Article / Prospective Article
PhD from Faculty of Political Science and Public Administration in the Lebanese University
Malek El Husseini / Maya Abou Zahr
Dubai POBox 213011 Dubai
13 September 2020 ; 7 November 2020
The demand for global healthcare services is experiencing tremendous growth. Patients are seeking to reduce their expenditures on healthcare through obtaining treatment on an internationally competitive basis. Medical tourism can be defined as the organized travel outside one’s local environment for the maintenance, enhancement, or restoration of the patient wellbeing in mind and body. In other words, medical tourism is a growing dimension of healthcare globalization, whereby consumers select to travel across borders or to overseas destinations to receive their treatment.
In fact, medical tourism is not a new phenomenon. In terms of cross-border travel for healthcare, there is a long history including the use of spas and wellness tourism that gained a mass market throughout eighteenth and nineteenth century Europe. Traditionally, consumers from all continents and forms of health systems have travelled abroad for their healthcare to avoid waiting lists or access state-of-the-art techniques and receive better aftercare services.
Globally, there has been tremendous growth in the health service sector, catalyzed by inadequate national public health services, the spiraling cost of health services and the availability of cheaper alternatives in developing economies. Moreover, the healthcare infrastructure in developed countries is not growing in line with the ageing population and this increases the demand for travel for care. According to World Tourism Organization, export earnings generated by tourism have grown to USD 1.7 trillion in 2018. This makes the sector a true global force for economic growth and development, driving the creation of more and better jobs and serving as catalyst for innovation and entrepreneurship. The overall demand for health and wellness services has generated a global market in health services.
Many factors contribute towards shifts in patterns of consumption and production of domestic and overseas health services. To choose the healthcare facility, specific characteristics influence the country of choice including economic conditions, cultural acceptability, advertising practices, political climate, safety measures, credibility of the country, and regulatory policies. Certain factors _ such as costs, credibility of the hospital, hospital accreditation, quality of care, pioneering forms of treatment, availability of relevant expert doctors, and physician training _ similarly influence the selection of healthcare facility.
Medical Tourism Index (MTI) considers three dimensions as the drivers of medical tourism: destination environment; medical tourism industry; and quality of facilities and services. In addition to that, treatments outside one country include many purposes such as cosmetic and dental surgery; cardio, orthopedic, and bariatric surgery; IVF treatment; organ and tissue transplantation; Spa tourism; culinary tourism; wellness tourism; and circumvention tourism which is a travel to have medical services that are legal in the host country but illegal in the home country.
The role of the state is pivotal in providing an affirmative policy environment (such as regulations and safety), and in playing a major role in marketing healthcare to the international medical tourist market. Moreover, policy makers must use the different factors to evaluate the impact medical tourism continues to have on the healthcare system in order to effectively compete in today’s global and consumer-driven healthcare market.
Patients often wait months to obtain appointments with specialists, undergo diagnostic tests, and receive treatment. Lack of access to family physicians can also make obtaining care particularly difficult. Therefore, faced with long waiting lists and cues, the high cost of elective treatment in some countries, and fewer barriers to travel, the idea of seeking healthcare in another country is gaining greater appeal to many.
Further fundamental research lacks in Medical Tourism including further development of reliable and comparable data, the push and pull factors for engaging in health and medical tourism, and the impact of health tourism on local healthcare systems. Moreover, the emerging trend of health tourism needs more research specifically in the following topics: 1- description of the policy and planning barriers to be overcome in building stronger linkages between medical tourism and traditional healthcare professionals; 2- recommendation of policy and planning shifts that are needed to create stronger synergistic connections among the tourist industry, healthcare, and government agencies; and 3- an integrated theoretical framework for the holistic study of the medical tourism industry.
At approximately 37 per cent, Asian medical tourists were the largest segment of visitors. Arab and GCC countries were the second largest market, accounting for 31 per cent of tourists, and visitors from Europe accounted for 15 per cent of the total. Below are some examples of country experiences with medical tourism.
Medical tourism has taken off in a noticeable manner since the 1997 Asian financial crisis. Singapore, Malaysia, and Thailand, in particular, have developed deliberate marketing strategies to attract foreign patients. For example, in Malaysia, the emergence of medical tourism was from within the context of ongoing health-care privatization reform. Medical tourism to Malaysia has been induced politically both to advance domestic health-care reform and to cast off the country’s ‘underdeveloped’ image not only among foreign patient-consumers but also among its own nationals, who are themselves increasingly envisioned by the Malaysian state as prospective health-care consumers. Between 2011 and 2018, the number of international tourists travelling to Malaysia for medical treatment doubled from 643000 to 1.2 million, with visitors arriving from China, the UK, and the US.
Healthcare is one of the largest sectors, in terms of revenue and employment, and this sector is expanding rapidly. Medical tourism in India has gained momentum over the past few years. There are several factors that make India a good destination for visitors seeking health services. These include its well-trained health practitioners, a good English-speaking medical staff, a good mix of allopathic and alternative systems of medicine, the availability of super-specialty centers, use of technologically advanced diagnostic equipment, and remarkably, the availability of these services at competitive cost.
In Canada, with the unavailability of treatments, and other medical interventions availability only after long delays, medical tourism agencies use issues with Canada’s provincial healthcare systems to encourage out-of-country healthcare. Though few Canadians can afford the high price of care at US medical centers, the international facilities offer less expensive access to private healthcare. The Canadian medical tourism agencies send their clients countries such as Argentina, Brazil, China, Costa Rica, Cuba, France, Germany, India, Malaysia, Mexico, Pakistan, Poland, Russia, Singapore, South Africa, Sri Lanka, Thailand, Tunisia, Turkey, the United Arab Emirates, and the United States. Supporters of medical tourism in Canada argue that the practice promotes improved access to care for patients able to pay for treatment and helps citizens who cannot afford to travel abroad by shortening waiting lists at home. However, interest in the medical tourism option may decline if Canadians gain improved local access to elective surgical procedures, such as hip and knee replacements.
Legislation, professional codes, and institutional policies place strict legal and ethical duties upon Canadian physicians to disclose risks, benefits, treatment alternatives, and the consequences of not receiving medical care. These documents state that medical tourism agencies have no legal obligations if patients are harmed while receiving care at destination sites. Companies will presumably try to use these documents to shield themselves from litigation if their clients are harmed while receiving care outside Canada. Finally, in countries with publicly funded healthcare programs such as in Canada and the United Kingdom, medical brokerages attract customers tired of waiting for many medical procedures especially hip and knee replacements, cataract surgery, and other procedures. In general, traditional medical tourists are residents of industrialized countries.
The popularization of medical tourism is related to social inequalities, loss of employer-provided health insurance, rising premiums for health insurance, limited public funding of healthcare, and lack of access to affordable healthcare. Middle-class Americans are losing employer provided health insurance. Moreover, as premiums for health insurance climb, jobs in manufacturing and service industries are moving to countries where labor costs are lower than the ones in the United States. Just as automobile manufacturing and textile production moved outside the United States, American patients are ‘offshoring’ themselves to facilities that use low labor costs to gain competitive advantage in the marketplace. Many American agencies have out-of-country travel options in their health insurance plans. For instance, West Virginia is considering legislation that will provide financial incentives to state employees willing to travel outside the United States for healthcare.
UAE ambition is to become a regional medical tourist hub. In the UAE, the healthcare market experienced tremendous growth in the coming years. In 2015, global business consultancy RNCOS forecasted that this market would grow at a compound annual rate of 7% between 2015 and 2020. In 2018, the UAE rose to one of the top 20 medical tourism destinations in the world, according to the Medical Tourism Index. Moreover, the Department of Culture and Tourism in Abu Dhabi signed a Memorandum of Understanding with the Medical Tourism Association (MTA) in 2018. As part of this agreement, the MTA’s annual World Medical Tourism & Global Healthcare Congress event will be hosted in Abu Dhabi.
According to Dubai Health Authority or DHA, Dubai received 337,011 in 2018 health tourists. DHA expected the number of tourists to increase by 13% each year. In 2014, Dubai announced a medical tourism strategy that entailed building 22 hospitals so as to attract 500,000 medical tourists per year by 2020. Additionally, beginning in January 2019, the DHA have rated all private and public sector healthcare facilities in Dubai on their level of care and expertise. This policy is designed to provide patients with information improve the quality of healthcare and strengthen Dubai’s growing medical tourism sector. Furthermore, the Department of Health Abu Dhabi and Department of Culture and Tourism – Abu Dhabi, have launched the Abu Dhabi Medical Tourism e-portal, a digital platform that provides visitors to Abu Dhabi with all medical offerings and healthcare facilities available throughout the duration of their visit.
The UAE’s medical education sector is now very much at par with international standards. This is because the UAE has been developing a world class healthcare infrastructure and a health regulation framework, which has helped ensure quality healthcare, a catalyst for medical tourism. And, more and more private players are being encouraged to enter the healthcare sector. This is in addition to the UAE’s strategic position, for example, it is approximately an eight-hour flight away from two-thirds of the world’s population. In 2017, the UAE government made significant steps towards setting up PPP schemes to promote private sector investments. In particular, the UAE Cabinet issued a resolution on the procedures manual for partnerships between federal entities and the private sector. UAE similarly decided to reduce license fees and introduce a 10-year visa for investors and professionals. The overall result is that medical tourism sales in the UAE increased 5.5 per cent year-over-year to reach Dhs12.1 billion in 2018 with growth supported by a number of government-led initiatives.
However, there are shortages of skilled Emirati medical professionals, partly due to prevailing cultural norms and the general situation of the country. There also tends to be high turnover among expatriate medical staff, as many medical personnel consider the UAE a passing locale to have experience before seeking careers in the West. The rapid growth of the UAE’s healthcare industry also poses the challenge of containing costs. This is provoked by the fact that healthcare in the UAE tends to be more costly than elsewhere in the region. The UAE’s Vision 2021, the highest-level UAE government strategic plan, makes achieving ‘world-class healthcare’ one of its priority goals. It aims to do so by accrediting all public and private hospitals according to clear national and international standards. In parallel, the opportunities to educate and develop UAE medical professionals within the nation are expanding.
One of the risks of Medical Tourism is that some of the individual and public health risks of medical tourism are not usually integrated into considerations of its potential economic benefits. Furthermore, there are many difficulties of applying economic theory to ‘health’ per se result in health economic discussion being focused on healthcare.
Other risks of Medical Tourism are related to: quality of care, infectious diseases, post operative care, complications and follow up, and legal issues. Despite grounds for concern about quality of care and patient safety in the global health services marketplace, there is limited evidence with which to judge and compare the quality of medical care around the world. For instance, of all individuals traveling for healthcare, cosmetic surgery patients are perhaps at greatest risk when they travel for inexpensive surgery, sometimes performed by unlicensed practitioners in unaccredited facilities. The illegal purchase of organs and tissues for transplantation has also been proved and studied in many third world countries’ medical tourism, with all the ethical questions around this topic. Consequently, claims about patient safety and quality of care are used to promote healthcare facilities and reassure potential customers that inexpensive medical care is also high-quality care. Until these claims are subjected to serious critical inquiry, they should be regarded simply as components of broader marketing initiatives.
At present, international patients can frequently do comparison shop on the basis of price. Nevertheless, they do not always have reliable ways of comparing the safety and quality of care they are likely to receive at international facilities. Improving the quality of information available within the global healthcare marketplace would require major changes to processes of international hospital accreditation. A global health services market will enable some patients to obtain medical care that they could not afford to purchase in their local communities. It will probably also contribute to the spread of a consumerist ethos in which healthcare providers serve the needs of customers, rather than respecting medicine as a practice with internal normative standards. However, serious efforts to set high standards for international accreditation could play a valuable role in promoting access to reliable, publicly accessible information on Medical Tourism, and Global Marketplace in Health Services. This will guarantee patient safety and quality of care at international healthcare facilities.
Moreover, as the global spread of for-profit health centers benefits customers with the financial resources to purchase care, it risks harming low-income patients by undermining public access to affordable care and pulling healthcare providers from the public sector into private facilities. The rise of medical tourism is related to the global spread of a form of capitalism that tolerates striking inequalities in income and health.
Additional potential threats due to medical tourism include the following topics:
The potential for earning revenue through medical tourism could become an important argument for private hospitals to demand greater subsidies from the government in the long run. This could potentially lead to a situation where specialty corporate hospitals are established using public funds and subsidies, thus diverting resources from the public health system and exacerbating the disparities in a two-tiered healthcare system with a corporate segment and a public-sector segment, the former concentrating on high-level technology and services which do not address broader social needs. The two-tiered system may also cause ‘cream skimming’, whereby those who need less but can pay more are served at the expense of the poor and more deserving.
- Increased Shortages of Skilled Health Professionals:
The private sector is the prime employer of health personnel predominantly trained in public health institutes
- Increased Cost of Medical Treatment:
It has been predicted that one effect of the increase in medical tourists would be a rise in the overall cost of healthcare in the country.
- Inequitable Growth and Gaps between the Public and Private Sectors:
At present the gains from trade in health services have been restricted to the private sector. It will also be worthwhile to consider mechanisms to divert revenue generated from trade in health services to develop the public healthcare sector. The government is expected to play an important role in regulating the private sector. However, there is lot of cases where there is no policy framework to have a common set of regulations for the private healthcare sector.
There is a need to institute a common minimum standard of care for both the public and private sectors. There is also a need to establish links between the public and private sectors. The potential to become a ‘global health destination’ will only be meaningful if the opportunities provided by medical tourism can also be utilized to improve the access, delivery and quality of services in the public health system. Additionally, the quality of care is a serious concern. Though medical tourism companies typically broker arrangements through internationally accredited hospitals, quality of healthcare around the world is variable. Quality of care and patient safety could be serious concerns with other medical procedures.
Throughout Europe, Middle East, and Asia, the volume of international patients has been growing in the past 15 years, with developing countries gaining a larger market share. Healthcare spending is growing internationally, and governments are increasingly realizing the significance of investing in healthcare to attract patients to their country. The success of online travel agencies (OTA’s), such as Expedia, Booking. com, TripAdvisor, and Ctrip has paved the way for the parallel healthcare vertical, online medical agencies (OMA’s). Medical tourism is seeing healthy growth, despite a lack of institutional and corporate support until January 2020. However, during Covid 19 epidemic, telehealth’s ongoing contributions have grown tremendously. As a result, less discussed have been the benefits to medical travel providers and patients.
The main developments can be categorized as follows:
The current European Commission’s proposal for a Directive on Patients’ Rights in Cross-border Healthcare arose as the result of several European Justice Court rulings over patient mobility and the rights of patients to be reimbursed for treatments received in another EU country.
A key driver in the Medical Tourism phenomenon is the platform provided by the internet for gaining access to healthcare information and advertising. Developments in medical tourism are linked to the emergence of specialized internet web sites. Within the field of healthcare, the internet provides a range of options for accessing information relating to professional diagnosis, self-diagnosis, aftercare and support. This includes the possibility of obtaining a second opinion; to allow the patient to access further information; to promote the purchase of diagnosis services and treatments; and the development of support groups around conditions. The internet offers a range of functionalities and formats including discussion forums, file sharing, posting information and sharing experience, member only pages, advertisements, and online tours. The Internet is altering how people consume healthcare, the way in which they obtain information and the manner in which they evaluate treatment alternatives”. For medical tourism the truth of this statement is tempered by the need to advance our understanding of the internet’s role in facilitating access to treatments.
Because the medical tourism industry is driven by international differences in the cost of health services, most company websites include charts and graphs comparing the costs of care at hospitals in various countries. This strategy enables brokerages to significantly increase customer volume. Their ultimate goal is to negotiate contracts with major health insurers and large employers.
Many universities are developing initiatives in global health; satellite campuses enable them to expose students and faculty at their home institutions to other parts of the world. For instance, centers in North America recognize that the fastest growing markets for professional training are now in Asian nations.
Co-branding initiatives play major roles in international marketing campaigns. The ‘Harvard’ name is on Work hard hospitals throughout India. Partnerships with elite organizations such as Harvard, Johns Hopkins, and the Mayo Clinic confer instant status and brand-name recognition. In brief, just as international accreditation, training at elite institutions, and partnering with global ‘brands’ are used to sell health services on the global market, symbols of advanced biomedical technologies convey the message that hospitals offer top-tier healthcare.
- They tend to stay longer – 5 times longer.
- Combine hospital stay with convalescence, plus leisure, and shopping.
- They are often accompanied by one or more persons.
- They are more likely to be higher-income individuals – higher per capita spend.
- Medical tourism promotes patient choice and gives con¬sumers access to treatment alternatives not found in their local communities.
- Increased capacity and demand contributes toward retention of medical staff and procurement of state of the art technol-ogy.
- Reinvestment in the country rather than offshore.
- Improvement private/public healthcare facilities.
- Accommodation, retail, entertainment, and transport.
- Medical tourists spend more time in metropoles and spend more per capita.
- Employment opportunities for semi-skilled sector, especially women and young people.
- Low barriers to entry in tourism sector (guided tours, taxi ser¬vices, B&Bs, etc).
Improve information sharing.
- Increase efficiency of patient care process, reducing / cutting of waiting lists.
- Technology and knowledge transfer.
- Better logistics performances both in internal and external.
- Clustering of medical Travelers – new business fields.
- Global Marketing and Medical Trade relations.
- Patient satisfaction and Competitive advantage.
- Fosters competition and puts pressure on more expensive healthcare facilities to lower their prices.
- Cost advantages in tariff over the developed countries.
- Creating attractive working places.
- Opportunity for development in infrastructure in Health, Tourism, and Travel.
- Health opportunities for foreign patients may lead to bet¬ter healthcare standards for Nationals.
- Scope for Research and Development to offer comprehen¬sive medical solutions.
- International acceptance and reputation for the country as a global healthcare provider.
- Social and cross cultural experience.
- International customer relations.
- Strategic Public – Private Partnerships.
- Strategic alliances with business partners within and out¬side the country.
- Better utilization of Infrastructure and skilled manpower.
- Connectivity & synergy effects with air, road, rail and in¬formation and communication industries.
- Brand image of nation as world class healthcare destina¬tion – attractive investment place.
- Promoting economic and social development by building healthcare economies in developing societies.
In brief, proponents of medical tourism note that internation¬ally accredited healthcare facilities are located around the world. Supporters emphasize the high quality of care at private hospitals and clinics in Asia, the Caribbean, Eastern Europe, and South America. Proponents of medical tourism also ar¬gue that a global market in health services will promote con¬sumer choice, foster competition among hospitals, and enable customers to purchase high-quality care at medical facilities around the world. Skeptics raise concerns about quality of care and patient safety, information disclosure to patients, legal re¬dress when patients are harmed while receiving care at interna¬tional hospitals, and harms to public healthcare systems in des-tination nations. Some companies promoted ‘discount’ surgery or ‘first world healthcare at third world prices’. Typical adver-tising pitches featured ‘surf and surgery’ holidays in Thailand and ‘surgeon and safari’ trips to South Africa. Healthcare was packaged together with more commonplace tourist attractions. Marketing executives proclaimed that their goal was to “put the ‘hospital’ back in ‘hospitality’.
Before Covid-19, medical tourism was a significant source of revenue for some health systems and countries. However, the outbreak of Covid 19 hampered medical tourism, as agencies removed non urgent services, and patients stayed in their res-idences due to travel complications and the new ‘behavior’ guidelines. For hospitals that meant all but essential healthcare was prohibited. With international borders closing all over the world, it was a hammer blow to medical tourism.
Across the world it has been similar stories. The medical tour¬ism market, worth up to $87.5 billion annually, is expected to shrink until 2021 as patients avoid unnecessary travel. Experts are predicting a 28% drop in revenues by the end of 2020. For example, prior to the pandemic, Dubai projected that the sec¬tor would contribute about 500,000 visitors in the emirate by 2021. In the wake of the virus, the estimated numbers differed tremendously.
Nevertheless, with the lessening of the limitations and lifting of the flight bans, there are efforts and ideas of how medical tourism can re-centre itself with new guidelines. For instance, extensive testing of both foreigners and nationals will be es-sential to rebuilding patients’ confidence in medical tourism destinations, and similarly new hygiene conditions and disin-fections at all health sectors are also imperative. Finally, artifi¬cial intelligence, including robots and distance operations, has an important role for medical agencies to obtain a market share in medical tourism.