, high expenditure, highly paid staff and high re-investment. Medical tourism can in fact bring about a situation of reverse-dependency, where the wealthier West becomes dependent on poorer countries for its medical services.  The UK National Health service for example is now dependent on Indian hospitals and one in five doctors worldwide is estimated to be Indian. The Philippines exports 15,000 nurses a year generating huge remittances from the developed world to the less developed world.

“Without medical tourism, the Caribbean nations lack the requirements to sustain a first world medical care system, but with the addition of the medical tourism industry, the potential for quality first class care available to everyone arises: we  diversify each country’s economic base, stimulating a secondary tourism industry.” Dr Roger Mason of the Bahamas, speaking at the World Medical Tourism and Global Health Congress, 2009

Questions remain however about whether local populations actually benefit from medical tourism, and national health systems from the revenues that they generate. Experience from both Thailand and India (heralded as the world’s leading medical tourism destinations) suggests that private medical tourism hospitals attract health professionals away from the public sector and rural areas, and this would be a real threat for St Kitts and Nevis as this internal brain drain creates shortages of trained health workers, thus reducing access to healthcare for local populations and exacerbating inequalities. The Public Citizen Health Research Group’s report on the two leading medical tourism destinations, India and Thailand, examines the implications of medical tourism in these countries. It shows that in both countries medical tourism has caused private hospitals to emphasise treatment over prevention, and promote technology-intensive tertiary services at the expense of primary care. The World Bank (2009) has reported that this  has created distortions in the allocation of resources and spending that doesn’t match the needs of local people. Medical tourism can create further health inequalities between those who can and those who cannot afford to pay for care.

 

Hence it was recommended that the Government of St Kitts and Nevis, in welcoming development, does not overlook the negative impacts that medical tourism can have on local populations, in particular on access to services and availability of public health professionals. Rather than shying away from medical tourism however, a policy document has been drawn up with EU assistance recommending embracing the opportunity which, if well managed, medical tourism can bring. Private-public partnerships with existing facilities, in need of upgrade, are recommended. This opportunity is recognised by the islands’ Ministry of Health. Policies and strategies to expand and foster greater trade in medical tourism must, as far as possible, support, and be complementary to national healthcare efforts. There are real opportunities to fill gaps in health service provision in return for granting tax concessions. There are opportunities to link with existing products, such as medical and nursing schools which have developed on the islands to serve the USA and Canada. The challenge is to find ways of ensuring that the facilities developed for, and revenues accrued from, health tourists are used also for the development of the islands’ overall health.

Robert Travers is an independent consultant and Masters student at the ICRT. He worked in St Kitts and Nevis in May 2010 under the European Union’s Technical Assistance programme of Institutional Strengthening for Social and Economic Development.

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