Medical Tourism

WHO Global Health Histories

Seminar

2nd October 2013

Dr Neil Lunt (University of York)

Dr Johanna Hanefeld (London School of

Hygiene and Tropical Medicine)

Overview

Background

Comments on patient choice

Comments on risk and External Quality

Assessment

Comments on system considerations

Background

Patient mobility has many forms

One variant : Medical tourism/ medical travel/ global healthcare receiving a great deal of attention

Old wine in new bottles?

Few countries that do not seek to develop medical travel services

“when consumers elect to travel across

international borders with the intention of

receiving some form of medical treatment. This

treatment may span the full range of medical

services”

(Lunt et al., OECD Health Working Paper, 2011)

Precise numbers not available but some

patterns of travel appear well-established

Familiarity and cultural similarity allows

services targeted at Diaspora populations

Europe two varieties of

individual choice

“Cross border care” – 2011 EU Patient Mobility Directive – codified our rights as EU citizens with costs paid by socialised system/3rd party payer.

Medical tourists may be seen as consumers - out of pocket spending or with portability of insurance - to access a range of dental, cosmetic, IVF and elective surgery.

A Medical Tourism Paradox

Most patients prefer to be treated close to

home. So what are the boundary conditions to

explain the unusual?

Reasons for medical include

costs

quality

speed

treatments not available (or legal)

confidentiality

combine tourist attractions with procedures

Diaspora of particular groups

These differ across treatments

Cosmetic surgery and price

sensitivity

For cosmetic patients cost is a key

consideration.

The mind-set that surrounds cosmetic

treatment is perhaps then different to other

forms of treatment (i.e. to seek cosmetic

treatment is to seek private treatment).

UK experience of bariatric travel

Public provision, postcode lotteries and proximity

For bariatric patients cost was not a driving factor.

Focused instead on expertise (in bariatric surgery).

The decision rarely the result of a single motivating factor; rather it was a combination of cost, expertise, availability and distance.

For most treatments abroad

While cost is an important factor, it is not the

sole motivation, equally important is the

perception of services received (decision-

making is a complex matrix of personal

factors and context).

Networks are a central but understated and

misunderstood feature within medical travel.

Tourism was far from everyone’s mind.

On-line information

Risks of treatments are not fully detailed; unsurprisingly there exists an imbalance of information and marketing material.

The onus is on prospective medical tourists to locate guidance and advice.

Solutions: codes of conduct, self-taken quality labels, user guidance tool, third party quality and accreditation labels?

Safety and risk

Patients travelling overseas leave the regulatory safety of their home country.

Aftercare in some form is usually required.

Prospective patients often unaware of lack of clear avenues for redress should treatment abroad give rise to unexpected complications.

Longstanding safeguards for healthcare (e.g. professional registration) may have little relevance if given treatment is received out of jurisdiction.

Medical tourists are unlikely to be fully informed or understanding of all associated clinical risks.

Medical tourists pay more heed to soft information rather than hard clinical information.

There is little effective regulation of information, hard or soft, online or overseas.

External Quality Assessment:

Europe

There is a plethora of EQA and registration details displayed on websites.

There are no clear patterns in take-up of different EQA forms, perhaps reflecting that European clinics within the medical tourism market are relatively small.

How EQA and registration details are presented assumes significant health literacy by web users.

EQA appears limited in providing relevant signposting to patients.

National strategy development

In 2009, Korean Government launched medical tourism as new growth engine for economic development.

Large international trade fairs, via advertising within the overseas press, and official support for activities.

From 2009 Korean Government allowed hospitals/ clinics to fully market health services to foreign patients, and a major national coordination/ marketing role.

Medical visa was newly adopted.

Presenting places as highly customer-focused service providers is prevalent emphasis in advertising.

An emphasis on marketing services as high technology and high quality.

Focus on clinicians that have overseas experience (training, employment, registration).

Securing accreditation from international programmes.

Medical Tourism Myths

First, do published figures and projections “add-up”, are figures from multiple sources consistent, and what decisions and interests are involved for compiling statistics?

Definition (individuals/episodes)

Who counts?

Wellness?

Cosmetic?

Cross-border/outsourced/ tourists?

And who is counting?

Estimates; projections, extrapolations

Global flows?

There are global flows from each and every

point criss-crossing the globe?

More typically they are bilateral flows or

relations. Bluntly, countries are open for

business but fewer are benefiting from it?

National Government Role?

Should be strategic and evidence-based.

Marketing budgets informed by market

intelligence and consideration of tangible

benefits?

In countries with longer term investment what

have been benefits?

Myth1: The rise and rise of medical tourism with exponential growth and runaway projections

Reality: projected growth has not resulted. Countries need to take a reality check on how much medical tourism activity they can attract.

Myth 2: Global market opportunities with open, global and competitive markets.

Reality: networks, history and relationship may explain a great deal about bilateral flows and the success of particular destinations. There is not necessarily a level playing field.

Myth 3: National government role can stimulate medical tourism sector

Reality: governments would be wise to question emphasis of high tech investment targeted at patients who may not exist (Myth1) or who because of historical and network reasons prefer to travel elsewhere (Myth 2)

emerging markets may be more mundane (e.g. dental) or with

wellness displacing high-tech medical intervention.

activity may involve fewer strangers but many more familiar visitors

(2nd Generation and Diasporas).

Medical tourist provision is not context-free

regulatory framework

state and regional support

professional bodies support and involvement;

structure of health care provision;

cultural and ethical standpoints of providers;

market opportunities, niches and potential for profit;

economic position, exchange rate, comparative

advantage;

policy traditions and trajectories;

health care reform & existing capacity within systems;

the role of national/ international quality frameworks.

Evidence from low and middle income

countries

Qualitative studies have focused on potentially negative consequences in

recipient countries. Most research, data free, but for 13 countries systematic

investigation of country level economic impact for recipient countries.

Country Findings

Tunisia

Lautier 2008

• Health services exports generate an

estimated 10,500 jobs in the health and

tourism sectors.

• Concentrated in private sector, small

number of clinics.

• an additional 0.5% of the GDP

11 countries in Middle East

Siddiqi et al 2010

• Focus less on impact, wider focus on

GATS.

• Regional trade does address gap in

services in some countries.

• Inequitable – crowding out.

• Positive effect on foreign exchange

Thailand

NaRanong et al 2011

0.4% of Thailand's GDP

Health workers move to private

hospitals

Increases costs in private sector.

Reflections

Highlight context specificity.

Regional dimension can alleviate genuine shortages in health services and skills.

Likely a small contribution to overall GDP.

Likely some job creation including in the health sector.

In some cases, evidence of displacement of health workers from public sector and increase in price

Equity impact

We do not yet know how to mediate these

Moving forward

Can Medical Tourism alleviate poverty and address health systems challenges ?

Health worker: return and retention to low income countries. Could public private mix work. We do not have the evidence from low income countries.

Limited understanding of the role of the private sector in low income countries in provision of health care and in business practices. What is the volume of FDI in health sector? What are employment policies? Are employees local or foreign? What are the tax regimes negotiated?

Moving forward

Training, surgical learning curves, developing specialism.

Regulation and risks. How can we ensure quality? Are bilateral agreements the way forward (Smith and Alvarez 2011)? Could we move toward an international standard or guideline?

How to mediate possible negative impact, especially inequities in access to services?

• Impact on recipient countries is diverse, but consensus that some increase in inequities, as well as some contributions to the economy overall.

BUT we do not know enough at system level:

• We are ‘blinded’ by the lack of evidence from mapping volume of trade in low income countries.

• Understanding causal pathways of impact both positive and negative – the how – of medical tourism is not understood.

Evidence is emerging but uneven

“… the lack of data is significant if countries are to

keep fully informed about the significance

(potential or actual) of medical tourism for their

health systems…The evidence-base is scant to

enable us to assess who benefits and who loses

out at the level of system, programme,

organisation and treatment”.

(Lunt, Smith et al, 2011, OECD Review)

Acknowledgements

HS&DR Funding Acknowledgement: This project was funded by the National Institute for

Health Research Health Services and Delivery Research Programme (project number 09/2001/21).

Department of Health Disclaimer: The views and opinions expressed therein are those of the authors and do not necessarily reflect those of

the HS&DR Programme, NIHR, NHS or the Department of Health.

Supported by the British Academy’s International Partnership and Mobility Scheme 2012-13

Lunt, N., Smith, R.D., Mannion, R., Green, S.T., Exworthy, M., Hanefeld Horsfall, D. Machin, L. & King, H. (2013, in press) Implications for the NHS of Inward and Outward Medical Tourism: a policy and economic analysis using literature review and mixed methods approaches, Report to the National Institute for Health Research HSR Project: 09/2001/21

www.medicaltourismresearch.co.uk

Dr Neil Lunt

University of York

neil.lunt@york.ac.uk