New report: Patients without borders: Medical tourism and medical migration in Southern Africa

Crush, J., Chikanda, A. & Maswikwa, B. (2012). ‘Patients without borders: Medical tourism and medical migration in Southern Africa’, Migration Policy Series, 57, Southern African Migration Programme (SAMP), Queen’s University. http://dspace.cigilibrary.org/jspui/bitstream/123456789/33006/1/Acrobat57.pdf?1

Patients without Borders: Medical Tourism and Medical Migration in Southern Africa, 2012

Series Editor: Jonathan Crush
Author: Jonathan Crush, Abel Chikanda and Belinda Maswikwa

Migration Policy Series No. 57

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.