Global Health Initiatives
Flat Medicine? Exploring Trends in the
Globalization of Health Care
Robert K. Crone, MD
Trailing nearly every other industry, alternatives. Much of this activity is only a significant first step for patients
health care is finally globalizing. Highly occurring in the emerging economies of in these emerging economies, but may
trained and experienced expatriate the Middle East, South and Southeast also present alternative solutions for
health care professionals are returning to Asia, and beyond. Three Harvard Medical those patients in wealthier nations who
their home countries from training in the International collaborations—in Dubai, nonetheless lack adequate health care
West or are staying home to work in Turkey, and India— highlight these coverage. The increase in health care
newly developed corporate health care trends and demonstrate the potential quality and competitiveness around
delivery systems that can compete quite for new models of global health care, the globe is important, but these
favorably with less-than-perfect providers as well as potential ramifications for improvements will need to be matched
in Europe and North America. In patients and providers in the established by the development of comprehensive
turn, these health care systems are economies of the West, including the payer solutions, to benefit as many
attracting patients from around the United States. Although globalization is people as possible.
world who are interested in exploring not a cure-all solution to achieving
high-quality, lower-cost health care universal access to health care, it is not Acad Med. 2008; 83:117–121.
T hroughout history, diseases and until recently, been roughly divided that is underway in many populous
individual providers have been crossing between the developed Organisation countries in Southeast Asia, South and
borders, primarily from developing to for Economic Co-Operation and Central America, and the Middle East.
developed countries. Now, well-trained Development (OECD) countries and the Here, life expectancy is increasing (and
and experienced expatriate providers “developing world” (Figure 1). The with it, the prevalence of chronic
from these developing countries are former group comprises 30 countries that disease), as are the numbers of health
returning home or staying home to work are home to 1.1 billion people. The latter consumers with the means and
in newly developed corporate health care includes just under a billion people living willingness to pay out-of-pocket for
delivery systems that can compete quite in the 50 least-developed countries in the one-time, life-transforming interventions
favorably with less-than-perfect providers world, most of which are in sub-Saharan like cardiac surgery, joint replacement,
in Europe and North America. In Africa. The remaining 70% of the world’s cosmetic surgery, and bariatric surgery.
turn, these corporate health care systems population— 4.5 billion people—live in These health consumers are better
are attracting patients from around the the emerging economies of Asia, the informed, less willing to wait for
world who are interested in exploring Middle East, and Latin America. It is the treatment, and beginning to demand that
high-quality, lower-cost health care advancement of health care in these these interventions be available close to
alternatives. Trailing nearly every other countries that is, in effect, globalizing home. They have a better understanding
industry, health care is finally globalizing. health care. of the value equation and will go where
it’s necessary to get the kind of care they
As the health care systems in this middle want. Most patient movement has been
The Changing Global Health group of countries develop critical mass to centers of excellence within their
Landscape through enhancing quality and patient region, particularly in Asia and the
Is the effect of these shifts truly global? safety, they will increase their ability to Pacific regions. However, increasing
One way of viewing the development of attract and retain health care professional numbers of patients are leaving one
health care infrastructure is to take a experts, originate new technologies, and region to seek care in another, and
revised view of how one might dissect the develop new centers of excellence that Western Europe and the United States
world health care landscape, which has, will begin to draw patient flows and are no longer the only health destinations
academic medicine away from the considered by patients from the Middle
Dr. Crone is managing director, Academic Medical
historic centers of excellence in OECD East and elsewhere.
Center Practice, Huron Consulting Group, Inc., countries. What will be the impact of
and clinical professor of anaesthesiology, Harvard globalization on patients, providers, Providers: New players and new
Medical School, Boston, Massachusetts. He served
as president and chief executive officer, Harvard
payers, and governments? opportunities
Medical International, from its founding in 1994 to In addition to patients, providers are also
November 2007. Patients: Demographics and demand on the move. It’s important to recognize
Correspondence should be addressed to Dr. Crone, The single biggest driver for the that the majority of medical professionals
Managing Director, Academic Medical Center
Practice, Huron Consulting Group, Inc., 470 Atlantic development of regional centers of health educated in developing countries receive
Avenue, 14th Floor, Boston MA 02210. care excellence is the demographic shift their training from tax-supported
Academic Medicine, Vol. 83, No. 2 / February 2008 117
Global Health Initiatives
Although it is not a measure of actual
LEAST DEVELOPED EMERGING ECONOMIES OECD COUNTRIES
health outcomes, accreditation is a
positive indicator that the building blocks
are in place, both structurally and from a
process perspective, to be able to provide
Afghanistan, Angola, Bangladesh,
111 Countries, Australia, Austria, Belgium, Canada, quality care.
Benin, Bhutan, Burkina Faso, Czech Republic, Denmark,
Burundi, Cambodia, Cape Finland, France, Germany,
Verde, Central African Republic, including Greece, Hungary, Iceland,
Chad, Comoros, Congo, India Ireland, Italy, Japan, Korea, Payers: Insurance beyond borders
Djibouti, Equatorial Guinea, China Luxembourg, Mexico, The
Eritrea, Ethiopia, Gambia,
Netherlands, New Zealand, In general, although conditions vary
Guinea, Guinea-Bissau, Haiti, Norway, Poland, Portugal,
Kiribati, Laos, Lesotho, Liberia, Central America Slovakia, Spain, Sweden, nationally and regionally, emerging
Madagascar, Malawi, Gulf States Switzerland, Turkey, United economies still have poorly developed
Maldives, Mauritania, Mozambique, Middle East Kingdom, United States
Myanmar, Mali, Nepal, Niger, SE Asia mechanisms for spreading financial risk,
Rwanda, Samoa, Sao Tome,
Senegal, Sierra Leone, Solomon
Indonesia and members of the middle class have
Islands, Somalia, Sudan, Togo, Pakistan limited insurance options available
Tuvalu, Uganda, Tanzania, Russia
Vanuatu, Yemen, Zambia Central Asia to them. But this is changing, as we
North Africa have observed in multiple settings.
New legislation in Dubai requires all
(0.9 billion people) (4.5 billion people) (1.1 billion people) employers to provide health insurance
Figure 1 The changing landscape of global economic development, from the world’s least- for their employees; Turkey currently
developed countries to the developed Organisation for Economic Co-Operation and Development has a public health care system and is
(OECD) countries. encouraging private systems to develop;
and in India, leaders have begun to
schools. Those individuals have been Crucial to the success of these hospitals advocate and develop new insurance
willing and able to migrate to the West are their willingness and ability to systems. In addition, U.S. payers are
for better training than is available in institute a culture of quality. They are now exploring an option that could
their home countries and very often have unhindered by legacy systems that are dramatically change the landscape in
remained there to pursue their careers. in place at older hospitals, so they can American medicine: offering insurance
One of the major attractions of training establish new practices and a new culture that includes foreign travel and treatment
and practicing in the West for these more easily. These entities are becoming for lower rates than the cost of
providers has been the wide availability extraordinarily successful regionally, they comparable treatment in the United
of postgraduate training, which is often are competing globally, and their rise is States. This could include sending
limited or nonexistent in their home the most important new phenomenon in uninsured and underinsured U.S.
countries. Although there is little the globalization of health care. patients abroad for interventions that
question that the best training is would be cost-prohibitive or out of reach
still offered in the United States, Their eagerness to compete globally with in the United States, but which would
opportunities are now arising in other health care systems is exemplified be relatively inexpensive abroad. One of
emerging countries, providing another by their moves to gain international the first payers to develop such a plan is
reason—in addition to cultural or accreditation. Recognition by Joint Blue Cross of South Carolina, which
financial factors—for providers at least to Commission International (JCI), the has made Bumrungrad International
evaluate the opportunity to remigrate international accrediting body of the Hospital in Bangkok the first provider
home. Joint Commission on the Accreditation
in its overseas network.2
of Health Care Organizations, has
Another important development in become a significant tool to help these
the emerging economies is the rapid hospitals attract patients and staff. In
emergence of privately financed specialty 2000, JCI had certified three such
hospitals. These hospitals are specialty- hospitals; today, the number of JCI-
focused green-field developments that Rise by Region in Number of
accredited institutions is over 100 (Table Institutions Accredited by the Joint
cater to international patients and 1).1 Even within the established market Commission International, 2000 to
citizens who are prepared to pay out-of- economies of Europe, JCI accreditation is March 2007
pocket for health care. They coexist with becoming increasingly important to those March
public hospitals (which provide care to seeking treatment or career opportunities Region 2000 2006 2007
those who cannot pay) and are able to at these types of hospitals. Africa 0 1 1
“berry pick” patients to some degree ...............................................................................................
Asia 0 19 39
to gain competitive advantage. At the same time that the number of ...............................................................................................
Europe 2 40 47
Operationally, they are being designed privately financed specialty hospitals ...............................................................................................
from corporate models that prize seeking JCI accreditation has increased, Middle East 1 7 19
efficiency and innovation, and their the process of qualifying for accreditation South America 0 4 10
lower-cost labor force, compared with has become more rigorous. However, it is Total 3 71 116
established market economies in Europe important to recognize that accreditation
Source: Joint Commission International1 (http://www.
and North America, allows them to price by JCI is the ground floor for quality jointcommissioninternational.com/23218/iortiz).
services competitively. benchmarks, rather than the ceiling. Accessed October 17, 2007.
118 Academic Medicine, Vol. 83, No. 2 / February 2008
Global Health Initiatives
Governments: Changing roles research programs. The government of the gamut from primary and specialty
Traditionally, governments have assumed Dubai has contributed land and funding care to health promotion and disease
the roles of both health care provider and to spur the development of DHCC, but, prevention, have drawn more than 6,000
payer, but this is shifting in the least- ultimately, the system will be financially local participants and have been taught
developed and emerging economies. The self-supporting and will represent a new by more than 140 faculty, largely drawn
governments in emerging economies are form of public–private partnership. from HMS. The research programs are
increasingly focusing on paying for care just getting underway. The Dubai
and building intrasectoral reform—that HMI’s role has been fourfold in this Harvard Foundation is on a pace to raise
is, they are getting out of the business program. First, HMI teamed with the $100 million targeted for the endowment
of providing care and encouraging government of Dubai to create the Center that will fund clinical, basic science, and
the development of public–private for Health Care Planning and Quality, health services research.
partnerships to fill that role. They are which is responsible for governance,
now looking to serve more as stewards licensing and credentialing, and The DHCC complex and its programs
and regulators of health care systems than rationalization of resources within the provide a model center of excellence for
as providers, and one of the governments’ campus. Second, HMI has created the clinical care education and research in an
most critical aims in this evolving role Harvard Medical School (HMS) Dubai integrated way, and they also create an
will be to develop comprehensive Center Institute for Postgraduate environment with the potential to draw
provider systems, to encourage the Education & Research (HMSDC) to internationally trained professionals back
expansion of services for their own anchor the educational infrastructure of to the region and encourage the public
residents or others. the campus. Third, HMI has developed sector to improve to an equivalent
the Dubai Harvard Foundation for standard. The Department of Health
Medical Research, based at HMS in and Medical Services of Dubai has
Perspectives from the Field Boston, Massachusetts, to support already requested that DHCC develop
collaborative research between scientists credentialing and licensing models for
Three Harvard Medical International public facilities outside the campus.
and laboratories at HMS, DHCC, and
(HMI) collaborations highlight these
other regional institutions. Finally, HMI
health care trends in emerging economies Acibadem Health Care Group
has played a major role in the design and
and demonstrate the potential for new
development of a 400-bed tertiary care Created less than a decade ago, the
models of global health care: Dubai
teaching hospital that, when completed Istanbul-based Acibadem Health Care
Healthcare City (DHCC) in the United
in 2009, will be the linchpin of the Group has grown rapidly into a network
Arab Emirates, Acibadem Healthcare
academic medical community at DHCC. of six JCI-accredited general hospitals
Group in Turkey, and Wockhardt
(two more are under development),
Hospitals Limited in India.
The building clusters in DHCC have together with six ambulatory care centers,
been planned so that tertiary, secondary, centralized laboratory facilities, and
Dubai Healthcare City and ambulatory clusters all have satellite clinical facilities. There are
The government of Dubai approached clinical education and clinical research outpatient care centers, and specialized
HMI in 2003 seeking assistance with the embedded in them, around a core centers for oncology, neurosurgery,
development of a health care provider platform of services that emphasize ophthalmology, infertility, molecular
system that would be based in a newly quality with good clinical and biology, cardiovascular diseases, and
created economic “free zone.” This administrative technology. Since orthopedics. The network has agreements
represented a unique opportunity in opening at the end of 2005, the DHCC with more than 1,000 physicians, has
medicine: to create a new provider community has grown rapidly to include more than 1,500 beds, and currently
system based on best practices from nearly 20 licensed clinical service treats more than 1.5 million patients.
around the world, in a zone where providers in areas such as cardiology, The network is beginning to extend
essentially all regulations and standards vascular medicine, nephrology, into Central Asia, where there is the
are created from scratch as the system ophthalmology, family medicine, plastic opportunity to develop private health
develops. The result of this collaboration surgery, and dentistry, as well as a care services for a growing middle class.
has been a system which is unburdened number of multispecialty clinics. As of
by existing systems and attitudes; which July 2007, more than 400 health care HMI has been working with Acibadem
is governed by its own rules and professionals, including approximately since 2004 to establish quality care
regulations, planning processes, and 170 physicians, were practicing in DHCC, models, particularly in the area of
system for adjudication of disputes; and the community had recorded more nursing. HMI and Acibadem are in the
and in which continuous quality than 50,000 outpatient visits. midst of a several-year collaboration to
improvement is guided by a robust establish performance-based nursing
licensing and credentialing process. Although there are medical schools in the methodologies and to build nursing
Persian Gulf region, there has been little leadership capabilities, with the goal of
The vision for DHCC since its or no postgraduate training there, and reducing nurse turnover. Eight nursing
conception has been to develop an there have been limited opportunities for leaders and about 100 nurse managers
integrated academic medical community continuing medical education (CME). across five hospitals have adopted quality
that serves the greater Middle Eastern HMI (now through HMSDC) has been methods. The results of the nursing
region, with comprehensive services, conducting CME programs in Dubai leadership initiative have been impressive
postgraduate medical training, and since 2003. The courses, which have run as well, as Acibadem has seen the
Academic Medicine, Vol. 83, No. 2 / February 2008 119
Global Health Initiatives
turnover rate for nurses drop from over departmental systems. Patients with
30% three years ago to between 13% and renal, cardiovascular, and neurovascular Table 2
15% in 2006 (personal communication, disease can similarly be treated by Comparing the Costs of Different
E. Brown, MSN, Harvard Medical physicians with different specialties. Types of Surgery in the United States
International, June 2007). Acibadem’s and India
goal is to reduce turnover to less than Finally, there are the financial advantages Surgery U.S. ($) India ($)
10% per year. to the corporate hospital model. Bone marrow 400,000 30,000
Wockhardt and other corporate hospitals transplant
Wockhardt Hospitals, Ltd. have the luxury of focusing on the most Liver transplant 500,000 40,000
The private health care sector in India remunerative procedures. They have, so Open heart 50,000 5,000
today is worth $16 billion, and it is far, little cost relative to research and surgery (CABG)
projected to double in the next five years. education (by choice), and costs related Neurosurgery 29,000 8,000
At the same time, less than 1% of India’s to malpractice and liability are low in this Knee surgery 16,000 4,500
gross domestic product is now spent on less litigious society. The cost of labor is
Source: India Brand Equity Foundation. India
health care by the public sector, whereas advantageous as well. A new nursing
Healthcare: A Report by Ernst & Young for IBEF.5
4% to 5% is spent by the private sector; graduate in the Wockhardt system earns Available at: (http://www.ibef.org/download/
in recent decades, the private system has between $3,600 and $4,200 a year; a Healthcare_sectoral.pdf). Accessed October 17, 2007.
eclipsed the public system in spending.3 specialist nurse in the ICU with six to
eight years of experience reaches $15,000.
locations offer more Western-style
Wockhardt, the second-largest hospital In both cases, the salaries are about 10%
chain in India, is emblematic of the new to 20% of comparable ones in the United
wave of high-tech corporate health care States (personal communication, V. Bali, In each of these venues, patients are
networks that includes Apollo Hospitals chief executive officer, Wockhardt treated by highly technically skilled
Group, Max Healthcare, and Fortis Hospitals, June 2007). doctors, and sometimes with greater
Healthcare. Wockhardt has grown during innovation than is available elsewhere.
the past decade into a 10-hospital In fact, some of the most promising
Implications at Home and Abroad
network with more than 1,500 beds. The procedures being performed on a routine
rate of growth can be attributed in large Putting the picture together, it is clear basis in India, such as hip resurfacing as
part to the cost-effectiveness of not only that great change is coming. The rise of an alternative to replacement, have
the network’s operations but also India’s medicine in Asia and the Middle East is not yet been adopted in the West. At
lower facility-construction costs. underway to such an extent as to pose a Wockhardt, surgeons have performed
Wockhardt and its competitors in the serious challenge to health care systems awake, beating-heart coronary bypass
private sector have employed a corporate in Western nations. procedures on more than 300 patients.7
quality model that governs development They report that the morbidity and
from the first shovel in the ground to Medical tourism, an industry worth an mortality associated with this alternative
the day the first patient comes in the estimated $60 billion and growing,4 is is much lower than with traditional
door. The corporate culture under another driver of change. High costs and procedures—patients are not intubated,
development in these facilities has long waiting lists have thousands of anesthesia is epidural, and ICU time and
Wockhardt and providers like it using patients in the United States and Europe hospital stays are shorter.8
international benchmarks for quality to looking abroad for life-altering care at an
assert themselves in the competitive affordable price. An estimated 500,000 The changing global landscape, however,
global health picture. patients will travel to India for care presents a number of questions. How
in 2007—a trendline that has some will patients choose the right facility and
As with other new health care providers, predicting that by 2012, medical tourism provider? How will we measure quality in
another key to Wockhardt’s cost- will infuse $2 billion into India’s outcomes? For example, should there be
effectiveness has been the lack of legacy economy.5 Thousands more patients will pretreatment screening for such medical
systems to contend with; Wockhardt turn to hospitals in Thailand, Malaysia, travel? Does the patient actually need his
has been able to create new health and Singapore, which has been a globally or her hip replaced in the first place?
information systems from the ground recognized health care destination for How will one ensure adequate short- and
up that are aligned with their years. long-term follow-up? Who is liable for
operational goals, rather than work with mistakes? How is continuity of care
multimillion-dollar systems that have Growing numbers of these patients are provided across geographic boundaries?
been patched together over the years, as from the United States. Many of them are Overall, one critical issue will be to
is the case in a large number of U.S. going to Mexico for cosmetic and other develop a service that will provide higher-
hospitals. kinds of relatively minor procedures, end benchmarking, one which will truly
but travel to Asia is increasing. For U.S. compare quality and outcomes from
Clinical services at Wockhardt have also patients, the lower cost of care abroad institution to institution.
been conceived along newer lines of will continue to be strongly attractive.
thinking rather than inside departmental Care in India costs 15% to 20% of the There have been and will be significant
lines. Thus, patients with diabetes can be same offered in the United States (Table implications of the global changes for
comprehensively cared for without 2). In Singapore and Istanbul, costs are U.S. hospitals. First of all, there already
worrying about several separate closer to 30% of U.S. values, but those has been a rapid decline in international
120 Academic Medicine, Vol. 83, No. 2 / February 2008
Global Health Initiatives
self-pay patient referrals to U.S. hospitals nations. The cost base is unlikely to be political will. Sustainable benefits in
since 9/11. For some American hospitals, reduced much if American institutions health care access will be attainable when
as much as 50% of their profits came are simply rebuilt overseas, therefore governments and citizens alike—in Iowa,
from the 5% of their patients who making it impossible for such institutions in India— commit themselves to the
were international patients; many of to compete with the lower-cost foreign concept that access to health care is a
those patients are now gone, seeking systems. Recruiting and staffing abroad right, not a privilege.
care elsewhere overseas (personal would be difficult, and creating new
communication, J. Pieper, Partners American institutions abroad can put the
Healthcare, June 2007). The highly home brand at risk. Acknowledgments
remunerative, often invasive procedures The author wishes to thank Chris Railey for help
are starting to trickle out of the country, Some of the alternate approaches being
in preparing this manuscript.
with ramifications that extend beyond tried now include partnerships between
the bottom line. For example, the chief of American institutions and successful
plastic surgery at one Boston hospital international regional players, the
creation of consulting and management References
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Academic Medicine, Vol. 83, No. 2 / February 2008 121