INBOUND MEDICAL TOURISM IN RUSSIA: FIRST RESULTS OFEXPORT OF MEDICAL SERVICES AND DEVELOPMENT PROSPECTS
Авторы: M. M. Dvoryashina, E. A. Tarasenko
Издание: Псковский регионологический журнал. 2021.
The purpose o f the paper is to consider development barriers and tools fo r targeted support and stimulation o f the growth o f this sector o f the economy, as well as the peculiarities o f the impact o f the pandemic COVID-19 on the growth and development prospects o f the Russian inbound medical tourism market. Methodology. The article is based on a qualitative sociological study conducted in November 2019 — December 2020, with focus groups and expert interviews method usage. In total, there were conducted 8 expert interviews and 4 focus groups. Findings. The launch o f the federal project «Development o f the export o f medical services» within the framework o f the federal program «Development o f healthcare», the creation o f the Moscow medical cluster, the development o f regional markets fo r inbound medical tourism are considered as institutional measures that can facilitate the target audience’s access to the resources o f Russian medical clinics. The value o f results. As part o f the research, the authors fo r the first time have introduced the analysis o f the first results o f inbound medical tourism development in 2017-2020 in Russia. The differences between the export o f medical services and the market o f inbound medical tourism were revealed. The authors put forward the thesis about the export o f medical services as the first phase o f the development o f the market o f inbound medical tourism. This analysis identifies areas fo r further research.
Целью статьи является исследование барьеров развития, инструментов адресной поддержки и стимулирования роста въездного медицинского туризма, а также особенности влияния пандемии COVID-19 на перспективы развития российского рынка въездного медицинского туризма. В основу статьи заложено качественное социологическое исследование, проведённое в ноябре 2019 — декабре 2020 гг., с применением методологии глубинного интервью и фокус-групп. Всего было проведено 4 фокус-группы и 8 глубинных интервью с экспертами. Запуск федерального Проекта «Развитие экспорта медицинских услуг» в рамках федеральной программы «Развитие здравоохранения», предполагающий рост числа иностранных пациентов российских медицинских учреждений, а также рост доходов от полученных нерезидентами медицинских услуг к 2024 г., создание Московского медицинского кластера, развитие региональных рынков въездного медицинского туризма рассматриваются авторами как меры институционального характера, способные облегчить доступ целевой аудитории к ресурсам российских медицинских клиник. В рамках проведённого исследования авторами впервые осуществлён анализ результатов развития рынка медицинских услуг за 2017-2020 гг. Выявлены различия между экспортом медицинских услуг и рынком въездного медицинского туризма, выдвигается тезис об экспорте медицинских услуг как первой фазе развития рынка въездного медицинского туризма. Данный анализ позволяет выявить направления для дальнейших исследований.
Introduction. Inbound medical tourism as a term denoting the movement of potential patients outside the borders of their country to obtain more affordable (less expensive) and high-quality medical services, came into circulation a little more than 2 0 years ago1. According to the most conservative estimates, the growth of the medical tourism market over the past 10 years is at least double the growth of world GDP, with the largest flow of incoming patients to Mexico, Southeast and South Asia2. The main drivers of this process are the aging processes of the population, at the same time the growth of its well-being, the speed of which exceeds the dynamics of the availability of high-quality health care resources. The imbalance between the growing personal costs of medical procedures and the resource problems of public health in many countries has only increased in recent years, forcing patients to resort to medical services abroad to save or reduce the waiting time for treatment. According to various estimates, the capacity of the global medical tourism market before the start of the COVID-19 pandemic was $ 70-90 billion. The search by governments of different countries for sources of economic growth stimulates interest in the topic of inbound medical tourism [12; 14; 18; 38], as a result of which, over the past 10 years, there has been a boom in the development and implementation of national programs for the development of inbound medical tourism, including the Federal project “Development of the export of medical services” 3 for the period 2019 2024. In this regard, a very productive review of the conceptual framework of the inbound medical tourism market, including the allocation of its differences from the export market of medical services [11; 13; 22]. Research methodology. The purpose of this article is to consider the features of the formation of a new segment o f the medical services market, analyze the first results of the development of the Russian inbound medical tourism market based on the export strategy of medical services. As part of the desk study, the authors also analyzed official reports and documents on the results of the implementation of the Federal Project “Export of Medical Services”, studied the reports of several Russian medical organizations subordinate to the Ministry of Health of Russia that is actively involved in the export of medical services. In April 2019 — December 2020, the authors conducted a qualitative sociological study using focus group methodology and in-depth interviews. In total, 4 focus groups were held (respondents were students of the discipline of their choice from the university-wide pool of “Marketing of medical services” for master’s programs of the Higher School of Economics, including those with experience in health care and marketing) and 8 in-depth interviews with experts — healthcare organizers holding managerial positions in the Ministry of Health of the Russian Federation, the Moscow International Medical Cluster, the Federal State Budgetary Institution “Central Research Institute of Organization and Informatization of Health Care” of the Ministry of Health of the Russian Federation, the Moscow State Medical Insurance Fund. The purpose of the author’s research was to identify the respondents’ assessment of the current state of the export of medical services, their attitude to the advantages, problems, and barriers to the development of the inbound medical tourism market, as well as their recommendations for improving the development of the inbound medical tourism market. Overview. Despite the sustainability of the use of the term Medical tourism (or Health tourism) in the world, an integral concept and methodology for the study of inbound medical tourism as a phenomenon have not yet been formed [8 ; 11; 23]. This makes it very difficult to try to “grow” a new market segment. The definition of “medical tourism” actually identifies the goals of obtaining medical services abroad as the basis for characterizing the strategy of a part of the tourist audience that travels abroad. By the beginning of the 2000s. two basic models have developed, one of which can be called the model of traditional inbound medical tourism (Med Travel), which means that potential patients in developing countries search for treatment options in medical centers and clinics in developed countries [6 ; 9; 10]. The second, to a greater extent, describes a new phenomenon (Med Tourism), characterized by the flows of patients from developed countries to developing countries in search of quality medical services at a relatively low cost, solving the problems of long waiting times for services in their country, the legal regime for the use of certain treatment technologies or access to resources (stem cell therapy, transplantation, etc.) [19; 24]. The selection of the second model, the transformation of the inbound medical tourism market as a whole is the result of the evolution of the international market of medical services in the context of globalization, as well as, not least of all, the wide expanse of marketing technologies [26; 29]. The traditional Med Travel model is represented by medical clinics in Europe, North America, whose reputation has been formed for decades, they not only offer medical services to residents and foreign patients but also act as world centers for training medical personnel, technological leadership in medicine. From the point of view of promotion technologies, the Med Travel model does not support third-party and does not develop its own agent networks; the medical clinic is the only “beneficiary” of the reception and treatment of foreign patients. The second model, typical for large hospitals in Southeast Asia, relies more on partner networks, outsourcing the tasks of finding potential patients, preparing them for hospitalization, communicating with a potential patient, including in terms of prognosis, duration, and cost treatment, taking into account his cultural and religious preferences [25; 27; 34; 36; 39]. Solving the problems of transporting a patient, accommodating and organizing the free time of accompanying persons are also taken out of the borders of the medical organization itself. Along with patients and clinics, accredited intermediaries become participants in the established value chains, who can act as partners of clinics and interact with them so that the clinic performs medical services in a short time, which is one of the main factors of patient loyalty. Training, coaching of such employees, constant monitoring of conversion and customer satisfaction, an effective system of incentives and bonuses are becoming a prerequisite for the success of the entire chain [21; 40; 42]. Health tourism (or Wellness tourism) is defined in comparison with medical tourism (Medical tourism) more broadly [31; 37; 41]. The key parameters based on which medical tourism can be distinguished from the sphere of health-improving (sanatoriumresort tourism) are the availability of medical (invasive) procedures, specialized medical institutions (clinics, centers, sanatoriums), medical personnel [5; 7; 20]. One of the largest professional associations, The Medical Tourism Association4, has developed a platform that acts as a kind of marketplace for the global medical tourism market, which acts as a platform for interaction between clinics, patients, insurance companies, governments, employers, etc. regularly by the association — MTI (Medical Tourism Index) — takes into account in the ranking of destinations the factors o f the attractiveness of the country/region of destination (economy, security, image, culture), the medical tourism industry (attractiveness, cost level) and the availability of facilities and services (quality o f treatment, reputation, international accreditation, consumer experience) [15; 16]. Currently, the top-recommended procedures include dentistry (veneers and implants), IVF and male infertility, orthopedics (joint replacement), cosmetic surgery (hair transplant, breast augmentation), neurology (epilepsy surgery and Parkinson’s treatment), weight loss surgery. For each area (nosology), potential patients can receive information about the country, accredited hospitals, etc. In 2020/2021, the most attractive destinations on a global scale are Canada, Great Britain, Israel, Singapore, and Costa Rica. In the ranking 2020-2021, Russia ranks 41st out o f 46 destinations. Another influential organization, patientsbeyondborders5, estimates the global market at $ 45.5-72 billion (2015), approximately 7-11 million patients receiving medical services abroad, costs an average of $ 3,800-6,000 per trip, including costs associated with treatment, as well as accommodation, transport and visa6. Medical tourism, along with the actual medical service, includes services for passenger transportation, rental housing, catering. Euromonitor International’s methodology7 includes in its medical tourism retail revenues from all domestic (within the country) and inbound tourism travel that is targeted at treatment. In this case, only the expenses ofpatients and accompanying persons for tourist services (accommodation, travel expenses (excluding tickets purchased in the countries of departure for inbound tourism), car rental, etc. are included, and medical expenses are excluded. Official statistics on the volume of medical services provided in Russia by public and private clinics to foreign patients are not currently published. A new form of federal statistical observation (No. 1-MED) for presenting information on the implementation of medical activities concerning non-residents was approved on November 25, 2019, and entered into force in January 202010 (submission of information starting from the 1st quarter of 2020). According to the Analytical Center for the Government of the Russian Federation11, the volume of retail revenues in the field of medical tourism in Russia in 2015-2019 increased by 51.2 % and amounted to about $ 646 million12 in 2019. Taking into account the expected number of treated foreign patients13 (564 thousand people), the average cost per patient was $ 1145 per person. According to the portal “Medical Tourism in Russia” in 2019, the number of treated foreigners was 3 million people14, which is most likely explained by changes in the calculation methodology (2017 — 120 thousand people, 2018 — 300 thousand people, 2019 — 3 million people), in value terms, the volume of exports of medical services for 2019 amounted to 470 million dollars. Definition of product and product market boundaries. The developers of the federal project “Development of the export of medical services” consider the terms “inbound medical tourism” and “export of medical services” as synonyms. In our opinion, this reflects a simplified understanding of the nature of the inbound medical tourism market. Methodological gaps associated with the definition of the target audience of the project, indicators of the number of patients of inbound medical tourism, calculation of income from inbound medical tourism, at least, do not contribute to a clear statement of the project’s objectives, as well as assessments of the effectiveness of its implementation. The characteristics of the mission of exporting medical services (EMO) 15 are defined by the project developers as the development of medical services received by foreign citizens in medical organizations of the exporting country on a commercial basis and regardless of the purpose of their arrival in the exporting country. The goal of the project is to increase the volume of exports of medical services by at least 4 times compared to 2017 (up to 1 billion US dollars) for the period up to 2024. Note that the export of medical services is a broader concept than inbound medical tourism since it involves the provision of medical services in Russian medical organizations to foreign citizens already living in Russia: any foreigner who is already in Russia and who has arrived in it for study/work or sightseeing can purchase medical services (for example, in modern conditions, this is a PCR test for COVID-19). Focusing on the export of medical services, in our opinion, explicitly or implicitly excludes the tourist component of the market product, which is the key driver of growth in the volume of medical services provided, outside the project brackets . Along with it, the mechanisms for stimulating the accreditation of medical hospitals and clinics, cooperative efforts to create medical clusters based on the most advanced regions for working with inbound medical tourism are automatically excluded from the brackets. The emphasis is shifting to the level of participants in the medical market, whose business strategy is associated with expanding the consumer audience at the expense of foreign patients [28; 32]. First results for 2017-2020. Among the most popular directions o f inbound medical tourism in Russia are obstetrics and gynecology and urology (about 25 %), plastic surgery (10 %), and ophthalmology (10 %), as well as cardiology (5 %) and orthopedics. The majority of foreign patients come from neighboring countries of Russia — Uzbekistan, Tajikistan, Kazakhstan, Ukraine, Azerbaijan, Belarus, Latvia, Moldova, as well as Serbia and Germany. According to the Ministry of Health of the Russian Federation, only about 20 thousand foreign patients were treated in 2016, in 2017 the number of treated foreign patients has already reached 120 thousand, and in 2018 — about 300 thousand people, which allowed medical institutions in 2017 earn about $ 250 million. The number of medical organizations accredited by the Joint International Commission has increased (by the beginning of 2019 — 4 organizations). In 2017, the start of a communication company to promote inbound medical tourism in the regions of the Russian Federation began16. In 2019, the volume of exports of medical services amounted to $ 470 million. In the same year, a system of marketing measures to promote inbound medical tourism in the Russian Federation was actively developed, including: — development of a program of communication activities to raise the level of awareness of foreign potential patients; — a communication company on federal TV channels with foreign broadcasting; — targeted advertising on social networks; — launch of in Russian and English; — in several subjects, regional sites for the promotion of inbound medical services began to operate (for example, the medtur.omskzdrav portal in the Omsk region). The start of the state program in 2019 was helped by all the flagship institutions of the industry, first of all, national medical and federal centers, third-level hospitals in the regions, large private providers17. By mid-2020, despite the pandemic, the annual budget of the federal project “Development of the export of medical services” in the national project “Healthcare” was fulfilled by 100 %18. Experts from the Coordinating Center for the Implementation of the Federal Project believe that in 2021 the volume of exports of medical services may grow to 348 million US dollars, and at least 828 thousand foreign patients will purchase medical services in Russia19. Regional structure of the inbound medical tourism market. Information on the regional structure of the inbound medical tourism market is not yet available in the public domain. Based on the results of in-depth interviews, it was found that by the end of 2019, 71 regions were actively involved in the project. It can also be indirectly estimated that 75 regions of Russia are potentially the most promising in terms of the development of the export of medical services. This conclusion can be made based on information presentations for potential foreign patients posted on the website of the Ministry of Health of the Russian Federation, indicating the number of medical care profiles and the number of medical organizations indicated in the presentations concerning a specific profile of medical care. FGBU “National Medical Research Center of Traumatology and Orthopedics named after Academician G. A. Ilizarov” in the Kurgan region. It is a world-class brand in the treatment of orthopedic and neuro-orthopedic pathologies since the days of the USSR. Now it is also the world’s largest purulent osteology clinic. The center has received international certification for quality standards — International quality level ISO 9001: 2015. The marketing group and the international department are engaged in promoting the export of medical services in the Center, the functions of which include support, organization of the initial examination of a foreign patient, planning a course of treatment and further processing20. For foreign patients on the Center’s website, all information is presented in English and French, including a price list for medical services provided. The center provides interpreters for foreign patients. According to data for 2017, 845 foreign patients received paid medical care on an outpatient basis, and 303 foreign patients received paid medical care in a hospital. One example o f the successful promotion and development of a medical tourism project is the Khabarovsk Territory, wherein in 2019 17.1 thousand foreign citizens used the services of medical organizations, from January to September 2020 — 10.9 thousand, mainly citizens of the CIS and China. The purpose of the latter’s treatment is mainly to carry out the in vitro fertilization (IVF) procedure, which is more affordable in Russia than in China. In 2019, more than 40 thousand foreign citizens received medical care in the Sverdlovsk region, including from the CIS countries (92 %), as well as Ukraine, China, Georgia, Bulgaria and Vietnam. The main directions of medical tourism were obstetrics and gynecology, phthisiology and oncology; such directions as plastic surgery and cardiovascular surgery, dentistry is also gaining popularity21. How to develop the market: expert opinion. To launch the Russian market of inbound medical tourism, an inflow of investments is required, and its active development will contribute not only to the spatial development of Russia, including the development of regional healthcare systems but also to improve the quality and availability of medical care in general [3; 18]. The development of the inbound medical tourism market will require the creation of integration associations and stable interagency cooperation [2 ]. The interviewed experts propose to conceptually distinguish between the concepts of “inbound medical tourism” and “export of medical services”. As a result of the launch of the Program under the leadership o f the FSBI “TsNIIOIZ”, an information portal in Russian and English of the Federal project “Development of the export of medical services”22, was created and actively launched, accumulating useful information for clinics involved in the export of medical services and bringing together the expert community, promoting export development medical services. The portal provides information on the receipt of medical services by foreigners in 35 medical areas. As part of interagency cooperation, guidelines were developed for working with foreign patients , as well as a service for Russian clinics to automate and organize work with requests from partners and independent requests of foreign patients for the purchase of medical services, including modules for working with finances and documents23. The goal of increasing the volume of medical care to foreign citizens by at least 1.8 times by 2025 assumed the development and implementation of a marketing strategy for inbound medical tourism and the export of high-tech medical services by Russian medical organizations subordinate to the Ministry of Health of Russia, FMBA of Russia, FANO of Russia, including: — raising the level of awareness of foreign citizens (through communication activities); — creation of a coordinating center for the export of medical services; — introduction of a system for monitoring statistical information provided by medical organizations on the volume of medical services provided, including to foreign citizens. On barriers to the export of medical services and recommendations for the development of the inbound medical tourism market. Based on the results of focus groups and expert interviews conducted by the authors, the following barriers to the development of the inbound medical tourism market can be identified: 1) insufficiently developed marketing communications: experts note the low activity of communication companies on foreign Internet portals and aggregators of medical services in other countries, aimed at promoting the Russian market of inbound medical tourism. It is worth noting the low level of use of the official websites of federal medical organizations as Internet sites for promoting inbound medical tourism, their closedness for certain segments of foreign patients. The experts also pointed to the insufficiently active exhibition and marketing activities to promote Russian inbound medical tourism abroad among healthcare organizers and doctors of foreign countries; 2 ) the service component o f medical services: most experts noted language barriers among Russian medical personnel when providing medical services to foreign citizens. Some respondents pointed to insufficient consideration of the cultural characteristics and religious preferences of foreign patients: for example, the lack of international certification of medical services for compliance with halal standards for labeling services that comply with the canons of Islam. Halal certification would attract an additional flow of foreign tourists from Muslim countries. Also, in most clinics there are no services related to the organization of the transfer of foreign patients and their attendants, their placement, the selection of nurses; 3) ensuring the quality o f medical services: respondents note that many medical organizations do not have any mandatory certification or accreditation for compliance with international quality standards, for example, the absence of ISO 9001: 2015. This can provoke distrust of potentially positive clinical outcomes in foreign patients; 4) administrative barriers to the development o f the inbound medical tourism market: experts note the presence of administrative barriers in obtaining a visa to Russia for treatment, including the absence of a simplified system for obtaining visas for foreign citizens to obtain medical services and the difficulty of extending business visas under article «Treatment»; 5) the financial infrastructure o f the inbound medical tourism market: the majority of respondents indicated the absence of agreements with international specialized insurers — companies that provide insurance products for inbound medical tourism, the lack of involvement of Russian doctors in the insurance of professional activities and professional liability. Some experts pointed to the barriers associated with the underdeveloped banking infrastructure operating in medical clinics: the availability of currency exchange in several medical clinics; 6 ) services o f telemedicine systems: some respondents note the limitation of the availability of foreign patients to telemedicine services and the system of electronic medical records due to the absence of rules regarding foreign citizens in a unified system of identification and authentication. Based on the results of the identified barriers to the export of medical services, the authors developed the following recommendations for improving the development of the inbound medical tourism market (Table 2). Table 2 Recommendations for improving the development of the inbound medical tourism market Strengthening activity in promoting the Russian market of medical services on foreign Internet portals and aggregators of medical services in other countries. You must have versions of the official websites of federal medical organizations participating in the export of medical services programs in Chinese and Arabic. Improving the management of exhibition and marketing activities to promote the latest achievements of medicine and tourism in Russia among healthcare organizers and doctors of foreign countries. Russia’s participation in the Medical Travel Summit 2021 is mandatory. Organization of online English language training courses for medical workers of clinics involved in the export of medical services. Medical clinic call centers must be fluent in foreign languages. The opportunity for foreign medical tourists to order the services of translators of Chinese, Arabic and other languages directly at the clinic. Providing at least 1-2 Russian clinics participating in the export of medical services to obtain international certification for the compliance of medical services with halal standards. For example, consider partnering with Halal Development Corporation (HDC).Ensuring the availability on the websites of clinics of information on transfer options for foreign patients and their attendants, search for housing, selection of nurses. Cooperation of medical clinics with travel agencies. Ensuring that all federal medical organizations involved in the export of medical services pass international certification and accreditation. Development of a more flexible system for the prompt obtaining of visas for foreigners in need of medical services, and the extension of business visas under the item “Treatment”. Conclusion of an agreement with the world’s best-specialized insurance companies in the field of medical tourism: IMG, Foyer Group, AXA, Generali Global Assistance, Cigna, Allianz Worldwide, Aetna International, Bupa Global, GeoBlue, Expacare Global Healthcare, A Plus International24. Introduction of international insurance systems for the risks of professional liability of medical workers. Installation of ATMs in the halls of medical clinics. Development of rules for foreigners’ access to the system of electronic medical records and accounting in a unified identification and authentication system. Impact of the pandemic on the new market and prospects for recovery. According to the Central Bank of the Russian Federation, in 2020, in general, the export of services of all categories decreased by almost 2 times, from $ 4.6 in January to $ 2.7 billion in June 2020. the COVID-19 pandemic virtually zeroed inbound medical tourism revenues in Q2 2020. At the same time, for the whole year, the situation was not so bad. The demand for offlabel surgeries remained particularly high, in particular in the field of aesthetic medicine and plastic surgery. It is known that in the United States in the second quarter of 2020 alone, more than 177,000 planned operations were postponed indefinitely. High pent-up demand will drive the recovery of the medical tourism segment at an even faster pace than the tourism industry as a whole25. The pandemic has undoubtedly adjusted the growth forecasts for the inbound medical tourism industry both in Russia and abroad [17; 35]. Nevertheless, the factors determining the growth of this market: the high cost of treatment in developed countries, as well as access to the latest treatment technologies, a high level of service, health insurance resources, as well as advertising and marketing, remain the drivers of medical tourism. For 9 months of 2020, revenues from inbound medical tourism in Russia amounted to $ 145 million. Conclusion. Inbound medical tourism is a form of tourism that provides good resources and conditions for foreign tourists looking not only for the treatment of diseases and / or meeting the needs for the proposals of medical institutions, but also a comfortable environment to restore their health. It is necessary to conceptually distinguish between the concepts of “inbound medical tourism” and “export of medical services”. At the moment, we can state a fairly confident growth in the export segment of medical services among citizens of neighboring countries who already live and work in Russia and are interested in receiving medical services in our country. This is a self-organizing patient flow of foreign citizens, which is little controlled by Russian clinics. The focusing of the program documents considered in the work on the export of medical services excludes the tourist component of the market product from the brackets of the project, and together with it the mechanisms for stimulating the accreditation of medical hospitals and clinics, cooperative efforts to create medical clusters based on the most advanced ones for working with incoming medical tourism of the regions. The efforts undertaken at the level of implementation of the federal project, considered as an institutional marketing strategy of players in healthcare, are not enough to launch the dynamic processes of formation of the market of inbound medical tourism in Russia when the main purpose of entry of foreigners is to receive medical services. A significant increase in the organized and controlled patient flow from Russian clinics is possible, first of all, with the wider use of marketing technologies, attraction, and adaptation to the peculiarities of the new sphere of experience in the formation and management of partner networks of private medicine companies.