What is wellness? And what is the role of health care providers?

This short article is part of the What is Wellness? Expat Family Wellness Survey 2018, in which we spoke to 32 families living around the world to explore what ‘wellness’ means to expats.

What should the role of health care and health care systems play in expat family wellness? And what are the barriers to accessing it around the world?  

Health care is recognised as being one of the most important aspects of life overseas but is typically not adequately researched or planned for in advance. Many of the families that we spoke to said that they had preconceptions or expectations about the quality of health care in their new country, but that these were not based on anything concrete. People’s basis for comparison will always be what they’re used to, what they have grown up with at home. People often seek a second opinion from their home country even when their home country's health care system is not considered particularly sophisticated.

Health care is unquestionably a challenge for some and a potential concern for everyone. Few families found the need to use health care systems in their new country for anything serious but their experiences of more straightforward primary care (general doctor consultations) don’t necessarily reassure:

“We’ve only had to use the doctors on a few occasions and not for anything major, but if it did come to something serious then I’d be pretty worried. I should try not to think about it.” — Anonymous in Mexico

Health care systems can be a challenge for those whose first language is not the native language as it makes them harder to navigate. It can create doubt in the patient if they do not fully understand the medical professional:

“I don’t know what I’ve been given to take for my back pain. It’s twice as hard because I’m not a medical expert and I don’t speak good Chinese or English. Is it safe if I don’t know the medicine?” — Cherry (Filipino in Hong Kong)

Health care issues our families encountered:

• Cost
  In some destinations (including Hong Kong, Dubai and Canada) the cost of using the health care system — including prescriptions, visits to the GP or visits to the hospital — is very high. Additional costs of insured procedures can also be significant¹.
• Access to medicine
  Not having access to medicines people are used to in the home country. This is an issue for prescribed medicines but also over-the-counter medicines from pharmacies with a combination of unfamiliarity and language barrier.
• Information
  The process of having to find where to go, who to visit and where to get medicine is stressful when set amongst everything else that needs to be dealt with and sorted when first arriving in a new country.
• Insurance
  Having adequate insurance as a newcomer to the country before you are registered as a citizen is important, but is a worry and a cost. A few people mentioned that travel insurance wasn’t enough but PMI is too expensive when all they need is ‘temporary cover’.

“Though not top-of-mind until it’s needed, health care access and options are critical components of health and wellness, especially when things go wrong.”
Source: Wellness Culture Today, The Hartman Group

Public health care

The quality of public health services is typically assumed to be in line with the infrastructure, wealth and development of the country in general. Those who had looked into public provision (quality of hospitals, access to primary care etc.) were the exception, and even they had based their view entirely on online searches.

“We did look at the web to see what support was given to foreign workers but it wasn’t clear and we wouldn’t have come here (Dubai) without insurance anyway.”  — Anonymous

Parents didn’t really expect to need to use health care, other than for minor, short-term problems, so there is less focus on this aspect of expat life than other areas such as housing, finances and administration — which are all seen as necessities.

“Health is obviously first priority for you, but health care is a bit of a sideshow because it’s an ‘if it happens’ not a ‘when it happens’ thing, not like those other things (housing, schools).”

Best health care systems in the world
Source: USNews.com

1. Denmark
2. Sweden
3. Canada
4. UK
5. Germany
6. Netherlands
7. Australia
8. France
9. Austria
10. New Zealand

Families and children

In general, families are much more focused on children in terms of physical health issues and their views on the quality of the health systems and health professionals is often defined by the way they manage their children’s problems:

“I don’t think I’ve had to use the system in the time we’ve been here, but we’ve had to with the children and that’s always been fine. That’s often the way, it’s children and older people who need to see doctors.”  — Sharma (Nepalese in India)

“If it was just me it would be very different, in lots of ways and you’d take more chances, but when you’re in a less familiar place with your children it all changes. I’ve travelled before and when I was on my own and I’d stay anywhere, go anywhere… insurance wouldn’t come into it.”  — Anonymous in Mexico

Health insurance

Some of the families used private health insurance to side-step the issue of unknown or low-quality health care systems but didn’t see it as a complete health solution:

“The best insurance can’t provide better hospitals or clinics. If there aren’t enough medicines, there aren’t enough medicines — private health doesn’t change that.” — Vogt (Germans in Mexico)

The quality of health systems in the countries we researched varied enormously, but there were generally consistent views from those within a country:

Dubai

Our families said that health care systems in Dubai were good but very expensive and that insurance is a requirement. They said access to facilities (and the number of facilities) is very good and care for women and children is seen to be a priority, but the actual quality of doctors isn’t as good as other countries:

“As a local, if you don’t have insurance you’re doomed.”  — Waqas (Pakistani in Dubai)

“We’ve found that we’ve actually been ill less often since we’ve been here – fewer viruses or other infections, but I get the sense that it’s a good place to be ill!”  — Anonymous

“It’s a painless process… in an emergency the response time was very quick but the best doctors aren’t always available here and it makes sense to get a second opinion.”  — Kumarswamy family (Indians in Dubai)

Health care for employees

The majority of people that have private medical insurance through their employer said that they were happy with the level of cover and don’t supplement it with a personal plan:

“The health care system in Hong Kong is very good for anyone with a visa/ID card. It’s not always too expensive for private health care or use of the public system. The doctors here are trained in English-speaking countries and it’s the doctors that give out the medicines rather than pharmacies.”  — Kirwan (Australians in Hong Kong)

It would have cost the Shiroi family $20,000 to have a single baby in Hong Kong let alone two! So, they used the public system which suited them well — which is a blessing as they had twins!

“The doctor recommended to us that we go to a public provider because it is the same high-quality level of care you would receive from going private.”  — Shiroi (Brits in Hong Kong)

The role of insurers

Many traditional insurance companies are increasingly repositioning themselves as health care providers: covering a range of ongoing health and wellness products and services, rather than simply covering the cost of treatments. But how do expats and insurance users view insurers?

Almost all of our families feel that health insurers are important and a positive part the jigsaw when moving away, but very few see them as part of a support network that goes beyond the core provision of payment for a claim: health insurers do not play a specific role in family life other than to be there should the worst happen.

People purchase health insurance for peace of mind more than anything else — and they’d prefer not to have to use it.

“My insurance company is good, they pay when I claim and that’s really all I need. I wish we didn’t have to go through all the paperwork though: paying up-front and having to claim back. — Leung (Hong Kongers in Singapore)

Most families found it difficult to come up with other ways in which an insurer could help be a part of their lives more regularly — it’s not something they have ever really experienced. We did note however, that people are more likely to talk positively about their employer if they have provided iPMI.

Click on the links below to read what our families said about various topics:

• Introduction and conclusions
• Wellness while living away from home
• Expat mental health
• Physical health, diet and exercise
• Expat health care 
• Personal security and safety

Click here to view the full What is Wellness? Expat Family Wellness Survey 2018.

This short article is part of the What Is Wellness? Expat Family Wellness Survey 2018, in which we spoke to 32 families living around the world to explore what ‘wellness’ means to expats. Each family was from a different country and, in some cases, the family includes parents from different countries. As part of this study, we asked them to describe their experiences of the health care in their new host nation. We wanted to see how people from different places viewed a certain nation’s health care: did everyone feel the same, or do people have different views — and does this depend on where they’re from?

Health care in Hong Kong

Our families explained that overall, Hong Kong has a very good system which is easy to access but the quality of hospitals can vary. The public system is reasonably easy to use and there are relatively small charges for using the system:

“Even though you pay $5 to register to use the system and $10 per night if you have to stay, the fact that you are paying towards your care makes the care you get better. We had a friend that hit her head very badly. Within minutes she had an MRI. While we were in France we had to sit in A&E for four hours before even being seen.” said Brits Georgina and Nick Shiroi.

Health insurance isn’t mandatory in Hong Kong but our respondents felt that it would be very expensive to go without:

“We have been lucky because everything has been provided for us through insurance.” — Cherry (Filipino in Hong Kong)

The Leung family (Hong Kongers in Singapore) found that the cost of maternity care was extremely high in Hong Kong but wasn’t covered by their particular health insurance policy:

“The maternity and childbirth wasn’t included and that was an issue — it’s much more expensive than in Singapore. Other than that we’ve found that the medical insurance has been great and we’ve had no issues”

Health care in Spain

The health service in Spain was widely reported as being “basic, but efficient”. There weren’t usually long waits to be seen and the administrative side of the system is straightforward. Downsides were felt to be the availability of more specialist services and the fact that some medicines and treatments are only available privately.

We heard that doctors are too quick to prescribe medicine, even when it doesn’t seem appropriate or for issues that will resolve over time without medication:

“We’ve got insurance and we can go private, but sometimes I think you get better treatment in the public (system) — it really works.”  — Zamuraev (Russians in Spain)

“I wish there was more time to assess the real issues but I think the doctors just want to get it sorted so they give you antibiotics when really all that’s needed is a painkiller.”  — Anonymous

Health care in Mexico

We received very mixed views on the Mexican system. Some people said the system was flawed and slow but there was also praise for the ‘human’ side of the medical staff.

“I’ve become much more health-conscious since living here because I absolutely don’t want to get seriously ill in Mexico. There’s not enough medicine and we had a lot of trouble findings vaccinations anywhere. Being in the private system with health insurance makes a major difference. Something that can take months to be sorted in the public system can be sorted for the next day.” – Astacio (Canadians in Mexico)

“Mexico is an absolute nightmare, you’re more likely to get ill from visiting the hospital than you were before you went. It’s so bad that a lot of people self-medicate: they check online and see if they can source those medicines themselves. You even have to take your own blood.” — Anonymous

For Americans living in Mexico, the pay-as-you go service is looked upon favourably because it costs less than the amount paid in co-payments for health insurance in U.S. However, for non-Americans it is felt to be very expensive.

Health care in India

There are mixed reports on the health care system in India. This is reflected in other reports that highlight big differences between hospital quality – especially urban versus rural. Responses often depended on where the family were from – those from similarly developing countries viewing it more favourably than those from countries with more sophisticated health care systems.

Coming from Nepal, the Sharma family said: “The healthcare system in India seems to work well. It’s better than Nepal at least.  It’s fairly easy to access and the quality of care is good.”

And the Indian Kumaswarmy family in Dubai said that “if I had an emergency, I’d be happier returning to India for treatment than having it here in Dubai. The best doctors aren’t available here so I would want second opinion from an Indian doctor.”

Many expats in India choose to access high-quality private services through their insurers.

“If you have the money you can survive in India. The poor struggle to get all the facilities in the hospital and if you pay you get the best among the rest.” — Boppuri family (Malaysians in India)

“That is why you end up consulting the chemist because the doctor process is so long.”

Expats in India are far more likely to have international private medical insurance (iPMI) and be aware of health costs than Indian citizens.
Source: Aetna Pioneering Change study 2016

Health care in Nigeria

As was reported on Nigeria’s infrastructure, health care is slow and inefficient when they work at all. It took a year for the American Godwin family to get a diabetes testing kit and some respondents said it’s hard to know who to trust.

And be prepared to pay for absolutely everything.

“They don’t even provide food or sheets for the bed, you need to bring this.”  — Godwin (Americans in Nigeria)

Some reported particularly bad service from doctors in saying they were more interested in making money than helping the patient:

“We went because one of the children had an allergic reaction and needed treatment. The doctor was appalling, not interested in us at all and only interested in presenting the bill.”  — Witter (Brits in Nigeria)

Nigeria is another country where problems in the health system and a lack of faith in medical staff, both in private and public systems, resulted in people self-diagnosing and self-medicating, often using the internet as the ‘trusted source’.

“You are your own doctor.”  — Godwin (Americans in Nigeria)

Health care in Singapore

It is compulsory to have insurance in Singapore and the fact that people have to pay is viewed positively by some. Health care quality is good and there are fewer waiting lists and queues.

The Sek family (Chinese in Singapore) has a child with a peanut allergy which was dealt with quickly and efficiently. “Collecting medicine is quick and easy, much better than the UK. The GPs aren’t reluctant to give out medicine.”

Not everyone sees readiness to give out medicine as positive. People would much rather be given advice on prevention rather than just cure. This can also lead to a lack of trust towards the doctors and result in people either self-medicating or researching symptoms online rather than going to the doctor.

Expats in Singapore are more likely to be aware of international private medical insurance (iPMI) and health costs than Singapore citizens.
Source: Aetna Pioneering Change study 2016

Health care in Canada

In Canada, it is normal for new residents to wait for at least three months before being covered by a Health Card, and everyone — including babies — needs their own Health Card. So it is important to arrange your own private health insurance in advance to see you through at least these initial three months.  The waiting period begins on the date that you establish your residence in Canada and ends after three calendar months

“You’re on edge for that initial period. I looked everywhere online and couldn’t find a suitable temporary health insurance to cover us.” — Lagnado (Brazilians in Canada)

The public health care system is looked on favorably amongst those that have used it. The Lagnado family likened the quality to the private system in Brazil (where they are from).

A more critical view of the Canadian system came from Angela (American in Canada), who had cause to use both physical and mental health services:

“It’s an abysmal system in Canada. They call it accessible but it isn’t and there aren’t enough doctors. You can only cover one issue at each visit so if you have a number of things to manage you have to come back again and again.”

If you’d like more information about health care in these or other countries, why not head to our Destination Guides section. With more than 16 national guides, each covers topics from health care to finding a house, from settling in to job hunting.

Conclusion

What follows is the summary and conclusions from the health care aspects of the What Is Wellness? Expat Family Wellness Survey 2017 — click to download the survey.

Our families recognised health care as one of the most important aspects of life overseas, but our conversations indicated that it was often inadequately researched or planned for in advance. Health care providers like Aetna International offer support from pre-trip planning to virtual health care which help families settle; giving peace of mind, offering on-going advice and support, as well as covering the cost of treatment. Why put something as important as access to the right care and support in the hands of a quick internet search?

Many people are cynical about insurers but describe wanting services such as those offered by companies like Aetna International: advice, country guides, virtual health care — both preventative care and condition management, pre-trip planning, on-going support, and mental health support. An ecosystem of health care such as this helps to keep people well, which in turn eases the burden on health and wellness resources, and keeps premiums in check. 

Click on the links below to read what our families said about various topics:

• Introduction and conclusions
• Wellness while living away from home
• Expat mental health
• Physical health, diet and exercise
• Expat health care 
• Personal security and safety

Download the ‘What is Wellness?’ Expat Family Health & Wellness Survey 2018

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