Idyllic islands, beautiful beaches, tropical paradise: all synonymous with the Caribbean. Healthcare and evacuation, not so much – though possibly crucial for visitors to the region.
Seeing the inside of a local hospital is not usually on the itinerary for holidaymakers to the Caribbean, let alone requiring treatment in one. But should the worst happen, it is important to know what to expect from the healthcare system in situ, and whether treatment elsewhere would be better suited. Where travellers go, and where they’re from, can make a real difference in the healthcare they receive, where they are treated, and the cost.
Bare(foot in the sand) necessities
Globally, the Caribbean is the region most reliant on travel and tourism. According to the World Travel & Tourism Council’s (WTTC) ‘Travel & Tourism in the Caribbean: Prospects for growth’ report, eight out of the 10 most tourism-dependent countries in the world in 2019 were in the Caribbean region. In fact, that year, international visitors accounted for 73.7 per cent of total travel and tourism spending in the area, reported the WTTC. Of all spending in the sector, leisure made up the majority of total expenditure (88.8 per cent), showing that international holidaymakers are key to the Caribbean economy.
The most visited countries in the region, according to numbers from the United Nations World Tourism Organization (UNWTO), are the Dominican Republic, Puerto Rico, Jamaica, the Bahamas and Aruba.
For the Dominican Republic, travel and tourism represented 11.8 per cent of its total economy in 2021, according to research findings from the WTTC. International visitors to the country spent RD$296.6 billion (approximately US$5.2 billion).
Puerto Rico saw travel and tourism make up 3.8 per cent of its total economy in 2021, and international visitors spent just over US$2 billion, which was a decrease on 2020 numbers of 14.8 per cent. Eighty-five per cent of visitors to Puerto Rico came from the US, which would be considered as domestic travel due to the island’s status as a US territory.
In 2021, nearly a fifth of Jamaica’s total economy came from travel and tourism – JA$409.8 billion (US$2.725 billion). International tourists spent JA$294.1 billion (approximately US$1.9 billion) in 2021, with nearly three quarters arriving from the US (74 per cent).
A third (28.1 per cent) of the Bahamas’ economy came from travel and tourism in 2021, and over BS$2.2 billion (approximately US$2.2 billion) was spent by international tourists, a 116.8 per cent increase on the previous year. US visitors made up the majority of visitors.
The fifth most popular island, Aruba, relies heavily on travel and tourism for its economy; in 2021, the sector made up 59.6 per cent. Just over ƒ2.6 billion (approximately US$1.4 billion) was spent by international travellers to the country in 2021.
Reciprocal healthcare agreements are used to strengthen the global healthcare community
It is clear that the economies of Caribbean nations are heavily dependent on international arrivals. Covid-19 had a huge impact in 2020, with dramatic levels of recovery the following year showing that tourists are clearly the backbone of the region.
The extended EU
The Caribbean is closer to the European Union (EU) than geography would suggest. Some member states have territories in the region and these islands – and tourists to them – benefit from their EU status, should they need healthcare while in these destinations.
Reciprocal healthcare agreements are used to strengthen the global healthcare community by helping the visitors to certain countries access the local healthcare system for treatment. The European Health Insurance Card (EHIC) is one such example. This card is offered to citizens of the European Economic Area (EEA) and Switzerland, allowing them to receive medical treatment at a reduced rate or free of charge in another member state. So, for EEA citizens, should they travel to Guadeloupe, Martinique, Saint Martin and Saint Barthélemy, which are French Overseas Territories, and require medical attention, they would be able to use their EHIC.
However, the Netherlands, another EU and EEA member state, also has overseas territories in the Caribbean – Curaçao, Aruba, Sint Maarten, Bonaire, Sint Eustatis and Saba – yet an EHIC cannot be used by EEA citizens. These islands do not have the same memberships to the EU and EEA that the Netherlands does.
Another reciprocal travel agreement that has been recently established is the Global Health Insurance Card (GHIC), which was a part of the post-Brexit deal between the UK and the EU. It was introduced on 30 December 2020 as a replacement for the EHIC, but functions in a similar way – it covers medically necessary state-provided healthcare at a reduced cost or free of charge, until the patient returns home. The GHIC can only be used in the 27 EU countries though, whereas the EHIC included these as well as Norway, Iceland, Liechtenstein, and Switzerland. The EU countries, though, also refer to the same Caribbean nations as before – Guadeloupe, Martinique, Saint Martin and Saint Barthélemy – where this discounted or free treatment is available for GHIC holders.
Luke Banks, Regional Chief Medical Officer, UK/Europe, World Travel Protection, has a warning about reciprocal healthcare agreements: “Most agreements are only for emergency treatment which can’t wait until you get home, and the emergency treatment or capabilities you need may not be available on the island where you are staying,” he explained. “Emergency flights to other islands are expensive, and usually aren’t covered by these agreements, making it still important to have valid private travel insurance in place and not rely wholly on these agreements.”
US citizens, for example, cannot rely on these types of agreements as the US does not have reciprocal healthcare agreements with any other countries. Its government does not provide citizens with healthcare, meaning that they do not have the services or facilities available to reciprocate healthcare. Therefore, even though travellers from the US make up the largest number of visitors to the top five most visited Caribbean nations, they would not receive healthcare for free, should they need it.
Holiday care quality
If a holidaymaker does fall ill while abroad, they and their insurer want and expect the healthcare treatment they receive to be of a certain standard.
The US is generally avoided due to high cost. Medical care here often exceeds the cost of the air ambulance
In the most visited islands – Dominican Republic, Puerto Rico, Jamaica, Bahamas and Aruba – the healthcare quality differs and the advice given changes. Banks confirmed this: “Despite the Caribbean often being referred to collectively, travellers should note there are quite a few different countries located within the area, all of which have differing medical capabilities,” he said.
The UK Foreign, Commonwealth and Development Office (FCDO) publishes objective, updated information and travel advice for UK travellers, based on local knowledge from embassies, local authorities and, in some cases, intelligence agencies. It reports that in the Dominican Republic, public medical facilities are ‘generally limited’, but private hospitals ‘offer good standards of care, although they can be expensive’.
Banks said: “Within the Dominican Republic, medical care is adequate in Santo Domingo, but limited outside of major urban centres, where the quality of care varies widely among facilities. Medical complications in rural areas may require medical evacuation to the capital and life-threatening conditions abroad.”
The FCDO also warns that travellers should have adequate travel insurance, as well as any additional funds to cover any medical treatment or repatriation, as in some cases, ‘if visitors are not able to pay their hospital bills, they have been prevented from leaving the country until the debt is settled’.
As Puerto Rico is a US territory, travel advice from the FCDO is more favourable, due to the quality of healthcare in the mainland. Banks agreed: “Puerto Rico has one of the best healthcare systems in the Caribbean, with quality medical care available in the capital San Juan and across the island.”
In Jamaica, healthcare quality ‘can vary ... and may not meet UK standards’, and ‘getting access to medications can be challenging’, according to the FCDO. “Medical facilities in Jamaica are adequate in all tourist areas and in Kingston,” explained Banks. “Medical care and hospitals are limited in remote areas, with smaller public hospitals or clinics located in each parish.” If you need medical treatment there, the FCDO advises that it can be expensive, and doctors and hospitals often expect immediate cash payment for health services. He also warned that ‘serious medical emergencies will require evacuation due to lack of equipment’.
In the Bahamas, medical treatment is said to be of a ‘good standard’ but can be expensive. Emergency medical facilities are limited on the Family Islands (the smaller, sparsely populated islands), states the FCDO, and serious cases will be transferred to the capital Nassau, Freeport or Miami, via air ambulance. Banks agreed: “Medical facilities in the Bahamas are generally limited to major urban centres including Nassau and Freeport and are not equipped to handle many emergencies; serious conditions will likely require medical evacuation,” he said.
In terms of Aruba’s healthcare quality, Banks explained: “While Aruba is a very small island, medical care is good throughout. However, serious medical emergencies will require evacuation to Puerto Rico or the US.”
The unexpected connecting flight
Sometimes the quality of healthcare offered in situ may not be up to the standard that an insurer expects for its customers and in which case, the option of evacuation could be explored.
Carter Roberson, Medical Network Support Specialist at AXA Partners US, explained that evacuations would take place ‘when a patient presents with a medical condition that cannot be improved by local care in the region’. He added: “Evacuations can also occur during political unrest and natural disasters.”
Chief Commercial Officer of Helidosa Aviation Group, based in the Dominican Republic, Sergio Abril clarified the factors that are considered before evacuating patients. “The priority or main justification to approve and execute the transport will usually define the destination during the assessment: the level of care; proper equipment; where the patient is ‘in network’; and how cost can be contained,” he said.
Another nearby destination with a higher quality of healthcare can offer a solution. The proximity of the Caribbean to the US makes it seem like an obvious choice. However, for the quality of US healthcare, a large amount of money is needed to pay for it, which some insurers might not be willing to spend. Roberson concurred: “The US is generally avoided due to high cost. Medical care here often exceeds the cost of the air ambulance. Patients, families and clients occasionally prefer ‘international’ treatment in San Juan or Colombia.”
Evacuation back home can be an option too. Abril added that this could be advantageous to the patient on a personal level. “Needing to be hospitalised is always a difficult experience for anyone, but having to be hospitalised while travelling adds an element of complexity that creates additional pressure on how it is experienced by the patient and their loved ones,” he explained. “By getting them either closer to family, their home or a higher level of care is always a benefit in how they experience the event and how quickly they recover from it.” This is not a common occurrence though, as Roberson qualified: “Occasionally it makes sense to take the patient home, but that’s at the jurisdiction of the insurer as repatriations home generally aren’t medically necessary as it falls outside of nearest facility of excellence criteria.”
However, there is one key disadvantage to evacuation: the cost. “Air ambulance evacuation is very expensive,” said Roberson. “[It is] traditionally used as a last resort for emergent or urgent cases.”
With revenge travel at the forefront of people’s minds after the pandemic, it is essential that suitable healthcare is available to travellers, especially in destinations where tourism is vital to the economy like Caribbean nations. However, it is clear to see that quality can vary a lot throughout the Caribbean, so insurers must be careful when formulating agreements and building networks, whilst also mitigating the costs. They still need to ensure that the quality they expect for their customers is provided, and that alternatives, like evacuation, are available should it change. Because, after all, patient care comes first.