Medical tourism today: what is the state of existing knowledge?

The analysis of the medical tourism expansion policy in Taiwan: a policy analysis using Kingdon's multiple streams

BACKGROUND

Since 2006, Taiwan has actively pursued the development of its medical tourism industry. In 2013, the government sought to bolster this sector by integrating medical tourism into the Free Economic Pilot Zones. Despite narrowly missing the mark, the initiative failed to materialize into law. This qualitative study endeavors to discern the pertinent factors influencing the agenda-setting process for incorporating medical tourism into the Free Economic Pilot Zones in Taiwan.

METHODS

A comprehensive examination of policies concerning the legitimation of medical tourism within the Free Economic Pilot Zones was undertaken through semi-structured interviews and a thorough review of policy documents. Key informants were strategically selected using purposive and snowball sampling techniques. Thematic analysis was applied to scrutinize the amassed data and organize it within the framework of Kingdon's multiple streams.

RESULTS

In the problem stream, increasing financial strains and cost containment pressures under the National Health Insurance program have long driven health care providers to seek further opportunities in medical tourism. The existing barriers to expanding medical tourism in Taiwan included diplomatic tensions (specifically cross-strait relations), public concerns about commercialization of medical care and reduced their access to care, and legal and language barriers. Within the policy stream, factors such as franchise fees to support national health insurance, limited number of demonstration medical tourism sites and services allowed, the allowance of foreign medical personnel, regulations governing domestic physicians, the importance of demonstration, regulation, and accreditation, as well as restrictions on investment from China, were emphasized. The politics stream highlights factors such as governmental support, opposition from opposing parties, public concerns and critics from academia and non-governmental organizations, and skepticism from medical faculties.

CONCLUSION

Acknowledging the recognized challenges in enacting the medical tourism provision of the Free Economic Pilot Zones Special Act and emphasizing the political will of leadership, a viable policy solution remained elusive. Although a window of opportunity existed for the passage of the bill, it waned as public concerns sidelined the issue from the national agenda. The Taiwan case underscores the necessity for meticulous consideration of issues, proposed solutions, and political dynamics to achieve successful policy enactment.

Cosmetic Medical Tourists' Use of Online Support Communities: Sharing Information, Reciprocity, and Enduring Relationships

Cosmetic procedures are amongst the most popular procedures sought after by medical tourists. Cosmetic medical tourists utilise numerous sources of information when planning their trips including, where available, discussing their decision with previous medical tourists. Current research on online support communities has investigated the interactions of patients with various health conditions with online support; however, limited research exists on cosmetic medical tourists' participation in online support communities. Here we report findings from our qualitative interview study of Australian cosmetic medical tourists. We found that many of our participants experienced stigma regarding their intention to receive cosmetic procedures and to travel overseas from within their local social networks. Participating in online communities (Facebook groups) enabled them to access information and support from other cosmetic medical tourists. Through using public posting and messaging functionality of the communities, they performed two distinct roles in the groups that parallel the temporal transitions of their journeys: they were information and support seekers pre-surgery and information and support providers post-surgery. The reciprocity they practiced in the provider role occurred due to their desire to 'pay forward' the support they had received from others pre-surgery. This role was performed as a collective, community-based reciprocity rather than a direct mutual exchange. Some participants also transitioned their online relationships into enduing offline friendships demonstrating how online interactions may become enmeshed with broader social networks.

Revisiting the Policy Implications of Medical Tourism in the Post-COVID-19 Pandemic From a Malaysian Perspective: A Qualitative Study

Background Malaysia has been one of the most prominent destination countries for medical tourism. The industry received significant government support to create a conducive environment for its growth, such as the provision of an investment tax allowance for the facilities participating in medical tourism and the establishment of the Malaysia Healthcare Travel Council (MHTC) to coordinate collaboration between various industry stakeholders to promote medical tourism activities at the international level and facilitate inbound medical tourists. The establishment of the MHTC facilitates collaboration between various industry stakeholders. In addition to facilitating medical tourism activities, MHTC is also involved in analysing relevant data, including but not limited to the socio-demography of medical tourists, the trend of their healthcare service utilisation, revenue generated, and market intelligence to promote the industry's growth. The council serves as a medium to facilitate the collaboration of stakeholders such as the hospitals participating in medical tourism, the Association of Private Hospitals Malaysia, the Malaysian Society for Quality in Health, and various government agencies, including the Ministry of Health and the Department of Immigration, Malaysia. We explore the policy-related implications of medical tourism and its relationship with the Malaysian national healthcare system. Methodology We revisited Pocock and Phua's conceptual framework of policy implications for medical tourism to explore its relevance after more than a decade of intensive government support and the aftermath of the COVID-19 pandemic. We employed a qualitative case study design using semi-structured, in-depth interviews with stakeholders from the Ministry of Health Malaysia, the private health sector, professional bodies, academics, and health-related civil society organisations. Results Our study found that many issues identified in the original framework remain relevant after over a decade. However, we also identified additional implications, such as the role of insurance portability in encouraging the growth of international hospital accreditation and the issue of equitable access to healthcare within the context of the current Malaysian healthcare system in the aftermath of COVID-19. Conclusion Due to its vulnerability, there is a need to develop a strategic collaboration that includes incorporating medical tourism activities into a broader framework, such as promoting aged care within the retirement destinations package for expatriates, which could ensure its sustainability instead of relying solely on medical tourism activities. In the meantime, policy implications arising from the industry remain relevant and should be addressed through a comprehensive structural reform of the national healthcare system involving stakeholders from the public and private health sectors.

Determinants of Bangladeshi patients' decision-making process and satisfaction toward medical tourism in India

Objectives

The aims are to explore the factors influencing Bangladeshi patients' decision-making process and their satisfaction level toward medical tourism in India.

Methods

The study used a quantitative research approach with a cross-sectional survey. Data were collected from the patients or their relatives (N = 388) who would have decided to travel to India for medical and treatment purposes at the Chittagong Indian visa center (IVAC). Data were collected using a structured, pre-tested, and facilitator-administered questionnaire, which mainly included the social demographic characteristics, health status, medical tourism information and medical tourism index. Hierarchical regression analysis was performed to explore the factors influencing their satisfaction level toward medical tourism in India.

Results

More than three-fourths of the participants had visited India for self-treatment. Of the participants, 14% were cardiology patients, and 13% suffered from cancer. The relatives were the key source of information regarding medical tourism for more than one-fourth of the respondents. India's availability of well-experienced doctors, hospital/medical facilities with high standards, well-trained doctors, reputable doctors, and quality treatments and medical materials were top-ranked items. Regression results depict that facility and services appeared as the strongest factor (β = 0.24, t = 4.71, p < 0.001) followed by tourism destination factor (β = 0.16, t = 3.11, p = 0.002), medical tourism costs factor (β = 0.16, t = 3.24, p = 0.001) and country environment factor (β = 0.15, t = 2.69, p = 0.007).

Conclusions

We found that the factor related to facility and services is one of the strongest predictors in our models. Therefore, home countries must strengthen the health care providers' advanced professional training, including service attitudes. Moreover, it is important to lessen the language barrier, reduce the airfare for medical tourists, and make the treatment cost more affordable for patients.

Health Tourism-Subject of Scientific Research: A Literature Review and Cluster Analysis

The purpose of this article is to identify main research areas in health tourism in scientific research. The data used in this analysis span from 2000 to 2022, was retrieved from the Web of Science database, and comprises a total of 1493 bibliometric records of publications. The paper includes both a quantitative and a qualitative analysis. The following four main research areas were identified based on the results: (1) patient satisfaction built upon trust; (2) health impacts of the destination (including the economic aspect, which plays a decisive role in choosing a tourism destination); (3) health behavior as a major part of human activity; and (4) traveling with a view to regain one's health. Note that the limitations of this study-which mostly affect the methodological part-need to be taken into consideration. This is the consequence of the selected publication database and of the search criteria used, such as the publication year or language.

Gender, health, and labor in Thailand's medical hub

As global economic and political conditions shift, Asian countries have placed technologies at the center of their development strategies, fostering new levels of wealth and expertise, but also generating new inequities. Among the most successful of these state-supported strategies have been efforts to develop and invest in new medical technologies, and recruit patients willing to travel across national borders for health care, in a process known as medical tourism. Medical tourism has afforded countries like Thailand greater wealth and prestige, and can also increase disparities for people in destination countries by encouraging specialized and privatized services catered towards wealthier patients. However, sparse research has focused on how these state strategies to promote medical tourism affect the health outcomes of people in destination countries, nor on the gendered labor that supports these state strategies. This article fills these gaps by analyzing medical tourism in Thailand as a gendered techno-development strategy, or a state-sponsored initiative which incorporates gendered labor and technologies, while also creating gendered health inequities. The article bridges a political economy approach to global health with gendered analyses of health and labor. The analysis draws on 14 months of ethnographic fieldwork in Thailand, conducted in 2016 and 2017-2018, and in-depth interviews with 62 participants. It illuminates the gendered labor relations that help foster state development strategies such as medical tourism, as well as gendered health outcomes for people in a destination country.

Coupling Coordination and Spatiotemporal Dynamic Evolution Between Medical Services and Tourism Development in China

This work constructs an evaluation index system and quantitatively explores the coupling coordination relationship between the tourism development system and the medical services system in China. Results show that the degree of coupling coordination between the tourism development system and the medical services system showed a good upward trend in China during the period 2012–2019. However, the relationship was barely balanced, with tourism development lagging. The overall layout shows a spatial pattern of “high in the north and low in the south, high in the east and low in the west.” The degree of coupling coordination tends to be randomly distributed from clustered distribution, and the cold–hot spots show a spatial development pattern of “cold in the northwest and hot in the southeast” as time passes. The power of government to regulate has always been an important mechanism affecting the degree of coupling coordination. The study aims to provide reference for the rationalization of medical tourism layout and sustainable development.

Strategies for mitigating the effects of a pandemic on Indian medical tourism

India is a favorable destination for medical tourism because ofits quality healthcare services and affordable treatment costs. Itis a continuously growing industry across the globe. But wheneverany pandemic situation arises, it adversely affects the industry.Currently, COVID-19 has a severe negative impact onthe medical tourism sector. This paper discusses the effects of apandemic, critical issues, SWOT analysis, and components thatmitigate the adverse effects of pandemic diseases on medicaltourism in India. During this phase, it is crucial to encouragedomestic medical tourism for the sustainability of this sector. India’sheritage of ancient medicine promotion, along with modernmedicine can captivate the medical tourists. The destinationcountry requires meeting the expectations of tourists throughquality services. With India entering this unexpected downturnin this sector, destination country it must emphasize the slowand steady growth of medical tourism against the current andpotential future pandemics.

The Benefits of Blockchain Technology for Medical Tourism

The paper discusses the benefits of blockchain technology for medical tourism. The major focus is placed on pre-procedure and post-procedure of medical tourism. The authors argue that blockchain technology can facilitate several stages of medical tourism by enabling disintermediation, allowing cryptocurrency payments, ensuring secure data sharing and privacy, and empowering trusted review systems. With regard to COVID-19 pandemic, the paper outlines the current challenges of the medical tourism industry and prop oses the opportunities for blockchain technology use. The paper attempts to provide important insights regarding the positive implications of blockchain technology use within the medical tourism industry as well as to further advance the current knowledge about blockchain technology’s effects for medical tourism.

Medical, Health and Wellness Tourism Research-A Review of the Literature (1970-2020) and Research Agenda

Medical, health and wellness tourism and travel represent a dynamic and rapidly growing multi-disciplinary economic activity and field of knowledge. This research responds to earlier calls to integrate research on travel medicine and tourism. It critically reviews the literature published on these topics over a 50-year period (1970 to 2020) using CiteSpace software. Some 802 articles were gathered and analyzed from major databases including the Web of Science and Scopus. Markets (demand and behavior), destinations (development and promotion), and development environments (policies and impacts) emerged as the main three research themes in medical-health-wellness tourism. Medical-health-wellness tourism will integrate with other care sectors and become more embedded in policy-making related to sustainable development, especially with regards to quality of life initiatives. A future research agenda for medical-health-tourism is discussed.

Lessons from COVID-19's impact on medical tourism in Cambodia

Making medical tourism a more valuable healthcare system is a significant public health issue. However, little discussion has been conducted on what lessons can be learned from the impact of COVID-19 on medical tourism. This study aimed to discuss the issues and barriers faced by patients unable to seek medical tourism, and the medical care experience at private general hospital in capital, Cambodia. First, when patients seeking medical tourism were unable to go abroad due to the pandemic or other reasons, some of them could not easily visit domestic health care facilities. Second, even if patients received medical care in the home country's hospitals due to the interruption of medical tourism, sharing the patient's medical information between domestic and overseas medical institutions was difficult. The third problem in medical tourism is that dependence on overseas medical resources might hinder the development of medical professionals, facilities, and other environments in the country of origin. This experience revealed the need to encourage patients who were unable to undertake medical tourism to visit domestic medical facilities, make efforts to share patient information across countries, and to invest in developing each department in domestic hospitals. Support for patients who are unable to undertake medical tourism is urgently needed.

Functional Outcomes and Health-Related Quality of Life Before and After Primary Total Knee Replacement for Patients From Diverse Geographic Regions

BACKGROUND

The purpose of this study was to investigate whether patient-reported knee function and health status before and after primary total knee replacement (TKR) at an academic medical center differs among patients from diverse geographic regions.

METHODS

We assessed patient-reported outcomes (PROs) as measured by the Oxford Knee Score (OKS) and EuroQoL-5D (EQ-5D) in 2855 TKR patients at preprimary and one year postprimary TKR procedure between January 1, 2012 and June 30, 2014. We compared the demographic characteristics, response rates, and changes in OKS, EQ-5D, and EQ visual analog scale among local, regional, and national patient groups. Patient- or hospital-related predictors of the postoperative scores were identified after controlling for preoperative scores on the PRO measures.

RESULTS

Local patients had more comorbid conditions. Groups were similar in clinical outcomes such as length of stay at hospital, complication, and reoperation rates. Local, regional, and national patients had similar response rates and reported a similar level of knee function and health-related quality of life before and after TKR. Eighty nine percent had clinically important improvement on OKS, 69% on EQ-5D index, and 28% EQ visual analog scale, and there were no differences among groups in the proportions of clinically meaningful change. Better postoperative PRO scores were associated with older age, shorter hospital stay, fewer comorbidities, nonsmoking status, fewer complications, and private health insurance.

CONCLUSION

Some patient characteristics such as comorbidities were greater in the local patient cohort versus the national cohort. Nevertheless, clinical outcomes and PROs were comparable across all geographic tiers.

Bibliometrix analysis of medical tourism

Medical tourism is an expanding phenomenon. Scientific studies address the changes and challenges of the present and future trend. However, no research considers the study of bibliometric variables and area of business, management and accounting. This bibliometric analysis discovered the following elements: (1) The main articles are based on guest services, management, leadership principles applied, hotel services associated with healthcare, marketing variables and elements that guide the choice in medical tourism; (2) The main authors do not deal with tourism but are involved in various ways in the national health system of the countries of origin or in WHO; (3)cost-efficiency and analytical accounting linked to medical tourism structures and destination choices are not yet developed topics.

Travel-Related Antimicrobial Resistance: A Systematic Review

There is increasing evidence that human movement facilitates the global spread of resistant bacteria and antimicrobial resistance (AMR) genes. We systematically reviewed the literature on the impact of travel on the dissemination of AMR. We searched the databases Medline, EMBASE and SCOPUS from database inception until the end of June 2019. Of the 3052 titles identified, 2253 articles passed the initial screening, of which 238 met the inclusion criteria. The studies covered 30,060 drug-resistant isolates from 26 identified bacterial species. Most were enteric, accounting for 65% of the identified species and 92% of all documented isolates. High-income countries were more likely to be recipient nations for AMR originating from middle- and low-income countries. The most common origin of travellers with resistant bacteria was Asia, covering 36% of the total isolates. Beta-lactams and quinolones were the most documented drug-resistant organisms, accounting for 35% and 31% of the overall drug resistance, respectively. Medical tourism was twice as likely to be associated with multidrug-resistant organisms than general travel. International travel is a vehicle for the transmission of antimicrobial resistance globally. Health systems should identify recent travellers to ensure that adequate precautions are taken.

Knowledge management orientation and operational performance relationship in medical tourism (overview of the model performance in the COVID-19 pandemic and post-pandemic era)

Despite the considerable growth of interest in medical tourism in the last decade, there is no standard procedure to measure the pivotal factors in medical tourism destinations. Medical tourism is a rising global phenomenon that is strongly dependent on innovation and knowledge management. Being both innovative and systematic in medical tourism requires thought enrichment in knowledge management in hospitals. By applying a quantitative method, "knowledge management-oriented innovation" items have been used in this study to analyze new products or services related to active hospitals in medical tourism in Iran. This study presents the positive effects of the most essential knowledge management areas such as time, cost, and quality management orientation, on operational performance through the mediating role of innovation speed. In the current study, hospitals of Iran that are active in the medical tourism area have been considered as the final destination. Additionaly, because this study coincides with the coronavirus COVID-19 pandemic as the global health crisis which has a considerable effect on medical tourism, the managerial implications have been developed to help managers and decision-makers in order to apply the obtained findings during the pandemic and post-pandemic period.

"Not from home": Cancer screening avoidance and the safety of distance in Eswatini

This paper shows how travel and distance make cervical cancer screening safer for women in Eswatini. It is based on three months of original ethnographic research conducted in a semi-urban town in Eswatini from September to December 2014, involving daily participant observation and semi-structured, in-depth interviews with 20 women and 7 health workers. Results of the research show how women use travel to create safer clinical spaces and encounters in the context of cancer screening. Specifically, the research found that in the cervical cancer screening clinic, women's bodies are negatively judged and talked about. This creates fear - of judgment, verbal violence and gossip - all of which are intensified in hospitals and with nurses who are close to home. It is a fearful, laborious and difficult clinical encounter which causes a medical migration, where women seek screening in distant hospitals and with nurses who are "not from home." Distance provides anonymity and minimizes pathways of gossip, thus mitigating fear and making cervical cancer screening safer for women. The social rationale around distance shows how travel can create or recreate clinical spaces and experiences of care in the context of local medical migration. It also upsets culturalist assumptions about women's avoidance of cervical screening. Improving cancer screening programs in Eswatini calls for an approach sensitive to the clinical and social realities that create fear and constrain women's choices.

Medical Tourism and Diabetes Care: Experience from a Tertiary Referral Center

OBJECTIVE

Medical tourism, a form of patient mobility across international borders to seek medical services, has gained significant momentum. We aimed to assess the outcomes of medical tourism consultations on chronic diseases, more specifically diabetes mellitus, amongst a cohort of international patients, originating from different healthcare systems, and referred to the United States for medical care.

METHODS

We identified international adults with established diabetes mellitus, referred globally from 6 countries to the United States between 2010 and 2016 for medical care, and were seen at the Cleveland Clinic Foundation (CCF). Group 1 included adults seen by an endocrinology provider during their CCF medical stay, whilst group 2 included those not seen by an endocrinology provider. To assess the impact of our consultations, changes in hemoglobin A1c (HbA1c) were assessed between visit(s).

RESULTS

Our study included 1,108 subjects (771 in group 1, 337 in group 2), with a mean age (± SD) of 61.3±12.7 years, 62% male, and a median medical stay of 136 days (interquartile range: 57, 660). Compared to group 2, group 1 had a higher baseline mean HbA1c (8.0 ± 1.8% [63.9 mmol/mol] vs. 7.1 ± 1.4% [54.1 mmol/mol]; P<.001). After 1 visit with endocrinology, there was a significant decrease in mean HbA1c from 8.44 ± 1.98% (68.3 mmol/mol) to 7.51 ± 1.57% (58.5 mmol/mol) (P<.001). Greatest reductions in mean HbA1c were -1.47% (95% CI: -2.21, -0.74) and -1.27% (95% CI: -1.89, -0.66) after 3 and 4 visits, respectively (P<.001).

CONCLUSION

Short-term diabetes mellitus consultations, in the context of medical tourism, are effective.

Enhancing Research and Development in the Health Sciences as a Strategy to Establish a Knowledge-Based Economy in the State of Kuwait: A Call for Action

Kuwait Vision 2035 is an initiative that was launched in 2017 by His Highness the Emir of the State of Kuwait Sheikh Sabah Al-Ahmad Al-Jaber Al-Sabah. This initiative includes the implementation of a detailed development plan aimed at transforming the state of Kuwait into a regional leader in science, technology, and innovation. Health research will arguably prove to be one of the most impactful research arenas when it comes to accomplishing the goals set forth by the Kuwait Vision 2035 Development Plan. The high impact of health research is derived from its capacity to aid in the establishment of a knowledge-based health industry. The state of Kuwait lacks a system for promoting and managing national R&D efforts. At present, the research and development (R&D) expenditure in the state of Kuwait is far below the international standards that have been shown to lead to innovation and the subsequent development of a knowledge-based economy. Improvement of the weak and unstructured existing R&D apparatus in the State of Kuwait is among the most urgent challenges facing the nation as it strives toward innovation and development of a knowledge-based economy. Developing health research capacities in the State of Kuwait can significantly contribute toward improving public health, health promotion, disease prevention and treatment, and overall human welfare. Importantly, the positive impacts of such extensive benefits will not be restricted to the state of Kuwait and its citizens, but may in fact reap benefits for the global society as a whole. This article first analyzes the current status of healthcare services and health science research in the State of Kuwait, and then summarizes some essential R&D design principles that Kuwait needs to implement in order to achieve the milestones set forth in the Kuwait Vision 2035 Development Plan.

An Integrative Review of Patients' Experience in the Medical Tourism

Medical tourism has emerged as an industry due to the constantly improved information technology and decreasing cost for transportation. Evidence on how medical tourists develop their medical travel and their experience keeps growing. This article aims to provide an integrative review to understand medical tourism from the patients' perspective. PRISMA procedures were followed. All the literature was published from January 1, 2009, to May 4, 2019, in peer-reviewed journals in CINAHL and MEDLINE/PubMed. Johns Hopkins Nursing evidence level and quality guide were used to evaluate evidence level. Twenty-one studies including 8 quantitative, 10 qualitative, and 3 mix-method studies were reviewed. Low cost, short waiting list, quality, and procedures available were the motivators to treatment abroad. The Internet, former tourists' testimonial, and physician and facilitators' advice were the predominant resources consulted. Perceived value of medical quality directly affected patients' overall satisfaction. Our integrative review has led to the identification of many factors related to medical tourist's experience. We suggest further empirical researches on (1) the patients' decision-making process of motivators and barriers, (2) the factors related to patients' experience on the health care quality, and (3) the strategies to ensure the continuity of care.

Where is the policy? A bibliometric analysis of the state of policy research on medical tourism

Background

It is imperative that researchers studying medical tourism connect their work with policy, so that its real-world challenges can be better understood, and more effectively addressed. This article gauges the scope and evolution of policy thinking in medical tourism research through a bibliometric review of published academic literature, to establish the extent to which researchers apply public policy theories and frameworks in their investigation of medical tourism, or consider the policy imperatives of their work.

Methods

A Boolean search of the Web of Science (WoS) Core Collection was performed to identify policy-related publications on medical tourism. We analyzed the results using bibliometrics and a data visualization software called VOSviewer to identify patterns in knowledge production and underlying network linkages in policy research on the subject.

Results

Our findings suggest that only a small proportion of medical tourism research explicitly addresses policy issues or applies policy paradigms in their study approach. Field-specialized journals serving practitioners publish less research as compared to interdisciplinary social and health policy journals. Moreover, there are significant geographical and disciplinary disparities in the policy-orientation of research, and a predilection towards select policy areas such as reproductive and transplant tourism to the neglect of more holistic governance and health system considerations.

Conclusion

This article is a call to action for greater engagement by policy scholars on medical tourism, and for health researchers to more explicitly consider how their research might contribute to the understanding and resolution of contemporary policy challenges of medical tourism. Failure to clearly and consistently make the policy connection is a lost opportunity for researchers to frame the public debate, and influence policy thinking on medical tourism.

Early Surgical Management of Medical Tourism Complications Improves Patient Outcomes

BACKGROUND

Complications from medical tourism can be significant, requiring aggressive treatment at initial presentation. This study evaluates the effect of early surgical versus conservative management on readmission rates and costs.

METHODS

A single-center retrospective review was conducted from May of 2013 to May of 2017 of patients presenting with soft-tissue infections after cosmetic surgery performed abroad. Patients were categorized into two groups based on their management at initial presentation as either conservative or surgical. Demographic information, the procedures performed abroad, and the severity of infection were included. The authors' primary outcome was the incidence of readmission in the two groups. International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; and CPT codes were used for direct-billed cost analysis.

RESULTS

Fifty-three patients (one man and 52 women) presented with complications after procedures performed abroad, of which 37 were soft-tissue infections. Twenty-four patients with soft-tissue infections at initial presentation were managed conservatively, and 13 patients were treated surgically. The two groups were similar in patient demographics and type of procedure performed abroad. Patients who were managed conservatively at initial presentation had a higher rate of readmission despite having lower severity of infections (OR, 4.7; p = 0.037). A significantly lower total cost of treatment was shown with early surgical management of these complications (p = 0.003).

CONCLUSIONS

Conservative management of complications from medical tourism has resulted in a high incidence of failure, leading to readmission and increased costs. This can contribute to poor outcomes in patients that are already having complications from cosmetic surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

The north-south policy divide in transnational healthcare: a comparative review of policy research on medical tourism in source and destination countries

Medical tourism occupies different spaces within national policy frameworks depending on which side of the transnational paradigm countries belong to, and how they seek to leverage it towards their developmental goals. This article draws attention to this policy divide in transnational healthcare through a comparative bibliometric review of policy research on medical tourism in select source (Canada, United States and United Kingdom) and destination countries (Mexico, India, Thailand, Malaysia and Singapore), using a systematic search of the Web of Science (WoS) database and review of grey literature. We assess cross-national differences in policy and policy research on medical tourism against contextual policy landscapes and challenges, and examine the convergence between research and policy. Our findings indicate major disparities in development agendas and national policy concerns, both between and among source and destination countries. Further, we find that research on medical tourism does not always address prevailing policy challenges, just as the policy discourse oftentimes neglects relevant policy research on the subject. Based on our review, we highlight the limited application of theoretical policy paradigms in current medical tourism research and make the case for a comparative policy research agenda for the field.

The Theory of Planned Behaviour in Medical Tourism: International Comparison in the Young Consumer Segment

The Theory of Planned Behaviour (TPB) assumes the possibility of predicting and explaining humans' behaviour by identifying their intentions. The intentions are shaped by three groups of factors: attitudes towards, social norms and perceived behavioural control over the behaviour. The aim of the research is to examine the applicability of the TPB in medical tourism and to check whether there are differences in predicting the intentions of medical tourists from different countries. The study covered potential medical tourists-521 young consumers from three regionally important markets in medical tourism services: Jordan, Poland and Turkey. The study used a research survey to collect data, which were analysed using the multiple regression and analysis of variance methods. The research showed that the TPB model can be used in medical tourism. The results also show that the consumers' country of origin is a significant factor when predicting their intention to use medical tourism services.

Critical Success Factors of Medical Tourism: The Case of South Korea

The purpose of this study was to identify the key success factors of medical tourism using the case of South Korea. Medical tourism refers to the phenomenon of travelling across national borders intentionally to access a variety of medical treatments, especially modern medical treatment. Through conducting semi-structure face-to-face in-depth interviews with the service suppliers of Korean medical tourism, it was discovered that Korean medical tourism has been facilitated by the effect of Hallyu and advanced Korean brand power. More importantly, tourism activities for companions and extra support for patients’ convenience are identified as important success factors of Korean medical tourism, suggesting that the medical tourism industry not only includes medical services but also involves tourism perspectives, supporting the patient and their companions to stay in a comfortable and pleasurable environment. This study generated results which are valuable for both academic and industry perspectives, as this is a field which has not been extensively researched. Medical tourism representatives in other countries can consult these findings to develop the industry.

Medical Tourism in Guatemala: Qualitatively Exploring How Existing Health System Inequities Facilitate Sector Development

This article explores how existing health inequities in the Guatemalan health system facilitate the emergence of its medical tourism industry. We report on our thematic analysis of 50 key informant interviews conducted with 4 groups of stakeholders in the local medical tourism sector. Participants frequently discussed the interplay between the country’s longstanding health inequities and the promotion of medical tourism, characterized by 4 thematic viewpoints: the private health sector is already flourishing; the highly fragmented health system already faces multiple challenges; the underfunded public health sector has a weak regulatory capacity; and the commodification of health care has already advanced. Medical tourism and health inequities shape each other in low- and middle-income countries. In addition to the potential for medical tourism to exacerbate health inequities, previously existing health inequities create opportunities for the industry’s growth. Although regulation of the medical tourism industry is necessary, it needs to be implemented both at the domestic and supranational levels for it to be effective in preventing greater health inequities, and it needs to address the political and economic drivers that make health systems generate health disparities.

"Medical tourism will…obligate physicians to elevate their level so that they can compete": a qualitative exploration of the anticipated impacts of inbound medical tourism on health human resources in Guatemala

BACKGROUND

Medical tourism, which involves cross-border travel to access private, non-emergency medical interventions, is growing in many Latin American Caribbean countries. The commodification and export of private health services is often promoted due to perceived economic benefits. Research indicates growing concern for health inequities caused by medical tourism, which includes its impact on health human resources, yet little research addresses the impacts of medical tourism on health human resources in destination countries and the subsequent impacts for health equity. To address this gap, we use a case study approach to identify anticipated impacts of medical tourism sector development on health human resources and the implications for health equity in Guatemala.

METHODS

After undertaking an extensive review of media and policy discussions in Guatemala's medical tourism sector and site visits observing first-hand the complex dynamics of this sector, in-depth key informant interviews were conducted with 50 purposefully selected medical tourism stakeholders in representing five key sectors: public health care, private health care, health human resources, civil society, and government. Participants were identified using multiple recruitment methods. Interviews were transcribed in English. Transcripts were reviewed to identify emerging themes and were coded accordingly. The coding scheme was tested for integrity and thematic analysis ensued. Data were analysed thematically.

RESULTS

Findings revealed five areas of concern that relate to Guatemala's nascent medical tourism sector development and its anticipated impacts on health human resources: the impetus to meet international training and practice standards; opportunities and demand for English language training and competency among health workers; health worker migration from public to private sector; job creation and labour market augmentation as a result of medical tourism; and the demand for specialist care. These thematic areas present opportunities and challenges for health workers and the health care system.

CONCLUSION

From a health equity perspective, the results question the responsibility of Guatemala's medical education system for supporting an enhanced medical tourism sector, particularly with an increasing focus on the demand for private clinics, specific specialities, English-language training, and international standards. Further, significant health inequalities and barriers to care for Indigenous populations are unlikely to benefit from the impacts identified from participants, as is true for rural-urban and public-private health human resource migration.

The upside of trade in health services

Cross border movement of patients and health workers is often portrayed negatively but Johanna Hanefeld and Richard Smith discuss how it can benefit both source and recipient countries as long as the risks are properly managed

Factors influencing inbound medical travel to India

PURPOSE

The purpose of this paper is to explore the demand-side factors that influence the inbound medical tourists' (MTs) decision to travel abroad for medical treatment/surgery.

DESIGN/METHODOLOGY/APPROACH

The researchers conducted thematic analysis of in-depth interviews in India with 24 foreign MTs' to generate the themes, identify factors and propose a model with hypothesis for future quantitative survey.

FINDINGS

The findings conclude that patients ranked in ascending order less waiting time for surgery, healthcare quality and accreditation, staff/surgeons expertise, healthcare information, hospital facilities and services, patient safety, travel risk, surgical costs and holiday opportunity as important factors that influence the decision to travel abroad for medical treatment/surgery.

RESEARCH LIMITATIONS/IMPLICATIONS

Foreign patients from six private hospitals were willing to be interviewed with the permission of the hospital. Due to confidentiality and privacy policy, many hospitals declined interviews with foreign patients.

PRACTICAL IMPLICATIONS

The findings are generalised in case of foreign patients as MTs and all private hospitals treating foreign patients in India and other global healthcare destinations. Policy implications suggest that private hospitals in developing countries need to provide first-class quality of healthcare as foreign patients look for internationally accredited quality, no waiting time, patient safety, qualified and experienced surgeons, healthcare workers education and experience hospital facilities and post-surgery care with positive healthcare outcomes.

ORIGINALITY/VALUE

There is little empirical research on the views of inbound MTs, about factors influencing their decision to travel abroad for surgery to India.

Exploring The Migration Profiles of Primary Healthcare Users in South Africa

South Africa’s public healthcare system responses seldom engage with migration. Our exploratory study investigates migration profiles and experiences of primary healthcare (PHC) users. A cross-sectional survey involving non-probability sampling was conducted with 229 PHC users at six purposively selected PHC clinics in three districts of SA. The survey captured socio-demographic information, migration histories, and PHC experiences. Chi square and Fischer’s exact tests were used to compare categorical variables, whilst Mann–Whitney U tests compared continuous variables between groups. Most PHC users were migrants (22% internal South African; 45% cross-border) who generally move for reasons other than healthcare seeking. Length of time accessing services at a specific clinic was shown to be key in describing experiences of PHC use. Understanding population movement is central to PHC strengthening in SA and requires improved understanding of mobility dynamics in regard to not just nationality, but also internal mobility and length of stay.

Advancing Medical Tourism in the United Arab Emirates: Toward a Sustainable Health Care System

Medical tourism provides an essential advantage for destinations. On the other hand, the knowledge of developing competitive medical tourism destinations is still limited. This study models a conceptual framework on novel ways of sustaining the United Arab Emirate (UAE) Vision 2020 with reference to the existing models on behavior. In the current study, the Theory of Planned Behavior (TPB), which is health-related, along with the Finance, System and connection (FSC) model, is employed. Using an empirically based methodology, the data for the investigation is collected with the aid of a questionnaire. As such, the study employs finance, system, and connections variables which are commonly adopted in testing medical tourism development. The designed model incorporates these three important factors that have remained the focal points in the world of medical tourism. Hence, the result reveals empirical evidence suggesting that the finance, system, and the connection factors significantly foster the growth of tourist arrivals in Dubai. Moreover, it predicates that the significant improvement in the economy of Dubai administrative government is likely to be connected with the development of its medical infrastructure. Additionally, by employing the use of SMART PLS (partial least square) software package, the structural analysis tests, like model fit, further affirms the robustness of the results. In addition, the study presents policy implication for the stakeholders in the health sector, tourism sector, and the government.

Medical tourism and national health care systems: an institutionalist research agenda

Although a growing body of literature has emerged to study medical tourism and address the policy challenges it creates for national health care systems, the comparative scholarship on the topic remains too limited in scope. In this article, we draw on the existing literature to discuss a comparative research agenda on medical tourism that stresses the multifaceted relationship between medical tourism and the institutional characteristics of national health care systems. On the one hand, we claim that such characteristics shape the demand for medical tourism in each country. On the other hand, the institutional characteristics of each national health care system can shape the very nature of the impact of medical tourism on that particular country. Using the examples of Canada and the United States, this article formulates a systematic institutionalist research agenda to explore these two related sides of the medical tourism-health care system nexus with a view to informing future policy work in this field.

Modelling the factors affecting Indian medical tourism sector using interpretive structural modeling

Purpose

Medical tourism encourages the traveling of patients, expert healthcare professionals and promotes cross-border trade in healthcare services. The Indian medical tourism sector is facing new challenges as well as certain ethical and legal issues because of continuous market changes and patient’s requirements while at the same time advancements in current health services have also been observed. It is therefore very important to understand and address the issues of the medical tourists. The purpose of this paper is to evaluate the important factors which can make India an affordable medical tourism destination.

Design/methodology/approach

In this paper, the factors influencing Indian medical tourism sector have been explored by conducting literature review, they are ranked according to the results of a questionnaire-based survey and further analyzed by using the interpretive structural modeling (ISM) approach. The mutual relationships between these factors were identified to develop an ISM model so as to find out the important factors which can make India an affordable place for medical tourism.

Findings

The results of the survey and the model show that cost of medical procedures, facilitation, and care, the infrastructure of Indian hospitals, clinical excellence and the competence of doctors and staff are the top level factors.

Practical implications

It is very important to address the concerns of the patients coming to a developing country like India for availing medical services. This research has evaluated the important factors which can make India an affordable medical tourism destination.

Originality/value

This research assesses the effects of globalization on delivery of healthcare services in India by conducting critical analysis of the medical tourism industry by collecting original data from the international patients coming to India for different types of medical procedures so that a comprehensive model can be prepared which will help the hospitals and policymakers to improve the processes related to medical tourism.

Implications of Medical Tourism

Medical tourism is an emerging industry that facilitates travel to another country for people who seek medical, surgical, or dental care that is unavailable or more affordable than in their home countries. Rapid advances in electronic communication and the ease of international travel have fueled the growth of this industry. More than half of medical travelers are women, especially for services related to cosmetic or reproductive conditions. Medical tourism creates both opportunities and challenges for nurses and other health care providers. Consumers' increased access to the global health care market necessitates the development of a structure that shapes the medical tourism industry and addresses evolving ethical, political, and human rights concerns related to this industry.

How Medical Tourism Enables Preferential Access to Care: Four Patterns from the Canadian Context

Medical tourism is the practice of traveling across international borders with the intention of accessing medical care, paid for out-of-pocket. This practice has implications for preferential access to medical care for Canadians both through inbound and outbound medical tourism. In this paper, we identify four patterns of medical tourism with implications for preferential access to care by Canadians: (1) Inbound medical tourism to Canada's public hospitals; (2) Inbound medical tourism to a First Nations reserve; (3) Canadian patients opting to go abroad for medical tourism; and (4) Canadian patients traveling abroad with a Canadian surgeon. These patterns of medical tourism affect preferential access to health care by Canadians by circumventing domestic regulation of care, creating jurisdictional tensions over the provision of health care, and undermining solidarity with the Canadian health system.

Population Health Implications of Medical Tourism

BACKGROUND

Fifteen million U.S. patients each year seek medical care abroad; however, there are no data on outcomes and follow-up of these procedures. This study aims to identify, evaluate, and survey patients presenting with complications from aesthetic procedures abroad and estimate their cost to the U.S. health care system.

METHODS

A single-center retrospective review was conducted. A cohort of patients presenting with complications from aesthetic procedures performed abroad was generated. Demographic, complication, and cost data were compiled. Patients were surveyed to assess their overall experience.

RESULTS

Over a 36-month period, 42 patients met inclusion criteria (one man and 41 women), with an average age of 35 ± 11.4 years (range, 20 to 60 years). Comorbidities included four active smokers, two patients with hypertension, and one patient with diabetes. Average body mass index was 29 ± 4.4 kg/m (range, 22 to 38 kg/m). Procedures performed abroad included abdominoplasty (n = 28), liposuction (n = 20), buttock augmentation (n = 10), and breast augmentation (n = 7), with several patients undergoing combined procedures. Eleven patients presented with abscesses and eight presented with wound dehiscence. Eight of the 18 patients who were surveyed were not pleased with their results and 11 would not go abroad again for subsequent procedures. Average cost of treating the complications was $18,211, with an estimated cost to the U.S. health care system of $1.33 billion. The main payer group was Medicaid.

CONCLUSIONS

Complications from patients seeking aesthetic procedures abroad will continues to increase. Patients should be encouraged to undergo cosmetic surgery in the United States to improve patient outcomes and satisfaction and because it is economically advantageous.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Developing an informational tool for ethical engagement in medical tourism

BACKGROUND

Medical tourism, the practice of persons intentionally travelling across international boundaries to access medical care, has drawn increasing attention from researchers, particularly in relation to potential ethical concerns of this practice. Researchers have expressed concern for potential negative impacts to individual safety, public health within both countries of origin for medical tourists and destination countries, and global health equity. However, these ethical concerns are not discussed within the sources of information commonly provided to medical tourists, and as such, medical tourists may not be aware of these concerns when engaging in medical tourism. This paper describes the methodology utilized to develop an information sheet intended to be disseminated to Canadian medical tourists to encourage contemplation and further public discussion of the ethical concerns in medical tourism.

METHODS

The methodology for developing the information sheet drew on an iterative process to consider stakeholder feedback on the content and use of the information sheet as it might inform prospective medical tourists' decision making. This methodology includes a literature review as well as formative research with Canadian public health professionals and former medical tourists.

RESULTS

The final information sheet underwent numerous revisions throughout the formative research process according to feedback from medical tourism stakeholders. These revisions focused primarily on making the information sheet concise with points that encourage individuals considering travelling for medical tourism to do further research regarding their safety both within the destination country, while travelling, and once returning to Canada, and the potential impacts of their trip on third parties. This methodology may be replicated for the development of information sheets intending to communicate ethical concerns of other practices to providers or consumers of a certain service.

Reflections on 'medical tourism' from the 2016 Global Healthcare Policy and Management Forum

In October 2016, the Global Healthcare Policy and Management Forum was held at Yonsei University, Seoul, South Korea. The goal of the forum was to discuss the role of the state in regulating and supporting the development of medical tourism. Forum attendees came from 10 countries. In this short report article, we identify key lessons from the forum that can inform the direction of future scholarly engagement with medical tourism. In so doing, we reference on-going scholarly debates about this global health services practice that have appeared in multiple venues, including this very journal. Key questions for future research emerging from the forum include: who should be meaningfully involved in identifying and defining categories of those travelling across borders for health services and what risks exist if certain voices are underrepresented in such a process; who does and does not ‘count’ as a medical tourist and what are the implications of such quantitative assessments; why have researchers not been able to address pressing knowledge gaps regarding the health equity impacts of medical tourism; and how do national-level polices and initiatives shape the ways in which medical tourism is unfolding in specific local centres and clinics? This short report as an important time capsule that summarises the current state of medical tourism research knowledge as articulated by the thought leaders in attendance at the forum while also pushing for research growth.

"Ensure that you are well aware of the risks you are taking…": actions and activities medical tourists' informal caregivers can undertake to protect their health and safety

Background

When seeking care at international hospitals and clinics, medical tourists are often accompanied by family members, friends, or other caregivers. Such caregiver-companions assume a variety of roles and responsibilities and typically offer physical assistance, provide emotional support, and aid in decision-making and record keeping as medical tourists navigate unfamiliar environments. While traveling abroad, medical tourists’ caregiver-companions can find themselves confronted with challenging communication barriers, financial pressures, emotional strain, and unsafe environments.

Methods

To better understand what actions and activities medical tourists’ informal caregivers can undertake to protect their health and safety, 20 interviews were conducted with Canadians who had experienced accompanying a medical tourist to an international health care facility for surgery. Interview transcripts were subsequently used to identify inductive and deductive themes central to the advice research participants offered to prospective caregiver-companions.

Results

Advice offered to future caregiver-companions spanned the following actions and activities to protect health and safety: become an informed health care consumer; assess and avoid exposure to identifiable risks; anticipate the care needs of medical tourists and thereby attempt to guard against caregiver burden; become familiar with important logistics related to travel and anticipated recovery timelines; and take practical measures to protect one’s own health.

Conclusion

Given that a key feature of public health is to use research findings to develop interventions and policies intended to promote health and reduce risks to individuals and populations, the paper draws upon major points of advice offered by study participants to take the first steps toward the development of an informational intervention designed specifically for the health and safety needs of medical tourists’ caregiver companions. While additional research is required to finalize the content and form of such an intervention, this study provides insight into what practical advice former caregiver-companions state should be shared with individuals considering assuming these roles and responsibilities in the future. In addition, this research draws attention to the importance of ensuring that such an intervention is web-based and readily accessible by prospective caregiver-companions.

Ethical issues associated with medical tourism in Africa

Global disparities in medical technologies, laws, economic inequities, and social-cultural differences drive medical tourism (MT), the practice of travelling to consume healthcare that is either too delayed, unavailable, unaffordable or legally proscribed at home. Africa is simultaneously a source and destination for MT. MT however, presents a new and challenging health ethics frontier, being largely unregulated and characterized by policy contradictions, minority discrimination and conflict of interest among role-players. This article assesses the level of knowledge of MT and its associated ethical issues in Africa; it also identifies critical research gaps on the subject in the region. Exploratory design guided by Arksey and O'Malley's (2005) framework was used. Key search terms and prior determined exclusion/inclusion criteria were used to identify relevant literature sources. Fifty-seven articles met the inclusion criteria. Distributive justice, healthcare resource allocation, experimental treatments and organ transplant were the most common ethical issues of medical tourism in Africa. The dearth of robust engagement of MT and healthcare ethics, as identified through this review, calls for more rigorous research on this subject. Although the bulk of the medical tourism industry is driven by global legal disparities based on ethical considerations, little attention has been given to this subject.

What does the development of medical tourism in Barbados hold for health equity? an exploratory qualitative case study

Background

Although the global growth of privatized health care services in the form of medical tourism appears to generate economic benefits, there is debate about medical tourism’s impacts on health equity in countries that receive medical tourists. Studies of the processes of economic globalization in relation to social determinants of health suggest that medical tourism’s impacts on health equity can be both direct and indirect. Barbados, a small Caribbean nation which has universal public health care, private sector health care and a strong tourism industry, is interested in developing an enhanced medical tourism sector. In order to appreciate Barbadians’ understanding of how a medical tourism industry might impact health equity.

Methods

We conducted 50 individual and small-group interviews in Barbados with stakeholders including government officials, business and health professionals. The interviews were coded and analyzed deductively using the schedule’s questions, and inductively for novel findings, and discussed by the authors.

Results

The findings suggest that in spite of Barbados’ universal health care and strong population health indicators, there is expressed concern for medical tourism’s impact on health equity. Informants pointed to the direct ways in which the domestic population might access more health care through medical tourism and how privately-provided medical tourism in Barbados could provide health benefits indirectly to the Barbadian populations. At the same time, they cautioned that these benefits may not materialize. For example, the transfer of public resources — health workers, money, infrastructure and equipment — to the private sector to support medical tourism with little to no return to government revenues could result in health inequity through reductions in access to and availability of health care for residents.

Conclusions

In clarifying the direct and indirect pathways by which medical tourism can impact health equity, these findings have implications for health system stakeholders and decision-makers in Barbados and other countries attempting both to build a medical tourism industry and to protect health equity.

A qualitative exploration of how Canadian informal caregivers in medical tourism use experiential resources to cope with providing transnational care

Canadians travelling abroad for privately arranged surgeries paid for out-of-pocket are engaging in what has come to be known as medical tourism. They are often accompanied by friends or family members, who we call caregiver-companions. Caregiver-companions provide care in and across a variety of formal and informal settings, such as in hotels, airplanes and at home. This qualitative study examines the experiences of informal caregivers in medical tourism to learn more about the lived experiences or 'experiential resources' they draw upon to cope with providing care and avoiding caregiver burden. The care-giving literature has demonstrated that such burden can negatively impact caregivers' well-being. The unique, transnational context of care-giving in medical tourism and recent growth in popularity of this practice means that there are few supports or resources currently in place to assist informal caregivers. In this article, we report on an analysis that sought to detail how caregiver-companions draw upon their previous lived experiences to cope with providing transnational care and to minimise or avoid the onset of caregiver burden. We conducted semi-structured telephone interviews with 20 Canadians who had accompanied their friends or family members abroad for surgery between September 2013 and January 2014. Thematic analysis revealed the ways that participants had developed practical strategies to deal with the challenges they faced in medical tourism. The interviews revealed three important experiential resources drawn upon by participants: (i) previous experiences of international travel; (ii) previous experiences of informal care-giving; and (iii) dimensions of the existing relationship with the care recipient. Differences in access to and use of these experiential resources related to participants' perspectives on medical tourism and the outcomes of the trip. By identifying the experiential resources drawn upon by informal caregivers in medical tourism, we can more effectively identify supportive interventions.