by Maria K Todd, MHA PhD
Founder and Executive Director
Center for Health Tourism Strategy
Located across the Mediterranean Sea just one hour’s flying time from Rome, Tunis and Carthage welcome more than 6 million tourists annually to this cosmopolitan destination. Few people from the USA have been there, many confused by the tiny nation’s blurred destination brand differentiation from other Arabic speaking countries in the area.
Tunisia is not part of the UAE. It is in the region of North African continent known as The Maghreb, or the Greater Maghreb, is usually defined as much or most of the region of western North Africa or Northwest Africa, west of Egypt. Tunisia’s doctors and private clinics provide health services to patients sent from Algeria and Libya, and also from France, Morocco, Germany and other near-market health tourism neighbor countries in a way that most would not know without visiting and studying the destination. And that’s just what I did while I was there.
In terms of the World Bank rankings, Algeria, Morocco and Tunisia – ranked 156th, 68th, and 77th respectively out of 190 countries in the latest Doing Business 2017 report – are driving forward their efforts to improve their business environment in a wide range of socioeconomic contexts. For Libya, on the other hand, at 188th in the ranking, due to the ongoing instability, no reforms were reported by the Doing Business indicators. In terms of the Medical Tourism Association published rankings, the tiny country is the victim of inaccurate reports, obfuscated ranking criteria and listed as 36th among 41 countries ranked in 2016. The same publisher previously listed Canada as the top ranked destination for medical tourism despite the announcement by the Canadian authorities that it discourages growth of its fledgling medical tourism sector.
No one goes to Tunisia with the intention to access public health services, except perhaps medical refugees from Libya. Public health clinics are crowded, in need of updating, and responsible for the public health of the locals and training of local nurses and doctors. They do miracles with what they have. Their mission does not really include attracting outsiders for elective care. As such, public health clinics and hospitals there should not be factored into medical tourism rankings in the first place. Small private boutique clinics are located very close to the airport, are clean and pleasant. They don’t try to render services they aren’t capable of performing given their limited technology. Many don’t need fancy technologies (Like PET Scanners, etc, ) to do what they do. But all that’s about to change radically in the next 2-3 years.
One of our clients recently secured funding and rezoning for a new private flagship hospital, private medical clinics and a modern diagnostic center. The 11 story building with three towers is already built and ready for tenant finish. I’ve walked the building already. The new project – located about one mile from the Tunis-Carthage airport is on track to become the pivotal revitalizer project for private healthcare services in the Maghreb. A new service by an established local air commuter taxi service, Star Airlines will shuttle medical tourism visitors seeking transportation to and from their home countries in Western and northern Africa, France and other Mediterranean source markets seeking medical tourism services in Tunisia. They day I was there, they received government paperwork that was a positive sign that their medical commuter taxi service will become a reality.
In Tunisia, I was fortunate to meet key medical tourism stakeholders, tour clinics, and was well received and welcomed on very short notice by several heads of government important to the destination’s development for health and wellness tourism. I owe a debt to my host who leveraged personal and professional connections throughout the tourism, healthcare and hospitality and Prime Minister’s offices to show me what Tunisia has now and is capable of in the future.
Health and wellness tourism in Tunis will be supported by new hotel starts that have already broken ground. Leading business hotel brands have already declared their intentions to commence operations there. In 2014, there was talk about a new medical city within a planned Tunisia Economic City. During my visit there, the project was not discussed or mentioned further. I have no knowledge of its progress.
Le Lac de Tunis
A new area of renewed land use (Le Lac de Tunis) established around a natural lagoon located between the Tunisian capital city of Tunis and the Gulf of Tunis. The shallow lake covers a total of 37 square kilometres and is surrounded by open air restaurants, bars, and upmarket hotels serving Nespresso capsules at about USD $10 for a cappuccino, and a water show the likes of the one people enjoy in front of the Bellagio Hotel in Las Vegas.
While in Tunis, I was hosted at the Hotel Les Berges Du Lac Concorde (left). My stay was delightful. My room overlooked the lagoon. Prices were affordable (~ $140). A spa was situated within the hotel and the hotel was located in a place where I felt safe going for a walk outside to the various shops and restaurants.
My host took me to a place two walkable blocks away for some pizza in an open air restaurant with live rock music, great food, delicious gelato, amazing salads, and inexpensive wine selections. It was reminiscent of the places I frequented when I lived in Fort Lauderdale – one place in Dania, Florida (Tugboat Annies – now closed) in particular. Back then, the only difference was that the music was reggae. The ambiance was much the same. This is my favorite style of dining – al fresco, fresh food, good service, modest prices, live music well played by local musicians.
The new private clinics have their eye on medical tourism and have yet to organize the destination beyond an every clinic for himself approach to marketing. Despite the lack of formal organization as a sector these clinics do a fair amount of business from neighbor countries in the Maghreb, and accept medical refugees from Libya. Taxi drivers from Algeria know the clinics and direct referrals to the private clinics in Tunis. For a fare of about 100 dollars, Algerians pay a driver to take them to Tunis and help choose a clinic that will meet their needs. Many of the clinics are willing to pay the driver fee as a referral commission if you arrange in advance. Then, on discharge, they reverse the process to go back home. It is probably less expensive because any taxi can take them back home without the cost of the referral commission.
Medical tourism business quietly hums in the background to the beat of a different drum. But make no mistake: It beats. This may explain why we don’t notice the Tunisian health clinics renting stands at American medical tourism conferences, and why the medical tourism rankings of this tiny country were rated so low by an organization that makes its money selling market reports, certifications and organizing medical tourism industry conferences. One has to know where to look, whom to ask for details, and actually spend time observing the market and being able to analyze and interpret raw data. It helps to know someone who is “connected”. I am fortunate to have had all those benefits at my disposal.
The Beach
If you are attracted to the likes of South Beach in Miami, or the beaches of Turkey’s coastal resorts, you’ll enjoy Hammamet, about an hour south of Tunis via the Trans-African Highway #1. The cost to enjoy your stay there is lower than Miami Beach and the people friendly and receptive. Along the route to Hammamet, you’ll pass by idyllic scenes of Tunisia’s wine and olive growing regions, local bread makers, farm-to-table produce stands, and friendly people offering a warm greeting, a friendly wave and a smile. Stop and buy some. You won’t be disappointed.
The wait staff and bartenders of the beach resorts in Hammamet are professional and attentive, affable, and ready to be of service. You’ll find expensive yachts, sailboats bikinis and camels sharing the beach front with Jaguar and Mercedes sedans driven by uniformed drivers – and motorcycles – everywhere.
The traffic on a hot Sunday afternoon in Hammamet is reminiscent of the Art Deco festival on South Beach in Miami that I used to attend each year. People and cars everywhere, parking spaces at a premium, live music, food and beverages, arts and crafts for sale. Golf courses and cabana rentals are abundant, music and beach picnics everywhere, children playing and building sand castles, lovers walking hand in hand – and camels available for rent. Tunisia’s tourism product is of good quality and attracts destination weddings from Europe, beachgoers and patients seeking out of the way private health centers offering plastic surgery, vascular surgery and more. The price is lower. The quality is not.
English is widely spoken in shops, restaurants, hotels, resorts, clinics and in government centers.
Security concerns
People often push back when I mention Tunisia. They refer to the horrible terrorist attacks that occurred there in recent years. Tunisia is no longer alone in these unfortunate incidents that claimed innocent lives and targeted tourists. I must admit, shortly after the attacks, I curtailed my travel to Tunisia to speak at a medical tourism conference there. I later agreed to go and have no regrets. I cannot wait to go back with more time and bring others. You’ll see armed security at places where people gather. You’ll be stopped at random checkpoints in a residential neighborhood. Police were respectful, friendly, and diligent. The impression I had was not very different than what I’ve experienced in Colombia, Thailand, India, or the Philippines and many other nations. Currently, Tunisia has good internet service, excellent highways and infrastructure, modern hotels, potable water, the food I like, low prices, friendly people, and an interesting cultural history.
Thermal springs in Tunisia
As an recognized Academician of the Ukrainian Academy of Rehabilitation and Human Health, and a member of the Scientific Committee of Termatalia in Spain, I am always interested to learn about thermal springs and developed resorts near them. I am very interested in how the spring waters are used for pain relief, rehabilitation and pleasure at a destination.
In Korbous itself, you can find medicinal hot springs at Ain Kebira, Ain Chiffa, Ain Sbia, and Ain Araka. Each has developed a branded theme for the properties and reputation of the waters there. Non-medicinal cold springs are also there including Ain Smara. Outside of Korbous, Ain Oktor is a cold medicinal spring, Ain Fakroun — a combination of two springs, the first is cold and potable whereas the second is hot and medicinal. To the north, you’ll find Hammam El Atrouss. about 1 hour southeast of Tunis near Hammamet, is Hammam Jedidi. People access this via an 18-km long road from the Hammamet interchange on the Tunis-M’saken highway. The thermal pumped water is channeled to a reservoir on the hill to supply ancient and modern thermal resorts. Newer facilities with separate premises for men and women opened offering 48 bungalows in December 1993. Each resort has a common 5m x 1.5m swimming-pool, two large restrooms with changing-rooms, six showers and toilet stalls, and a reception desk. Each bungalow is supplied with thermal water 24 hours a day. The Hammam Jedidi thermal water is especially suited to treat arthritis and skin problems.
Investor sentiment
Before we were hired to conduct a medical tourism situation assessment in Tunisia, our clients had already commissioned a feasibility study by KPMG in France to open a modern, flagship hospital near the Tunis-Carthage airport (TUN). The report included excellent fact finding and data assessment and well-developed facts and market research on the need for the project and the market potential.
The private sector is skewed towards small scale activities. 74% of new job creation comes from self-employment (single-person firms). There are very few large firms. Barriers to growth stem from barriers to competition. Innovative and productive firms like medical tourism suppliers and clinics, are not really rewarded in Tunisia. Owners have to have wit, creativity and be prepared to be Mavericks. Its exports are concentrated in the direction of France and Italy, its near market neighbors. While the French do come to buy medical tourism services in Tunisia, the Italians tend not to purchase private health services from Tunisia.
According to reports from WorldBank, Tunisia is characterized by a protectionist regulatory framework which severely limits competition and private investment, notably FDI. More than half of Tunisia’s economy is open to only a limited number of firms. The lack of competition costs the economy over 2 billion dollars per year, nearly 5% of the wealth of the country. Many of the privileged firms allowed to operate in restricted sectors are public enterprises which account for 13% of GDP and 4% of total employment. They also often benefit from financial support from the government (3% of State budget in 2013) which makes it impossible for more efficient private sector firms to grow and compete with them.
One place where this hurts medical tourism is in the cost of international calls. The cost of international calls which would be used extensively in Tunisia for health and wellness tourism case management and logistics planning is 10x to 20x higher than the international market price.
Another constraint to the sector is that in addition, satisfying the heavy bureaucratic and regulatory burden on businesses drains 25% of the managers’ time and almost 13% of firms’ turnover. So for a physician to own a private health clinic, operate it, perform surgery, and market it, plus deal with the paperwork and administrative burden, the rate limiting factor is time. The other is lack of skills in hospital administration. I wanted to discuss this with the authorities over curriculum development at the university level, but in my short time there, that individual was not available. A health tourism management degree or certificate program from an accredited university (not some proprietary certifying body or trade association quickie wallpaper source) is needed that combines elements from a healthcare business administration and tourism business administration program would benefit Tunisia greatly. It could develop a regional program and the education itself could become an export product.
Opening service sectors could boost growth by 1% of GDP and contribute an additional 7,000 jobs per year, notably for graduates. Entry into services sector in Tunisia is among the most restrictive in the world. Barriers to entry have created rents and privileges, and as a result services sectors in Tunisia remain highly inefficient. This undermines the competitiveness of the entire Tunisian economy. High potential services sectors include the telecommunications and ICT, offshoring, professional services, air and maritime transport, logistics, tourism, health services and education. Each and every one of these service sectors is critical to the growth and development of Tunisia as a health and wellness tourism destination of distinction.
With the new government working hard to rebuild Tunisia as a health tourism destination of renown, the quality of the local and internationally-trained medical specialists and surgeons, and the warmth and friendly disposition of the people, Tunisia shows great potential to come into its own as a Medical Tourism Destination of Distinction in the next few years. I expect investors interested in medical tourism to be able to do well there if the destination will carefully plan its expansion with well-planned development from a dot to a diamond on the medical tourism map of the world. The medical tourism market will come from source market countries in the Maghreb, Mediterranean and Southern Europe, UAE, and perhaps from China. I expect that if Turkey doesn’t recover its tourism appeal soon, that those who went to Turkey looking for simple procedures will redirect their attention and curiosity towards Tunisia. When the flagship hospital is commissioned, Malta, Cyprus, Italy, Greece, Turkey, Morocco, Lebanon, Egypt, Israel, Jordan, Spain, and a few other nearby competing destinations will have to rerun their Porter’s Five Forces Analysis. The fungibility (capable of being substituted in place of one another) of destination offerings for medical tourism and thermal tourism in Tunisia will be a direct competitive threat in the health and wellness tourism market landscape.
My biggest fear for foreign investment is that Tunisia grows so quickly that it loses its local charm.
Speaker, Author, Medical Tourism Marketing and Strategy Expert
ABOUT THE AUTHOR
Maria Todd is a trusted adviser and expert specialist to hospitals, clinics, governments, healthcare business owners, investors, and independent professionals. Clients call on her to help them do a better job of marketing, branding, or contracting with insurers and employers, and to grow their business.
Maria is the CEO of Mercury Healthcare International, in Denver, Colorado and the founder of Mercury Health Travel, the leader of the Health Tourism Practice Group of Mercury Advisory Group, the Executive Director of the Center for Health Tourism Strategy, its research and education resource center, and a Board Member and Advisor at Higowell, the world’s first health tourism operations platform. She has been recognized as an Academician with the Ukrainian Academy of Rehabilitation and Human Health and is a member of the Scientific Committee of Termatalia in Spain. She is also a Board Member at Global Health Connections, a nonprofit organization associated with the University of Colorado MBA-HA program. She is the author of 15 internationally-published business improvement books in healthcare administration and health tourism.
Invite Dr Todd to speak at your next event. She presents a compelling workshop of interest to tourism and economic development officials, foreign investors, healthcare strategists, and suppliers on Opportunities for Economic Development through Inbound Medical Tourism Sector Development.
