An era of fruitful scientific investigation and medical breakthroughs in the early part of the twentieth century stimulated the evolution of modern medical institutions in Europe and North America. The latest technological innovations and clinical advances became increasingly available to the citizens of industrialised countries, however, people in less developed parts of the world continued to have limited access to medical services. Accordingly, patients from around the globe who had the resources to do so began to travel to major referral centres to have medical evaluation and treatments that were unavailable in their own countries.
In the recent past, patients from industrialised nations have started to travel to developing countries to have elective healthcare, bypassing services offered in their own communities. This phenomenon, known as medical tourism, has grown particularly rapidly. Indeed, a one-way pipeline towards industrialised nations has now become a twoway highway with patients travelling bidirectionally, from countless countries to medical destinations around the world.
There are no verifiable statistics on international medical tourism, and various studies report widely disparate estimates of the magnitude of this phenomenon. It appears that somewhere between 85,000 and 750,000 patients cross international borders for medical care annually, with the number projected to grow rapidly. The global economic value of the medical tourism industry is estimated to be between 20 billion dollars and 60 billion US dollars.
A large (and growing) number of countries around the globe are entering the international medical travel marketplace by offering a wide variety of services, including cardiac surgery, joint resurfacing or replacement, bariatric surgery, gynaecological procedures, ophthalmologic care, cosmetic dentistry and surgery, gender reassignment surgery, and executive health evaluations (Table 1). Other services being offered include organ and stem cell transplantation, assisted reproductive technology, and obstetrical care and delivery. Several countries in Asia, particularly Thailand, Singapore, Malaysia and India have been very successful at attracting medical travellers.
Why Patients Pursue Medical Tourism
The reasons patients seek care in medical tourism destinations are summarised in Table 2. Attractively low cost is the major reason that patients from the United States choose to travel to developing countries for medical services. For these patients, conservation of limited financial resources is of great importance. They are willing to accept the inconvenience of medical travel and uncertainties about quality of care in order to obtain services at prices they can comfortably afford. Patients travelling from the United States will generally fit one of two profiles. The first is a middle class adult who requires elective surgical care but has inadequate or absent health insurance coverage. The other is a patient who desires a discretionary procedure such as cosmetic surgery, dental reconstruction, fertility treatment or gender reassignment.
For patients from countries where a governmental healthcare system controls access to health services, particularly Canada and Britain, the primary motivation to bypass the local medical system is the desire to have timely treatment, circumventing delays associated with long waiting lists. Because government sponsored health systems generally do not pay for cosmetic surgery and similar type services, patients from countries with such programmes, like those from the United States, pursue medical tourism to benefit from lower prices. It is predictable that medical tourism will become increasingly popular among patients who lack insurance funding and for those who are impeded by waiting lists and other bureaucratic obstacles.
Patients also travel to offshore medical centres to have procedures that are not available in their own countries. Stem cell therapy, which shows promise for patients with a number of different diseases, is currently available in some medical tourism destinations, but unavailable or restricted to clinical trials in many industrialised countries. Concerns about lack of scientific rigour and patient exploitation in some destinations heighten the need for caution for all parties involved in these unproven interventions. Patients increasingly pursue international travel for various forms of reproductive treatment, including in-vitro fertilisation, commercial surrogacy, and acquisition of donor gametes. Finally, some patients travel to (and from) specific developing countries to undergo organ transplantation, unavailable to them in their own countries. Reproductive tourism and transplant tourism pose uniquely complex ethical issues and public health challenges.
Some patients choose to have medical care abroad because of the opportunity to experience travel to certain destinations and to have a vacation away from home. A business trip, tour of certain exotic destinations or a vacation may provide an opportunity to have elective health services abroad. Indeed, for people who travel for general health evaluations, routine diagnostic studies and limited surgical or dental procedures, the pleasurable non-clinical aspects of the trip may be particularly prized. The prospect of recovering from cosmetic surgery in a luxurious beachside resort is attractive to many potential medical tourists, particularly when the package can be purchased for less than the price of the operation in one’s own community. Although some medical tourism facilitators and travel professionals promote sightseeing and recreational endeavours, as the complexity and seriousness of the medical circumstances increase, the importance of the tourism activities rapidly diminishes. A patient who feels compelled to travel to a distant country for major surgery for a life-threatening condition that he cannot afford in his own country will probably not be particularly interested in visiting the local tourist attractions.
It is noteworthy that some patients seek offshore medical care to protect their privacy and confidentiality. In a distant country, patients can maintain anonymity with less concern that their privacy will be violated or that medical records will be viewed by any of the parties who may have access to such in their own country.
Impact of International Medical Travel
The movement of patients across international borders for medical care potentially impacts the public health of both the country of origin and the destination. Industrialised countries that have nationalised health systems with long waiting lists for certain procedures can clear backlogs by directing patients to low-cost offshore medical destinations without the difficulty, delay and expense of expanding local capacity. Britain and Canada have been able to reduce the queue for health services by utilising foreign providers in some situations. It is likely that there will be an increase of travel for medical care between member nations of the European Union.
The impact that serving foreign patients may have on developing nations is highly variable. In the best situations, providing healthcare to foreign patients generates substantial revenue, benefiting the healthcare facilities directly and the local community indirectly. This export trade can support jobs and may have a favourable impact on the healthcare workforce. Nevertheless, in poor developing nations, there are concerns that providing medical services to international patients may undermine local healthcare and exacerbate existing healthcare disparities. In addition, there are fears that service to foreign patients adversely impacts workforce distribution by creating an internal brain drain. Formulation and enforcement of appropriate macroeconomic redistributive policies are essential for developing nations to derive benefit from the medical tourism industry.
Michael D. Horowitz, MD, MBA
Medical Insights International
Full references available upon request