A new inequality? Privatisation, urban bias, migration and medical tourism

A new inequality? Privatisation, urban bias, migrationand medical tourismapv_1454 260..271

John ConnellSchool of Geosciences, University of Sydney, Sydney, NSW 2006, Australia.

Email: [email protected]

Abstract: Access to health care in developing countries, the main destinations of medical tourists,is notoriously uneven, and often becoming more so. Medical tourism, urban bias and privatisationhave combined to exacerbate this trend. This is exemplified in both Thailand and India, whereregional areas have been disadvantaged by the migration of health-care workers to hospitals focusingon medical tourism, neo-liberal national financial provision for medical tourism (and related tourismcampaigns) and evidence of trickle-down gains is lacking. Medical tourism challenges rather thancomplements local health care providers, distorts national health care systems, and raises criticalnational economic, ethical and social questions.

Keywords: Asia, equity, ethics, medical tourism, social justice

Medical tourism can be very loosely defined(although all definitions are contested) as themovement of patients across internationalborders for medical care that is more expensiveor less accessible at home. It is said to havegrown explosively since the late 1990s, withlarge numbers of patients moving across interna-tional borders to countries such as Mexico, Indiaand Thailand. A rapidly growing number ofstudies have variously documented the rise ofAsian, and also European and Latin Americandestinations, as countries have sought to diver-sify economies and build on existing tour-ism industries and health-care systems (e.g.Bookman and Bookman, 2007; Reisman, 2010).Increasing numbers of destination countrieshave enthusiastically marketed themselves ashealth tourism destinations, hundreds of medicaltourism companies have become travel agents,brokering and facilitating medical travel, andextraordinary claims have been made for thenumerical growth of medical tourism, especi-ally by industry participants and destinationcountries. Although numbers are ubiquitouslyboosted as marketing strategies and symbols ofsuccess, careful analysis indicates that the indus-try is significantly centred in South and SoutheastAsia, in India, Malaysia, Singapore andThailand.

Thailand is widely regarded as the ‘global leader’in terms of numbers of patients/tourists, probablyfollowed by India (Whittaker, 2008; Connell,2011; Medhekar, 2011). Social, economic andpolitical circumstances vary between countries,a situation of ‘ethical variability’ that underpinsgeographical variations in regulatory contexts(Roberts and Scheper-Hughes, 2011), which inturn influences the national structure andcontent of medical tourism.

Medical tourism has resulted in growing‘tourist’ numbers and significant income gains inseveral Asian countries, and widespread enthu-siasm from other countries, such as the Philip-pines and Vietnam, to be involved. It has nothowever been without controversy, althoughethical considerations and issues of social justicehave often been buried in a surfeit of studies thathave focused on marketing, product differentia-tion and so on (Connell, 2011). The rise ofmedical tourism raises questions about accessto health care in an era of neo-liberal globalisa-tion, marked in the health sector by privatisa-tion, deregulation and, especially in the case ofmedical tourism, commodification and compe-tition. Indeed neo-liberal conditions have pro-vided the context for the growth of medicaltourism, through the rise of a significant middle

Asia Pacific Viewpoint, Vol. 52, No. 3, December 2011ISSN 1360-7456, pp260–271

© 2011 The AuthorAsia Pacific Viewpoint © 2011 Victoria University of Wellington

doi: 10.1111/j.1467-8373.2011.01454.x

class in most countries, the parallel rise of privatehospitals, huge developments in medical tech-nology and the eventual search by hospitals fornew markets. This paper therefore constitutes aninitial approach to some of the more evidentlyethical, equity and social justice issues attachedto the rise of medical tourism in Asia, and to theparticular relationship between privatisationand medical tourism, as played out in differentgeographical contexts.

While most popular accounts of medicaltourism focus on relatively benign cosmetic andother relatively straightforward medical proce-dures with high success rates, there is an ‘under-belly’ of more complex procedures, such as stemcell therapy and transplants, where success ratesare lower. Such processes and procedures haveraised particular and distinctive ethical andmoral concerns, but the numbers involved areslight relative to most other areas of medicaltourism. Nonetheless, most ethical debates overmedical tourism have centred on such specificprocedures as organ transplants, stem celltherapy, reproductive tourism, fertility and surro-gacy (e.g. Turner, 2010; Whittaker, 2010;Widdows, 2011). However, this is a small,if problematic, part of medical tourism (andalso contested as a form of tourism) that hasbeen considered in detail elsewhere and is notdiscussed here.

All forms of medical tourism raise questionsabout the appropriate use of skilled healthworkers, the allocation of financial resourcesand the distribution of health care. These ques-tions are considered here principally with par-ticular reference to two of the leading medicaltourism destinations, India and Thailand. Healthcare systems in developing countries, some ofthe main destinations of medical tourists, arenotoriously uneven, and often becoming moreso, both geographically and in terms of socio-economic status, as scarce financial resourcesare directed elsewhere. Uneven developmenthas grown in circumstances where both urbanbias and the decay of remote and regional facili-ties have long occurred. Increased centralisationhas been hastened by privatisation, stagnantbudgets for health expenditure and, possibly,by medical tourism. Yet, despite considerableconcern, ‘most of the literature is “data free” andbased on theory, assumption and conjecture’(Lautier, 2008: 102), detailed analysis of the

national impacts of medical tourism is yet tooccur, and evaluations of its local social andeconomic effects are scarcely even fragmen-tary. This is therefore necessarily a preliminaryattempt to address this gap and extend beyondrhetoric.

Certain inherent negative consequences ofmedical tourism for national health-care systemsare assumed to exist. Thus, Bookman andBookman, 2007 state that:

More often than not, in developing countrieswhere medical tourism flourishes, basic healthcare for rural populations and the urban pooris rudimentary. A dual medical system hasemerged in which specialisation in cardiology,opthalmology and plastic surgery serves theforeign and wealthy domestic patients whilethe local populations lack basics such as sani-tation, clean water and regular deworming.(2007: 7)

Similar perspectives exist elsewhere (Turner,2007; Reisman, 2010). It is however question-able whether that duality is quite so rigid,whether there are no redeeming features ofmedical tourism and whether in regimes of pri-vatisation disadvantaged groups would be mar-ginalised and ignored in any case, as they haveso often previously been. In a context wheredata are notoriously poor, so that even anec-dote retains a role (Connell, 2011), the socio-economic consequences of medical tourism areexamined below.

Symbols and substance

There is a considerable disjuncture between thebranded corporate images of medical tourismand the sometimes harsh reality of majorityhealth care in particular countries. This is par-ticularly evident in India where the dividebetween the public sector and the advancingprivate sector is epitomised in medical tourismand the emergence of corporate medicalchains. Thus in 2007, the web site of ApolloHospitals, the largest national and internationalmedical chain in India, advertised:

With over 7000 beds in 38 hospitals, a string ofnursing and hospital management colleges,and dual lifelines of pharmacies and diagnosticclinics providing a safety net across Asia,

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Apollo Hospitals is a healthcare powerhouseyou can trust with your life. We unite excep-tional clinical success rates and superior tech-nology to match the best in the West withcenturies-old traditions of Eastern care andwarmth. Because at Apollo Hospitals webelieve the world is our extended family –something our 14 million patients from 55countries can warmly affirm. And by provid-ing patient care beyond compare, we dream ofa healthy, happy planet for all. (http://www.apollohospitals.com)

Apollo Hospitals thus provide something of theintended new face of medical care – a success-ful transnational phenomenon in a pleasant,modern context. As Tourism India noted in2006, ‘So the wheel has come full circle.Instead of Western missionary docs coming toIndia to treat the poor now we have rich FirstWorlders buying medicare here’. Even seem-ingly detached academic accounts have rhap-sodised over Apollo, with total deference totheir web page, concluding:

Its history of achievements, with its uniqueability of resource management and abledeployment of technology and knowledge inthe service of mankind, justifies its recognitionin India and abroad . . . Apollo has developedover time unassailable brand equity. (George,2009: 368–370)

Parallel eulogies exist in the pages of businessmanagement texts and industry journals. Anyflaws in Indian development and public healthmust therefore be carefully hidden, since theyaccentuate the challenges of marketing medicaltourism in India:

The sight of the country’s overcrowded publichospitals, open sewers and garbage litteredstreets would unsettle most visitors’ confidenceabout public sanitation standards in India.Private health care providers would argue thatforeigners can be sheltered from such nasti-ness. (Swain and Sahu, 2008: 2)

While India’s public sector health-care andsanitation systems are indeed largely detachedand distinct from medical tourism, they are allpart of a national political economy.

Similar divisions and dichotomies occur else-where if not in such stark terms. Even within

hospitals, as in Thailand, differences betweenthe private medical tourism sector and thepublic sector can be considerable. Phuket Inter-national Hospital, for example, has an air-conditioned wing for medical tourists ‘with thesleek furniture and lush floral arrangements of aboutique hotel. . . flat screened TVs and viewsof manicured gardens’, but after the writer tooka wrong turn she arrived ‘in the public ward, 40degrees hot and packed with “real” people’(Nash, 2009: 16–17). The two sectors are notdestined to meet, and there is little evidence ofservices and benefits being extended from theprivate to the public sector.

However, in an appropriate taxation regime,it is possible that medical tourism can leadto improved public health. In the lone medi-cal tourism guidebook that considers suchissues euphoria reigns: in the Philippines, ‘theincome from medical tourism serves to under-write health care for the poor’ and ‘virtually theentire medical system of Thailand is underwrit-ten by its medical tourism services. Medicaltourism throughout Asia is providing major gainsin quantity and quality of healthcare to the localpopulation’ (Gahlinger, 2008: 88, 35). No sup-porting evidence exists to support such boldclaims, and other sources are much less san-guine. While Indian private sector hospitalsargue that private payments for medical care,and hotels and other services, will trickle downand benefit the economy as a whole, there isminimal evidence of this, in the absence ofeffective taxation policies, and unless morerevenue is allocated to public health systemsimpacts will be negligible (Chinai and Goswami,2007: 165).

Migration

A direct outcome of medical tourism has beenthe more rapid expansion of a private healthsector labour market in medical tourism desti-nations, and the movement of health workersinto the urban, private sector, even where ‘alter-native’ care systems are significant (Spitzer,2009: 145). That sometimes involves migrationfrom rural areas. Such migration has empha-sised existing regional inequalities in access tohealth care.

India, like many other medical tourism desti-nations, including Thailand, has a shortage of

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doctors (and other health professionals). Indiahas just four doctors per 10 000 people,whereas the USA has 27, and accelerated inter-national migration of health workers has meantthat these numerical disparities are steadilyincreasing (Mudur, 2004; Connell, 2010). Ironi-cally, some part of medical tourism is aresponse to long waiting lists, which follow boththe rise in demand and restricted provision, pri-marily but far from exclusively in developedcountries, hence demand and waiting listsare transferred to relatively poor and middleincome countries. The flow of medical touristsaway from still better served countries empha-sises that medical tourism is a perverse flowin terms of overall national health systemcapacities.

Where medical tourism has been accompa-nied by a shift of workers from elsewhere in themedical care system, uneven development islikely to be intensified. In both Thailand andIndia, for example, the availability of doctors ismuch less in regional and remote areas (andIndia, like other parts of South Asia, also experi-ences the phenomenon of rural ‘ghost doctors’:officially present and earning salaries but neveractually there). Moreover, rural–urban migrationof health workers was intensifying even beforethe growth of medical tourism. Attractive privatesector opportunities, enhanced through medicaltourism, have been a significant influence onthat migration (Connell, 2010), intensifyingurban bias and national imbalances in health-care provision. A substantial part of the diseaseburden in India is infectious diseases, such asmalaria and tuberculosis that are not a focus ofmedical tourism; states where such diseasesflourish, such as Bihar and Uttar Pradesh, areparticularly disadvantaged by regional humanand physical resource shifts.

Urban bias in health-care delivery has inten-sified everywhere. In Malaysia, health care deliv-ery is increasingly inequitable (Rasiah et al.,2009), and in Thailand, ‘there is a huge drain onthe public health sector. To practise medicine inThailand you must pass a Thai language exami-nation, so the booming private sector can takestaff from only one place’ (Levett, 2005: 27). Asthe Secretary General of the Thai Holistic HealthFoundation has pointed out, ‘In the past we hada brain drain; doctors wanted to work outside thecountry to make more money. Now they don’t

have to leave the country, the brain drain isanother part of our own society’ (quoted inLevett, 2005: 27). Five years later, medicaltourism was regarded by the Secretary-Generalof the National Health Commission of Thailandas ‘the accelerator causing the brain-drain ofdoctors, super-specialists and other medicalworkers to private hospitals’ (quoted in Cham-bers, 2011: 46). InThailand, the main destinationfor medical tourism, the leading destination hos-pital, Bumrungrad International Hospital, arguesthat the current national health-care systemfunctions effectively and national patients ‘havethe opportunity to use public hospitals and seewell-qualified physicians at little or no cost.Private hospitals like Bumrungrad have tocompete on efficiency and value’ (BumrungradInternational Hospital, 2009: 5), hence Bumrun-grad does not detract from that system. However,while public sector patients do have the ‘oppor-tunity’ at low cost, there is a serious shortage ofdoctors in many parts of Thailand, alongside acontinued migration, an ‘internal brain drain’,from the peripheries (Wibulpolprasert and Peng-paibon, 2003; Wibulpolprasert and Pachanee,2008).

With significant sectoral income differentials,doctors have also moved into private sector hos-pitals where, even by 2003, ‘providing healthservices for foreign patients creates heavy invest-ment in advanced health technology for theprivate sector at the expense of public health.This enhances the existing tiered health caresystem, with shifting of human resour-ces for health from rural public to urban pri-vate services, resulting in increasing inequity’where ‘the resources needed to provide servicesto one foreigner may be equivalent to those usedto provide service to 4–5Thais’ (Wibulpolprasertet al., 2004: 5). A Thai doctor observed in 2006:‘Each time a foreigner sees a Thai doctor at“foreigner prices” he takes away an opportunityfor aThai person to see the same doctor at normalThai fees. In other words, this programme, whilepresumably bringing foreign capital to our hos-pitals, is sucking medical care from our ownpeople’ (quoted in Cohen, 2008: 250). Agrowing workload, coupled with a new liabilityto malpractice litigation, has induced manydoctors, and also nurses and pharmacists, totransfer from the public to the private sectorwhere they can draw high salaries to compensate

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for the professional risks (Poopat, 2010; UNDP,2010). Indeed, that flow is accentuated byforeign preferences for experienced and skilleddoctors (NaRanong and NaRanong, 2011).Some of Bumrungrad’s other 950 doctors, likethose working in health tourism (Wibulpolpra-sert et al., 2004; Chambers, 2011), have beendrawn away from the public sector. By contrast,apparently ‘no-one’ now wants to be involved inregional primary and preventive health care(Whittaker, 2008). Likewise in India, leadingspecialists in private hospitals have been drawnfrom the public sector so promoting a ‘braindrain’ into private corporate hospitals (Sengupta,2008). As Taiwan also moves towards a smallmedical tourism industry, a similar inter-sectoralmigration of doctors has become evident(Phipps, 2011). Alongside a geographical skilldrain there is therefore also an inter-sectoraldrain.The actual internal brain drain attributableto medical tourism alone, as opposed to privati-sation, may however be limited.

Waiting times in the public sector can beconsiderable. Waiting times for Thai cardiacpatients increased as doctors moved into theprivate sector and were expected to increasefurther as the Thai population aged (Phanayang-door, 2006). That has parallels in Israel wherewaiting times of medical tourists are shorterthan those of local people, especially in areassuch as in vitro fertilisation (IVF) where medicaltourism is popular. Some skilled workers arefound only in private hospitals; IVF nurses onlywork in the private sector where wages arehigher, hours are more congenial and patientloads rather less (Connell, 2011). Migrationfrom regional areas has however been occur-ring long before the rise of medical tourism.Inadequate capacity to pay is a function of theThai economy, taxation system and structure ofhealth-care provision and that of many othercountries. Medical tourism merely exacerbatesthis. In many countries the loss of doctors (andothers) from the public sector has resulted inefforts to replace them, but that has generallyproved impossible in such significant Asianmedical tourism destinations as India, Malaysiaand Thailand.

The higher earning capacity from employ-ment in medical tourism can play a part inreversing or slowing the international braindrain, a significant issue in such developing

countries as India, where many doctors andnurses have already migrated overseas, espe-cially from underserved rural areas. Althoughsome health workers have returned from over-seas to work in medical tourism, there is noevidence of them also working in the publicsector (Connell, 2010). Return and retention areprimarily beneficial only if additional healthcare is accessible to the population as a whole(Chee, 2010). Overseas health workers aremore likely to return home, and with new skills,if they are able to practice in medical tourismfor at least part of the time (Laing and Weiler,2008: 384; Jagyasi, 2010). While the ApolloHospitals chain claim to have attracted morethan 120 skilled medical professionals to returnand work in India (Cortez, 2008), they do nothowever primarily serve local citizens, andespecially the needy, while the extent of returnmigration is about a tenth of the annual flow ofskilled doctors from India to the United Statesalone (Connell, 2010). In Thailand, as many as80–90% of specialists and ‘super-specialists’ inprivate hospitals are said to be part of a reversebrain drain (Poopat, 2010). In Malaysia, theconsequences of medical tourism include agreater rate of movement of doctors, nurses andlab technicians out of the public sector, so that‘the demand-supply deficits in healthcarehuman capital resources in rural regions andthe poor states in Malaysia are expected to beaggravated further’ (Rasiah et al., 2009: 60).Partly because of this shortage, Malaysia soughtto encourage the return migration of doctorsfrom overseas to staff the growing medicaltourism sector, offering tax incentives andremoving the requirement to work for threeyears for the Ministry of Health, to provide moreequitable health care (Chee, 2007). There ishowever little evidence of such return.

When the Philippines sought to developmedical tourism in the mid-2000s, one objectivewas to stem emigration and encourage the returnmigration of overseas health workers, whosemigration had eroded the national system(Connell, 2010). Some local doctors thenopposed medical tourism, arguing that it ‘willsignificantly decrease services available tocharity patients, even as it opens up services topaying patients and foreigners or tourists. Suchinstitutionalized privatization of health care willonly further marginalize poor Filipino patients’

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(quoted in Gahlinger, 2008: 87). Sensitive tocriticisms that health tourism was unacceptable,and the Philippine national health system wasinadequate, officials spoke of founding a specialmedical charity for the needy; eleven hospitalstaking part in the scheme agreed to donate 10%of their beds to ‘deserving locals’ (Henderson,2009: 211). Such awareness of issues and needshas rarely been translated into effective policesfor the national poor there or elsewhere (seebelow).

Systemic pressures

Diversion of facilities and resources into medicaltourism has placed greater pressure on existingservices though, again, problems in healthsectors are not primarily the outcome ofincreased medical tourism. In Malaysia, somefacilities are currently underused, primarilybecause of migration of health workers ratherthan diversions into medical tourism (Idris,2008; Connell, 2010). Potential expansion ofmedical tourist numbers in Malaysia resulted inhospital officials seeking to assure Malaysiansthat the influx of Singaporean patients would notdrive up prices of medical services and result in‘multi-tier quality’, one declaring: ‘It is, and willremain, a one-tier policy, meaning: one priceand one same quality for anybody who wantsmedical treatment in a Malaysian hospital,whether patients are Malaysians or foreigners’(quoted in Burgos, 2010). Almost identical assur-ances were made in Singapore (Chee, 2010).

However, the slow emergence of dual tiers isgenerally more evident despite a rhetoric infavour of public–private partnerships (Poopat,2010; Medhekar, 2011). The provision of stemcell therapy in India has diverted resources fromrecognised therapies and basic health-care pro-vision, and forced up the price so that evenmiddle class Indian patients could experiencebankruptcy, while for the poor, ‘only the possi-bility of entering the most risky experimentaltrials remains’ (Patra and Sleeboom-Faulkner,2009: 160). In Mexico, growing numbers ofhealth tourists are burdening the nationalhealth-care system and distorting it in favour ofthe privileged (Bergmark et al., 2010). However,a large number of ‘tourists’ are returning Indiansand Mexicans, to India and Mexico, hence ser-vices are at least provided to diasporic popula-

tions (although, in India especially, a relativelyaffluent cohort). In two quite different contexts,resident local patients are disadvantaged.

Expansion of the private sector is at some costto the public sector where patients have verylimited ability to pay, especially if skilledworkers move away from that sector. The recentgrowth in Indian medical tourism has occurredin a context where, despite rapid national eco-nomic growth, some 40% of India’s populationlive below the poverty line and have minimalaccess to basic health care so that infant andmaternal mortality rates are high. Rural womenhave very limited or non-existent access tohealth care (Sengupta, 2011). Alternatively,where public sector hospitals are often so inad-equate, patients turn to the private sector fortreatment but may have to sell assets to payhospital costs and/or accumulate debts (Sen-gupta, 2008; Ergler et al., 2011). In Thailand toorapidly rising medical costs in private hospitalsare making it difficult for middle incomeThais tocontinue hospital care, and even more difficultfor the poor to access private care (NaRanongand NaRanong, 2011). As one health researcherhas pointed out:

The poor in India have no access to healthcarebecause it is either too expensive or not avail-able. We have doctors but they are busy treat-ing the rich in India. Now we have anothertrend. For years we have been providingdoctors to the western world. Now they arecoming back and serving foreign patients athome. (Ravi Duggal, quoted in Ramesh, 2005)

Ethical issues have consequently become signifi-cant at a national scale in terms of equity and themore competitive involvement of the market inmedical care. In India, Thailand and elsewhere,medical tourism both limits local access tohealth care and reduces the role and autonomyof the local state (Burkett, 2007: 233).

By contrast in the much smaller country andmore affluent city-state of Singapore, there is nosignificant shortage of doctors (though thenumber of nurses is limited) so that humanresources are not obviously drawn away fromunderserved population groups or areas intomedical tourism. As the Director of Health Ser-vices with the Singapore Tourist Board hasobserved:

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For Singapore, seeing international patients ismore than about earning tourism dollars. Sin-gapore is a very small country and our problemis that we can do things that are really high-endbut at the end of the day, you need thedemand. For example, we have three living-donor liver transplant teams here in Singaporebut if we didn’t have foreigners there wouldnot be the cases to sustain that. We’re servicinginternational patients so we can see our ownpatients also. (Quoted in Nicholas and Hyland,2009: 22)

In a high income city-state this means of retain-ing specialists, to meet the needs of the popu-lation as a whole, is probably exceptional. InTunisia too there is no evidence that medicaltourism has resulted either in an internal braindrain or the reduced availability of health ser-vices to the poor, partly because the publicsector is well funded, while underused capacityin the private sector reduced the possibility ofprice discrimination (Lautier, 2008). Tunisia andSingapore demonstrate that the impact ofmedical tourism is far from homogeneous butvaries considerably according to national finan-cial and institutional structures and policydirections, including wage policies and nationalhuman resource endowments. Relatively suc-cessful middle income countries such as Sin-gapore and Tunisia may thrive, whereas Indialacks the capacity to develop an equitablehealth-care system, and medical tourism hascrowded out a much needed public health-caresystem. Thailand and Malaysia rest in between.

Egalitarian responses

Either through recognising their vulnerability tocriticisms of elitism and inadequate responseto local needs or out of some degree of altruism,or both, some leading hospitals and chainsinvolved in medical tourism have developedprogrammes to serve the local poor. Apollo Hos-pitals set up the Save A Child’s Heart Foundationin 2003 with the aim of providing care to chil-dren in lower socioeconomic groups and subse-quently performed an estimated 900 interven-tions, with a claimed 97% success rate, and has‘touched the lives’ of over 50 000 children withheart diseases across India through the work of‘the most accomplished and distinguished car-diologists and cardiothoracic surgeons from

Apollo hospitals who tirelessly work on trans-forming the lives of afflicted children by per-forming complex surgeries on them’. ApolloHospitals were supported by several philan-thropic organisations and individuals. It wasargued that half the children operated onthrough the Foundation would have diedwithout this medical intervention (http://www.apollohospitals.com/community-initiatives.html). The equally large Wockhardt chain claimto screen 12 000 blind patients per year througha mobile eye clinic ‘in slums, rural areas andpoor location’, repair as many as 100 cleftpalates a month and conduct dewormingcamps (http://www.wockhardtfoundation.org/pro-smile.aspx). Other activities are discussedon their web site, but there is little indication ofwhether they are actually undertaken.

Particularly controversial have been promisesand programmes of serving poor patients in thesame facilities as medical tourists and richpatients and the extent to which it is merely acosmetic exercise. The Apollo group was said tohave provided free hospital beds for poor Indianswho were unable to pay, to have introduced atrust fund for the needy and pioneered telemedi-cine in rural and remote India, but there has beenno independent monitoring of any such activi-ties. In the mid-2000s an ABC television pro-gramme, seeking to find evidence of provisionfor the poor, merely found a ward full of emptybeds (ABC, 2005). Where such ‘free beds’ areoccupied, they have become part of systems ofnepotism and favouritism so that it has beenargued that ‘it is well known that the free patientson their list are relatives of hospital staff, bureau-crats and ministers’ (Duggal, 2003). Moreover,the Delhi High Court ruled in 2009 that theApollo Hospital in New Delhi was not honour-ing its mandate to provide a third of its beds freeof charge to the poor (Thomas and Krishnan,2010). The ‘free bed programme’ epitomised thedivisions in the national health system, as a dualstructure was consolidated. While Apollo arguesthat ‘India is now ready to heal the world’ to asubstantial extent, ‘the majority of its own peopleremain at the back of the queue’ (ABC, 2005;Thomas and Krishnan, 2010).Thailand has about10 000 vacant beds in private hospitals and notenough beds and long waiting lists in the publicsector but no mechanism for sharing resources(Poopat, 2010).

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Bumrungrad (‘care for the community’) arguethat their name is realistic since they provided103 no-cost heart surgeries ‘for needy Thai chil-dren’ in 2009, bringing the total of such opera-tions to 365 in a five-year period. A mobilemedical team from Bumrungrad works with stafffrom Bangkok Insurance Co. Ltd. to provide freetreatment once a year to some 10 000 villagers inMukdahan and Sakon Nakorn provinces innortheast Thailand. A handicraft-training pro-ject in Nong Kong village, Mukdahan province,was also initiated to provide supplementaryincome to underprivileged people (http://www.bumrungrad.com/Thailand-expat/about-us/bumrungradfoundation.aspx).

Generally, only the very largest hospitals inThailand and India make any mention of foun-dations or work with the poor. While severalsuch hospitals have provided health care torelatively poor groups, mainly in nearby urbanareas, their programmes have never been evalu-ated, and they are unlikely to have made sig-nificant contributions to national health. Thatcontribution may effectively be below nationalexpenditure that subsidises medical tourism,and is not allocated to the relatively poor whoare disadvantaged by it (Meghani, 2011).Medical tourism is most likely to have a role innational health care, not through its direct con-tribution through charitable programmes orbecause hospitals focussed on medical tourismhave higher proportions of national patients, butthrough a taxation regime that can ensure effec-tive trickle down in support of an appropriatenational health-care delivery system.

Trickle down?

The strongest argument for medical tourism indestination countries is that it creates a consid-erable flow of foreign exchange that directlybenefits the health, tourism and related sectors,and thus the national economy, and which canstimulate economic growth and development.Indisputably, it has contributed to the tourismsector and also to ‘backward sectors’ such aspharmaceuticals, construction, transport andcommunication (Lautier, 2008; Connell, 2011).However, to sustain an effective medical tourismindustry investment must be made into ancillaryactivities, including costly education and train-ing programmes and also transport, electricity,

water and sewerage, which may intensify urbanbias by drawing resources from rural andregional activities. In the health-care sector, newjobs have been created, some of which are indi-rectly related to health. Medical tourism compa-nies, such as Gorgeous Getaways, an Australian-based company, create employment; GorgeousGetaways alone employed 11 people in Malay-sia from office managers to drivers – all outsidethe health system (Connell, 2011: 153–154). InLatvia, the economic downturn following theGlobal Financial Crisis meant a substantialdecline in local demand for cosmetic surgeryand the overseas migration of many surgeonsand doctors, which in turn led to layoffs of nursesand others, so that marketing medical tourismwas seen as essential for retaining local employ-ment (Adams, 2010). Most such linkagesbetween sectors and the extent of employmentcreation are undocumented.

With progressive taxation policies, theincome generated by medical tourism couldsubsidise public health and improve overallaccess to health care, however there is littleevidence of this. Arguments that ‘even if specifichospitals in developing countries are open onlyto foreigners and local elites, the health caresystems of these countries will be enriched bythe influx of revenue, enabling them to offerlocal populations increased access to medicalcare’ (Herrick, 2007: 23) have not been vali-dated. Profits and taxable incomes can be redis-tributed to develop public health care, but thatdepends on strong economic and public healthpolicy, and such redistributive policies areelusive in most middle income countries. Sinceeven the hospitals that are most focused onmedical tourism have a majority of nationalpatients, many of whom include a wealthy elite,they are somewhat sheltered from domesticcriticism. Physically, they are largely cocoonedfrom the public sector. Private sector beds aremore likely to remain empty than be ‘donated’to public patients.

Medical tourism may benefit public health byimproving facilities, increasing the number ofskilled health workers and enabling betteraccess, but it may just as easily drive up prices, asit has done in Thailand, and reduce access.Moreover, as in Mexico, bilingual nurses may betrained specifically for the medical tourismmarket, diverting resources from national needs.

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Income generated from medical tourism accrueseither to those hospitals (and their staff) where itoccurs, or to standard (usually urban) compo-nents of the tourism industry. Any new skillsacquired by doctors and other health workersengaged in medical tourism are only likely tobenefit private national patients and have nobearing on the primary care needs of rural areas.

By contrast, governments have tended toprovide financial benefits to medical tourism tostimulate its growth. In India, Malaysia and Thai-land, special tax concessions have been given tomedical tourism providers and to tourism officespromoting medical tourism, while governmentshave not been held accountable for their obliga-tions to provide services to the poor. Likewise,various combinations of subsidies include hos-pitals being eligible for financial assistance foroverseas marketing and trade fairs, superior ratesof depreciation, loans and tax breaks for medicaltechnology, infrastructure funds, access to landat subsidised rates and funding of accreditationagencies (Gupta, 2008; Alsharif et al., 2010;Chee, 2010; Sengupta, 2011; Wilson, 2011).Growing national support for medical tourismthrough more active promotion, land provision,supportive employment tax regimes, etc., maysimultaneously weaken support for and reduceresources allocated to public health and primaryhealth care. In Thailand and Malaysia, powerfulinterest groups have driven the expansion of theprivate sector in tandem with medical tourism,with the government subsequently stimulatingthe expansion of medical tourism in the drive fornew market access (Rasiah et al., 2009). Thesame loose combination of privatisation, largeconglomerates and government nurturing – witha steady rise in private sector expenditure onhealth services – and intensified competition hasoccurred throughout Asia with similar out-comes, including greater specialisation in theprivate sector, limited preventive health-careprovision and the slow immiserisation of thepublic sector.

Although the private sector, including medicaltourism, cannot usually be blamed for the fail-ings of public sector health care, its growth hasmade it more difficult for that sector, especiallyin India where the private sector provides nearlythree-quarters of all health-care services. Asskilled workers, from health workers to manag-ers, move from the public to the private sector,

the task of meeting the needs of the poor, espe-cially in remote areas, becomes more difficult.Nonetheless, medical tourism remains in itsinfancy in most countries, and in most places itsdirect impacts are too slight (but largely unre-corded) to have had a very significant bearing onsuch issues as national equity and inequality. It isjust one component of the shift towards privati-sation of medical care and its multiple impacts.

Equity, capitalism and commodification

The rise of medical tourism has coincided withthe ascent of neo-liberalism, the privatisation ofhospital facilities in many places and decliningor static investment in the public sector.Medical tourism has both accompaniedchanges that have directly worsened access tohealth care, especially for the rural poor inmany parts of Asia, but, as a response to suchchanges, has itself contributed to growing ineq-uity. Medical tourism has thus exacerbatedproblems of access to health care. However,while trends in access to health care and theirrelationship to health care are consistent acrossa range of contexts, and have obvious implica-tions for equity and social justice and a humanrights approach to medical care, as the ratherdifferent cases of India and Thailand indicate,good data are very scarce, anecdote sometimesprevails, and conclusions must remain tentative.

While privatisation has raised standards ofcare and contributed to the improvement ofmedical facilities in many countries, includingIndia and Thailand, the most prestigious hospi-tals are inaccessible to most nationals, and tech-nological and other benefits have failed totrickle down structurally or geographically towhere they are most needed. Medical tourismhas emphasised and strengthened such trendsand made them more acute and more visible,especially in areas such as reproductivetourism, stem cell surgery (and adoption) wherecosts are very high, and only mobile elites canbenefit. Yet, even in the richest countries, thepoor have restricted access to medical care.Privatisation has preceded and proceeded irre-spective of the rise of medical tourism, whilenational development policies or their absencehave increased inequalities, weakened publichealth and preventive care and worsenedaccess in regional areas.

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Medical tourism has reinforced privatisationalongside technological and medicalised per-spectives on the health system where medicalservices can be bought ‘off the shelf’ from thelowest cost provider, rather than well-beingcreated by remedying the social, political andeconomic determinants of health: an analogywith the relationship between cosmetic surgeryand diet and exercise. The incursions of capital-ism and commodification into hitherto personaland intimate experiences, from birth throughto death, that are suggestive of a materialist,narcissistic entitlement society, are sympto-matic of much of medical tourism, which hasboth stimulated and responded to such trends.Medical tourism reduces pressures on govern-ments, as the more affluent nationals benefit asproprietors, skilled health workers and patients.Private medicine, epitomised in the principlecentres of medical tourism, offers examples ofplaces and providers that are not only sites oftreatment but key elements in emerging andhighly competitive neo-liberal landscapes ofdiscretionary consumption (Kearns et al., 2003),where advertising and marketing play a criticalrole, and links with international companies,from Starbucks to Flight Centre and Cooks, areas significant as those with pharmaceuticalcompanies (Connell, 2011). Medical tourismconsequently ‘represents the full integration ofmedicine with global capitalism’, and whereservice is purely a function of the ability to pay,redeeming features are elusive in a system thattolerates ‘striking inequalities in income andhealth’ (Turner, 2007: 113, 128). In this perspec-tive, medical tourism is both symbol and mani-festation of the failures of privatisation andnational health-care systems, involving perverseflows of both patients/tourists and health-careproviders. There is little evidence that it hasattracted nationally beneficial foreign invest-ment, except perhaps in parts of the touristindustry, that competition has benefited thehealth sector as a whole, that greater numbersof skilled health workers have been produced orcorporate social responsibility increased, evenon the part of the more successful hospitals.

Most criticisms of medical tourism are criti-cisms of capitalism and privatisation, albeitepitomised in medical tourism, and implicitly ofthe failings of health systems, especially in devel-oping countries, to provide more effective and

equitable health care. However without moreadequate data, critiques of (and support for)medical tourism must remain indicative ratherthan firmly evidence-based. Some criticismstems from repugnance at situations where for-eigners availing themselves of health servicesmust be ‘sheltered’ from adjacent poverty andpestilence while nationals are marginalised orexcluded. In overwhelmingly capitalist societ-ies, medical tourism is somewhat different fromother national development contexts in its directrelationship to life and death. Ethical questionsabound, and there is a complex and variableethical landscape. Yet, inside and outside the‘neo-liberal landscapes’ of corporate well-being,patients have been obvious beneficiaries, somemoving away from difficult local circumstances(such as from Burma and Yemen), waiting listsand spiralling costs and gaining new healthylives (even perhaps at the expense of somenational citizens). However inadequately mea-sured, or simply ignored, medical tourism hasalso contributed to employment and other formsof trickle down. As in almost every tourismcontext, large companies (the medical tourismcompanies, the travel industry and also thehealth providers) are the main beneficiaries, thetourists get more or less what they anticipate andhave paid for and the local population (espe-cially in rural and regional areas) are least likelyto experience trickle-down effects. Withoutdetermined public policy formation, unevendevelopment and privatisation are accentuated,raising questions over development and socialjustice.

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A new inequality? Privatisation, urban bias, migration and medical tourism