# Session Overview ## Learning outcomes By the end of this session you should be able to: - Reflect on medical tourism from a global health dimension; - Appreciate the economic and policy implications of medical tourism; - Provide an overview of the flows of medical tourism globally and critically review issues associated with the quantity and quality of the data available - To identify the pros and cons of medical tourism both for the 'importing' and 'exporting' country - To illustrate these issues with examples in different countries # 1. Introduction ‘Importing’ countries, are those where the medical tourists come from as they are the ones that import the health services. On the other hand, ‘exporting’ countries refer to countries that provide the health services to the medical tourists. ## 1.1 What is Medical Tourism? [[Question]] There are four ways in which health systems can be traded: 1. The remote provision of services known as 'telemedicine'. This involves health care being delivered at a distance, for example diagnostic tests or tele-consultations, and will be discussed in more depth at a later session. 2. **The movement of patients to other countries**. (The subject of this session) 3. Health service providers can migrate to other countries. This is often in the pursuit of better quality of life and career opportunities (this is discussed in Session 9) 4. Health services can be traded through foreign direct investment. This involves countries investing in other countries' health system, by building a private hospital, for instance, and will be covered in more depth in a later session. This session is concerned with the second mode of trade in health services: the movement of patients. It is generally accepted that ==medical tourism is “the movement of patients across an international border with the purpose of obtaining health care.”== This definition excludes “wellness” tourism, which is concerned with spas, homeopathy treatments or traditional therapies, and takes a more holistic approach to health care, encompassing the wellbeing of the body, mind and soul. The term ‘health tourism’, which is often found in the literature, refers to both ‘medical and wellness tourism’, and is therefore not to be confused with medical tourism. The definition of medical tourism used here excludes tourists who fall ill or have an accident whilst on holiday in a different country and need health care treatment. Foreign nationals seeking care in the country in which they reside are also excluded. In some countries medical tourism is referred to as Medical Value Travel. The definition we will use in this session will only include people who go abroad with the specific aim of accessing health services and who privately arrange and pay for the care they receive “out of their own pocket” (or from their individual income). As we will see, there is great potential for private or social health insurers to engage in medical tourism. This type of trade only takes place through patients arranging their own care privately due to legal and financial challenges, though nowadays there is a possibility of financial support from their social or private health insurance. ## 1.2 Why travel abroad to access health services? Based on the study of Ernst and Young LLP (2019), the key drivers of the growth of medical tourism are: affordability and accessibility of good healthcare services, availability of latest medical technologies, accreditations, facilitation around hospitality services, and minimal waiting time. These patients often choose to travel to another country in order to bypass waiting times at their home health system, which can be months long for non-emergency procedures. A further reason why people travel abroad for health care is unavailability of certain procedures in their home country. This often includes experimental treatments that have not been approved, such as stem cell therapy, or procedures that are deemed too expensive for the health system, such as hip resurfacing. Other reasons why patients travel for health care include increased confidentiality from the diaspora that return ‘home’ for treatment, as they feel more comfortable with the health system there. For instance, Mexicans living in the U.S for years sought a ‘Mexican Medicine’ that was perceived as rapid diagnosis with less laboratory tests, and of common linguistic and cultural background to this group. ## 1.3 Where do people travel to access health care? The majority of current medical tourism trade takes place regionally. In addition to some regional proximity, the country’s specialty also plays a role in patients’ decision of where to access care. This occurs because destination countries have [[comparative advantage|specialised in certain procedures]]. For instance, Thailand and India specialise in orthopaedic and cardiac surgery, whereas Eastern European countries are hotspots for dental surgery. Having looked at the reasons why patients travel for health care, and where they go to, we will now discuss what types of health care are accessed This new trend is driven by the ability of private facilities even in less rich countries to offer high quality services, with virtually no waiting time, at affordable prices. ## 1.4 What medical procedures do people travel for? Types of diseases also play an important role whether to engage or not in medical tourism. Aspects such as whether a condition is acute or chronic will be important. It would not make sense, for instance, for someone with any type of emergency condition to board an eight-hour long flight to obtain care. | Essential procedures | Elective procedures | Preventive care | | -------------------- | ---------------------- | ---------------- | | Cardiac surgery | Knee replacement | Medical checkups | | Transplants | Hip replacement | | | | Eye surgery | | | | Dental treatment | | | | Reproductive treatment | | | | Gastric bypass | | | | Comestic surgery | | | | Gender reassignment | | These procedures can be classified as essential procedures, elective procedures and preventive care. The essential procedures that patients travel for include cardiac surgery and transplants. Within cardiac surgery, many patients travel for cardiac bypass surgery, which countries like India and Thailand specialise in. Less affluent patients travel from developed countries to low- and middle-income countries for high quality complex surgery that is available at lower prices. The cost savings are considerable. For instance, at 2020 prices, a coronary artery bypass graft procedure costs around $7,900 (India), $15,000 (Thailand), $12,100 (Malaysia), $17,200 (Singapore), $13,900 (Turkey), and $26,000 (South Korea). The same procedure costs between $33,000 to $63,000 in developed countries. By far the most popular procedures in medical tourism are elective ones. These include orthopaedics operations, which are often heavily priced in many countries, and for which there are normally long waiting times. This arises because the demand for such operations is high, given that the conditions which lead to the need for treatment are very common and they are typically non-emergency procedures. Other types of elective procedures for which patients travel include eye surgery, dental treatment, gastric bypasses, cosmetic and gender reassignment surgery. ## 1.5 Other types of medical tourism There are disagreements over whether "[[Transplant tourism]]" should be treated as part of medical tourism. The main driver of transplant tourism is the lack of donor organs available in many countries. However, transplant tourism raises a different set of ethical issues, as the destination countries often have unregulated organ markets, and it is difficult to ensure the wellbeing of the donor. Also, follow up procedures may be more difficult, as the patient will need further treatment upon returning to their ‘home’ country. Another form of medical tourism is reproductive treatment. There are again concerns regarding whether “reproductive tourism” should be included into the wider category of medical tourism. This is again due to the different issues this raises, such as patients travelling for procedures that are not approved in their home countries, or ethical issues regarding complications. Preventive care is another form of medical tourism. This represents a recent shift, as traditionally medical tourism was associated with curative care. However, healthy individuals are also now travelling to have full body check-ups, such as CT scans to ensure they do not have any ‘hidden’ conditions. ## Activity 1 Name one country that is known to be a destination for medical tourism. Explain why. Name another known importing country and discuss why. Post your answer in moodle. Singapore is a famous hub for medical tourism for my country, Indonesia. Unsurprisingly, since Singapore is dubbed as one of the best in the world and relatively near Indonesia, many chose to fly to Singapore and be treated there. For the pull factors, Singapore has several factors: 1. Strong regulatory governance, including strong clinical research which contributes to excellent long-term care, and access to blockbuster medicine and new medical technology. ASEAN briefing in 2022 noted that US $600 million in Singapore's overall medical tourism receipts were from Indonesian patients 2. Singapore's pro-business climate, with pharmaceutical and biomedical industries driving the economic growth contributes to the access to wide-range innovative medicines in Singapore 3. The country's approach to becoming a hub for biomedical research and development in Asia by pledging huge amounts of money for R&D, science, and technology was able to draw world-renowned scientists, and foreign students, which in turn, improved the quality of its universities (NUS and NTU, notably) and attracted companies in the field of biomedical sciences R&D and collaborate with local and international research institutes. For the push factors from Indonesia, here are some of them: 1. Basic healthcare problems have plagued the countries for decades, arguably because of its decentralization policy which left the program provision under regional provinces' purview. 2. Shortage of healthworkers, with a mismatch of health labor market exacerbating high turnover of workers in rural and remote areas. In addition, there are security issues, with several cases of threats and rapes, and low quality of life in rural areas. 3. Over-focus on donor-funded vertical programs, which was pointed out by Elisabeth Pisani from a decade ago, e.g. tuberculosis, HIV, and malaria programs. 4. Weak national health insurance scheme with low cost ceiling and absence of Coordination of Benefit (COB) which prohibits middle-income citizens from accessing the already over-stretched health system. 5. Additional push factors include high travel costs within Indonesia compared to outbound flights from major cities to Singapore. # 1.6 Medical tourism facilitators Facilitators are individuals or agencies who mediate between hospitals and a medical tourist or patient. They can provide information, arrange services such as travel, accommodation, and arrangements as well as the actual medical care. # 2. Considerations for countries engaging in Medical Tourism ## 2.1 Opportunities for Importing Countries The biggest advantage for importing countries is financial. In terms of importing countries, it translates into lower costs of health care. | Importing countries | Exporting countries | | ------------------------------ | -------------------------- | | Lower prices | Source of foreign exchange | | Decreased waiting time | Reversal of brain drain | | Increased patient choice | Improved health care | | More privacy and personal care | | Please note that, for most procedures, the cost of going abroad includes travel costs. For orthopaedic procedures such as knee surgery the difference in cost is almost seven times, compared to that in India. For shoulders arthroplasty or replacement and gastric bypass surgery the cost of getting care in the US is almost four times as much as going abroad, if one assumes the lower bound cost in India. In terms of cost, this can be an advantage to both patients (when paid out-of-pocket and the importing country’s health system more generally (when the social health insurance shoulders the cost). The reasons why exporting countries can keep their prices so low are due to low staff wages, cheaper rents and less stringent malpractice regulations. As we saw earlier, ==the type of health system that a country has influences how it benefits from medical tourism. However, in the case of lower costs, both countries with a market-based health system and those with a national health system can greatly benefit. This pertains to payments shouldered by a private health insurance or the social health insurance.== Besides financial benefits and tackling the problem of waiting lists, there are other factors that attract patients from importing countries. ==For instance, they may be offered an increased choice of procedures, some of which are not available in their own country, including specialties that have not been approved or are deemed too expensive== (Johnston et al., 2010). Patients can also benefit from increased confidentiality if they go abroad, as no-one will be informed of what procedures they have received. This is particularly the case with plastic (cosmetic) surgery. Although this lack of records can also be a problem for patients and physicians. Finally, hospitals in exporting countries pride themselves in the quality of the services offered, and patients are often offered a higher degree of personal care, with much higher ratios of doctors and nurses per patient than they would have at home. These factors all contribute to the market based approach of medical tourism. Better services offered result in more demand for that service and the more patients that a particular hospital/country will have. ## 2.2 Opportunities for Exporting Countries [[Financial prospects of medical tourism has encouraged LMICs government to invest in medical tourisms as "deemed export" and awarded fiscal incentives]] As previously stated, the most important reason why countries engage in medical tourism is financial. Exporting countries are no exception to this. Although the data available on medical tourism is not readily available or are somewhat variable, the estimates of the financial benefits reported from some of the leading exporting countries are substantial. For instance, ==Thailand is reported to have generated US$3 billion in 2017, and India is predicted to generate US$8 billion by 2020 from this industry alone (Medhalt, 2016)==. Although medical tourism tends to be organised through the private sector, the prospects of such high profits have encouraged governments to invest in it. For instance, the Indian government has considered medical tourism a “deemed export”, and has awarded it fiscal incentives, such as tax concessions, land at a subsidised rate and lower import duties. [[LMICs who engage in medical tourism must ensure that the extra revenue from medical tourism must be invested back into the national health system]] Given that many destination countries are low- and middle-income, and that they often have over-stretched and under-resourced health sectors, this extra revenue is most welcome, especially if invested back into the national health system (Chen and Flood, 2013). Funds raised through medical tourism are not restricted solely to health care, but also include expenditure associated with accommodation of accompanying persons and/or tourism activities that the patients may engage in while in the country. In addition, medical tourists often travel for other reasons (tourism and leisure travel, business trip, family visit, etc.) and once they are in the exporting country they obtain medical treatment. This is especially the case for the diaspora who return ‘home’ primarily for care but also takes the opportunity to visit family members and undertake personal businesses. Funds raised from medical tourism have to be considered as the extra money raised from people obtaining health care, rather than taking into account their whole trip. In economic terms, this would be referred to as the marginal benefit gained from tourists obtaining health services, over what would have been gained by them engaging in standard tourism activities alone. Another main benefit from medical tourism for exporting countries is the opportunity to reverse their ‘brain drain’ (Chen and Flood, 2013). The brain drain is a process by which health care professionals leave their countries of origin to work in other countries, and was the subject of the previous session on health care worker migration. This migration is often motivated by higher salaries and better career prospects. All types of health workers migrate, including doctors, nurses and pharmacists. It is worth reiterating here that the effects of this migration on the health system can be acute, and staff shortages in some countries are so high that only 35% of the available posts are filled. Private hospitals that care for medical tourists are often able to provide health professionals with much better paid jobs, and more promising career prospects. Some countries are therefore attracting some of the health workers that migrated abroad back to work in these private hospitals. Other advantages of engaging in medical tourism trade from the perspective of exporting countries include improved health care and improved country image. As we shall see later, one of the key concerns of medical tourism is the quality of care. To address this, hospitals in exporting countries apply for international accreditation, ensuring the care they deliver is at least of the same quality of that offered in importing countries. This raises standards of the hospitals, which also benefits the local population, as these hospitals do not exclusively treat foreign patients. In terms of improved country image, the more people that visit the country, and are happy with the services they receive, the better the country’s image will be, and the more tourism and trade it will be able to attract. ## Activity 2 1. Cheaper medical treatment 2. Wellness concept - preventive care 3. One stop shopping - comfortable 4. It also shows "hospitality" from health workers as if it's a hotel instead of hospital ## 2.3 Disadvantages for Importing Countries There are risks importing countries have to take into account when considering whether to enter into a trade agreement on medical tourism. These include quality of care, litigation, lack of follow up, lack of information flow between doctors and ethical considerations. Regardless of how high the quality of care is, mistakes, and medical malpractice, will eventually take place, and when they do, there may be little recourse for compensation. Concerns of importing countries regarding medical tourism are not limited to the patients’ experience while abroad. There may be a host of problems that can arise upon the patients’ return. One important concern is what is going to happen when patients return home and need follow up care. There may also be a reluctance from the ‘home’ physicians to give follow up treatment to patients who have already been treated abroad, as these physicians may be worried about potential litigation that could affect them. A similar situation can arise when patients are given medication to take back home with them, as the medication may not be available in the importing country, or it may not be used in the same way. ## 2.4 Disadvantages for Exporting Countries - Creation of two-tiered health system - The second concern from the perspective of exporting countries is the creation of an internal brain drain. - Other concerns regarding medical tourism from the point of view of exporting countries include potentially unsuitable resource diversification to serve the needs of the local population and whether the profits reach these populations (different medical needs of medical tourists compared to local population). # 3. Trade agreements As a result, discussions on medical tourism are framed within the World Trade Organisation’s, [[General Agreement on Trade in Services (GATS)]], or the GATS led by governments. However, it is important to take into consideration that some of the issues associated with medical tourism only apply to this multi-lateral mode of trade (Mattoo and Rathindran, 2006). In section four, we will look at the benefits and risks of medical tourism from the perspective of a different trade agreement by using a case study. Let us first examine the GATS in a bit more detail, and what it means for health systems. The GATS agreement was a result of the 1995 Uruguay Round Negotiations, and is the basis of the multi-lateral sector trading system. GATS divides the service sector into four modes of trade. These are all applicable to the health service sector. Mode one covers cross-border supply of services, which in the case of health services refers to the remote provision of health services. Mode two is concerned with the consumption of services abroad, which refers to medical tourism. Mode three relates to commercial presence, or foreign direct investment into another country’s health system. Finally, mode four covers the presence of a natural person, which in the case of health systems refers to health worker migration. Although medical tourism trade is framed within a multi-lateral context, this does not reflect the reality, where regional and bi-lateral trade play a more prominent role. As seen earlier in medical tourism flows, ==most of this trade takes place regionally==. This is logical, as patients would generally prefer to travel shorter distances, and to places where there is a similar culture and no time difference. The European Union’s free movement of people is an example of this, where patients can travel for health care to other countries within the European Union and be reimbursed by their home health system. Although this trade is not as formalised in other regions of the world, patients still travel to their neighbouring countries. This is the case, for example, of the Association of Southeast Asian Nations, or ASEAN region and in the Americas. # 4. Medical Tourism and Health Systems ![[Medical tourism and policy implications for health systems conceptual framework.png]] In this framework the following variables are considered: ==governance, delivery, regulation, human resources and financing==. In order to assess governance, in terms of quality, the following are suggested as possible indicators: the number and content of GATS health sector commitments; the number and size of medical tourist government committees or agencies; the availability of medical tourist visas. When it comes to the delivery aspect, the indicators suggested are the number of hospitals in the public and private sector treating foreign patients, and the consumption of health services by domestic and foreign population (hospital admissions). The financing aspect focuses on revenues from medical tourists, type of medical tourist payment (service fee or insurance, level of co-payment), and foreign direct investment in the health sector. Human resources would pertain to medical doctor and nurse ratios per 1000 population; the proportion of specialists in the public and private sectors; and the number of specialists treating foreign patients. Such data is required to be able to measure the impact of medical tourism. The last aspect is regulation which may pertain to the number of Joint Commission International-accredited hospitals, and to the volume of medical tourist visits facilitated by brokers. The latter can be used as an indication of the quality of care, as brokers may be subject to certain compliance and will not want to experience reputational damage arising from inadequate practice. # 5. A Case Study of a Bilateral Relationship between India and the UK India’s health system is made up of a mix of public and private services. It has a very low coverage of healthcare for its population, with only about 60% of the population having access to health care due to a yet developing system. This results in a significant proportion of the population paying for health care “out of pocket” (directly from their household income), which has led to the development of a thriving private health sector. India is already a key player in other forms of trade in health systems, such as remote provision of health services and the movement of health care professionals. It is also an important destination for medical tourism. India holds 5th position among 41 major medical tourism destinations as per [[Medical Tourism Index Overall]] ranking with a market value supposedly at US$ 9 billion by 2020. The major destination cities are Delhi, Mumbai, Chennai, Bangalore, Hyderabad and Kolkata. A total of 27% of medical travellers visit Maharashtra out of which 80% goes to Mumbai, Chennai attracts nearly 15% while Kerala handles around 5-7%. Medical tourists are expected to save up to 50% compared to developed western countries. The average daily cost of travel within India is US$ 31 compared to USA having US$ 223. There are 38 Joint Commission International (JCI) and 619 National Accreditation Board for Hospitals & Healthcare Providers (NABH) accredited hospitals. The Indian government has granted medical tourism tax subsidies and land concessions. They have also introduced a medical visa, known as the ‘M’ visa, to facilitate the entrance of medical tourists to the country. Furthermore, Indian hospitals are very committed to obtaining national and international accreditation. There are many reasons for India’s success in medical tourism. The country has invested in world-class technical equipment, which together with the quality of health care professionals many of whom have been trained abroad and brings back good practice equating to very high standards of care. Second, the price of care is considerably lower than in most high-income countries. Third, English is widely spoken, which gives it an advantage over countries such as Thailand, that need to provide translation services at their hospitals. ==For the exporting country entering the bi-lateral relationship, in this case India, there are also options to capitalize on the benefits offered by medical tourism. First, provisions can be made on the contract signed by both countries to ensure that the profits made from this type of trade are incorporated into the public health system. In addition, the contract will pre-select hospitals that are following internationally acceptable standards, which will serve as an incentive for other centres to improve their services to reach the same standards.== Let us now turn to the risks posed by medical tourism, and how these can be minimised through a bi-lateral relationship. ==In the case of the UK, the importing country, the chief concern outlined earlier was quality of care==. This can be addressed by having a contract with India, and pre-selecting which hospital or hospitals patients would be sent to, either based on the Department of Health’s own assessments or by selecting accredited hospitals only. In this way, high standards of care would be ensured. In addition, the contract signed between the two countries can pre-establish the procedures that will be followed when malpractice arises, and who is responsible for what at each stage of the care process. In this way, the UK’s Department of Health would protect itself from expensive lawsuits that may offset the benefits made by sending patients abroad. [[Open Question]] Since Indonesia imports patient to Singapore, what are the concerns from Indonesia regarding healthcare? While it is definitely not quality of care, what are we looking at? Can bilateral relationship minimise the risks? Is it In the case of India, the exporting country, a bi-lateral relationship can also help reduce some of the risks posed by medical tourism. First, the contract can ensure better enforcement of regulations that allow the poor access to private facilities at no cost. If hospitals do not comply with these rules, they risk losing the contract with the UK National Health Service. In addition, a mechanism can be set up to ensure that the profits made from Medical Tourism benefit the local population. Again, mechanisms can be built into the contract signed by the two countries, whereby if these commitments are not adhered to, the contract will be breached and the trade in services stopped. Last, in order to tackle potential problems of the internal brain drain that may develop as a result of increased medical tourism, doctor exchange and training programmes can be set up, either as part of the bi-lateral contract or as future programmes built on this relationship. In conclusion, although medical tourism is often discussed from a multi-lateral, GATS-based perspective, much can be gained from countries engaging in a bi-lateral relationship. As we have seen in the example of India and the United Kingdom, a contract can be drawn out between the two countries that pre-sets conditions so that benefits can be maximised and risks reduced. However, this has not been achieved to date. Please note that although the UK and India were used as a case study here, this is by no means a unique example. There are many other countries that share similar historical and cultural ties that can engage in this type of agreement across the world, who are facing health systems challenges that can be addressed by engaging in bi-lateral medical tourism trade. # 6. Integrating activity # 7. Summary After working through this session, you should have a good grasp of what medical tourism is, and although the data available on it is inadequate and incomplete, understand that it is already happening and on a large scale. As part of this session we have explored how countries can benefit from engaging in medical tourism, by cutting health care costs, alleviating waiting lists, generating foreign exchange and reversing the brain drain. We have also seen that there are risks from this practice that countries need to take into consideration, including concerns regarding quality of care and malpractice, the creation of a two-tiered system leading to inequalities in health care provision and an internal brain drain. We have also briefly considered the different trade arrangements through which medical tourism can take place, namely multi-lateral, regional and bi-lateral. This session has ended by exploring how the issues posed by medical tourism can be addressed through a bi-lateral relationship, using the UK and India as a case study. Although trade agreements of this type are not currently in place, there is evidence that they may be best placed to address the concerns related to the practice of medical tourism. Finally, we make the point that there is a need for more empirical data on the scale of medical tourism trade that is currently taking place and the effect it is having on both importing and exporting countries. At present, policy decisions are being made without recourse to adequate data, and are often more influenced by other factors like ideology than evidence. # 8. References ## 8.1 [[Essential readings]] [[@luntMarketSizeMarket2014]] [[@chenMedicalTourismImpact2013]] [[@smithMedicalTourismReview2011]] ## 8.2 [[Recommended reading]] [[@hanefeldMedicalTourismCost2013]] [[@johnstonWhatKnownEffects2010]] #to-read Mattoo and Rathindran (2006) Measuring Services Trade Liberalization and Its Impact on Economic Growth: An Illustration. Journal of Economic Integration. 21: 64-98 Med Tourism Co (2020) Available at: https://www.medicaltourismco.com/ Accessed: 20 September 2020. #to-read Medhalt (2016) How Economies are Earning Billions in Medical Tourism Revenues. Available at: http://www.medhalt.com/blog/economies-earning-billions-medical-tourism-revenues. Accessed: 20 September 2020 #to-read Mutalib NSA, Ming LC, Mei Yee SM, Wong PL and Soh YC (2016) Medical Tourism: Ethics, Risks and Benefits. Indian Journal of Pharmaceutical Education and Research. 50: 261-270. doi:10.5530/ijper.50.2.6. #to-read Pocock N and Phua KH (2011) Medical tourism and policy implications for health systems: a conceptual framework from a comparative study of Thailand, Singapore and Malaysia. Globalization and Health, 7:12. doi:10.1186/1744-8603-7-12 #to-read Ruggeri K, Zalis L, Meurice CR, Hilton I, Ly TL, Zupan Z and Hinrichs S (2015) Evidence on global medical travel. Bulletin of the World Health Organization. 93:785-789. doi: http://dx.doi.org/10.2471/BLT.14.146027 #to-read Smith R, Martínez Álvarez M, and Chanda R (2011) Potential for bi-lateral agreements in medical tourism: a qualitative study of stakeholder perspectives from the UK and India. Global Health. 11