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There is also scope for the provision of consumer services, such as taxi services, car rentals, accommodation rentals, hair grooming, cosmetic and beauty services, and recreational activities. It is important to note that to a large extent, the leading motivation of investors in OMUs in the Caribbean has been capitalizing on fiscal incentives on offer to generate a substantive return on investment i.

Thus this speaks to the need for a reevaluation of the modalities employed by regional economies to achieve sustainable development in the Caribbean. Local competitiveness factors As previously mentioned, US students seeking tertiary level medical education tend to pursue studies at Caribbean OMUs. A number of factors favor the Caribbean as a choice location for the OMUs. In Grenada, a nursing school was started with 28 students, all of which were locals.

In the case of the nurses, upon the end of their training, they would provide their medical services to Grenada. In the case of the doctors, after they complete their residency and obtain their ECFMG certification, they target the US market for work.

Location The Caribbean islands are in close geographic proximity to the US. In fact, the distance between Miami, Florida, and Havana, Cuba, one of the more northern Caribbean islands, is approximately miles.

Such close geographic proximity results in a relatively low cost to travel between the US and the Caribbean. Indeed, the lower transport cost would make traveling to the Caribbean from the US more economically attractive than traveling to India.

Language The official language of the US is English. The official language of many islands in the Caribbean is 24 also English. Some exceptions exist, for example, the official language in Cuba is Spanish. In Sint Maarten both Dutch and English are spoken.

The similarity in language would allow easy communication between US students and people residing in the English speaking Caribbean islands. Low costs for tuition and living expenses Tuition at the Caribbean offshore medical universities is lower than US medical universities.

Table 4 provides an outline of the tuition costs and living expenses costs for students in both the US and the Caribbean offshore medical universities. Table 4 Expenses of students US medical university Caribbean offshore medical university Tuition fees USD —, 47 — Rent and living expenses 60 —, 60 — 80 Total — , — Source: updated Swedish development advisers ,and Eckhert Tax incentives and full repatriation of profits Tax incentives are provided by the governments of the host countries. Since many of these Caribbean countries have an undiversified economy, they are willing to provide tax incentives to foreign investors.

He was shot during the coup in Kitts and Nevis, St. Lucia, St. Maarten, St. Virgin Islands Alleyne Swedish Development Advisers report that the owners of the medical schools identified in their sample were allowed to repatriate all profits, dividends and capital. Less stringent requirements for setup In the Caribbean there are less stringent requirements to establish an OMU. Indeed it has been suggested that one of the reasons for the explosive growth of offshore medical universities in the Caribbean within the last decade are the less daunting requirements for their establishment and operation.

In North America, most medical universities have a teaching hospital to facilitate clinical rotation. The medical universities usually make significant investment in facilities including staff and equipment in their teaching hospital. In fact, a medical student can complete their entire medical degree at one campus.

Furthermore, research is typically performed at the universities, and contributions are made to scientific knowledge. Additionally, the teaching hospital affiliated to the medical university typically provides medical services to local communities. Not all the offshore medical universities in the Caribbean have well developed facilities. Indeed, some Caribbean offshore medical universities don not have an associated teaching hospital.

Furthermore, lecture halls used for teaching have been known to lack sufficient seating to accommodate full classes. Moreover, there may be insufficient and or inadequate dorm facilities to accommodate the foreign students.

In the Caribbean, only a business license is required to open an offshore medical university Parolini and Platek ;Babcock et al. There are no additional requirements imposed by the government of the host countries to open and operate an offshore medical university.

For example in SGU in Grenada, the government imposes no additional requirements for building and operating an 26 OMU other than the standard requirements to build buildings and operate a business.

This is in contrast to the medical universities in the US which have a rigorous series of standards covering academics, finances, and operations that the medical university must comply with in order to gain 27 accreditation from the Liaison Committee on Medical Education LCME. The World Health Organization reports that medical universities have a social obligation to focus research, clinical and training activities on local health priorities Boelen and Heck This has led to the development of a global consensus statement on medical education, which states the moral and social obligations of a medical university GCSAMS However, Caribbean governments do not impose such requirements of the OMUs.

Thus, Caribbean OMUs do not meet such social obligations, as they train international students to practice elsewhere. This lack of social mandate undoubted makes it easier to operate a medical university in the Caribbean. Diagram 3 outlines the step required for an entrepreneur to establish a medical university in a Caribbean country. It is noteworthy that the low requirements for setup has both allowed the cluster to grow, and compromise the quality of education offered.

This results in US medical universities seeking such accreditation. In the Caribbean it is practiced on a voluntary basis. A website can be buit and used for adversiting. There have been reports of high dropout rates28 and students performed poorly on the USMLE step 1 examination. In contrast, Caribbean OMUs admissions are two to three times per year, with as many as students per class Halperin and Goldberg Parolini and Platek reports that the teaching structure at offshore medical universities is designed specifically to prepare students for USMLE examinations.

Parolini and Platek ibid also report that the teaching frequently occurs over the internet and through distance learning programmes. Such teaching methodology runs contrary to the North American medical university model where attendance at lectures is mandatory. First time takers from North American medical schools tend to experience a 96 per cent pass rate. However, first time takers from offshore medical universities, including the Caribbean, tend to experience a 78 per cent pass rate.

Those students in the OMUs are statistically likely to perform not as well as their US counterparts, notwithstanding the quality of education.

Nevertheless, there is a general perception that weaker performance of the students of the OMUs at the USMLE 28 In some instances more than 50 per cent of the enrolled students dropped out within the first year of study Korcok All medical graduates, whether from US or non-US medical universities, must pursue their residency training in the US in order to later practice medicine in that country.

In some countries, such as Cuba and the Dominican Republic, accreditation is carried out by a local governmental agency. In countries lacking a nationalized medical accreditation system, the university may opt for accreditation by a foreign agency.

For example medical universities in the Cayman Islands and Netherlands Antilles may seek accreditation from the Accreditation Commission on Colleges of Medicine based in the Republic of Ireland van Zanten and Boulet However, the UWI medical degree programme can be classified categorized as regional since it accommodates students from the Caribbean seeking to practice medicine in the sub-region.

Some Caribbean offshore medical universities have never undergone formal accreditation because the process is noncompulsory in nature van Zanten and Boulet Table 6 provides an overview. However, they were later revised in to incorporate the standards of the Liaison Committee on Medical Education. Neither in the US nor Canada is there is a formal authority mandated to accredit foreign offshore medical university programmes. It is important to note that these four schools are located on the Caribbean islands with the highest ECFMG certification rates.

Residency Residency matching refers to the degree of success a medical graduate is able to land a residency in the specialty area they desire. There is also disparity in the IMGs success at landing residency.

The success of US IMGs tend to range between 22per cent and 72per cent in the different specialty areas. However, Internal Medicine and Family Medicine are non- procedural specialties. However, US MGs attained high success rates in matching in the aforementioned areas. The ECFMG does not report the individual success rates of offshore universities at residency matching.

RUSM reported that of their students attained residency appointments for RUSM definition of success includes those students who did not get their first choice of specialty but obtained residency in one of their alternative fields.

Georges University reported that more than of their students managed to obtain residency matching for AUC reports that they managed to obtain residencies matching for Matthews University SMU reports only 43 of their students were successful at residency matching for Lack of transparency in the residency matching is a major cause for concern, since students may commit time, resources, and loans to pursuing medical education in an offshore university.

If they fail to land a residency, it would prevent them from becoming a physician in the US. Other challenges — case study of SGU in Grenada Apart from the accreditation and residency limitations, the OMUs in the Caribbean tend to be affected by the infrastructure limitations of the respective Caribbean islands.

For example, the quality of the road network in Grenada surface, lack of sidewalks, and lack of speed bumps has negatively affected the students of SGU. In fact, on March 24, , and on April 12, , the lives of two students of SGU were lost via road fatalities.

A related concern regarding road safety in Grenada is the lack of enforcement of the laws for the mandatory use of helmets by motor scooter riders. In response to concerns from students and their families, SGU is considering the development and implementation of policies on the certification of off-campus housing.

Travelers originating from the west coast of the US in particular will subsequently have to overnight in Miami in order to catch the early morning flights to Grenada.

Strategies for developing the cluster The main concern that arises regarding the offshore medical university industry is the questions surrounding the quality of education offered by the medical universities Boulet et al.

Subsequently it has announced that, effective in , all physicians applying for ECFMG Certification will be required to graduate from a medical university that has been appropriately accredited. As previously indicated, accreditation is currently on a voluntary basis. This allows many Caribbean offshore universities to continue to legitimately operate without ever seeking any form of accreditation. Governments of the host countries accommodating the offshore medical universities can implement legislation that mandates all universities operating in their country to obtain CAAM-HP accreditation as a perquisite for continued operation.

Furthermore, the host Caribbean countries can adopt a coordinated and harmonized approach to mandatory accreditation. Such approach should be taken to encourage collaboration rather than competition between the host Caribbean countries. Moreover, governments of Caribbean countries can synchronize the educational requirements for medical practitioners, allowing the medical practitioners to be mobile between Caribbean and CARICOM member states.

While this is a bold recommendation, it is uncertain if such policy would ever be taken. The economic contribution of the Caribbean offshore medical universities can be increased if more regional medical doctors are hired as lecturers in the university. The host country can also experience a greater economic benefit if a greater percentage of its citizens pursue programmes in the offshore medical university. Thus, the offshore medical university can construct programmes that can prepare local students for the domestic or regional physician market.

Caribbean offshore medical universities can also increase their contribution to the economies of host countries by forming partnerships with regional hospitals to allow their students to pursue their clinical rotations. When such students are training on their clinical rotations, they may increase the amount of health care services offered to citizens of the host country.

Such partnership will benefit both the university and the hospital since the university may gain access to hospitals for its students.

Moreover, emphasis should be placed upon improving the quality of health care administered in the host Caribbean countries. Another one of the major short comings of Caribbean offshore medical universities is their failure to conduct research. Universities typically contributed to the economic development of countries by engaging in research, building human capital, building knowledge, and dissemination of such knowledge.

Indeed, given that the Caribbean region tends to experience high rates of mortality from non-communicable diseases Murray and Lopez ; Boutayeb ; Legetic et al. Governments in the host countries can engage the offshore medical universities in talks to engage in research and disseminate their findings to medical hospitals.

A policy framework can be developed to encourage the offshore medical universities to form partnerships with local hospitals and create research units. The policy framework can also be designed to develop a medical tourism cluster. The research from the universities as well as some of the IMGs can be retained and used locally to support the potential medical tourism cluster.

It is important to note, the OMUs are established in the Caribbean with the objective of earning a profit, not to achieve any economic development of the host country. Currently, there is nothing to motivate on mandate the OMUs to take actions which will maximise the welfare of the host countries. Presently, any rents earned are a positive spillover to the region.

Thus, there is room to develop an organized local content type framework that would encourage more local inputs labour, services, goods, etc being directly used by the OMUs. Moreover, there is room for governments to develop an enabling environment, which would enhance the amount of domestically produced inputs for the OMU cluster.

Conclusion Excess demand for medical education and constraints to training in US medical university seem to be key factors that caused the cluster to emerge.

However, The Caribbean is an ideal location for the establishment of offshore medical schools given the close proximity to the US, language similarities, and relative ease in the establishment in the medical universities. This answers the first research objective. As regards the characteristics of the cluster, the OMUs in the Caribbean are for profit institutions, training students seeking to become physicians in the US.

The Caribbean OMUs act as a substitute for US medical universities, allowing students to attain pre-clinical training. Moreover, there is weaker performance of the students on the USMLE step 1 examination, and their success rates at residency matching. This answers the second research objective. The OMUs contribute to the economies of the host countries by the taxes directly paid by the universities, and expenditure incurred by the staff and students.

Developers of housing, and groceries located in close proximity to the OMUs stand to benefit from the immigration inflows. However, SMEs can benefit by the provision of more consumer goods and services to the immigrating staff and students.

This answers the third research objective. Two strategies have been taken to improve the quality of the Caribbean medical offshore universities. Addressing such challenges can certainly alleviate the operational constraints on the OMUs in the Caribbean. The contribution of the OMUs can be increased by the hiring of more local staff both academic and non-academic , increasing students enrolment, and by forming partnerships with regional hospitals.

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