PASCUALITO GUTAY 

D.12.1 Why repatriate

The seafarer may be repatriated for ongoing care at home if:

• a seafarer’s illness or injury may worsen with work,
• the disease may spread to affect coworkers on the ship,
• recovery may take longer than a few days or
• the disease may affect the productivity of the seafarer,

Additionally, some diseases that occur on board can wait for treatment in the seafarer’s home country at the end of their contract or the seafarer may need to continue treatment started on board or overseas after they arrive home. 

The many and varied nationalities and cultures of seafarers offer various challenges to their medical management. Treatment in the home country is advantageous as seafarers

• have a better opportunity to be treated in an environment where they can more easily relate their signs and symptoms,
• can be treated customary to their beliefs and medical treatment exposure, and most importantly,
• can heal with the help, care, and support from family members in an atmosphere they are familiar with. 

Whilst the seafarers are treated far and wide (within the city or in another region) with varied costs and modes of treatment, the control of the seafarer’s medical care at home by their employer is usually centralized through a company designated physician in coordination with the company’s medical department or an appointed claims handler. 

D.12.2 Medical Care at home

Seafarers go home to many different countries and ensuring that their ongoing medical care is in line with the contractual obligations of the employer and is appropriate, based on globally accepted treatment guidelines, presents a difficult task. 

Expectations

Medical management at home should proceed based on currently accepted international clinical practice parameters. However, it must also take into account what is available in the home country. Exposure to the internet and the availability of voluminous medical information – old, new and experimental – may influence the expectations and demands of patients and their families. It is not uncommon for patients to request procedures or materials available in a different country, however it is always advisable to use locally and customarily available procedures and materials as much as possible.

Contractual obligations

Contractual, work related agreements between the seafarer and the company are taken into account when planning the care of repatriated seafarers. Because of this, care may differ from that which may be received in ‘regular’ medical care. Company designated physicians are utilized in the huge majority of the ‘crewing’ countries to coordinate the seafarer’s medical management,  treatment schedule, report on their care, and provide for their medical needs. They regularly update the local ship owner representatives or P & I Clubs on the progress of care, including attendance and non-compliance of seafarers to medical advice. These coordinators are critical to ensuring the facilitated and proper management of the seafarer based on policies agreed between the seafarers and the companies. 

Cover for medical expenses

Determination of whether or not the injury or illness is work related helps employers determine the company or insurer’s liability for cover and their potential cost exposure for the total care of a seafarer until they are able to return to work. The financial cover for care may be restricted to a certain time period, whilst ship owners, their Insurance or Protection and Indemnity Clubs, or their manning agencies must usually approve the total cost.

Some non-work –related diseases that can resolve quickly and where patients are likely to completely recover without any limitations of their activities may be covered by the company depending on an assortment of factors including the length of employment of the seafarer with the company, generosity of the employer (ex gratia), as well as local government laws and regulations. On the other hand, other companies will over the costs for a seafarer’s treatment for any condition that occurs on board regardless of its relationship, or not, to work.

The payment for and management of sick and injured seafarers’ care is limited to treatment only for the medical issue related to the reason for the repatriation. Comorbid diseases such as hypertension or diabetes mellitus in a seafarer with, for example, a fractured finger needing surgery, will also need treatment because control of these diseases is essential to the success of the management of the fracture. Otherwise, diseases that seafarers complain about during treatment that are unrelated to the primary reason of referral will need to be evaluated for pre-existence before employment and their relationship to the main medical condition currently being managed will need to be investigated.

D.12.3 Medical Coordination

Coordinators of medical care are common in the so called ‘crewing countries’ and their role is to ensure that the costs of treatment and the timeline involved is beneficial to both the seafarer and the employer. It is advantageous to have a country coordinator who has a medical background but they also need to be aware of local and national legal policies and the policies and guidelines of the shipping company or ship owner and the relevant P&I club in order to ensure effective coordination.

Countries without coordinators rely on the seafarers themselves to update them of their health status. In addition, the company designated physician regularly updates the company’s approving person and other stakeholders of the progress of the case management in line with data protection and confidentiality rules and guidelines. Further information on this complex area is available in section xxx.

Seafarers are referred to medical and surgical specialists and subspecialists for proper and facilitated medical treatment. Coordinators can assist in guaranteeing the timely treatment of seafarers by scheduling their medical appointments and acting as triage or medical evaluators ensuring the comprehensive and proper management of the referred condition. They also safeguard against the fragmentation of treatment by subspecialty care that has the risk of overlooking the whole. Company designated physicians ensure reliable, cost-effective and facilitated management of repatriated seafarers. 

D.12.4 Financial support

Repatriated seafarers receive financial assistance whilst they are receiving medical care. This includes sick pay and/or maintenance pay. They may also get financial support for medications, transportation and accommodation, if they are receiving care far from home. Reimbursement of expenses for treatment and other expendables that the seafarer may be paying for themselves becomes necessary. Fortunately, with advances in technology and communication, online payments may be made to the seafarer and these can be arranged even before their disembarkation.

D.12.5 Maximum Medical Improvement or Cure

The aim of ongoing medical care at home is obviously the return to work of the seafarer. Nevertheless, for some, it may become apparent during their treatment that they will be unlikely to obtain a fitness certificate for work at sea at any point in the future due to their health. Fit or likely to be unfit, the time will come when all diagnostic and therapeutic modalities have been exhausted in the medical care of a sick seafarer and any further treatment will not change his medical condition or his fitness to work at sea. That is, the point at which maximum medical improvement has been reached, whether or not the seafarer is cured. This point signals the termination of cover by the employer and needs to be clearly defined. 

Discussion between the attending physicians, the company or its representatives and the seafarer is critical and the seafarer must be included in his care throughout. The active participation of seafarers in their care, especially in defining the direction of their management, should make reaching and explaining the point of maximum medical improvement easier. This is especially important for seafarers likely to be permanently unfit for sea service. Even for seafarers who are likely to be fit, they may feel more confident proceeding towards a medical examination by the appointed pre-employment clinic, if they have been involved in their care. 

D.12.6 Further Medical Selection Examinations

After receiving ongoing medical care, medically repatriated seafarers are required to undergo a new Pre-Employment Medical Examination (PEME) before they can return to work at sea. This will include a flag state medical and may involve an examination and tests required by the government in jurisdiction, the respective principal/ ship owner, the employer and the P&I Club. Further information about the medical selection of seafarers is available in Ch. 4.8.

The Doctor conducting the PEME evaluates the reports from previous specialist consultations, especially the latest results, for an understanding of the present condition and the capability of the seafarer. Further, comprehensive history taking and thorough physical examination with reference to the general health of the seafarer but also to the cause of the medical repatriation will determine any additional diagnostics, consults and or procedures needed in order for the Doctor to make a fitness decision. This medical repatriation illness or injury focused examination and the truthfulness of the seafarer in his declarations during PEME, are in addition to the appropriate medical examinations and eventual determination of the seafarer’s fitness to go back to work.

In a population of over 100,000 seafarer PEMEs between October 2017 and September 2018 at SuperCare Clinics in the Philippines, 1.7% had been repatriated for medical care. The following (in order of incidence) were the top ten most common conditions.

D.12.7 Return to Work

The aim of rehabilitation for repatriated seafarers is recovery to a physical capability that is compatible with continued employment. Some rehabilitated seafarers however cannot return to work if they do not meet the PEME standards applicable to them. The ILO/IMO Medical Examination Guidelines for Seafarers (2011)^[1], requires that seafarers are medically fit to resume their duties and do not suffer from any medical condition that would be aggravated by work at sea or endanger the health of their fellow crewmembers. For other industry stakeholders such as the ship owners and the P&I Clubs, guidelines that are more stringent apply. This accounts for the stricter PEME guidelines and enhanced post repatriation screening schemes required by these organisations.

Of 2,028 seafarers considered to be completely rehabilitated or recommended as maximally medically improved and referred to SuperCare clinics for PEME, 94.67% were eventually declared fit to return to work and received a certificate of medical fitness. Looking at the different guidelines, 11.61% had the basic Philippines’ Department of Health PEME, 7.3% underwent a P&I Club PEME whilst 81.09% were part of other PEME schemes. With the different applicable standards the 5.33% who were not found fit to work at sea based on their applicable PEME standards, are not necessarily unqualified to work for other employers. 

During the PEME and before the release of medical certificates, seafarers who have been repatriated are advised on their medical conditions and the health measures to be taken to reduce the likelihood of recurrent problems and to maintain their health to ensure their safety on board, and the safety of others.   

^[1] The International Labour Office. (2011). Guidelines on the Medical Examinations of Seafarers. The International Labour Office. https://www.ilo.org/wcmsp5/groups/public/---ed_dialogue/---sector/documents/normativeinstrument/wcms_174794.pdf