When you hear an acquaintance is leaving the country for treatment, you automatically justify the tour thinking they wouldn’t find similar quality of care here. The burden of this practice can be huge as in Fiscal Year 2018-2019 when Tk9,933 crore was expended in overseas healthcare from Bangladesh (Dhaka Tribune).
But, surprisingly, “quality” is not the only aspect that pushes people to seek healthcare elsewhere, another important reason is the “cost” of the treatments. In many cases, an episode of healthcare tourism may cost just up to 50% or 30% or even 10% of the expenditure of local treatment (UNWTO, 2008). But for Bangladesh, those who visit a developed country usually incur high costs and the core focus is the better quality of the treatment. Hospitals abroad that routinely perform complex procedures can most likely ensure better quality. Those who visit another developing country from Bangladesh, both the cost and quality matter.
Other core reasons for healthcare tourism include unavailability of treatment, lack of advanced medical technologies, tendency of misdiagnosis, along with wrong treatments and inaccurate pathological reports, and an overall lack of concern for the patients’ wellbeing. In some cases, the behaviour of the medical professionals and extensive wait times are bad enough to send an exodus of Bangladeshis outside for treatment.
These wait times are often a scenario of the government hospitals of the country which follow the Beveridge Models’ problems of Long Queues. All of these create an environment of distrust and perception of low quality about the healthcare provided inside the country whether the provider is a public or private entity. The situation exacerbates as 65% of new doctors would prefer to settle abroad (Adkoli, 2006) which means there is a migration of skilled medical labour.
Is this really a global trend?
Before we think more about Bangladeshi healthcare tourism, it can be helpful to know why such trends are rising worldwide. The growing participation of the private sector in the healthcare system, along with insurance coverages and increased mobility of patients due to transportation privileges, are important factors to consider for the rise in healthcare tourism.
Rising number of private facilities may indicate availability and quality of healthcare while insurance coverage reduces the effective price patients have to incur. Healthcare is a normal good, which means better quality or greater amount is sought due to rise in income level worldwide. All these factors push global citizens to tour to another part of the world to receive the best possible services. The rising expenditures along with growing queues of the developed world pushes patients to seek healthcare in the developing countries (Lee, 2007), which created the Asian health tourism industry.
India, Thailand, Singapore, and Malaysia have made extensive investments to attract health tourists (Henderson, 2004). This means Bangladeshi patients can more easily travel to these global healthcare destinations and avail required treatment thanks to shorter distance and greater mobility. Singapore has a bulk of doctors who are trained in the western countries in their world-class standards, Indian healthcare professionals have significant presence in the medical sector in the western world, and Malaysia has aced the low-cost treatment benefits, all of which contribute to the success of the Asian healthcare tourism industry.
What about private hospitals?
The private healthcare sector of Bangladesh performs complex medical procedures which isn’t enough to stop the outward tourism flow because of constant complaints about the quality of the treatment conducted. The quality deterioration includes the long queues and wait times that often reduces the effectiveness of treatment. These hospitals, contrary to the government ones, claim to have superior “world class” service for treatments that often require expenditures that are worth years of savings for the general people.
The focus on profitability has led these organizations to lower the standards of their treatments which can often be life-threatening for patients. Some major complaints about these hospitals are: Disregard of standard medical protocols, untrained and low-skilled nurses, and diagnostic tests that are not mandatory or required (World Bank, 2003). This is a classic example of Physician Induced Demand (PID), which results in wasteful expenditures for the patients and the hospitals, and causes moral hazard from the perspective of health insurance. The centralization of healthcare services makes the people living in Dhaka more able to access somewhat better-quality treatments, whereas the majority of the population outside of Dhaka are often deprived of the care they require.
Before opting for foreign treatment, people in Bangladesh usually attempt local treatment for a month or two. The income and education level of the family and the decision-maker usually affects the decision of health tourism (Hasan, Hassan, 2013). According to the same study, the criterions for a foreign treatment are: Successful procedure, quality of service, cost efficiency. These aspects are of considerable importance even in evaluating local medical performance.
How to reduce the waste from ‘ethical hazard’?
The insurance holder population in Bangladesh should be restricted from having the privilege of being covered by insurance for health expenditures abroad. That is, to reduce the ethical hazard caused by price distortion, the insurer will not cover healthcare tourism related expenses. In many cases, the required treatments are locally available and healthcare tourism only exacerbates the expenses resulting from quantity distortion. To reduce this kind of hazard, health tourism should require thorough screening with doctors’ recommendation stating that the concerned treatment must be taken from abroad.
For the top 5% tax bracket of the country, health tourism is often a sort of vacation which they indulge in quite often. The total probable expenditure for the treatment can be taxed, limiting these ultra-rich from expenses in foreign treatment that can be availed locally.
Quality enhancement, obviously
At the end of the day, without enhancing the quality of the available medical services, limiting people’s tendency for foreign healthcare tourism would be a difficult and often constraining process. Specialists should have greater scope for world-class training in the developed countries, which provides a competitive advantage of available skill as was the case for Singapore. The government can initiate partnerships with the best medical universities around the world as well as collaborate with leading hospitals for internship programs.
Alongside medical training, healthcare professionals must receive impression and communication management training to help them communicate with patients in a more empathetic and respectful manner. But the retention of high-skilled medical personnel is another aspect, and competitive benefits packages as well as social prestige should be offered to stop brain-drain from the medical sector. Motivating doctors, nurses, and other treatment providers with attractive benefit packages can naturally ensure their emotional commitment to the cause, helping them connect with patients better and behave more sincerely with empathy.
Better work on what we already have
Even if the country cannot increase the number of available services, it can work on infrastructural development for the available hospitals, nurses, facilities, etc. The trust of the general public needs to be brought back, and mass communication can still be an effective medium for spreading healthcare information and proving legitimacy of treatment, especially for emergency situations. Mass media communications appeal to general people and seem more trustworthy. For example, the Kidney Foundation has kidney transplant services which have completed 585 renal transplantations with a 98% success rate from 2006-2023 costing on average only Tk2,60,000 (Kidney Foundation Website).
These are the success stories and statistics the general people need to be informed about for them to be aware of available local options. Patients can endorse their treatment experiences at different facilities. Treatment options along with expenditure comparisons abroad should be regularly communicated allowing people to be fully aware of their options. An accreditation body can be established on governmental level that will nationally provide the quality assessment of different hospitals and procedures to help patients build up the right expectations and compare their local healthcare options. This method is followed by the UK's NHS Website that compares mortality rates of hospitals.
Collaboration among medical service providers
Government hospitals can collaborate with private sector hospitals and incentivize them to expand service beyond metropolitan areas. Private sector can avail tax benefits if they serve underprivileged demographics and operate in certain poverty-induced areas of the country with low Fee-for-Service. This would enhance the trust of the general public across the country. Another collaboration can be through telemedicine which will enable patients to connect with physicians beyond the border and take consultation which does not require physical visits. This can be overviewed by specialists and General Physicians of the collaborated hospitals offering a scope of learning-by-sharing for local doctors.
Feedback mechanism and accountability
Policy should include physician and facility-based evaluation mechanisms that are conducted multiple times over the year along with ensuring effective complaints management. Hospitals need to have lawfully mandated transparent grievance redressal systems in place. The accountability of doctors needs to increase through proper review and implementation of medical malpractice law. Another layer of accountability can be ensured through Electronic Health Record (EHR) for patients enrolling into any hospital of the country, which will allow subsequent treatment of chronic conditions to be more effective due to lowered information loss along with records of previous treatments. This will ensure trust of the patients and support better health outcomes.
Bangladeshis need to feel safe and proud of their local healthcare. So, what can be a better time for a nationalistic push than the year of 2024 to initiate a reformation movement throughout the healthcare sector of the country?
Nafisa Kabir Rhyin, Takrin Rahman, Md Salauddin Rony are graduate students at East West University.