Medical tourism’s main challenge: Branding ‘Team Philippines’

Written by Miguel R. Camus

Wednesday, 25 March 2009 18:44

A UNIFIED marketing message, stronger public- and private-sector collaboration, infrastructure spending, as well as better data-collection efforts are needed to bring the country’s medical-tourism sector to the next level, according to leading hospital and government officials involved in this industry considered lagging behind competitors in the region. These, among other recommendations, were shared during Friday’s BusinessMirror forum, which brought together leaders from private health and tourism institutions, as well as officials from the Department of Tourism (DOT) and the Department of Health (DOH). “The Philippines is unlike other countries [where] there is a singular [marketing] approach to medical tourism. They all shout and sing one tune,” said Jun Amistoso, marketing and business development leader of Asian Hospital and Medical Center in Alabang. “At the moment, I would say that there is an institutionalized approach in medical tourism in as far as individuals—but not as a singular voice in medical tourism,” he added. Alma Jimenez, who heads the Philippine Association of Health Organizations in Medical Tourism (PhilAsHOMe) added: “You cannot play in this industry if you deliver fragmented service. We [need] to come up with a more unified product development, with the principle that hospitals need to unite and sell the Philippines [as a whole].” PhilAsHOMe is a private nonprofit organization that counts as members several top hospitals in Metro Manila. Meanwhile, Eva Trinidad, president of Philippine Medical Tourism Inc., a private company catering to medical tourists, said marketing efforts should highlight the Filipino’s own brand of hospitality alongside the country’s renowned medical excellence. Industry still growing fast DESPITE these challenges and the fact that the Philippines is a latecomer in this sector relative to its Asian neighbors, medical tourism in the country is considered an area of growth. DOT director Cynthia Lazo said overall tourism arrivals this year are expected to remain flat but, in contrast, the number of medical tourists is expected to grow. DOH Undersecretary Jade del Mundo expects medical-tourism revenues to increase this year, but did not provide figures. However, citing a 2007 report undertaken by the DOH, del Mundo said there were some 28,000 foreign-based visitors who sought medical treatment in the country and brought in over P1 billion in revenues. Hospitals, too, have been boosting their spending. Amistoso said Asian Hospital’s medical tourist patients represented under 5 percent of the business last year, but they expects this number to grow to at least 8 percent this year. He added that depending on 2009’s performance, the hospital is considering building expansion next year. Dr. Andre Villanueva, vice president of business operations and development at Makati Medical Center, said that since the hospital started counting medical tourists as a separate category, he noticed numbers accelerating in recent years. “Every day we have an average of four to five inquiries coming in, directly from abroad,” said Villanueva. In an earlier interview, Jose Ledesma, St. Luke’s Medical Center president, said the hospital has earmarked P500 million to P1 billion for improvements this year. Del Mundo said part of the expansion will stem from incentives provided by the DOH along with the Philippine Economic Zone Authority, which will allow the tax-free importation of diagnostic and therapeutic equipment. Government agencies are also credited with facilitating initial contact with the international community. Government needs to do more Some feel, however, that the government’s efforts are not enough and the problems are more fundamental. Amistoso said government support is “far from what we would have wanted it to be” particularly in the infrastructure and marketing components. For her part, Jimenez said medical tourism—as well as tourism, in general—will accelerate if the proper infrastructure like better roads and public facilities is made available. Jimenez added that better collaboration between the different government agencies and the private sector is the key to moving the industry forward. “If the government agencies [DOH, DOT and Department of Trade and Industry] work together and recognize their core competencies, we have a good chance of [succeeding] in the medical tourism market,” she said. Dearth of figures Jimenez noted that apart from the DOH’s 2007 report, there are no baseline figures to work with. This, she said, is part of the reason the government is unable to set industry targets as well due to the lack of historical data. Many hospitals, including some of the largest, have only begun to separate medical tourists under a different category—and, in some cases, as recent as last year. In addition, Angel Bognot, who chairs the National Association of Independent Travel Agencies, noted that it is difficult for them to track these individuals as well, since patients seeking treatment may not want this fact to be known to travel authorities; hence, many go unreported. PhilAsHOMe has pressed for the government to conduct a study this year to systematically document the medical-tourism industry, such as the country’s current level of exposure to the international community, and specific ways the Philippines can market itself to different countries. She noted, for instance, that they can have government campaigns targeting the United Kingdom for dental services or Japan for cancer treatments since there are opportunities in these countries. “It’s difficult for hospitals to craft a sensible marketing plan without marketing intelligence,” she said adding, that the government should point the industry in the right direction. Ground expectations While Jimenez noted small steps, particularly in successfully marketing under a single banner during the first World Medical Tourism Congress in San Francisco, California, in September 2008, she said the industry still has a long way to go. She said the local medical-tourism industry’s goal is to become a player in the export market, where visitors will be enticed to visit the country for treatment, spend their money and add value to the economy. “With just three years since we started this, we’re already achieved this much. How much more if we’re doing this as long as Thailand or India,” she said. “We’re not there yet, but we’re intending to get there.” N EXCERPTS: We’ve been looking at how things are developing very quickly since last quarter and we decided that we should start early with medical tourism because it’s one of the few bright areas. We would like to think that at least there are certain sectors, like medical tourism, which is quite upbeat. This forum is also timely because of the World Health Tourism Congress. This is the first time that a country in Asia-Pacific is going to host such a prestigious event so, is this a sign that global medical tourism is taking note of the Philippines’ attractiveness as a medical tourist destination? Are we finally catching up with all the others that have preceded us in the industry? Cynthia C. Lazo, director, Domestic Tourism Promotions, Department of Tourism: Maybe the word is not catching up. Well, the truth of the matter is that other countries have been there in the arena ahead of us. In all probability, we haven’t gotten the message across.... We’ve have had reinforcement of that message in our last Philippine Health and Wellness Summit last year in October in Sofitel, Philippine Plaza. If there is any indication that we are indeed in the global market, we could ask our stakeholders—the one beside me had already enunciated that he already had good contacts prior to the B-to-B [business to business] on March 26 and March 27. We have good contacts on buyers related to the global health-care solution that could be provided by the Philippines. How would you call the industry at this point? Is it thriving? What is the status of the industry here in the Philippines at the moment? Alma Rita D.R. Jimenez, president and chief operating officer, St. Frances Cabrini Medical Center, and president, Philippine Association of Health Organizations in Medical Tourism Inc.: Well, I think the DOH [Department of Health] undersecretary [Jade del Mundo] and the DOT [Department of Tourism] will agree with me that we actually don’t have a good system of reporting out patients. We sort of took it for granted that the Philippines is ready and available, and capable and competent to handle foreign patients. But as director Lazo had stated, it’s not really that we are latecomers; it’s just that we haven’t realized early on that this is a niche industry that we can probably play in terms of offering our services in the international market. So that the hospitals are aware of that possibility, we’ve started to come up with expansion programs and investments so that we can increase the capacity and capability of the hospitals, as well as make investments in the improvement in the quality of health care here also. As well as marketing investments, and for that, the public sector has been helping us a lot, specifically the DOH and the DOT and the Department of Trade and Industry [DTI], which has helped us in making initial contacts with the international market. It’s well-known that the hospital industry is a little bit closed. When I say closed [I mean that] we sort of operate like a village association. We just interact among ourselves and even that isn’t something that we do as a matter of routine. But knowing the possibilities of playing in a larger market like medical tourism and also recognizing the fact that you just can’t play in a market if you are delivering fragmented service, we’ve tried to come up with a more unified product development with the principle that the hospitals need to unite, go out there and sell the Philippines. Well, of course, you have to sell individual hospitals, but, first and foremost, you have to sell the country. Because if you go out there and keep repeating the message, eventually at the third hospital presentation, they will get tired already. But if you go out there and say, we are a complete package of services starting from this end to that and every hospital is capable of doing these and let each and every hospital highlight or showcase a niche service that they can do best, then we will have a chance in getting the attention of the market and the paradigm shift is—it shouldn’t matter which one of us gets the market because right now, we’re already profitable. It’s just icing on the cake if we get more. But we have to look beyond profitability or more revenues and ask what medical tourism can do, potentially, for our country. And for that, I keep on urging the other hospitals to do this as an act of patriotism. We go there, make investments and market because every tourist that we bring to the country, the value added to the economy is like for every $1, there’s 70 cents that’s spent for the economy. And can you imagine the many jobs that that can create in the country. So what we want to do is just unite, bring in the dollars here—it doesn’t matter if Andre [Villanueva of Makati Medical Center] gets all the market as long as we get the market. I think that’s the bottom line. So when we shifted to that mode of thinking, I think we’re trying to get to be more united now and coming up with a more cohesive marketing program that will allow us to position the Philippines in the marketplace, not just as a fragmented service provider, but as a united Philippines that can offer a lot in terms of health care. And we’re a natural for that market because this is the country where the medical professionals are coming from. Dr. Villanueva, Director Lazo says that even before the last wellness summit last October, you were getting a lot of positive messages from contacts abroad. Can you elaborate on these messages? What are these potential markets and what were they particularly interested in? Dr. Andre Villanueva, vice president for business operations and development, Makati Medical Center: Even before medical tourism was formalized by the DOT in 2006, at least for Makati Med, we have been servicing our own share of international clients. And the services we offer are known worldwide. It’s a brand already. But when medical tourism came into being, Makati Med, for one, became a formal member, or has been accredited by the DOT formally just early last year. So we are very new when it comes to medical tourism per se, the program per se. We really find this useful—this public-private partnership—we started joining the DOT conferences starting in February [or April or March] in Malaga, Spain, followed by one in San Francisco, which I personally joined and found it very productive and through that one involvement, we were able to create several contacts that has progressed through the months. To date, we were able to formalize agreements—at least with three to four contacts I’ve been able to make in San Francisco. But you just don’t close a deal at the time you meet up in San Francisco. As a matter of fact, the follow-through was in October when the same people I met in San Francisco came over, again, through the DOT. When you say contacts, what kind of contacts were these? Dr. Villanueva: Various, because when you talk of medical tourism congresses, you meet with various lines of businesses—HMOs, insurance companies, medical facilitators or intermediaries, third-party administrators and so on—and them knowing about the existence of the Philippines in terms of health care is very important. I’ve heard them say, like, we didn’t even know that you provide these services, we didn’t even know that such a facility exist in your country, because part of the October summit was a hospital tour and they for themselves saw the different facilities, hospitals, at least in Manila at that time. Now I think they might also be going to Cebu…. But to see is to really believe, so to speak. I should say, as what Alma was saying earlier, that we never really took down statistics with regard to medical-tourism patients coming in to, say, Makati Medical Center, before we really signed up for the program. So it’s only like this year that we really put it into our system how to segregate international patients. Because like we have a lot of embassy patients coming over or their families but we cannot count these as part of medical tourists, at least we don’t classify them as medical tourists. Because for us, when you talk of medical tourism—I don’t know if there are other definitions—there’s a travel-related aspect. People would travel across international borders to seek medical care, be it in conjunction with a vacation or to really come over for a heart bypass. So, what, for us, we would like to count would-be patients coming in from overseas. Maybe a Filipino in Qatar would come over—we would count that as medical tourist. But a client staying in Dasmariñas Village who is a son of an embassy official—we will not count him as a medical tourist but we will count him as part of our statistics for foreign clients. But not really under the medical tourism program. So when we started counting this, I should say, little by little, we are accumulating clients coming through the program. And maybe they don’t really come, but if you ask me, because we also have a web site and daily we have an average of five inquiries coming in directly from abroad, and not through any of the medical intermediaries that we have arrangements with at this time. So it’s picking up. Little by little we are making ourselves known, that the Philippines is a destination for health and wellness. Dr. Jade del Mundo, undersecretary, Department of Health, head of the DOH’s Office for Special Concerns: In January to December 2007, we gathered statistics from hospitals and clinics in mostly Metro Manila—and these hospitals are St. Luke’s Medical Center, Medical City, Asian Hospital, Makati Medical Center, Manila Doctor’s Hospital, Medical Center Manila, Capitol Medical Center, UST Hospital, St. Frances Cabrini Medical Center, Perpetual Succor Hospital, American Eye Center, Belo Medical Group, Calayan, A.T. Reyes Dermatology Center, Home Health Care, Philippine Heart Center, SELF Foundation, and others. There are only a few which didn’t submit and out of those which submitted, there were about a total of 28,124 clients. This is for January to December 2007. And most of those who came here were from North America. Actually what we did was we made a matrix and e-mailed all the hospitals to submit data based on this matrix. They were segregated as to foreigners, those who came here purposefully for medical treatment or surgical treatment and we did not include foreigners, expatriates who were here already, living in the Philippines who went to the hospital for emergency and other purposes. About 45 percent who came to the Philippines were from North America, that’s 12,692 in absolute numbers and Northeast Asia, about 6,843. From Micronesia, 3,269; from Europe, 2,161; South Asia, 1,015; and Australia and New Zealand, 947. So, out of these 28, 124 clients, we generated a total of P1.066 billion in revenues from these patients. From the geriatric and drug-rehab centers—because they also had foreign patients—they generated P1.854 million. Last year we have asked them to submit data and we’re waiting for the hospitals to submit these. This is contrary to what came out of the International Medical Tourism Journal. It was a very dismal figure for the Philippines, although we didn’t make a comment because that was based on 2008 partial figures. It came from the DOT, although I don’t think it came from Director Lazo. Is the local medical tourism industry targeting a certain amount in terms of revenues? Is there an ideal figure that we should be achieving? Del Mundo: We are expecting revenue close toward, I mean, increasing, 2009. But we don’t have a target; we don’t even project. Because last 2007, there was actually a study made by a certain group and this was corroborated by a consulting group that came to the Philippines and made some studies. The projection was $250 million. In 2007 alone, St. Luke’s alone had raw data, which showed that they generated some P6 billion. Is there any incentive program by the government to medical establishments under the medical tourism program? Tax breaks and the like, perhaps? Del Mundo: Yes, actually, we have a memorandum of agreement with the Philippine Economic Zone Authority (Peza) in which the DOH will be endorsing hospitals to avail themselves of income-tax holidays and duty-free importation of equipment as long as they are to be used for diagnostic and therapeutic purposes. So this alone, St. Luke’s has applied for duty-free importation and the technical evaluation committee in the DOH has evaluated such request for duty-free importation and we will soon submit to Peza and the Bureau of Customs the list of those we have approved. We also have guidelines in approval of these equipment, instruments, etc. They have submitted to us a shopping list and we have more or less approved—as long as these are used for diagnostic and therapeutic purposes. This is a big incentive for the hospitals. For the St. Frances Cabrini Medical Center, we have approved in 2007 their request for duty-free importation of a machine for cancer radiotherapy. What we did was to ask hospitals, which are partners in medical tourism to submit—as long as they have a DOH license and are accredited for endorsement to the Peza for these tax breaks. So we are encouraging the hospitals to do so. We are coming up with a web site, because we’ve found out in researches that 80 percent of successful deals or medical-tourism transactions with hospitals happen through the web.… And we will publish in the web site the data that will be important for foreigners to know, like data on the availability of state-of-the-art equipment, the services, the surgical success rate, the infection rate, etc., so that they will have a basis for engaging the hospital of their own choice. And we are also going to publish on this web site promotional materials for these hospitals free of charge. Joel Garcia, Director, Philippine Medical Tourism Inc.: We probably all see the industry as a growth industry. There’s one hospital in Thailand that had claimed in the past couple of years to have about 500,000 foreign hospitals. And this is just one hospital—Bumrungrad. I don’t know what it is now, given the political situation there. But you see the potential for this and alluding to what Alma mentioned earlier, in terms of marketing the Philippines as a whole, that includes the hospitals, the out-patient facilities, the medical facilitators, I think that is a must. Some of this, in terms of the growth, may be hampered by perception—I travel to the US quite often and I try to sell the Philippines, doesn’t even have to be medical [tourism], but people still have questions about their safety. All they hear in the news is what’s going on in Mindanao, but what they don’t hear enough about are the beautiful resorts, the facilities, the world-class doctors, many of whom are trained in the US and board-certified. So, in essence, we’re here, medical tourism is here, but definitely I think a lot more is expected of us and what Alma said earlier also in terms of getting all the fragmented pieces together. I think if there is a concerted marketing effort, a joint marketing effort, I think we can really make a go of this. Living and working in the US for many years, health care is not going to get any cheaper anytime soon, no matter if it’s an Obama administration or whoever comes after him. There is a growing number of uninsured Americans who have disposable income that cannot afford health insurance so they have to look elsewhere. I think right now, this year, presents a very opportune time for the Philippines, given what has happened in India and Thailand now, I think this is our year to capitalize. The fact that someone from Dubai is the event organizer of the World Health Tourism Congress that’s going to be held here in Manila, does that mean that the Middle Eastern countries are looking more keenly on the Philippines as an attractive medical-tourism destination? Angel Bognot, president, National Association of Independent Travel Agencies: We believe as the handler and a promoter of medical tourism, this will really put the Philippines on the world medical tourism map. And the kind of recognition we want will be finally there. The most important thing is the Philippines has been finally recognized. You know the organizer is really very serious, so the mere fact that they have granted the bid to us, that means the interest and the recognition for the Philippines as one of the best medical-tourism destination is there. What are your clients’ predominant impressions about the Philippines? Eva Trinidad, president, Philippine Medical Tourism Inc.: Immediately they say, “You are all so kind and you are all so hospitable.” Those are the first things I always hear them say. And when they leave, they come out with letters saying they really had a great time, that we’ve been very helpful and people were all kind to them. That includes the hotel where they stayed, the people who were servicing them at their hotel or the taxi driver who drove them and, hopefully, our taxi drivers will continue to be kind because one taxi driver who will steal from them or misbehave, that could really bring us down. Lazo: I think Eva just described the complete visitor experience that should be expected out of a destination that has already gotten its message across that this is the preferred health-and-wellness destination in this part of the world. And nothing can replace the complete visitor experience because when they get back to their own home countries, they will echo this to some of their associates, their families, friends, relatives. By the way, our records show that we do have repeat visitors and this is coming from testimonials of those who have already come to the Philippines. I believe that that should be the message that should be put across. And talking of marketing, we’ve already created our national brand, and the best reinforcement about this is also coming from those who attended the last Philippine Health and Wellness Summit, the international buyers, key experts who shared anything and everything about the topics under global health and wellness say about the Philippines that we have world-class medical expertise familiar with global technologies. And as Eva earlier said, the care and compassion, happiness and culture sensitivity of the Filipino, our proficiency in English, our emphasis on the patient’s safety and quality health care give our brand of medical tourism a big boost. And also our traditional and indigenous health practices and medicinal plants that abound here in the country make us capable of not only focusing on medical tourism but also the wellness component, which includes alternative medicine. The buyers and international speakers also, some of them reinforced that manifest in the Philippines are the following: the bio-regenerative medicine and protection medicine, cosmetics and longevity medicine and wellness revolution that we have picked up—it’s wellness in body, mind and spirit. And that what we have reiterated and echoed is that it’s time for the Philippines to dialogue across the seas, to bring this message across. And here we also have acquired the shifting paradigm of medicine and continuously the language of medical-tourism industry is being shaped and we are also onboard on this. What we also would like to emphasize is that there’s a potential for us to focus on continuing health care. Meaning to say that once we discharge the medical tourists here in the Philippines and they are back to their own home countries, that it is also possible for us to be able to take care of them while they’re there because of the potential partnerships and tie-ups that we could do with the countries from where these medical patients have come from. Trinidad: There is such a thing as postcare after they’ve gone back to their own country. They have continuing medical requirements that are normally included in the package even before they come. So that you can ensure that they are taken cared of, whether it is another doctor or their own personal doctors. Jimenez: I think the main concern of everyone here is what are the prospects for growth for the industry. Already, we have seen certain service providers spawned as a result of the initiative. We are now looking at certain segments that are coming up as part of the continuum of service providers in the industry. The medical intermediaries, for instance, are seeking to bridge the gap between the medical care being discharged by the hospitals and the tourism side of it and the hand-holding. Eva has adequately explained that. Somebody has got to pick up the patient from the airport and deliver them to the hospital. Somebody’s got to explain the culture and methodologies—and sometimes, that’s something that we can’t do in the hospital. Really, the medical intermediaries and the travel operators, they make life easier for us because that’s not our core competence. As we look at a growing medical-tourism market, we look at other industries that hopefully will also come up. For example, if you go to a certain place and the family is there, we are also looking already at the possibility of putting up industries other than hotels, like condotels which are very much in demand among the patients because they want a place where they can cook because they’re going to be staying here for some time. So, what is really the context of growth in the industry? I think you will have to look at it from a bigger picture of global medicine. If you want to put it this way, it’s actually business-process outsourcing (BPO). It’s saying that if I cannot do it cheaply in my country, what’s to stop me from outsourcing the service to somebody else. So in that respect, we know that it is a growth sector. But at the same time, we also said in our San Francisco congress that it is a choice. When we say it is a choice, we call the dismantling of buyers across nations when it comes to health. Because health care, supposedly, is a universal language. When you want alleviation of pain and you feel pain, it’s a natural human mechanism to seek for comfort and aid. And the country buyers should be seamless, it should be universal—that is the language of health care. Eventually, we look at countries specifying on certain niche markets. In fact, the discussion among us has gone beyond the issue of how do we position ourselves in the market, how do we look at the seamless process of integrating the patients with the service? We are already looking at the bigger picture, which is what is it that we can do very well where no other country can really step in. We’re looking at the discipline of taking in market intelligence and that is where we think the government should be helping us so that we can identify what should be the niche service that the Philippines could be good at. If it’s going to be cardiovascular surgery, like India’s already taken that niche market—so what’s left for the country? That means we should do a country-by-country study so that we will know what is it that the other countries are seeking from other countries that we can potentially offer as a nation. And then get the providers in the market to be very good, even excellent in that field. And by then, we can say like dental surgeries for instance, you can do it in the Philippines. And everybody’s capable of doing dental surgery. Why is that an imperative for us? Because to make huge investments in health care you really have to have a lot of resources. But if you can just niche on a certain market and then be very good at that, it streamlines everything. So even in health care that has to happen. And we look at the future of global medicine as something like that. It will happen. Eventually, countries will have to specialize on something because right now, if you look at country-to-country presentation, we all present the same thing. Thailand will say they do cardiovascular services, they do reconstructive surgery and India, Singapore, the US, Costa Rica and Uruguay, even the Ukraine will all say the same thing, everybody’s doing it. So if I’m the patient, how do I now choose from all these provider countries, where do I go? So at some point in time, the countries will also get wise. It will look for a niche. I’m looking at maybe 10 to 20 years down the road where every country will be specializing on something and if you, say, want dental surgery, you just go to one certain country. And all of the providers, they will feature that service. So that has to be looked at as if it’s a BPO business. It’s outsourcing the health-care system of other countries into other countries that are capable of doing that cheaper, with better or comparable quality and that, in turn, should redound to the benefit of the locals here. I think one of the major debates in the earlier stages of medical tourism was how right would that be for local Filipinos who don’t always have decent access to health care. And we always say that you go there because at one point in time, it’s a Robin Hood thing. We’re not saying that we’re going to charge Juan de la Cruz the same as Uncle Sam. We will probably charge Uncle Sam higher, but hopefully that difference between what we charge Uncle Sam and our regular rates can go the health care of other Filipinos. That will make us contain our goals, that is, keep our prices for the local market and eventually for us to be able to provide better access and equity and health care for all the patients that we service. What is the one thing that the Philippines can offer which no other country, likewise, involved in medical tourism can? Or not as well as the country can? Trinidad: I think, right off the bat, I would say, I wouldn’t know how to package but we should really let everybody know the kind of care we do in the Philippines. Our nurses are universally known as very caring people. I mean, they’re not plastic—when they take care of you, it’s from the heart. So I don’t know. DOT, I think, is trying to package on how we take care of the patients. It’s really something if we can put that across as our best asset. It this global financial crisis going to affect the number of people coming over for medical tourism purposes? Trinidad: I look at that as an opportunity. Take the US. Health-care cost there will just go up and up. They’re not going to fix that mess of a health-care system there anytime soon even if President Obama says, I’m looking at this. It will take a long time. In the meantime, people get sick. And they have to go somewhere. And if we’re ready to receive them, then good for us. Jimenez: Do you know that the biggest market of Thailand and Malaysia is actually neighboring Asian countries? I’m telling the association that we should actually look at our neighbors also. Indonesia, for instance. Why couldn’t we market to Indonesia? They don’t have decent hospitals. They go to Malaysia or Singapore. Vietnam has grown by leaps and bounds. They have already overtaken us in terms of growth rate. And yet their nationals go to Singapore or Malaysia for health care. Why do we set our sights so far away when we have so many neighboring countries with no decent health-care system? So these are markets that we can fruitfully explore, just ripe for the picking. All we have to do is to make sure that we can interface with them and see how the market will open up for us. And besides, Asians feel more comfortable going to another Asian country. In fact, it sounds like a hard sell when you’re talking about Europe or other countries. So I think this crisis creates an opportunity not in terms of the influx of patients coming to the Philippines but it will force us to consider other markets than the US.