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N T I S201016) Health ServicesBackgroundThere is no doubt that international trade in health services will gain importance in the future. With ageingpopulations in rich countries and steadily increasing health care costs, more and more people are seeking healthcare services abroad. Several countries, for example Thailand or India, are already attracting large numbers offoreign patients. Whether this will become a significant export sector for Nepal remains a question.As other services, trade in health services can occur in different forms: Mode 1: cross-border (e.g. telemedicine, laboratory services) Mode 2: consumption abroad (e.g. patients travel to another country for treatment) Mode 3: commercial presence (e.g. foreign company opens a hospital), and Mode 4: presence of natural persons (e.g. doctor travels abroad to treat patients).Most of these modes occur in Nepal, and some of them as both export and import. There is ‘consumptionabroad’ (mode 2) between Nepal and India, with Nepalese seeking treatment in India and vice versa. Manytourists are receiving treatment in Nepal, though they usually do not travel to Nepal for that purpose. SomeIndian health providers have opened hospitals in Nepal (mode 3), with some Indian doctors and nursesworking in these hospitals (mode 4). These hospitals are usually linked to medical colleges. There are also alarge number of Nepalese doctors and nurses who are working abroad. However, we will not focus on thelatter aspect of health services export.Despite numerous problems in the healthcare sector, Nepal has at least two significant advantages: a traditionof Ayurvedic medicine and a moderate climate. The climate makes it very suitable for Indian medical collegesto open branches in Nepal.The Three-year Interim Plan (TYIP) of Nepal recognizes the potential for health service trade and incorporatesstrategies like establishing, promoting, and expanding telemedicine, developing and expanding Ayurvedic andother alternative health service systems, providing computers and internet access to facilitate telemedicine,collecting information regarding herbs and intellectual property, and enhancing research activities. However,no concrete strategies have been delineated for mode-specific supply of this service.Information on trade in health services is scarce. There are no reliable statistics and, therefore, our assessmentrelies mainly on the information obtained on the ground. One study was undertaken in 2008 to assess thepotential for health services export (SAWTEE, 2008).Index 1: Export PerformanceExport Value: No reliable statistics exist for the export value of health services. The NRB data seems togrossly undervalue even the assumingly existing low health services export (SAWTEE 2008). SAWTEE (2008)undertook a survey in several institutions that receive foreign patients (all of them being from India and oftenwith family links to Nepal). An estimate of export value was only given for one institution, Birat NursingHome (US$22,000 annual income). Scattered information collected during the fieldwork from several otherinstitutions suggests very low export values as well (see below for more details). Data for some of the leadinghospitals, which may also treat foreign tourists, are not available. 112112For example Norvic International Hospital.NEPAL TRADE INTEGRATION STRATEGY 2010BACKGROUND REPORT105
N T I S2010Current Export Destinations: Most of the trade in health services occurs with India, and as both export andimports. In fact, all foreign patients in several healthcare institutions identified in the SAWTEE study (2008)were from India. According to industry sources that ITC spoke to, there are occasionally patients seekingtreatment in gynaecology, obstetrics and eye health services from other countries, including Tibet (China),Afghanistan, the Maldives, Germany, and NRN. The other major part is treatment of tourists, mainly fromdeveloped countries (EU, USA, Japan).Trade Balance: If one includes Nepalese medical workers abroad, then Nepal is probably a net exporter ofmedical services. No reliable data exist on the value of ‘mode 2’ imports from India. Nepal is also importinghealth services through ‘mode 3’. Indian medical schools and teaching hospitals affiliated to them areproviding medical services. Staff consist of both Nepalese and Indian doctors and nurses, but practically allpatients are Nepalese.Export Prospect: We rate the prospect for health services export as rather poor. Nepal does not have adeveloped healthcare sector that can provide services according to international standards, except may bein a few institutions. The existing trade is mainly local trade across the border, where Indians living relativelyclose to the border and often with personal links to Nepal seek treatment in Nepalese health institutions.Other foreigners receiving treatment in Nepal are usually tourists or expatriates who do not come to Nepal formedical purposes. Ayurvedic medicine could be a niche in which Nepal can become more successful. But theavailable information is too scarce to make any definite judgment on the export potential. A more detailedstudy by health sector exports, possibly along Lautier’s 2008 study of Tunisia, would have to be undertakento properly assess the potential. Whether such exports are desirable is another question that needs to becarefully evaluated (see below).Index 2: World Market ConditionsGlobal Trade in Health Services: Health services, like most other services, are still mainly ‘produced’ and‘consumed’ locally. But there has been a strong upward trend in international trade in healthcare. Somecountries report these trade flows in their BoP statistics, but unfortunately some of the new emergingexporters of healthcare services, including Thailand, Singapore, India, and Malaysia, do not. Therefore, usingBoP statistics would give us a fairly incomplete picture of the global market. Lautier (2008), in a paper thatassesses the Tunisian potential for health exports, provides an overview of the global market by combiningofficial statistics and estimates, resulting in an estimated size of the global trade of US$11.8 billion for 2003and annual growth rate of 15 per cent. If we assume a 10 per cent annual growth rate for the following years,then the 2008 size of the global market would have reached US$19 billion. 113The US has an estimated market share of 27 per cent, but some developing countries are emerging as majorplayers in global health trade. Data from Thailand show that 1 million foreign patients were treated in 2004,resulting in export revenue of US$500 million. India received 150,000 medical tourists in 2005 (WHO, 2008),including from developed countries such as the USA and the UK, apart from countries around the region.Index 3: Domestic Supply ConditionsMedical Services in Nepal: Health services in Nepal are being provided by four sectors, namely the government,community (called health cooperatives), NGOs, and private sector. Export of health services is being carriedout by NGOs (i.e. Tilganga Eye Hospital) and private health sectors (hospitals and nursing homes). Ayurvedic113Recorded trade flows based on BoP statistics have grown by 10 per cent annually between 2003 and 2007 (Source: TradeMap, based on IMFdata).106NEPAL TRADE INTEGRATION STRATEGY 2010BACKGROUND REPORT
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Nepal Trade Integration Strategy 20
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Table of ContentsForewordAbbreviati
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Table 2.17 Acreage and Production o
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List of BoxesBox 2.1 A Nepalese IT
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LoD Limit of DetectionM&E Monitorin
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Chapter 1Trading Environment, Expor
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N T I S20101.3 Capacity Development
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N T I S2010Table 1.1Balance of Paym
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N T I S2010Changes in the Nepalese
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N T I S20101.5 Expanding an ‘Incl
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N T I S2010 Index 4 measures the po
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N T I S2010Table 1.9Impact of 19 Ex
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N T I S2010Table 1.10Geographical D
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N T I S20101.7 Declining Importance
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N T I S2010negotiate for the inclus
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N T I S2010Types of Exported Produc
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N T I S2010Table 2.2Large Cardamom:
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N T I S2010Index 4: Socio-economic
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N T I S2010Index 1: Export Performa
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N T I S2010exporters. Nepal permits
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N T I S2010RankCountryExports Nepal
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N T I S2010like China and Australia
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N T I S2010The opportunities for pr
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N T I S2010Lentils are subject to o
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N T I S2010Production Capacity: Nat
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N T I S2010Gender Impact: This sect
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N T I S2010Export Prospect: Accordi
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N T I S2010Cost and Quality of Infr
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N T I S2010Attractive markets for T
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N T I S2010Market Access Conditions
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Page 70 and 71: N T I S2010Information from industr
Page 72 and 73: N T I S2010Cost and Quality of Infr
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Page 76 and 77: N T I S2010# Botanical Name 41 Spec
Page 78 and 79: N T I S2010Current Export Destinati
Page 80 and 81: N T I S2010significant attention fr
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Page 84 and 85: N T I S2010Availability and Quality
Page 86 and 87: N T I S2010Attractive Markets for S
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Page 92 and 93: N T I S201012345678910# Name of Ste
Page 94 and 95: N T I S2010Export Prospect: Accordi
Page 96 and 97: N T I S2010Gender Impact: Female wo
Page 98 and 99: N T I S2010The value added of those
Page 100 and 101: N T I S2010sheep population, which
Page 102 and 103: N T I S201013) TourismBackgroundTou
Page 104 and 105: N T I S2010Index 2: World Market Co
Page 106 and 107: N T I S2010There are also about 24
Page 108 and 109: N T I S2010Index 1: Export Performa
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Page 112 and 113: N T I S2010Contribution to Skill De
Page 114 and 115: N T I S2010Types of Exported Servic
Page 116 and 117: N T I S2010Cost and Quality of Infr
Page 120 and 121: N T I S2010medical services are bei
Page 122 and 123: N T I S201017) Education ServicesBa
Page 124 and 125: N T I S2010should be interpreted ca
Page 126 and 127: N T I S2010foreign students. The me
Page 128 and 129: N T I S2010Under mode 4 (presence o
Page 130 and 131: N T I S2010Index 4: Socio-economic
Page 132 and 133: N T I S2010generate revenue of US$3
Page 134 and 135: N T I S2010monopsony power. Several
Page 136 and 137: N T I S2010The possibility of direc
Page 138 and 139: N T I S2010Dairy Products, specific
Page 140 and 141: Chapter 3Access to the Indian Marke
Page 142 and 143: N T I S2010The Nepal-India Trade Tr
Page 144 and 145: N T I S2010Most issues reported abo
Page 146 and 147: N T I S2010Nepalese Domestic Issues
Page 148 and 149: N T I S2010India’s view is that t
Page 150 and 151: Chapter 4Access to the Chinese Mark
Page 152 and 153: N T I S2010products must be wholly
Page 154 and 155: N T I S2010The findings discussed h
Page 156 and 157: N T I S20104.5 Other Impediments to
Page 158: N T I S20104.7 Recommendations: Cha
Page 161 and 162: N T I S2010inflow between 2000 and
Page 163 and 164: N T I S2010Industrial Parks and SEZ
Page 165 and 166: N T I S2010Lack of up-to-date polic
Page 167 and 168: N T I S2010Apart from the critical
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N T I S2010capabilities in all five
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N T I S20105.5. Combining Investmen
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Chapter 6Trade FacilitationN T I S2
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N T I S2010In the 2005 Trade Facili
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N T I S2010The latest phase of impl
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N T I S2010improve efficiency. Few
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N T I S2010Figure 7.1Future Organog
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N T I S2010EU countries, special pr
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N T I S2010Act 1980. So far, 130 fi
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N T I S2010The current projects inc
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N T I S2010The NBSM as a secretaria
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N T I S2010Many more organizations
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N T I S2010Table 7.8Existing Nepal
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Table 7.9Standards Issues for Ten E
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N T I S20107.14 Priority Actions an
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N T I S2010It is not clear what amo
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N T I S2010GeneralNepal’s general
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N T I S2010a crucial part of the PR
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N T I S2010residue limits (MRLs) ar
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N T I S2010The viral diseases chirk
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N T I S2010SPS issues Affecting Tra
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N T I S2010Indian phytosanitary sta
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N T I S20108.5 Conclusions and Reco
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N T I S2010Simpler requirements suc
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Table 8.4Summary of Export Environm
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N T I S2010To register a patent, a
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N T I S2010breaches of law. The Nep
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N T I S2010Intellectual Property is
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Chapter 10Barriers to Service Trade
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N T I S2010Constraints in the touri
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N T I S2010Table 10.2Nepal GATS Com
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N T I S2010locations favourable for
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N T I S2010Barriers to Exports of H
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N T I S2010Institutional IssueThe s
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N T I S2010 Strengthening sub-natio
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N T I S2010Observations from enterp
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N T I S2010Nepal Ginger Producers a
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N T I S2010 Helping paper manufactu
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N T I S2010Computer Association of
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N T I S20105. Also related to the a
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N T I S2010The key principles inclu
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N T I S2010That being said, Nepal h
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N T I S2010Nepal Business ForumOn M
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N T I S2010Third, capacity developm
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N T I S2010expected to emerge from
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N T I S201012.7 Possible Options fo
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N T I S201012.8 RecommendationsThe
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N T I S2010GoN / MoF (2009), Econom
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N T I S2010Thapa, Ajit N.S. (2006).
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N T I S2010NEPAL TRADE INTEGRATION
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N T I S2010MainOutcomes Recommended
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N T I S2010NEPAL TRADE INTEGRATION
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N T I S20102. GINGERStrengths Tradi
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N T I S20104. LENTILSStrengths High
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N T I S20105. TEAStrengths Very fav
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N T I S20106. INSTANT NOODLESStreng
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N T I S2010 Review, simplify, and i
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N T I S20109. SILVER JEWELRYStrengt
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N T I S201011. CHYANGRA PASHMINA PR
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N T I S201013. TOURISMStrengthsNatu
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N T I S201015. IT AND BPO SERVICESS
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N T I S201017. EDUCATION SERVICESSt
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N T I S201019. HYDRO-ELECTRICITYStr
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Appendix 1Methodology for Export Po
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N T I S2010B. Data SourcesThe analy
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Appendix 2Market Attractiveness Ind
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N T I S2010Rank13) Tourism1 Germany
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Appendix 3Updated Legislative Actio
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N T I S2010specified management sys
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N T I S2010than pesticide residues
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Appendix 5Malaysia GAP (Skim Amalam
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N T I S2010E. Document ControlQMS d
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Appendix 7Good Agricultural Practic
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