In spite of the potential rewards to U.S. healthcare players entering overseas markets, there are also plenty of obstacles and risks. The first step to minimizing the chances of being burned is to recognize some of the major pitfalls in and demands of the emerging markets that provide the most opportunity for international partnerships. Here’s a quick look at five trends in the Middle East, Asia and Latin America markets, each backed by one or more examples of how these trends play out in different countries.
Trend: China healthcare could experience rapid fluctuation from government policy shifts
Example: China’s military hospitals
There are roughly 300 military hospitals across China. Often named “People's Liberation Army” and “Armed Police” hospitals, they tend to have access to more advanced technologies and specialty-care physicians than public hospitals. They have also long been free to see and charge civilian patient — and haven’t been subjected to the same tight regulation as public and private hospitals. They’ve even been free to partner with private facilities. The government, meanwhile, has gone back and forth on whether military hospitals should continue to operate as somewhat ambiguously open to patients as quasi-private organizations, or should be restricted from seeing non-military patients, or should simply be converted to public hospitals. Any big policy change on this issue would likely send waves through the healthcare system, both public and private.
But as is often the case in China, predicting what the government will do — or even what it’s doing right now — is tricky at best, and often revolves around rumors and contradictory statements. In March 2016, government representatives served up a statement suggesting that military hospitals would no longer be allowed to operate as quasi-private facilities, followed just a few days later by a different government press conference that sought to assure the public that military hospitals would remain open to civilians. The looser regulation has cut both ways, too, allowing military hospitals to provide experimental treatments not available in other hospitals, but also leading to patient deaths that some tie to lax oversight. No one seems to be sure how these questions will be settled — just more riddles in the confusing picture presented by China healthcare.
Trend: Governments are investing more in healthcare — and much of it’s going to the private sector
Examples: Dubai and Abu Dhabi
“Governments are increasingly looking toward the private sector to create leaner, more efficient, and cost-effective healthcare infrastructure, which makes this market ripe to enter and invest,” says Ron Lavater, a director at Optegra Eye Health Care, and former CEO of UAE’s Al Noor Hospital Group and of Bangkok’s Bumrungrad Hospital.
In the GCC region, Dubai and Abu Dhabi, which account for close to 80 percent of the total health spending in the UAE, are spearheading this trend. According to Ahmed Faiyaz, senior manager at A.T. Kearney, about two-thirds of inpatient and outpatient services were being delivered in the public sector in Dubai in 2009. Today, it’s almost the reverse: Nearly 40 percent of inpatient and outpatient services come from the public sector. “Out of the 35 or so hospitals in Dubai, only four are government-run,” Faiyaz explains. “The remaining ones are mostly operated by private providers.”
Meanwhile Abu Dhabi is putting public hospitals and health facilities under the management and operational control of the private sector. For example, Ohio-based Cleveland Clinic now manages the Sheikh Khalifa Medical City, while Johns Hopkins Medicine International gained complete managerial responsibility over Ain Tawam Hospital. Faiyaz says the same trend applies to Kuwait, Oman, Bahrain, and Saudi Arabia, where two-thirds of healthcare spending still falls under the public sector. Saudi Arabia’s Ministry of Health, for example, plans to privatize 295 hospitals and 2,295 health centers by 2030. “Other Emirates need to look at Dubai’s free zones as models for allowing full ownership by international providers,” Faiyaz adds.
Trend: Logistics gaps, corruption and restrictive regulation will remain an issue in many markets
Examples: Latin America shipping, India’s courts
Ingrid Ritter, Latin America Healthcare Strategy Manager for UPS, has been overseeing the company’s growing involvement in the shipment of medical equipment, pharmaceuticals and hospital supplies into and across the continent. She notes that while more and more global healthcare players are shipping into Latin America as patient demand and spending on healthcare rises, many are struggling with the challenges of shipping, clearing customs, warehousing product and distributing, all across an infrastructure that is often lacking in key ways.
The results can include product damage, spoilage and even disappearance. “Transiting temperature sensitive pharmaceuticals in a region like Latin America, where local infrastructure for cold chain is not always available, can be difficult,” Ritter notes as an example. She adds that the company has had to step up security in the face of outright theft. “When we talk about biopharmaceuticals, we can be talking about a million dollars on one pallet of product,” she notes. “We have to conduct risk assessments on all operations and transportation flows to address a chronic security issue.”
Meanwhile, in India, the government and the courts have at time left healthcare players reeling with uncertainty over foreign direct investment limits, taxes and patient-safety regulations, among other issues. Dr. Krishna Udayakumar, head of global innovation for Duke Medicine, notes that one of Duke’s healthcare joint ventures in India was broadsided by an unexpected India Supreme Court ruling that effectively halted new clinical trials. “Having a strong local partner helped,” he says. “But despite our best attempts at trying to meet a local need and actually addressing some of the quality standards, we found ourselves unable to take on much work.”
Trend: Cultural gaps in healthcare remain a challenge
Example: Nursing in Thailand
Bangkok’s Samitivej hospital struck a deal in 2014 with Oregon Health and Science University’s (OHSU) Doernbecher Children’s Hospital, under which OHSU would advance Samitivej’s critical care programs. Jan Freitas-Nichols, the director of OHSU’s Southeast Asian Children’s Health projects, notes that one of the ongoing challenges has been difficulty in upgrading the status of nurses. The problem, she says, is the nurses themselves, who tend to shy away from accepting the elevated authority they’ve been offered.
Samitivej’s traditional medical culture tended to stymie nurses’ development and limited substantive interactions between staff members, says Freitas-Nichols. That became an especially big problem in patient-transport practices and the intensive care units. As a result, OHSU staff and their counterparts at Samitivej have had to settle for gradually improving practices. OHSU has employed training sessions and simulations to encourage nurses to play a greater role in determining patient care, and has brought Thai nursing staff to Doernbecher to see the benefits of a team-based system for themselves. “You can’t quickly change hundreds of hundreds of years of culture,” says Freitas-Nichols. “We can’t just tell them to stop bowing when doctors enter the room. But we can at least get them to speak up about what they’ve observed in the patients during their shift.”
Trend: U.S. healthcare organizations must shift to a peer relationship with overseas partners
Examples: The Middle East, Thailand
Duke’s Krishna Udayakumar notes that U.S. academic medical systems used to be able to go into emerging markets and get well paid for upgrading relatively low-quality facilities to basic standards. Not any longer. “Partners in the Middle East, for one, are becoming much more sophisticated in what they’re looking for from international partners,” he says. “What I expect to see in the coming years is much more of a bidirectional approach. I firmly believe that we have as much to learn from what others are doing as we have to teach or to build.”
Oregon Health and Science found that to be true in Thailand, says Freitas-Nichols. She points out that the country’s medical system exceeds U.S. healthcare when it comes to hospitality. In Thai medical centers that hospitality extends to employing a holistic approach to care not only for patients, but also for their families. That approach has long attracted patients from around the region and even around the world who are seeking more attentive care for emotional needs as well as for their physical complaints. U.S. medical professionals and hospitals could learn from that, says Freitas-Nichols.
— Tarsilla S. Moura
Tarsilla S. Moura is the managing editor at GHCi. (The following writers contributed to this article: Changhong Zhang, Emily Mininberg, Catherine Elton, Reena Karasin, and Ben Rabin)