global medical tourism case study

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• Published: 16 July 2018

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

• Daniel Béland 1 &
• Amy Zarzeczny 1  

Globalization and Health volume  14 , Article number:  68 ( 2018 ) Cite this article

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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.

In this era of globalized medicine, when international travel and access to online health information are readily accessible, medical tourism is an important issue both for national health care systems and from a global health perspective [ 1 , 2 , 3 ]. Patients from countries around the world are exercising increasing degrees of autonomy over their health care options by obtaining information from sources other than their regular health care providers and, in some cases, by electing to pursue care alternatives outside their domestic medical system. Medical tourism is a broad and inclusive term that captures a wide range of diverse activities [ 3 ]. It has been defined as “the practice of travelling to another country with the purpose of obtaining health care (elective surgery, dental treatment, reproductive treatment, organ transplantation, medical checkups, etc.),” and is generally distinguished from both care sought for unplanned medical emergencies that occur abroad and from formal bi-lateral medical trade agreements [ 4 , 5 ]. Individual motivations for engaging in medical tourism vary widely and may include imperatives such as avoiding wait times, reducing costs, improving quality, and accessing treatments not available or legal in the home jurisdiction, or for which the individual is not eligible [ 5 , 6 , 7 , 8 ].

While medical tourism is far from new, shifting patient flow patterns and a growing recognition of the complex ethical, social, economic, and political issues it raises are underscoring renewed efforts to understand this phenomenon and its future [ 3 , 9 , 10 ]. Some of the current attention focused on medical tourism concerns its implications and potential risks for individual patients and health care systems [ 11 , 12 , 13 ]. Medical tourism impacts both importing and exporting health care systems, albeit in different ways [ 14 ]. Various terms exist to describe trade in health services [ 15 ]. For the purpose of this discussion, we will use importing or destination to describe systems whereby patients come from other jurisdictions to receive care, and exporting to describe the departure of individuals from their domestic medical system to pursue health services elsewhere. Recognizing that there are important knowledge gaps and a need for definitional clarity and further empirical work to understand the effects of medical tourism on the countries involved [ 16 ], concerns for importing or destination systems include, though are not limited to, ethical questions about inequity of access for local residents versus high paying visitors and about the “brain drain” of local talent into private, for-profit organizations focused on non-resident care [ 15 ]. Conversely, the issues exporting systems face often revolve around implications for domestic health care providers, the potential for patients to avoid domestic wait lists, and the costs of follow-up care upon patients’ return [ 12 ]. For example, research from Alberta, Canada, suggests that the financial costs associated with treating complications from medical tourism for bariatric surgery are substantial, and complication rates are considerably higher than similar surgeries conducted in Alberta (42.2–56.1% versus 12.3% locally) [ 6 ].

Although a growing body of literature has emerged to study medical tourism and address the policy challenges it creates for health systems [ 3 , 16 ], the comparative scholarship on medical tourism remains too limited in scope, a remark that should not hide the existence of a number of recent comparative studies in the field [ 17 , 18 , 19 ]. These studies demonstrate that comparative research is helpful in identifying both the unique and the most common policy challenges facing each country [ 20 ] and can, if done appropriately, offer learning opportunities [ 21 ]. Indeed, this process can facilitate policy learning (related terms include lesson drawing, policy transfer, diffusion, and convergence) whereby ideas, policies, or practices (e.g., regulatory tools) in one jurisdiction inform or shape those in another [ 22 , 23 ].

With a view to ultimately informing policy related to medical tourism, this article discusses the value of a comparative research agenda about medical tourism that stresses the multifaceted relationship between medical tourism and the institutional characteristics of national health care systems. On the one hand, these characteristics may shape the content of the demand for medical tourism among the citizens of a particular country [ 24 ]. From this perspective, as argued, existing typologies of health care systems can shed light on the varying features of the demand for medical tourism across countries. In other words, different types of health care systems are likely to produce different configurations of demand for medical tourism, which influences the range of policy instruments available to governments and other actors seeking to influence decision-making and behavior within their particular context [ 25 ]. On the other hand, the institutional characteristics of each national health care system may also shape the very nature of the impact of medical tourism on that system. Accordingly, the institutional characteristics of health care systems, such as insurance structures [ 26 ], may impact both citizens’ demand for medical tourism and the ways in which medical tourism affects each country. Obtaining a better understanding of these relationships may inform new ways of thinking about both the challenges and opportunities medical tourism presents. As medical tourism markets continue to grow and diversify, and as domestic health care systems increasingly feel the stress of limited resources, this kind of work will be critical to support policymakers and health system leaders in their efforts to mitigate the potential harms of medical tourism while, at the same time, responding to the needs of the citizens they serve [ 3 ].

Using the examples of Canada and the United States (US), this article proposes the use of an institutionalist research agenda to explore these two related sides of the medical tourism-health care system nexus as a central element of future policy strategies. We first take a comparative perspective on medical tourism and present what we see as key aspects of the issue from a policy perspective. Drawing on current evidence and leading literature in the field, we highlight ways in which national health care systems shape the demand for medical tourism and then, in turn, how medical tourism impacts national health care systems. From this discussion, we identify four key lines of enquiry that we suggest are of critical importance in the medical tourism policy landscape and propose an agenda for future comparative research on medical tourism and national health care systems that could play an important role in informing future policy decisions in this area.

Medical tourism in comparative perspective

Although gathering robust data on the magnitude of medical tourism continues to be a challenge and more empirical work in this area is needed [ 3 , 5 , 10 , 12 ], a strong body of literature addresses different aspects of the issue. For example, research is improving understandings of how medical tourism impacts destination and departure jurisdictions [ 16 , 27 ], affects relationships with domestic health care providers [ 28 ], relates to economic factors including health system costs [ 29 ], and impacts clinical outcomes for patients [ 30 ], among other important lines of enquiry. However, much of this valuable scholarship focuses on particular forms of medical tourism in specific contexts (bariatric surgery [ 31 ], dental care [ 32 ], reproductive services [ 33 ], etc.) or on the policy and health system implications for individual jurisdictions [ 13 ]. There is an increasing amount of comparative research exploring how different features of health care systems may in some cases help drive demand for medical tourism and in other cases constrain it (i.e., push/pull factors), and how they relate to the impact of medical tourism [ 24 ], but more work remains to be done in this important area [ 4 , 10 ]. The potential value of data on the impact of medical tourism in one jurisdiction to structurally- similar systems (e.g., other universal public health care systems) has already been recognized [ 34 ]; we agree and suggest that going further with an associated analysis considering the role of their institutional features is critical. This approach is particularly valuable from a policy perspective, especially when it comes to maximizing opportunities for policy learning from other jurisdictions and to identifying and evaluating the respective strengths and limitations of different policy options for decision-makers seeking to, for example, discourage particular forms of medical tourism (e.g., organ transplant tourism [ 35 ]).

The governance of medical tourism in its various forms is complex and highly fragmented given its broad range of influential stakeholders (both state and non-state, individual and institutional), its international market-based nature, and its engagement of vastly different and often competing priorities and interests (e.g., profit-driven, patient care, autonomy, ethics, etc.). As a result, policy makers and health system leaders face considerable challenges when it comes to seeking to influence medical tourism markets, whether by encouraging their development or restricting access to them. Obtaining a better understanding of the institutional forces that shape the demand for, and impact of, medical tourism—and connecting those forces to the policy context—may help identify a broader range of tools and options decision- makers can employ to achieve their particular objectives with respect to medical tourism.

Looking at Canada and the US is an appropriate starting point for this comparative work and we use this comparison to ground our analysis of the value of an institutional research agenda as a policy strategy for addressing potential concerns and opportunities associated with medical tourism. While these neighboring countries are similar in many ways, there are dramatic differences in important institutional features of their respective health care systems, including funding and delivery models. The US is both an established importer and exporter of medical tourists, the latter supported in part by insurers offering medical tourism coverage in an effort to reduce the high costs associated with domestic health care services [ 11 , 36 ]. In contrast, the structure of Canada’s largely publicly-funded, single-payer medical system limits foreign access to non-emergent care and makes it challenging for Canadians to be reimbursed for care received abroad via medical tourism [ 7 ]. It also makes the current involvement of Canadians in medical tourism [ 37 ] a public policy issue because of its implications for the public purse.

How national health care systems shape demand for medical tourism

Because health care systems can be understood as relatively stable institutional settings that shape human behavior [ 38 , 39 ], their features are likely to impact the demand for medical tourism in a particular country or even, in the case of decentralized health care systems subject to considerable regional variation, in a particular region. Health care systems can vary greatly from one country to the next, or even from one region to the next within the same country. Accordingly, what citizens might be looking for when they seek medical treatment abroad is likely to fluctuate based on the nature of health care coverage, financing, and regulation they have at home. Research about these and other drivers is growing but important gaps in knowledge remain [ 5 ]. In other words, alongside factors like geographical mobility and travel costs, the institutional configurations of health care systems likely shape, at least in part, the types of services people are looking for based on what health services they can access in their home country, with what degree of quality and timeliness, and at what cost [ 24 ].

A comparison between Canada and the US is illustrative here. Starting with the Canadian context, universal coverage has existed in Canada since the early 1970s [ 40 , 41 ]. Under this framework, regardless of the province or territory in which they live, Canadian citizens and permanent residents are entitled to medically necessary health care services with no user fees, which are strictly prohibited under the 1984 Canada Health Act (CHA). Yet, although the CHA mandates comprehensive coverage for “all insured health services provided by hospitals, medical practitioners or dentists,” many services do not fall under this umbrella and the Canadian health care system has long waiting lists for many non-emergency surgeries like hip replacement [ 40 , 42 ]. Wait times vary from province to province but they are a source of frustration for many Canadians, some of whom elect to go abroad to get their non-emergency procedure done faster, even if they have to pay for it themselves, instead of relying on the slower public system back home [ 7 ]. Gaps in coverage within the single-payer system in important areas such as prescription drugs [ 43 ] and dentistry [ 44 ] also sometimes push Canadian citizens and permanent residents to go elsewhere for care to reduce costs. There are also a wide variety of medical treatments and health-related interventions offered in private markets that are either not available or not publicly funded in Canada. There are a variety of reasons for this lack of public funding, including those related to evidence (or, more precisely, the lack thereof) regarding safety and efficacy. For example, there is a large international market for unproven stem cell interventions that are not part of the approved standard of care in Canada or available in the publicly funded health care system [ 45 ]. Therefore, key motivations underlying the pursuit of Canadian medical tourism often relate to a desire to access care faster, to reduce out of pocket costs for care not covered by provincial health insurance, and/or to access options that are not available in Canada [ 7 ].

In the US healthcare system, where about 9% of the population remains uninsured despite the enactment of the Affordable Care Act (ACA) in 2010 [ 46 ], people who lack insurance coverage but who face a medical need might go abroad to seek cheaper treatment. In fact, the high cost of care in the US has been recognized as a major factor pushing Americans to seek care at lower cost outside the US, an option that is facilitated by health care globalization [ 2 ]. For example, there is research documenting the strong market in the Mexican border city of Los Algodones for Americans seeking dentistry, optometrist, and pharmacy services [ 47 ]. Others may be motivated to return to systems with which they are more familiar, as is the case with the Mexican diaspora [ 24 ]. In the US, in contrast to Canada where universal coverage prevails, the lack of health care coverage is likely to be a key factor driving the demand for medical tourism. At the same time, waiting times are much less likely to drive the demand for medical tourism in the US, where waiting lists are less of an issue [ 40 ].

These brief remarks highlight how key institutional features in both Canada and the US shape patterns in the demand for medical tourism in these two countries, creating both similarities and differences between them. At the same time, regional differences in health system institutions within the two countries can also shape the demand for medical tourism within their borders. For instance, in states like Texas, where elected officials have thus far refused to expand Medicaid as part of the ACA [ 48 ], more people live without health care coverage than elsewhere (about 18% of the population as of March 2016 [ 49 ]), which may push them to look to Mexico for cheaper health care. Here the institutional characteristics of a state’s health care system and the geographical proximity to Mexico, coupled with the presence of a large population of Mexican descent who speak Spanish, are likely to favor cost-saving medical tourism from Texas to Mexico. This example highlights how geographical and even ethno-cultural factors can shape medical tourism alongside and even in combination with the institutional features of a particular health care system. This is also the case when we deal with issues such as dental care and cosmetic surgeries, which are not covered by many US public and private insurance plans [ 50 ].

How medical tourism impacts national health care systems

At the most general level, existing national and sub-national institutions may mediate the impact on particular countries of transnational processes stemming from globalization [ 20 , 51 ]. This general remark also applies to global medical tourism, which is unlikely to affect all national health care systems in the same way. Put bluntly, systems will react differently to external pressures, based in part on their own institutional characteristics. Those same institutional characteristics also form part of the policy matrix that shapes the options available to decision makers.

There are two central aspects to this story. First, we can look at how domestic health care institutions are specifically impacted by inbound medical tourism (i.e., destination countries at the receiving end of medical tourism). Research suggests that the way in which health care systems cope with foreign users, and what impact those foreign users have on the system, will vary according to the institutional characteristics of that system [ 16 ]. For instance, countries that attract many medical tourists could witness price increases and the diversion of services away from their less-fortunate citizens [ 1 ]. At the same time, the institutional features of national health care systems can explain why some countries attract more medical tourists than others. The comparison between Canada and the US is particularly revealing here. On the one hand, although some provinces have considered alternate approaches that would encourage inbound medical tourism as a source of revenue generation [ 52 ], at present the limited scope of private health care in Canada restricts the availability of medical tourism opportunities for wealthy foreigners seeking treatments. On the other hand, the large scope of private health care in the US makes that country an obvious target for wealthy medical tourists who can afford its high medical costs.

Second, and more important for this article, national health care institutions may also shape the way in which each country is affected by outbound medical tourism. For example, in a single-payer health care system such as Canada’s, both routine follow-up care and complications resulting from medical acts performed abroad are typically dealt with within the public system, engendering direct costs to taxpayers and potentially impacting access for others in the system (i.e., if physicians’ time is diverted to attend to emergent issues) [ 6 ]. The extent of these concerns varies depending on the urgency of the issue and whether it falls within hospital and physician services covered by the universal system (versus, for example, dental care where public coverage is more limited) [ 52 ]. By comparison, within the fragmented public-private US health care system, public programs may only absorb a fraction of the costs of complications related to outbound medical tourism, thus reducing their direct negative impact on taxpayers, whereas private insurance companies or individuals themselves might bear the majority of these costs.

The potential savings for outbound countries medical tourism generates are also likely to depend on the institutional features of each national or sub-national health care system [ 16 ]. In Canada, for instance, people who decide to go abroad for non-emergency surgeries might help reduce the length of waiting lists, although this positive impact might be limited by the fact that some of these surgeries are simply not available in Canada or, at least, not available to the individuals who seek treatments abroad (e.g., because of their age or health status). Because waiting lists are much less of an issue in the US [ 40 ], this potential benefit of medical tourism to domestic health care systems may be less relevant there.

Conversely, the prospect of affordable medical tourism may convince people in the US who do not have access to Medicaid, Medicare, or employer-based coverage that they do not need coverage at all, because they can always go abroad and save money should they need medical treatment. In this context, global medical tourism could interact with the question of whether people will seek coverage or not. At the same time, to save money, “US companies, such as Anthem Blue Cross and Blue Shield and United Group Programs, are now exploring the idea of including medical tourism as a part of their coverage,” a situation that could increase their administrative burden and create further complications along the road [ 53 ].

Policy implications

Our aim with the preceding high-level overview was to draw on existing knowledge to highlight not only that national health care institutions may shape the demand for medical tourism in a particular country or region, but also that the consequences of such tourism for national health care systems are likely similarly mediated by the institutional features of these systems. These connections have a number of important potential implications for health system governance of medical tourism and, more specifically, for the options available to policy makers seeking particular objectives. For example, depending on the jurisdiction, efforts to reduce demand for medical tourism could include a range of options such as investing resources targeted at reducing domestic wait times, expanding public health insurance, limiting public coverage for follow-up care needs, or educating the public about the potential risks associated with medical tourism [ 2 ], among other options. Conversely, efforts to encourage the development of a medical tourism industry within a particular jurisdiction might involve regulatory change to expand options for private system offerings and targeted marketing campaigns, again among other possibilities [ 5 , 17 ].

In fact, it has long been recognized the governments have a variety of tools or policy levers at their disposal when they seek to influence behavior [ 54 ]. Identifying which tool (or combination of tools) is likely to be most effective in a particular set of circumstances, such as medical tourism, requires a nuanced understanding of relevant institutional characteristics and situational factors. Accordingly, we propose that a comparative research agenda should be a key element of future analysis and decision-making efforts in this field. Such an agenda would not only help empirically test the above hypotheses about the institutional-medical tourism nexus, it could also help facilitate lesson drawing between jurisdictions that have attempted different approaches by helping pinpoint salient commonalities and points of difference between the systems that might initially explain, and ideally ultimately even predict, the likely results of particular policy initiatives.

Research agenda

We propose a comparative research agenda that aims to explore the relationship between medical tourism and key institutional features of national health care systems. Although some aspects of our research agenda are already present in the existing literature, we think studying these elements together and with a comparative policy lens would be of tremendous value to health system decision -makers seeking to navigate different objectives including, for example, avoiding “brain drain” from public to private health care, minimizing added costs to publicly funded systems, protecting vulnerable individuals, and facilitating patient autonomy.

Drawing on our review of the health care systems in Canada and the US, we have identified three key institutional features that we suggest are particularly relevant to medical tourism and its broader policy context. These key features are health care funding models, delivery structures (e.g., public/private mix, provider payment models, role of user choice, and competition between providers), and governance systems (e.g., location of authority, health care provider regulation, liability systems). Future empirical research may identify other more salient features and certainly an iterative approach may be valuable. Nonetheless, we suggest that these features would provide a useful starting point for the next step, which we propose be an exploration of how these institutional features relate to the following areas:

Patient flow patterns – e.g., inbound versus outbound, treatment destinations, types of treatment sought.

Patient motivations – e.g., cost reduction, wait list avoidance, pursuit of quality, circumvention tourism.

Health system interactions – e.g., costs and options for follow-up treatment, roles of domestic health care professionals.

Existing policy levers – e.g., public and private insurance structures, incentive schemes, information campaigns, regulation.

These four areas are not intended to serve as a comprehensive list of all relevant lines of enquiry. However, they present a valuable starting point, particularly because of their relevance to policy instrument selection processes. Having said that, and although it is beyond the scope of this piece to go further than laying a foundation for this proposed research agenda, we suggest that future research take a broad and scoping approach to draw on existing data and information and, where possible, conduct new empirical work addressing these critical areas. With a view to identifying patterns and generating hypotheses, researchers will likely need to continually refine the initial assumptions, outlined above, about the relationships between different institutional features and aspects of medical tourism. Doing so will require careful thought regarding the selection of an appropriate scientific paradigm, with a view to research validity and reliability [ 55 ].

We also anticipate that end-users and important stakeholders, including elected officials, civil servants, health care providers, and patients and families, would have an important contribution to make to the research design and with respect to interpreting the findings, particularly as they relate to the identification and evaluation of policy options. One important limitation in this type of work will relate to data availability. We expect that comparative work of this nature and any future empirical analyses it includes will highlight gaps in knowledge and potentially trigger future research agendas. Overall, the research envisioned here should complement and augment ongoing efforts in the field to improve understandings of important factors including patient flows, expenditure trends, system impacts, and individual decision-making determinants, among others.

Conclusions

This article discussed the relationship between medical tourism and key institutional aspects of national health care systems with a view to highlighting the value in a comparative research agenda focused on identifying and evaluating policy options. First, we argued that these characteristics directly affect the demand for medical tourism in each country. Second, we suggested that such institutional characteristics shape the actual impact of medical tourism on that particular country . This discussion led to the formulation of an institutionalist research agenda about medical tourism. It is our hope that this proposed agenda will trigger discussion and debate, help develop future research, and inform new ways of thinking about medical tourism in the global landscape. Medical tourism is a complex phenomenon and we suggest that applying a comparative, institutional lens will shed new light on its drivers, constraints, and impacts and, in so doing, ultimately help inform policy development in this area.

Hall C. Health and medical tourism: a kill or cure for global public health? Tourism Rev. 2011;66(1/2):4–15.

Google Scholar  

Maniam G. Medical tourism as the result of rising American healthcare costs in the context of healthcare globalization. J bus. Behav Sci. 2015;27(2):112–22.

Hanefeld J, Smith R, Horsfall D, Lunt N. What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. J Travel Med. 2014;21(6):410–7.

PubMed   Google Scholar  

Smith R, Martinez Alvarez M, Chanda R. Medical tourism: a review of the literature and analysis of a role for bi-lateral trade. Health Pol. 2011;103:276–82.

Crooks VA, Kingsbury P, Snyder J, Johnston R. What is known about the patient’s experience of medical tourism? A scoping review BMC Health Servi. 2010;10:266. https://doi.org/10.1186/1472-6963-10-266 . Accessed 12 June 2018.

Kim D, Sheppard C, de Gara C, Karmali S, Birch D. Financial costs and patients' perceptions of medical tourism in bariatric surgery. Can J Surg. 2016;59(1):59–61.

CAS   PubMed   PubMed Central   Google Scholar  

Snyder J, Crooks V, Johnston R, Kingsbury P. What do we know about Canadian involvement in medical tourism? A scoping review Open Med. 2011;5(3):e139–48.

Horowitz M, Rosensweig J, Jones C. Medical tourism: globalization of the healthcare marketplace. Med Gen Med. 2007;9(4):33.

Connell J. From medical tourism to transnational health care? An epilogue for the future. Soc Sci & Med. 2015;124:398–401.

Behrmann J, Smith E. Top 7 issues in medical tourism: challenges, knowledge gaps, and future directions for research and policy development. Glob J Health Science. 2010;2(2):80–90.

Turner L. “Medical tourism” and the global marketplace in health services: U.S. patients, international hospitals, and the search for affordable health care. Int J Health Serv. 2010;40(3):443–67.

Hopkins L, Labonte R, Runnels V, Packer C. Medical tourism today: what is the state of existing knowledge? J Public Health Policy. 2010;31(2):185–98.

Lunt N, Mannion R, Exworthy M. A framework for exploring the policy implications of UK medical tourism and international patient flows. Soc Policy Admin. 2013;47(1):1–25.

Cohen IG. Medical tourism: the view from ten thousand feet. Hast Cent Rep. 2010;40(2):11–2.

Chanda R. Trade in health services. B World Health Organ. 2002;80(2):158–63.

Johnston R, Crooks VA, Snyder J, Kingsbury P. What is known about the effects of medical tourism in destination and departure countries? A scoping review Int J Equity Health. 2010;9:24. https://doi.org/10.1186/1475-9276-9-24 . Accessed 12 June 2018.

Snyder J, Crooks VA, Johnston R, Cerón A, Labonte R. “That’s enough patients for everyone!”: local stakeholders’ views on attracting patients into Barbados and Guatemala’s emerging medical tourism sectors. Glob Health. 2016;12:1–13.

Leng CH. Medical tourism and the state in Malaysia and Singapore. Glob Soc Policy. 2010;10(3):336–57.

Pocock NS, Phua KH. Medical tourism and policy implications for health systems: a conceptual framework from a comparative study of Thailand, Singapore and Malaysia. Glob Health. 2011;7(1):12.

Béland D. What is social policy? Understanding the welfare state. Cambridge: Polity Press; 2010.

Marmor T, Freeman R, Okma K. Comparative perspectives and policy learning in the world of health care. J comp. Foreign Policy Anal. 2005;7(4):331–48.

Stone D. Transfer and translation of policy. Policy Stud. 2012;33(6):483–99.

Benson D, Jordan A. What have we learned from policy transfer research? Dolowitz and marsh revisited. Polit Stud Rev. 2011;9:366–78.

Bustamante A. Globalization and medical tourism: the north American experience. Int J Health Policy Manag. 2014;3(1):47–9.

PubMed   PubMed Central   Google Scholar  

Howlett M. What is a policy instrument? Tools, mixes, and implementation styles. In: Eliadas P, Hill MM, Howlett M, editors. Designing government: from instruments to governance. Montréal and Kingston: McGill-Queen’s press; 2015. p. 31–50.

Laugesen M, Vargas-Bustamante A. A patient mobility framework that travels: European and United States-Mexico comparisons. Health Policy. 2010;97:225–31.

For example, seeSnyder J, Crooks V, Turner L, Johnston R. Understanding the impacts of medical tourism on health human resources in Barbados: a prospective, qualitative study of stakeholder perceptions. Int J Equity Health. 2013; https://doi.org/10.1186/1475-9276-12-2 .

For example, seeSnyder J, Crooks V, Johnston R, Dharamsi S. “Do your homework … and then hope for the best”: the challenges that medical tourism poses to Canadian family physicians’ support of patients’ informed decision-making. BMC Med Ethics. 2013; https://doi.org/10.1186/1472-6939-14-37 .

For example, seeMilstein A, Smith M. Will the surgical world become flat? Health Aff. 2007;26(1):137–41.

For example, seePrasad GV, Shukla A, Huang M, D’A Honey RJ, Zaltzman J. Outcomes of commercial renal transplantation: a Canadian experience. Transplantation. 2006;82(9):1130–5.

Snyder J, Crooks VA. Medical tourism and bariatric surgery: more moral challenges. Am J Bioeth. 2010;10(12):28–30.

Turner L. Cross-border dental care: ‘dental tourism’ and patient mobility. Brit Dent J. 2008;204:553–4.

CAS   PubMed   Google Scholar  

Deonandan R. Recent trends in reproductive tourism and international surrogacy: ethical considerations and challenges for policy. Risk Manag Healthc Policy. 2015;8:111–9.

Hanefeld J, Horsfall D, Lunt N, Smith R. Medical tourism: a cost or benefit to the NHS? PLOSOne. 2013; https://doi.org/10.1371/journal.pone.0070406 .

Gill J, Diec O, Landsberg DN, Rose C, Johnston O, Keown PA, Gill JS. Opportunities to deter transplant tourism exist before referral for transplantation and during the workup and management of transplant candidates. Kidney Int. 2011;79(1):1026–31.

Kumar S, Breuing R, Chahal R. Globalization of health care delivery in the United States through medical tourism. J Health Comm. 2012;17(2):177–98.

Runnels V, Labonte R, Packer C, Chaudhry S, Adams O, Blackmer J. Canadian physicians’ responses to cross border health care. Glob Health. 2014; https://doi.org/10.1186/1744-8603-10-20 .

Hacker JS. The historical logic of national health insurance: structure and sequence in the development of British, Canadian, and U.S. medical policy development. Stud am Polit. Dev. 1998;12(1):57–130.

Tuohy CH. Accidental logics: the dynamics of change in the health care arena in the United States, Britain, and Canada. Oxford: Oxford University Press; 1999.

Maioni A. Parting at the crossroads: the emergence of health insurance in the United States and Canada. Princeton: Princeton University press; 1998.

Marchildon GP. Health systems in transition: Canada. Toronto: University of Toronto Press; 2013.

McQuigge M. Canadian health care wait times still unacceptably high, two reports say. National Post. 2015; https://nationalpost.com/health/canadian-health-care-wait-times-still-unacceptably-high-two-reports-say . Accessed 3 Nov 2016.

Boothe K. Ideas and the pace of change: national pharmaceutical insurance in Canada, Australia, and the United Kingdom. Toronto: University of Toronto Press; 2015.

Locker D, Maggirias J, Quinonez C. Income, dental insurance coverage, and financial barriers to dental care among Canadian adults. J Pub Health Den. 2011;71(4):327-34.

Berger I, Ahmad A, Bansal A, Kapoor T, Sipp D, Rasko J. Global distribution of businesses marketing stem cell-based interventions. Cell Stem Cell. 2016;19:158–62.

Cohen RA, Martinez ME, Zammitti EP. Health insurance coverage: early release of estimates from the National Health Interview Survey, 2015. Washington, DC: Centers for Disease Control and Prevention (National Center for Health Statistics); 2016. https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201605.pdf : 1. Accessed 3 Nov 2016.

Judkins G. Persistence of the U.S. – Mexico border: expansion of medical tourism amid trade liberalization. J Lat Am Geog. 2007;6(2):11–32.

Béland D, Rocco P, Waddan A. Obamacare wars: federalism, state politics, and the Affordable Care Act. Lawrence, KS: University Press of Kansas; 2016.

Mangan D. Big drop in Texans without health insurance, but poor lag. CNBC I June. 2016; http://www.cnbc.com/2016/06/01/big-drop-in-texans-without-health-insurance-but-poor-lag.html . Accessed 3 November 2016

IMTG. Most medical tourism to Mexico is dental or cosmetic. Int Med Travel Journal (Intuition Communication). 26 August 2015; http://www.imtj.com/news/most-medical-tourism-mexico-dental-or-cosmetic/ . Accessed 3 November 2016

Campbell JL. Institutional change and globalization. Princeton: Princeton University Press; 2004.

Snyder J, Johnston R, Crooks VA, Morgan J, Adams K. How medical tourism enables preferential access to care: four patterns from the Canadian context. Health Care Anal. 2017;25:138–50.

Kirchner E, Carroll J, Nious K. US insurance companies expanding medical tourism coverage. NBC (Bay Area). 4 December 2013; http://www.nbcbayarea.com/news/local/Medical-Tourism-The-Future-of-Healthcare-233414371.html . Accessed 3 November 2016

Hood C. The tools of government. Chatham: Chatham house: Publishers; 1986.

Healy M, Perry C. Comprehensive criteria to judge validity and reliability of qualitative research within the realism paradigm. Qual Market Research. 2000;3(3):118–26.

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Acknowledgements

The authors thank Rachel Hatcher for the copy-editing support and anonymous reviewers for their helpful suggestions. DB acknowledges support from the Canada Research Chairs Program, and AZ funding from the Canadian National Transplant Research Program.

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Béland, D., Zarzeczny, A. Medical tourism and national health care systems: an institutionalist research agenda. Global Health 14 , 68 (2018). https://doi.org/10.1186/s12992-018-0387-0

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Article Contents

Magnitude/overall volume, reasons for seeking care abroad and problems associated with medical tourism, infectious diseases associated with medical tourism, measures to assure quality and safety from medical tourism and control of infections.

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The Globalization of Healthcare: Implications of Medical Tourism for the Infectious Disease Clinician

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Lin H. Chen, Mary E. Wilson, The Globalization of Healthcare: Implications of Medical Tourism for the Infectious Disease Clinician, Clinical Infectious Diseases , Volume 57, Issue 12, 15 December 2013, Pages 1752–1759, https://doi.org/10.1093/cid/cit540

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Travel abroad for healthcare has increased rapidly; interventions include organ transplant; cardiac surgery; reproductive care; and joint, cosmetic, and dental procedures. Individuals who receive medical care abroad are a vulnerable, sentinel population, who sample the local environment and can carry home unusual and resistant infections, documented in many reports. Medical tourists are at risk for hospital-associated and procedure-related infections as well as for locally endemic infections. Patients may not volunteer details about care abroad, so clinicians must inquire about medical procedures abroad as well as recent travel. Special infection control measures may be warranted. Healthcare abroad is associated with diverse financial, legal, ethical, and health-related issues. We focus on problems the infectious disease clinician may encounter and provide a framework for evaluating returned medical tourists with suspected infections. A better system is needed to ensure broad access to high-quality health services, continuity of care, and surveillance for complications.

Healthcare is undergoing dramatic globalization. Throughout history, the sick and lame have embarked on pilgrimages to find cures. In the past, this was primarily to access facilities or technologies unavailable at home. Now travel for medical treatment has expanded enormously and many travel from developed countries to low- or middle-income countries, often to avoid high costs or long delays. Travel to another country for medical treatment has been called “medical tourism” and “cross-border healthcare” [ 1 , 2 ]. Globalization of medical care is a multi-billion-dollar phenomenon, associated with economic, cultural, ethical, legal, and health consequences. A growing literature describes its dimensions and complexities [ 3–6 ]. This paper will focus on infectious disease implications.

Common destinations for medical tourists include India, Thailand, China, Mexico, Latin America, the Caribbean, Europe, Singapore, the Middle East, and Pakistan [ 7 ]. Notably, destinations include many low- and middle-income plus a few high-income countries. Patients often seek treatment in their World Health Organization (WHO) region of residence, but the diaspora population may combine medical treatment with family visits [ 8 ]. Seventy percent of patients going to Singapore and Malaysia are from countries in the Association of Southeast Asian Nations; those going to Cuba are mainly from the Caribbean and Central America, and those going to Jordan are mostly from Middle Eastern countries [ 8 ]. The main constraint on medical tourism is the challenge of insurance portability. High-quality medical professionals, often trained in the United States or United Kingdom, are found in many institutions treating medical tourists; US medical schools are increasingly cooperating with foreign institutions in educational efforts. Meanwhile, lower costs of services, including labor, provide developing countries a substantial cost advantage [ 8 ].

Complete and accurate data on medical tourism volume, destinations, services, and procedures are unavailable. One source estimated 4 million international patients annually [ 8 ]. Thailand attracted 1.28 million international patients in 2005, [ 9 ] with India, Singapore, and Malaysia each approaching this number by 2012 [ 8 ]. The Asian market had been forecast to generate $4.4 billion in 2012 [ 8 ]. Singapore has launched an initiative to develop new areas, such as stem cell treatment and transplant. Widely variable estimates of global medical tourism value (US$20–$60 billion) are unreliable [ 10 ]. Guidelines for consistent definitions and reporting methodologies for medical tourism have been recently published (2011) [ 11 ] and may permit more accurate reporting.

One debatable source estimated that 750 000 Americans traveled abroad in 2007 for medical procedures (45% to Asia in 2005) [ 12 ]. In 2005, an estimated 55 000 Americans received care at Bumrungrad Hospital (Bangkok), a hospital that currently estimates treating 420 000 international patients annually [ 13 ].

Among the motivations for medical tourism (Table 1 ) are lower cost, avoidance of long waits, legal or cultural restrictions at home, privacy and opportunity to recover away from home, incentives offered by employers or insurers, and interest in combining an exotic vacation with a medical procedure [ 1 , 2 , 7 , 14 ]. Common procedures include dental work; arthroplasty; cataract, bariatric, cosmetic, and cardiac surgery; reproductive care; and tissue and organ transplant. More than 40% of unrelated stem cell transplants worldwide involve donors from a different country [ 15 ]. Vast cost differences exist: a hip replacement may cost $7000–$12 000 (India) or $6500–$14 000 (Thailand) versus $43 000–100 000 (United States) [ 12 ]. Medical tourism is sufficiently common that the Centers for Disease Control and Prevention and professional societies have developed patient guidelines (Table 2 ).

Summary of Reasons for Seeking Overseas Medical Treatment, Potential Benefits to Receiving Countries, and Current Challenges and Concerns Associated With Medical Tourism

Source: Heible [ 1 ], Milstein and Smith [ 2 ], Horowitz et al [ 7 ], Turner [ 14 ].

Internet Resources From Professional Societies and International Organizations Focusing on Quality and Safety and Accreditation of Healthcare Abroad

Problems associated with medical tourism have become evident: lack of regulation, complications and poor outcomes, exploitation of donors and surrogates, diversion of skilled specialists to hospitals serving foreigners, and fragmented follow-up care (Table 1 ). Some professional associations and international organizations have developed quality-of-care standards and have established accreditation procedures [ 1 , 3 ] (Table 2 ). The International Organization for Standardization (ISO) and Joint Commission International (JCI) perform procedural assessments on quality and safety associated with medical tourism, although they do not assess outcomes. JCI had accredited 368 international hospitals as of March 2012 [ 16 ]. Globally, 55 countries have JCI-certified hospitals; Singapore alone had 22 (2013).

Medical tourists are at risk for procedure-related infections—eg, wound and blood-borne infections—and those related to regional travel. Broader population consequences can follow if pathogens or resistance determinants spread during care or after return home. Consequences following healthcare abroad can appear early or late. Although this paper focuses on individuals who travel to obtain healthcare, similar risks exist for travelers who require care during travel (inadvertent medical tourists) and persons visiting friends and relatives who undergo procedures while abroad (incidental medical tourist). A Boston-area survey found that about half of international travelers experienced health problems, 7% sought medical care, and 1% required hospitalization [ 17 ].

Healthcare-associated infections overlap with those elsewhere, though the prevalence in developing countries is substantially higher than in Europe and the United States [ 18 ]. A meta-analysis found that developing-country adult intensive care units had infection rates at least 3-fold higher than those reported from the United States, and surgical site infection rates were also higher (5.6 vs 1.6–2.9 per 100 surgical procedures) [ 18 ]. Higher rates of infections [ 19 ] complicate procedures done abroad, but no system-wide database currently tracks procedures and outcomes. Because quality of care varies greatly by institution, it is difficult to make meaningful generalizations about risks outside the United States.

Many countries with robust medical tourism programs lie in tropical and subtropical regions where malaria, dengue fever, enteric fever, and other endemic infections exist. Many have high background rates of tuberculosis, antibiotic resistance, and hepatitis B, hepatitis C, and human immunodeficiency virus (HIV). Blood and blood products used in hospitals certified by JCI are expected to be screened for common blood-borne pathogens, but not necessarily for all region-specific agents. Dengue and West Nile viruses, for example, cause rare infections after transfusion, and screening for these is not done in most regions [ 20 ].

Kidney Transplantation

As of 2010, 98 countries reported having organ transplant services and together performed about 100 000 transplants annually [ 21 , 22 ]. An estimated 10% of organ transplants worldwide in 2007 resulted from transplant tourism [ 23 ]. The US national waitlist removal data from 1987–2006 indicated 373 likely cases of transplant tourism; male sex, Asian ethnicity, resident alien status, and college education were independently associated with overseas transplant, most often in China, the Philippines, and India [ 24 ]. It seems that Chinese transplant programs routinely sold organs to nationals and foreigners until 2007 when the practice was banned [ 25 ]. India outlawed buying and selling kidneys in 1994 [ 26 ]. Organ vending is illegal in all countries except Iran, yet the practice persists [ 27 ]. Formalized at the 63rd World Health Assembly, the WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation stated that “organs should be donated freely without any monetary payment or reward of monetary value” [ 28 ]. Despite their promulgation, the guiding principles are not necessarily followed; a thriving black market persists in some countries.

Although kidney transplants have raised many concerns about human rights [ 27 ]—including transplanting organs from executed prisoners—they are similar to other solid organ transplants where the organ can be a source of infection and complications arise from immunosuppression. Some transplant-associated infections are geographically restricted, including human T-lymphotropic virus types 1 and 2, West Nile virus, rabies, malaria, Leishmania , Trypanosoma cruzi , and several fungi, among others [ 29 ]. The source of infection may be the transplanted organ or transfused blood [ 29 ]. At least 45 cases of malaria have occurred in organ transplant patients (36 renal); at least 14 (3 heart, 5 liver, 6 renal transplants) had evidence supporting donor-to-host transmission via the graft [ 29 ]. Strongyloides stercoralis , endemic in tropical and subtropical regions, has been transmitted from a donor with unrecognized infection to kidney and liver transplant recipients [ 30 ].

A systematic review of outcomes found inferior patient and graft survival after commercial transplants (performed in South Asia, East Asia, and the Middle East) compared to results described in the United Network for Organ Sharing [ 26 ]. Commercial transplants had a higher incidence of infections including hepatitis B, hepatitis C, malaria, HIV, and tuberculosis, and markedly increased incidence of postoperative surgical interventions [ 26 ]. Likewise, patients who had renal transplants overseas (n = 87, mostly in China) followed at Seoul National University Hospital, Korea (2000–2009), had higher risk of infections, acute rejection, and hospitalization than did patients with local donors (n = 577) [ 31 ]. A meta-analysis (39 centers globally) concluded that transplant tourists had lower 1-year graft and patient survival than domestic kidney transplant recipients and were more likely than domestic kidney transplant recipients to develop cytomegalovirus, hepatitis B virus, HIV, and wound infections [ 32 ].

Cosmetic Surgery

A cluster of wound infections caused by Mycobacterium abscessus following cosmetic surgery (including abdominoplasty, breast surgery, liposuction) in Santo Domingo, Dominican Republic, was reported in the United States in 2003–2004 [ 33 ]. A 2005 survey of North American infectious disease specialists found that 6% of 425 respondents had encountered infectious complications from cosmetic surgery performed abroad in the previous year [ 34 ]. No comparator or denominator data were available.

Resistant Organisms

Prominent bacterial species causing nosocomial infections and resistance patterns vary geographically. In many countries, antibiotics are available without prescription; overuse is common and resistance widespread, so nosocomial infections may be caused by unusually resistant bacteria that reflect problem pathogens in that hospital or region. For example, extended-spectrum β-lactamase (ESBL) rates exceed 80% in India, and vancomycin-intermediate-resistant Staphylococcus aureus is prevalent in parts of Asia [ 35 , 36 ].

Travelers sample the microbial milieu of another region and can acquire resistant bacteria in the absence of illness or medical treatment [ 37 ]. Travelers cultured before, during, and after travel to Mexico showed increase in resistance in their fecal Escherichia coli , even if they took no antibiotics [ 38 ]. In a Canadian study, patients with diarrhea who had recently traveled had a 5.2-fold increase in colonization with ESBL-producing E. coli [ 39 ] . Twenty-four of 100 Swedish travelers acquired new ESBL-producing E. coli during travel (median duration, 2 weeks), with highest rates from India (7 of 8 travelers) [ 40 ]. The ESBL colonization rate in Australians increased from 7.8% pretravel to 49% posttravel, with resistant E. coli isolated from 50% to 79% of travelers to Asia (excluding Japan), South America, and/or Middle East/Africa [ 41 ]. At 6 months posttravel, 18%–24% remained colonized [ 40 , 41 ]. Resistance enzymes varied by region: CTX-M-15 from India, Europe, and Africa, and CTX-M-14 from elsewhere in Asia [ 42 ]. CTX-M β-lactamases carried in feces also spread within households [ 43 ]. A UK study found that recent international travel or antibiotic use were independent risk factors for septicemia following transrectal prostate biopsy. All blood and urine E. coli isolates from septic patients were resistant to ciprofloxacin, the agent used for prophylaxis [ 44 ]. Many studies document the role of travelers, including medical tourists, in moving bacteria and resistance genes globally [ 45–48 ].

Current Gram-Negative Concerns

Resistance genes may be found in commensals as well as in pathogenic organisms; international travel played a key role in the global dissemination of CTX-M–, KPC ( Klebsiella pneumoniae carbapenemase)–, VIM (Verona integron-encoded metallo-β-lactamase)–, OXA-48 (oxacillinase group of β-lactamases)–, and NDM (New Delhi-metallo-β-lactamase)–producing Enterobacteriaceae [ 45–49 ]. Although some infections resulted from treatment for injuries or acute during-travel problems, many were acquired via medical tourism [ 45 , 49 ]. In one case, carbapenem-resistant K. pneumoniae in Colombia in 2008 was traced to a medical tourist from Israel who traveled for liver transplant, exemplifying the ability of the medical tourist to introduce resistant organisms to the country providing medical care [ 50 ].

Travelers have provided specimens that have helped to map the global distribution of NDM enzymes [ 48 , 51 ]. This metallo-β-lactamase was first characterized from an isolate in a Swedish patient (Indian origin) who had been hospitalized in India in late 2007 and early 2008 [ 52 ]. In Sweden, a multidrug-resistant K. pneumoniae from his urine and an E. coli cultured from a fecal sample were both positive for what was subsequently designated NDM. These carbapenemases have been identified primarily in Enterobacteriaceae but can spread to multiple gram-negative bacterial species, including other pathogens (eg, Vibrio cholerae , Pseudomonas aeruginosa , Salmonella ), and to commensals. Bacteria may carry NDM-1 along with other resistance determinants; they are typically pan-resistant. The genetic element encoding NDM-1 is carried on plasmids and occasionally on chromosomes [ 53 ]. A 2010 paper identified 37 NDM-1–producing isolates in the United Kingdom, a high proportion in travelers to India or Pakistan within the previous year (n = 17/37); 14 had antecedent hospital treatment abroad, including renal or bone marrow transplant and cosmetic surgery [ 46 ]. The earliest documented NDM-1–producing isolates were in India in 2006 [ 54 ]. NDM-1–producing isolates are widespread in clinical isolates in India and Pakistan (Varanasi 6.9%, Mumbai 8%, and Rawalpindi, 18.5%), [ 54–56 ] and were also found in environmental samples (eg, water samples, Delhi) [ 57 ]. Nosocomial spread has been documented in multiple regions (Europe, Africa, Middle East, North America) [ 48 ].

Since first detected in the United States in 2010, 14 of 16 NDM-producing isolates were linked to medical care in South Asia [ 58 ]. In 2012, a hospital outbreak in Denver, Colorado, involved 8 patients [ 58 ]. Although the source of introduction was unclear, 5 isolates were from asymptomatically colonized patients, a reminder of potential spread by unrecognized carriers [ 58 ].

Current Gram-Positive Concerns

Transfer of resistant gram-positive organisms, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and hypervirulent Clostridium difficile , also occurs [ 35 , 36 , 45 , 59 ]. Reportedly, a quarter of MRSA cases from 2000 to 2003 in Sweden were attributed to exposure abroad, and the majority were healthcare-associated [ 45 ]. Ireland, France, and Australia have described the transfer of hypervirulent Clostridium difficile (ribotype 027) from the United Kingdom, Belgium, and North America, respectively [ 45 ].

Mycobacterium Tuberculosis

Resistance to antituberculous medication is a global problem; high levels of resistance are found in parts of Asia and exposures can occur in hospitals [ 36 ]. In Singapore, extensively resistant tuberculosis was diagnosed in 2010 in a patient from Indonesia who required several months of multidrug treatment and surgery before being able to return home [ 60 ].

Other Concerns

Other concerns related to medical procedures abroad include reuse of syringes or equipment without adequate sterilization, exposure to falsified or substandard medications [ 61 ], and inadequately screened blood donations. Travelers to tropical and developing countries risk acquiring locally endemic infections; recent studies provide destination-specific risks [ 62 ]. Medical tourists, sometimes with family, may travel regionally, thus facing risk for vector-borne and other locally endemic infections. They may encounter new and emerging threats such as influenza A(H7N9) or novel coronavirus, which may spread nosocomially. The SARS (severe acute respiratory distress syndrome) outbreak led to nosocomial transmission in countries with substantial medical tourism, although medical tourists were not specifically identified then. Finally, major surgery away from home environment carries the risk of perioperative deep vein thrombosis from long-haul flights.

Patients contemplating medical tourism should be advised of procedure-related as well as typical travel-associated risks. The public should be informed of potential infectious disease risks associated with overseas hospital care. Efforts such as the Chennai Declaration—a consensus report resulting from a 2012 meeting in Chennai, India, of healthcare representatives, experts, and policy makers from India and WHO, which aimed to formulate a plan to address the global challenge of antimicrobial resistance from the Indian perspective—attempt to tackle the resistance problem [ 63 ]. For medical tourists, a tracking system is needed as patients from one institution may return to many different countries and institutions, making it difficult to identify problems at a particular institution. Improved communication is essential to optimize continuity of care of medical tourists who may have follow-up on a different continent by a clinical team unaware of site(s) of medical and surgical care. Medical tourists may carry home unusually resistant microbial flora; patients hospitalized after return from medical care in high-risk destinations such as South Asia should be placed on contact isolation and cultured for resistant organisms. Decisions about empiric therapy and surgical prophylaxis should consider recent travel history and procedures abroad. Surveillance networks such as GeoSentinel (55 travel–tropical medicine clinics on 6 continents) can be refined to capture data on antimicrobial resistance. The International Health Regulations 2005 contain criteria to determine whether an event may “constitute a public health emergency of international concern” [ 64 ]; thus, WHO can potentially champion coordinated global surveillance of antimicrobial resistance as well as international response [ 65 ].

Travel abroad for healthcare will likely continue to increase, given the market forces. Knowledge of this trend is critical in incorporating a global perspective into clinical care. Patients may not freely volunteer information about medical care, so today's medical history must include explicit queries about travel and details of medical care or procedures carried out abroad. The differential diagnosis of illness after a procedure in another country is often broader than that in the United States. Infection control issues must be considered, as patients may be colonized or infected with multidrug-resistant bacteria. Complicating infections may appear early or late, with the latter more common in those who have received blood or blood products, tissue or organ transplants, and immunosuppressed hosts. Healthcare abroad is an integral part of the knowledge base required of infectious disease clinicians. More generally, a better system is needed to gather information on these global patients and the outcomes of their treatment. Infectious diseases associated with medical tourism have been recognized primarily through case reports or case series. Collection of data including demographics, procedures sought, and outcomes in a systematic and standardized fashion is needed to inform physicians caring for patients seeking medical care abroad or returning from their overseas medical treatments. Policy makers must consider economic, ethical, and legal aspects of medical tourism in trying to balance healthcare access and affordability.

Acknowledgments.  We thank Professors I. Glenn Cohen, George Eliopoulos, Ann Marie Kimball, and Karin Leder for their thoughtful review and suggestions for the manuscript.

Potential conflicts of interest.  L. H. C. has received honoraria for serving on the editorial boards for Thompson Media LLC and Shoreland Inc, research funding from Xcellerex Inc, and royalties from Wiley Publishing. M. E. W. reports no potential conflicts.

Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

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Medical, health and wellness tourism research—a review of the literature (1970–2020) and research agenda.

1. Introduction

2. scholarly reviews and meta-analyses of medical, health and wellness tourism, 3.1. data collection, 3.2. data analysis, 4.1. overview of articles published, 4.2. source journals, 4.3. author productivity and authorship analysis, 4.4. author regions and affiliations, 4.5. thematic analysis of research, 4.6. markets: demand and behavior, 4.7. destinations: development and promotion, 4.8. development environments: policies and impacts, 5. discussion and conclusions, 5.1. generation discussion, 5.2. future research trends, 5.2.1. industrial perspective, 5.2.2. destination development perspectives, 5.2.3. tourist perspectives, 5.3. limitations, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

• Enzensberger, H.M. A theory of tourism. New Ger. Crit. 1996 , 68 , 117–135. [ Google Scholar ] [ CrossRef ]
• Tabish, S.A. Healthcare: From good to exceptional governance. JIMSA 2012 , 25 , 147–150. [ Google Scholar ]
• Koncul, N. Wellness: A New Mode of tourism. Econ. Res. -Ekon. Istraživanja 2012 , 25 , 525–534. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Mueller, H.; Kaufmann, E.L. Wellness tourism: Market analysis of a special health tourism segment and implications for the hotel industry. J. Vacat. Mark. 2001 , 7 , 5–17. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Pereira, R.T.; Malone, C.M.; Flaherty, G.T. Corrigendum to: Aesthetic journeys: A review of cosmetic surgery tourism. J. Travel Med. 2018 , 25 , tay051. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Yaman, H. Travel Medicine in Turkey: Current State and Implications for the Future. J. Travel Med. 2006 , 10 , 68–69. [ Google Scholar ] [ CrossRef ]
• Bauer, I.L. Looking over the fence—How travel medicine can benefit from tourism research. J. Travel Med. 2015 , 22 , 206–207. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Jones, C.A.; Keith, L.G. Medical tourism and reproductive outsourcing: The dawning of a new paradigm for healthcare. Int. J. Fertil. Women’s Med. 2006 , 51 , 251–255. [ Google Scholar ]
• Leggat, P.; Kedjarune, U. Dental health, ‘dental tourism’ and travellers. Travel Med. Infect. Dis. 2016 , 7 , 123–124. [ Google Scholar ] [ CrossRef ]
• Crozier, G.K.D.; Thomsen, K. Stem cell tourism and the role of health professional organizations. Am. J. Bioeth. 2010 , 10 , 36–38. [ Google Scholar ] [ CrossRef ]
• Nikezic, S.; Djordjevic, M.; Bataveljic, D. Improvement of spa tourism in the Republic of Serbia as a pattern of positive impact on ecology and regional development. Tech. Technol. Educ. Manag.-TTEM 2012 , 7 , 920–925. [ Google Scholar ]
• Sayili, M.; Akca, H.; Duman, T.; Esengun, K. Psoriasis treatment via doctor fishes as part of health tourism: A case study of Kangal Fish Spring, Turkey. Tour. Manag. 2007 , 28 , 625–629. [ Google Scholar ] [ CrossRef ]
• Lunt, N.; Carrera, P. Medical tourism: Assessing the evidence on treatment abroad. Maturitas 2010 , 66 , 27–32. [ Google Scholar ] [ CrossRef ]
• Turner, L. “Medical Tourism” and the Global Marketplace in Health Services: U.S. Patients, International Hospitals, and the Search for Affordable Health Care. Int. J. Health Serv. 2010 , 40 , 443–467. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Chaulagain, S.; Pizam, A.; Wang, Y. An integrated behavioral model for medical tourism: An American perspective. J. Travel Res. 2021 , 60 , 761–778. [ Google Scholar ] [ CrossRef ]
• Jaramillo, J.; Goyal, D.; Lung, C. Birth Tourism among Chinese Women. MCN Am. J. Matern. Nurs. 2019 , 44 , 94–99. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Li, E.P.H.; Min, H.J.; Lee, S. Soft power and nation rebranding the transformation of Korean national identity through cosmetic surgery tourism. Int. Mark. Rev. 2021 , 38 , 141–162. [ Google Scholar ] [ CrossRef ]
• Xie, L.; Guan, X.; He, Y.; Huan, T.-C. Wellness tourism: Customer-perceived value on customer engagement. Tour. Rev. 2021 . [ Google Scholar ] [ CrossRef ]
• Lwin, H.N.N.; Punnakitikashem, P.; Thananusak, T. The level and determinants of international patient satisfaction with dental tourism in Bangkok, Thailand. Cogent Bus. Manag. 2021 , 8 , 1898316. [ Google Scholar ] [ CrossRef ]
• Zhang, Q.; Zhang, H.; Xu, H. Health tourism destinations as therapeutic landscapes: Understanding the health perceptions of senior seasonal migrants. Soc. Sci. Med. 2021 , 279 , 113951. [ Google Scholar ] [ CrossRef ]
• Lee, H.K.; Fernando, Y. The antecedents and outcomes of the medical tourism supply chain. Tour. Manag. 2015 , 46 , 148–157. [ Google Scholar ] [ CrossRef ]
• Wang, K.; Xu, H.; Huang, L. Wellness tourism and spatial stigma: A case study of Bama, China. Tour. Manag. 2020 , 78 , 104039. [ Google Scholar ] [ CrossRef ]
• Rokni, L.; Park, S.-H. Medical Tourism in Iran, Reevaluation on the New Trends: A Narrative Review. Iran. J. Public Health 2020 , 48 , 1191–1202. [ Google Scholar ] [ CrossRef ]
• Rouland, B.; Jarraya, M. From medical tourism to regionalism from the bottom up: Emerging transnational spaces of care between Libya and Tunisia. J. Ethn. Migr. Stud. 2020 , 46 , 4248–4263. [ Google Scholar ] [ CrossRef ]
• Hanefeld, J.; Smith, R.; Horsfall, D.; Lunt, N. What Do We Know About Medical Tourism? A Review of the Literature With Discussion of Its Implications for the UK National Health Service as an Example of a Public Health Care System. J. Travel Med. 2014 , 21 , 410–417. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Hanefeld, J.; Lunt, N.; Smith, R.; Horsfall, D. Why do medical tourists travel to where they do? The role of networks in determining medical travel. Soc. Sci. Med. 2015 , 124 , 356–363. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Hopkins, L.; Labonté, R.; Runnels, V.; Packer, C. Medical tourism today: What is the state of existing knowledge? J. Public Health Policy 2010 , 31 , 185–198. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Hall, C.M.; James, M. Medical tourism: Emerging biosecurity and nosocomial issues. Tour. Rev. 2011 , 66 , 118–126. [ Google Scholar ] [ CrossRef ]
• Imison, M.; Schweinsberg, S. Australian news media framing of medical tourism in low-And middle income countries: A content review. BMC Public Health 2013 , 13 , 109. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Yu, J.; Lee, T.J.; Noh, H. Characteristics of a Medical Tourism Industry: The Case of South Korea. J. Travel Tour. Mark. 2011 , 28 , 856–872. [ Google Scholar ] [ CrossRef ]
• Crooks, V.A.; Kingsbury, P.; Snyder, J.; Johnston, R. What is known about the patient’s experience of medical tourism? A scoping review. BMC Health Serv. Res. 2010 , 10 , 266. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Pessot, E.; Spoladore, D.; Zangiacomi, A.; Sacco, M. Natural Resources in Health Tourism: A Systematic Literature Review. Sustainability 2021 , 13 , 2661. [ Google Scholar ] [ CrossRef ]
• Salehi-Esfahani, S.; Ridderstaat, J.; Ozturk, A.B. Health tourism in a developed country with a dominant tourism market: The case of the United States’ travellers to Canada. Curr. Issues Tour. 2021 , 24 , 536–553. [ Google Scholar ] [ CrossRef ]
• Chi, C.G.-Q.; Chi, O.H.; Ouyang, Z. Wellness hotel: Conceptualization, scale development, and validation. Int. J. Hosp. Manag. 2020 , 89 , 102404. [ Google Scholar ] [ CrossRef ]
• Stará, J.; Peterson, C. Understanding the concept of wellness for the future of the tourism industry: A literature review. J. Tour. Serv. 2017 , 8 , 18–29. [ Google Scholar ]
• Kazakov, S.; Oyner, O. Wellness tourism: A perspective article. Tour. Rev. 2021 , 76 , 58–63. [ Google Scholar ] [ CrossRef ]
• Chen, C.; Ibekwe-SanJuan, F.; Hou, J. The structure and dynamics of cocitation clusters: A multiple-perspective co-citation analysis. J. Am. Soc. Inf. Sci. Technol. 2010 , 61 , 1386–1409. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Chen, C. CiteSpace II: Detecting and visualizing emerging trends and transient patterns in scientific literature. J. Am. Soc. Inf. Sci. Technol. 2006 , 57 , 359–377. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Miles, M.B.; Huberman, A.M.; Huberman, M.A.; Huberman, M. Qualitative Data Analysis: An Expanded Sourcebook ; SAGE: Thousand Oaks, CA, USA, 1994. [ Google Scholar ]
• Uçak, H. The relationship between the growth in the health sector and inbound health tourism: The case of Turkey. SpringerPlus 2016 , 5 , 1685. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Whittaker, A.; Manderson, L.; Cartwright, E. Patients without borders: Understanding medical travel. Med. Anthropol. 2010 , 29 , 336–343. [ Google Scholar ] [ CrossRef ]
• Singh, N. Exploring the factors influencing the travel motivations of US medical tourists. Curr. Issues Tour. 2013 , 16 , 436–454. [ Google Scholar ] [ CrossRef ]
• Snyder, J.; A Crooks, V.; Turner, L.; Johnston, R. Understanding the impacts of medical tourism on health human resources in Barbados: A prospective, qualitative study of stakeholder perceptions. Int. J. Equity Health 2013 , 12 , 2. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Runnels, V.; Carrera, P. Why do patients engage in medical tourism? Maturitas 2012 , 73 , 300–304. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Han, H.; Kiatkawsin, K.; Koo, B.; Kim, W. Thai wellness tourism and quality: Comparison between Chinese and American visitors’ behaviors. Asia Pac. J. Tour. Res. 2020 , 25 , 424–440. [ Google Scholar ] [ CrossRef ]
• Fetscherin, M.; Stephano, R.-M. The medical tourism index: Scale development and validation. Tour. Manag. 2016 , 52 , 539–556. [ Google Scholar ] [ CrossRef ]
• Hartwell, H. Medical Tourism: The Ethics, Regulation and Marketing of Health Mobility. Tour. Manag. 2014 , 45 , 1–2. [ Google Scholar ] [ CrossRef ]
• Moghimehfar, F.; Nasr-Esfahani, M.H. Decisive factors in medical tourism destination choice: A case study of Isfahan, Iran and fertility treatments. Tour. Manag. 2011 , 32 , 1431–1434. [ Google Scholar ] [ CrossRef ]
• Ormond, M.; Sulianti, D. More than medical tourism: Lessons from Indonesia and Malaysia on South–South intra-regional medical travel. Curr. Issues Tour. 2017 , 20 , 94–110. [ Google Scholar ] [ CrossRef ]
• Wang, H. Value as a medical tourism driver. Manag. Serv. Qual. Int. J. 2012 , 22 , 465–491. [ Google Scholar ] [ CrossRef ]
• Han, H.; Hyun, S.S. Customer retention in the medical tourism industry: Impact of quality, satisfaction, trust, and price reasonableness. Tour. Manag. 2015 , 46 , 20–29. [ Google Scholar ] [ CrossRef ]
• Han, H.; Hyun, S.S. Medical Hotel in the Growth of Global Medical Tourism. J. Travel Tour. Mark. 2014 , 31 , 366–380. [ Google Scholar ] [ CrossRef ]
• Abubakar, A.M.; Ilkan, M. Impact of online WOM on destination trust and intention to travel: A medical tourism perspective. J. Destin. Mark. Manag. 2016 , 5 , 192–201. [ Google Scholar ] [ CrossRef ]
• Crooks, V.; Cameron, K.; Chouinard, V.; Johnston, R.; Snyder, J.; Casey, V. Use of medical tourism for hip and knee surgery in osteoarthritis: A qualitative examination of distinctive attitudinal characteristics among Canadian patients. BMC Health Serv. Res. 2012 , 12 , 417. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Kingsbury, P.; Crooks, V.A.; Snyder, J.; Johnston, R.; Adams, K. Narratives of emotion and anxiety in medical tourism: On State of the Heart and Larry’s Kidney. Soc. Cult. Geogr. 2012 , 13 , 361–378. [ Google Scholar ] [ CrossRef ]
• Margolis, R.; Ludi, E.; Pao, M.; Wiener, L. International adaptation: Psychosocial and parenting experiences of caregivers who travel to the United States to obtain acute medical care for their seriously ill child. Soc. Work Health Care 2013 , 52 , 669–683. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• An, D. Understanding Medical Tourists in Korea: Cross-Cultural Perceptions of Medical Tourism among Patients from the USA, Russia, Japan, and China. Asia Pac. J. Tour. Res. 2013 , 19 , 1141–1169. [ Google Scholar ] [ CrossRef ]
• Yu, J.Y.; Ko, T.G. A cross-cultural study of perceptions of medical tourism among Chinese, Japanese and Korean tourists in Korea. Tour. Manag. 2012 , 33 , 80–88. [ Google Scholar ] [ CrossRef ]
• Altın, U.; Bektaş, G.; Antep, Z.; İrban, A. The international patient’s portfolio and marketing of Turkish health tourism. Procedia-Soc. Behav. Sci. 2012 , 58 , 1004–1007. [ Google Scholar ] [ CrossRef ]
• Connell, J. Contemporary medical tourism: Conceptualisation, culture and commodification. Tour. Manag. 2013 , 34 , 1–13. [ Google Scholar ] [ CrossRef ]
• Johnston, R.; Crooks, V.A.; Snyder, J.; Whitmore, R. “The major forces that need to back medical tour-ism were… in alignment” Championing development of Barbados’s medical tourism sector. Int. J.-Health Serv. 2015 , 45 , 334–352. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Chinai, R.; Goswami, R. Medical visas mark growth of Indian medical tourism. Bull. World Health Organ. 2007 , 85 , 164–165. [ Google Scholar ] [ CrossRef ]
• Gupta, V.; Das, P. Medical Tourism in India. Clin. Lab. Med. 2012 , 32 , 321–325. [ Google Scholar ] [ CrossRef ]
• Snyder, J.; Johnston, R.; Crooks, V.A.; Morgan, J.; Adams, K. How Medical Tourism Enables Preferential access to Care: Four Patterns from the Canadian Context. Health Care Anal. 2017 , 25 , 138–150. [ Google Scholar ] [ CrossRef ]
• Gambarov, V.; Gjinika, H. Thermal Spring Health Tourism in Albania: Challenges and Perspectives. In Strategic Innovative Marketing and Tourism ; Springer: Cham, Switzerland, 2017; pp. 455–465. [ Google Scholar ]
• Kumar, S.; Breuing, R.; Chahal, R. Globalization of Health Care Delivery in the United States through Medical Tourism. J. Health Commun. 2012 , 17 , 177–198. [ Google Scholar ] [ CrossRef ]
• Besciu, C.D. The impact of corruption on the performance management of European Health Systems. Manag. Res. Pract. 2016 , 8 , 5–22. [ Google Scholar ]
• Qadeer, I.; Reddy, S. Medical tourism in india: Perceptions of physicians in tertiary care hospitals. Philos. Ethic-Humanit. Med. 2013 , 8 , 20. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Kazemha, A.S.; Dehkordi, K.S. The Principles of Designing Hospital Hotel with the Approach of Health Tourism in Kish Island. J. Hist. Cult. Art Res. 2017 , 6 , 515. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Ghosh, T.; Mandal, S. Medical Tourism Experience: Conceptualization, Scale Development, and Validation. J. Travel Res. 2018 , 58 , 1288–1301. [ Google Scholar ] [ CrossRef ]
• Crooks, V.A.; Turner, L.; Snyder, J.; Johnston, R.; Kingsbury, P. Promoting medical tourism to India: Messages, images, and the marketing of international patient travel. Soc. Sci. Med. 2011 , 72 , 726–732. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Farahmand, A.A.; Merati, E. It Strategies for Development of Health Tourism. Turk. Online J. Des. ART Commun. 2016 , 6 , 1086–1092. [ Google Scholar ] [ CrossRef ]
• Moghavvemi, S.; Ormond, M.; Musa, G.; Isa, C.R.M.; Thirumoorthi, T.; Mustapha, M.Z.B.; Chandy, J.J.C. Connecting with prospective medical tourists online: A cross-sectional analysis of private hospital websites promoting medical tourism in India, Malaysia and Thailand. Tour. Manag. 2017 , 58 , 154–163. [ Google Scholar ] [ CrossRef ]
• Chang, I.-C.; Chou, P.-C.; Yeh, R.K.-J.; Tseng, H.-T. Factors influencing Chinese tourists’ intentions to use the Taiwan Medical Travel App. Telemat. Inform. 2016 , 33 , 401–409. [ Google Scholar ] [ CrossRef ]
• Turner, L. Beyond “medical tourism”: Canadian companies marketing medical travel. Glob. Health 2012 , 8 , 16. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Mohamad, W.N.; Omar, A.; Haron, M.S. The moderating effect of medical travel facilitators in medical tourism. Procedia-Soc. Behav. Sci. 2012 , 65 , 358–363. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Cormany, D.; Baloglu, S. Medical travel facilitator websites: An exploratory study of web page contents and services offered to the prospective medical tourist. Tour. Manag. 2011 , 32 , 709–716. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Dalstrom, M. Medical travel facilitators: Connecting patients and providers in a globalized world. Anthr. Med. 2013 , 20 , 24–35. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Smith, M. Baltic Health Tourism: Uniqueness and Commonalities. Scand. J. Hosp. Tour. 2015 , 15 , 357–379. [ Google Scholar ] [ CrossRef ]
• Bjerke, R.; Polegato, R. How well do advertising images of health and beauty travel across cultures? A self-concept perspective. Psychol. Mark. 2006 , 23 , 865–884. [ Google Scholar ] [ CrossRef ]
• Lee, H.; Wright, K.B.; O’Connor, M.; Wombacher, K. Framing medical tourism: An analysis of persuasive appeals, risks and benefits, and new media features of medical tourism broker websites. Health Commun.-Cation 2014 , 29 , 637–645. [ Google Scholar ] [ CrossRef ]
• Connell, J. Medical tourism: Sea, sun, sand and …. surgery. Tour. Manag. 2006 , 27 , 1093–1100. [ Google Scholar ] [ CrossRef ]
• Connell, J. A new inequality? Privatisation, urban bias, migration and medical tourism. Asia Pac. Viewp. 2011 , 52 , 260–271. [ Google Scholar ] [ CrossRef ]
• Perfetto, R.; Dholakia, N. Exploring the cultural contradictions of medical tourism. Consum. Mark. Cult. 2010 , 13 , 399–417. [ Google Scholar ] [ CrossRef ]
• Smith, K. The Problematization of Medical tourism: A Critique of Neoliberalism. Dev. World Bioeth. 2012 , 12 , 1–8. [ Google Scholar ] [ CrossRef ]
• De Arellano, A.B.R. Patients without borders: The emergence of medical tourism. Int. J. Health Serv. 2007 , 37 , 193–198. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Johnston, R.; Adams, K.; Bishop, L.; A Crooks, V.; Snyder, J. “Best care on home ground” versus “elitist healthcare”: Concerns and competing expectations for medical tourism development in Barbados. Int. J. Equity Health 2015 , 14 , 15. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• NaRanong, A.; NaRanong, V. The effects of medical tourism: Thailand’s experience. Bull. World Health Organ. 2011 , 89 , 336–344. [ Google Scholar ] [ CrossRef ]
• Vijaya, R.M. Medical Tourism: Revenue Generation or International Transfer of Healthcare Problems? J. Econ. Issues 2010 , 44 , 53–70. [ Google Scholar ] [ CrossRef ]
• Adler, A.; Shklyar, M.; Schwaber, M.J.; Navon-Venezia, S.; Dhaher, Y.; Edgar, R.; Solter, E.; Benenson, S.; Masarwa, S.; Carmeli, Y. Introduction of OXA-48-producing Enterobacteriaceae to Israeli hospitals by medical tourism. J. Antimicrob. Chemother. 2011 , 66 , 2763–2766. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Green, S.T. Medical tourism–a potential growth factor in infection medicine and public health. J. Infect. 2008 , 57 , 429. [ Google Scholar ] [ CrossRef ]
• Chen, L.H.; Wilson, M.E. The globalization of healthcare: Implications of medical tourism for the infectious disease clinician. Clin. Infect. Dis. 2013 , 57 , 1752–1759. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Turner, L. News media reports of patient deaths following ‘medical tourism’ for cosmetic surgery and bariatric surgery. Dev. World Bioeth. 2012 , 12 , 21–34. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Barclay, E. Stem-cell experts raise concerns about medical tourism. Lancet 2009 , 373 , 883–884. [ Google Scholar ] [ CrossRef ]
• Lindvall, O.; Hyun, I. Medical Innovation Versus Stem Cell Tourism. Science 2009 , 324 , 1664–1665. [ Google Scholar ] [ CrossRef ] [ Green Version ]
• Penney, K.; Snyder, J.; A Crooks, V.; Johnston, R. Risk communication and informed consent in the medical tourism industry: A thematic content analysis of canadian broker websites. BMC Med. Ethic. 2011 , 12 , 17. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Evans, R.W. Ethnocentrism Is an Unacceptable Rationale for Health Care Policy: A Critique of Transplant Tourism Position Statements. Arab. Archaeol. Epigr. 2008 , 8 , 1089–1095. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Johnston, R.; Crooks, V.A.; Ormond, M. Policy implications of medical tourism development in desti-nation countries: Revisiting and revising an existing framework by examining the case of Jamaica. Glob. Health 2015 , 11 , 29. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Pocock, N.S.; Phua, K.H. Medical tourism and policy implications for health systems: A conceptual framework from a comparative study of Thailand, Singapore and Malaysia. Glob. Health 2011 , 7 , 12. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Maguire, Á.; Bussmann, S.; zu Köcker, C.M.; Verra, S.E.; Giurgi, L.A.; Ruggeri, K. Raising concern about the information provided on medical travel agency websites: A place for policy. Health Policy Technol. 2016 , 5 , 414–422. [ Google Scholar ] [ CrossRef ]
• Álvarez, M.M.; Chanda, R.; Smith, R.D. The potential for bilateral agreements in medical tourism: A qualitative study of stakeholder perspectives from the UK and India. Glob. Health 2011 , 7 , 11. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
• Exworthy, M.; Peckham, S. Access, Choice and Travel: Implications for Health Policy. Soc. Policy Adm. 2006 , 40 , 267–287. [ Google Scholar ] [ CrossRef ]
• Cohen, I.G. How To Regulate Medical Tourism (And Why It Matters for Bioethics). Dev. World Bioeth. 2012 , 12 , 9–20. [ Google Scholar ] [ CrossRef ] [ PubMed ]
• Lunt, N.; Horsfall, D.; Smith, R.; Exworthy, M.; Hanefeld, J.; Mannion, R. Market size, market share and market strategy: Three myths of medical tourism. Policy Politics 2014 , 42 , 597–614. [ Google Scholar ] [ CrossRef ]

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Share and Cite

Zhong, L.; Deng, B.; Morrison, A.M.; Coca-Stefaniak, J.A.; Yang, L. Medical, Health and Wellness Tourism Research—A Review of the Literature (1970–2020) and Research Agenda. Int. J. Environ. Res. Public Health 2021 , 18 , 10875. https://doi.org/10.3390/ijerph182010875

Zhong L, Deng B, Morrison AM, Coca-Stefaniak JA, Yang L. Medical, Health and Wellness Tourism Research—A Review of the Literature (1970–2020) and Research Agenda. International Journal of Environmental Research and Public Health . 2021; 18(20):10875. https://doi.org/10.3390/ijerph182010875

Zhong, Lina, Baolin Deng, Alastair M. Morrison, J. Andres Coca-Stefaniak, and Liyu Yang. 2021. "Medical, Health and Wellness Tourism Research—A Review of the Literature (1970–2020) and Research Agenda" International Journal of Environmental Research and Public Health 18, no. 20: 10875. https://doi.org/10.3390/ijerph182010875

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Medical Tourism

Leveraging testimonials and case studies in medical tourism.

Patient testimonials and case studies are invaluable resources in building trust and credibility in medical tourism. They act as 'social proof', validating your healthcare services through the experiences and satisfaction of past patients. Here's how to use testimonials and case studies effectively:

Testimonials: Amplifying Patient Voices

Authentic patient testimonials can be powerful tools in demonstrating the quality of care and service your organization provides.

· Seek Permission: Always seek permission from patients before using their testimonials.

· Use Different Formats: Use text, video, or audio formats depending on the context. Videos can be particularly effective as they allow potential patients to see and hear from your satisfied patients directly.

· Showcase a Variety of Experiences: Aim to gather and display testimonials that represent different procedures, patient demographics, and nationalities. This diversity helps resonate with a broader audience.

Case Studies: Illustrating Success Stories

Case studies offer a more detailed insight into a patient's journey, from the challenges they faced to the solutions you provided and the outcome of their treatment.

· Detail the Process: Outline the patient's problem, the solutions your organization provided, and the end results. This can help potential patients visualize their own journey.

· Use Quantifiable Results: Whenever possible, use clear, quantifiable results. This could include improved health metrics, recovery times, or patient satisfaction scores.

· Maintain Patient Privacy: While case studies require more detailed information, patient privacy is paramount. Always seek consent and anonymize information as necessary.

Where to Showcase Testimonials and Case Studies

· Your Website: Your website is the primary place to display testimonials and case studies. Consider creating a dedicated page or section for these.

· Social Media: Sharing testimonials and case studies on your social media platforms can boost their reach.

· Marketing Materials: Incorporate testimonials and case studies into your brochures, emails, and other marketing materials.

Through effectively leveraging testimonials and case studies, medical tourism providers can foster trust and significantly increase their conversion rates.

One of the key ways to build this trust is through accreditations from internationally recognized organizations like Global Healthcare Accreditation www.ghaaccreditation.com . GHA provides a robust framework for hospitals and clinics to deliver safe, high-quality care to medical tourists. Its accreditation is a globally recognized trust signal that asserts an institution's commitment to maintaining international healthcare standards, ultimately making it a valuable tool in building patient confidence. The future of medical tourism indeed looks promising with resources like GHA fortifying trust in global healthcare.

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The Medical Tourism Magazine (MTM), known as the “voice” of the medical tourism industry, provides members and key industry experts with the opportunity to share important developments, initiatives, themes, topics and trends that make the medical tourism industry the booming market it is today.

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Supreme Court Reviews RG Kar Medical College Tragedy

The supreme court has begun hearings on a suo motu case concerning the rape and murder of a medical postgraduate student at rg kar medical college in kolkata. the incident has led to nationwide protests and escalated to a cbi investigation. the court blames the state government for delays in action..

The Supreme Court on Thursday commenced hearing a suo motu case related to the rape and murder of a postgraduate medic at the RG Kar Medical College and Hospital in Kolkata.

A bench comprising Chief Justice DY Chandrachud and justices J B Pardiwala and Manoj Misra is hearing the matter.

The top court on Tuesday had constituted a 10-member National Task Force (NTF) to formulate a protocol for ensuring the safety and security of doctors and other health care professionals.

Terming the incident as ''horrific'', the apex court had excoriated the state government over the delay in filing the FIR and allowing thousands of miscreants to vandalise the state-run facility.

The alleged rape and murder of the junior doctor in a seminar hall of the state-run hospital has sparked nationwide protests.

The medic's body with severe injury marks was found inside the seminar hall of the hospital's chest department on August 9. A civic volunteer was arrested by the Kolkata Police in connection with the case the following day.

On August 13, the Calcutta High Court ordered the transfer of the probe from the Kolkata Police to the CBI, which started its investigation on August 14.

(With inputs from agencies.)

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

Daniel béland.

Johnson Shoyama Graduate School of Public Policy, 101 Diefenbaker Place, Saskatoon, SK S7N 5B8 Canada

Amy Zarzeczny

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.

In this era of globalized medicine, when international travel and access to online health information are readily accessible, medical tourism is an important issue both for national health care systems and from a global health perspective [ 1 – 3 ]. Patients from countries around the world are exercising increasing degrees of autonomy over their health care options by obtaining information from sources other than their regular health care providers and, in some cases, by electing to pursue care alternatives outside their domestic medical system. Medical tourism is a broad and inclusive term that captures a wide range of diverse activities [ 3 ]. It has been defined as “the practice of travelling to another country with the purpose of obtaining health care (elective surgery, dental treatment, reproductive treatment, organ transplantation, medical checkups, etc.),” and is generally distinguished from both care sought for unplanned medical emergencies that occur abroad and from formal bi-lateral medical trade agreements [ 4 , 5 ]. Individual motivations for engaging in medical tourism vary widely and may include imperatives such as avoiding wait times, reducing costs, improving quality, and accessing treatments not available or legal in the home jurisdiction, or for which the individual is not eligible [ 5 – 8 ].

While medical tourism is far from new, shifting patient flow patterns and a growing recognition of the complex ethical, social, economic, and political issues it raises are underscoring renewed efforts to understand this phenomenon and its future [ 3 , 9 , 10 ]. Some of the current attention focused on medical tourism concerns its implications and potential risks for individual patients and health care systems [ 11 – 13 ]. Medical tourism impacts both importing and exporting health care systems, albeit in different ways [ 14 ]. Various terms exist to describe trade in health services [ 15 ]. For the purpose of this discussion, we will use importing or destination to describe systems whereby patients come from other jurisdictions to receive care, and exporting to describe the departure of individuals from their domestic medical system to pursue health services elsewhere. Recognizing that there are important knowledge gaps and a need for definitional clarity and further empirical work to understand the effects of medical tourism on the countries involved [ 16 ], concerns for importing or destination systems include, though are not limited to, ethical questions about inequity of access for local residents versus high paying visitors and about the “brain drain” of local talent into private, for-profit organizations focused on non-resident care [ 15 ]. Conversely, the issues exporting systems face often revolve around implications for domestic health care providers, the potential for patients to avoid domestic wait lists, and the costs of follow-up care upon patients’ return [ 12 ]. For example, research from Alberta, Canada, suggests that the financial costs associated with treating complications from medical tourism for bariatric surgery are substantial, and complication rates are considerably higher than similar surgeries conducted in Alberta (42.2–56.1% versus 12.3% locally) [ 6 ].

Although a growing body of literature has emerged to study medical tourism and address the policy challenges it creates for health systems [ 3 , 16 ], the comparative scholarship on medical tourism remains too limited in scope, a remark that should not hide the existence of a number of recent comparative studies in the field [ 17 – 19 ]. These studies demonstrate that comparative research is helpful in identifying both the unique and the most common policy challenges facing each country [ 20 ] and can, if done appropriately, offer learning opportunities [ 21 ]. Indeed, this process can facilitate policy learning (related terms include lesson drawing, policy transfer, diffusion, and convergence) whereby ideas, policies, or practices (e.g., regulatory tools) in one jurisdiction inform or shape those in another [ 22 , 23 ].

With a view to ultimately informing policy related to medical tourism, this article discusses the value of a comparative research agenda about medical tourism that stresses the multifaceted relationship between medical tourism and the institutional characteristics of national health care systems. On the one hand, these characteristics may shape the content of the demand for medical tourism among the citizens of a particular country [ 24 ]. From this perspective, as argued, existing typologies of health care systems can shed light on the varying features of the demand for medical tourism across countries. In other words, different types of health care systems are likely to produce different configurations of demand for medical tourism, which influences the range of policy instruments available to governments and other actors seeking to influence decision-making and behavior within their particular context [ 25 ]. On the other hand, the institutional characteristics of each national health care system may also shape the very nature of the impact of medical tourism on that system. Accordingly, the institutional characteristics of health care systems, such as insurance structures [ 26 ], may impact both citizens’ demand for medical tourism and the ways in which medical tourism affects each country. Obtaining a better understanding of these relationships may inform new ways of thinking about both the challenges and opportunities medical tourism presents. As medical tourism markets continue to grow and diversify, and as domestic health care systems increasingly feel the stress of limited resources, this kind of work will be critical to support policymakers and health system leaders in their efforts to mitigate the potential harms of medical tourism while, at the same time, responding to the needs of the citizens they serve [ 3 ].

Using the examples of Canada and the United States (US), this article proposes the use of an institutionalist research agenda to explore these two related sides of the medical tourism-health care system nexus as a central element of future policy strategies. We first take a comparative perspective on medical tourism and present what we see as key aspects of the issue from a policy perspective. Drawing on current evidence and leading literature in the field, we highlight ways in which national health care systems shape the demand for medical tourism and then, in turn, how medical tourism impacts national health care systems. From this discussion, we identify four key lines of enquiry that we suggest are of critical importance in the medical tourism policy landscape and propose an agenda for future comparative research on medical tourism and national health care systems that could play an important role in informing future policy decisions in this area.

Medical tourism in comparative perspective

Although gathering robust data on the magnitude of medical tourism continues to be a challenge and more empirical work in this area is needed [ 3 , 5 , 10 , 12 ], a strong body of literature addresses different aspects of the issue. For example, research is improving understandings of how medical tourism impacts destination and departure jurisdictions [ 16 , 27 ], affects relationships with domestic health care providers [ 28 ], relates to economic factors including health system costs [ 29 ], and impacts clinical outcomes for patients [ 30 ], among other important lines of enquiry. However, much of this valuable scholarship focuses on particular forms of medical tourism in specific contexts (bariatric surgery [ 31 ], dental care [ 32 ], reproductive services [ 33 ], etc.) or on the policy and health system implications for individual jurisdictions [ 13 ]. There is an increasing amount of comparative research exploring how different features of health care systems may in some cases help drive demand for medical tourism and in other cases constrain it (i.e., push/pull factors), and how they relate to the impact of medical tourism [ 24 ], but more work remains to be done in this important area [ 4 , 10 ]. The potential value of data on the impact of medical tourism in one jurisdiction to structurally- similar systems (e.g., other universal public health care systems) has already been recognized [ 34 ]; we agree and suggest that going further with an associated analysis considering the role of their institutional features is critical. This approach is particularly valuable from a policy perspective, especially when it comes to maximizing opportunities for policy learning from other jurisdictions and to identifying and evaluating the respective strengths and limitations of different policy options for decision-makers seeking to, for example, discourage particular forms of medical tourism (e.g., organ transplant tourism [ 35 ]).

The governance of medical tourism in its various forms is complex and highly fragmented given its broad range of influential stakeholders (both state and non-state, individual and institutional), its international market-based nature, and its engagement of vastly different and often competing priorities and interests (e.g., profit-driven, patient care, autonomy, ethics, etc.). As a result, policy makers and health system leaders face considerable challenges when it comes to seeking to influence medical tourism markets, whether by encouraging their development or restricting access to them. Obtaining a better understanding of the institutional forces that shape the demand for, and impact of, medical tourism—and connecting those forces to the policy context—may help identify a broader range of tools and options decision- makers can employ to achieve their particular objectives with respect to medical tourism.

Looking at Canada and the US is an appropriate starting point for this comparative work and we use this comparison to ground our analysis of the value of an institutional research agenda as a policy strategy for addressing potential concerns and opportunities associated with medical tourism. While these neighboring countries are similar in many ways, there are dramatic differences in important institutional features of their respective health care systems, including funding and delivery models. The US is both an established importer and exporter of medical tourists, the latter supported in part by insurers offering medical tourism coverage in an effort to reduce the high costs associated with domestic health care services [ 11 , 36 ]. In contrast, the structure of Canada’s largely publicly-funded, single-payer medical system limits foreign access to non-emergent care and makes it challenging for Canadians to be reimbursed for care received abroad via medical tourism [ 7 ]. It also makes the current involvement of Canadians in medical tourism [ 37 ] a public policy issue because of its implications for the public purse.

How national health care systems shape demand for medical tourism

Because health care systems can be understood as relatively stable institutional settings that shape human behavior [ 38 , 39 ], their features are likely to impact the demand for medical tourism in a particular country or even, in the case of decentralized health care systems subject to considerable regional variation, in a particular region. Health care systems can vary greatly from one country to the next, or even from one region to the next within the same country. Accordingly, what citizens might be looking for when they seek medical treatment abroad is likely to fluctuate based on the nature of health care coverage, financing, and regulation they have at home. Research about these and other drivers is growing but important gaps in knowledge remain [ 5 ]. In other words, alongside factors like geographical mobility and travel costs, the institutional configurations of health care systems likely shape, at least in part, the types of services people are looking for based on what health services they can access in their home country, with what degree of quality and timeliness, and at what cost [ 24 ].

A comparison between Canada and the US is illustrative here. Starting with the Canadian context, universal coverage has existed in Canada since the early 1970s [ 40 , 41 ]. Under this framework, regardless of the province or territory in which they live, Canadian citizens and permanent residents are entitled to medically necessary health care services with no user fees, which are strictly prohibited under the 1984 Canada Health Act (CHA). Yet, although the CHA mandates comprehensive coverage for “all insured health services provided by hospitals, medical practitioners or dentists,” many services do not fall under this umbrella and the Canadian health care system has long waiting lists for many non-emergency surgeries like hip replacement [ 40 , 42 ]. Wait times vary from province to province but they are a source of frustration for many Canadians, some of whom elect to go abroad to get their non-emergency procedure done faster, even if they have to pay for it themselves, instead of relying on the slower public system back home [ 7 ]. Gaps in coverage within the single-payer system in important areas such as prescription drugs [ 43 ] and dentistry [ 44 ] also sometimes push Canadian citizens and permanent residents to go elsewhere for care to reduce costs. There are also a wide variety of medical treatments and health-related interventions offered in private markets that are either not available or not publicly funded in Canada. There are a variety of reasons for this lack of public funding, including those related to evidence (or, more precisely, the lack thereof) regarding safety and efficacy. For example, there is a large international market for unproven stem cell interventions that are not part of the approved standard of care in Canada or available in the publicly funded health care system [ 45 ]. Therefore, key motivations underlying the pursuit of Canadian medical tourism often relate to a desire to access care faster, to reduce out of pocket costs for care not covered by provincial health insurance, and/or to access options that are not available in Canada [ 7 ].

In the US healthcare system, where about 9% of the population remains uninsured despite the enactment of the Affordable Care Act (ACA) in 2010 [ 46 ], people who lack insurance coverage but who face a medical need might go abroad to seek cheaper treatment. In fact, the high cost of care in the US has been recognized as a major factor pushing Americans to seek care at lower cost outside the US, an option that is facilitated by health care globalization [ 2 ]. For example, there is research documenting the strong market in the Mexican border city of Los Algodones for Americans seeking dentistry, optometrist, and pharmacy services [ 47 ]. Others may be motivated to return to systems with which they are more familiar, as is the case with the Mexican diaspora [ 24 ]. In the US, in contrast to Canada where universal coverage prevails, the lack of health care coverage is likely to be a key factor driving the demand for medical tourism. At the same time, waiting times are much less likely to drive the demand for medical tourism in the US, where waiting lists are less of an issue [ 40 ].

These brief remarks highlight how key institutional features in both Canada and the US shape patterns in the demand for medical tourism in these two countries, creating both similarities and differences between them. At the same time, regional differences in health system institutions within the two countries can also shape the demand for medical tourism within their borders. For instance, in states like Texas, where elected officials have thus far refused to expand Medicaid as part of the ACA [ 48 ], more people live without health care coverage than elsewhere (about 18% of the population as of March 2016 [ 49 ]), which may push them to look to Mexico for cheaper health care. Here the institutional characteristics of a state’s health care system and the geographical proximity to Mexico, coupled with the presence of a large population of Mexican descent who speak Spanish, are likely to favor cost-saving medical tourism from Texas to Mexico. This example highlights how geographical and even ethno-cultural factors can shape medical tourism alongside and even in combination with the institutional features of a particular health care system. This is also the case when we deal with issues such as dental care and cosmetic surgeries, which are not covered by many US public and private insurance plans [ 50 ].

How medical tourism impacts national health care systems

At the most general level, existing national and sub-national institutions may mediate the impact on particular countries of transnational processes stemming from globalization [ 20 , 51 ]. This general remark also applies to global medical tourism, which is unlikely to affect all national health care systems in the same way. Put bluntly, systems will react differently to external pressures, based in part on their own institutional characteristics. Those same institutional characteristics also form part of the policy matrix that shapes the options available to decision makers.

There are two central aspects to this story. First, we can look at how domestic health care institutions are specifically impacted by inbound medical tourism (i.e., destination countries at the receiving end of medical tourism). Research suggests that the way in which health care systems cope with foreign users, and what impact those foreign users have on the system, will vary according to the institutional characteristics of that system [ 16 ]. For instance, countries that attract many medical tourists could witness price increases and the diversion of services away from their less-fortunate citizens [ 1 ]. At the same time, the institutional features of national health care systems can explain why some countries attract more medical tourists than others. The comparison between Canada and the US is particularly revealing here. On the one hand, although some provinces have considered alternate approaches that would encourage inbound medical tourism as a source of revenue generation [ 52 ], at present the limited scope of private health care in Canada restricts the availability of medical tourism opportunities for wealthy foreigners seeking treatments. On the other hand, the large scope of private health care in the US makes that country an obvious target for wealthy medical tourists who can afford its high medical costs.

Second, and more important for this article, national health care institutions may also shape the way in which each country is affected by outbound medical tourism. For example, in a single-payer health care system such as Canada’s, both routine follow-up care and complications resulting from medical acts performed abroad are typically dealt with within the public system, engendering direct costs to taxpayers and potentially impacting access for others in the system (i.e., if physicians’ time is diverted to attend to emergent issues) [ 6 ]. The extent of these concerns varies depending on the urgency of the issue and whether it falls within hospital and physician services covered by the universal system (versus, for example, dental care where public coverage is more limited) [ 52 ]. By comparison, within the fragmented public-private US health care system, public programs may only absorb a fraction of the costs of complications related to outbound medical tourism, thus reducing their direct negative impact on taxpayers, whereas private insurance companies or individuals themselves might bear the majority of these costs.

The potential savings for outbound countries medical tourism generates are also likely to depend on the institutional features of each national or sub-national health care system [ 16 ]. In Canada, for instance, people who decide to go abroad for non-emergency surgeries might help reduce the length of waiting lists, although this positive impact might be limited by the fact that some of these surgeries are simply not available in Canada or, at least, not available to the individuals who seek treatments abroad (e.g., because of their age or health status). Because waiting lists are much less of an issue in the US [ 40 ], this potential benefit of medical tourism to domestic health care systems may be less relevant there.

Conversely, the prospect of affordable medical tourism may convince people in the US who do not have access to Medicaid, Medicare, or employer-based coverage that they do not need coverage at all, because they can always go abroad and save money should they need medical treatment. In this context, global medical tourism could interact with the question of whether people will seek coverage or not. At the same time, to save money, “US companies, such as Anthem Blue Cross and Blue Shield and United Group Programs, are now exploring the idea of including medical tourism as a part of their coverage,” a situation that could increase their administrative burden and create further complications along the road [ 53 ].

Policy implications

Our aim with the preceding high-level overview was to draw on existing knowledge to highlight not only that national health care institutions may shape the demand for medical tourism in a particular country or region, but also that the consequences of such tourism for national health care systems are likely similarly mediated by the institutional features of these systems. These connections have a number of important potential implications for health system governance of medical tourism and, more specifically, for the options available to policy makers seeking particular objectives. For example, depending on the jurisdiction, efforts to reduce demand for medical tourism could include a range of options such as investing resources targeted at reducing domestic wait times, expanding public health insurance, limiting public coverage for follow-up care needs, or educating the public about the potential risks associated with medical tourism [ 2 ], among other options. Conversely, efforts to encourage the development of a medical tourism industry within a particular jurisdiction might involve regulatory change to expand options for private system offerings and targeted marketing campaigns, again among other possibilities [ 5 , 17 ].

In fact, it has long been recognized the governments have a variety of tools or policy levers at their disposal when they seek to influence behavior [ 54 ]. Identifying which tool (or combination of tools) is likely to be most effective in a particular set of circumstances, such as medical tourism, requires a nuanced understanding of relevant institutional characteristics and situational factors. Accordingly, we propose that a comparative research agenda should be a key element of future analysis and decision-making efforts in this field. Such an agenda would not only help empirically test the above hypotheses about the institutional-medical tourism nexus, it could also help facilitate lesson drawing between jurisdictions that have attempted different approaches by helping pinpoint salient commonalities and points of difference between the systems that might initially explain, and ideally ultimately even predict, the likely results of particular policy initiatives.

Research agenda

We propose a comparative research agenda that aims to explore the relationship between medical tourism and key institutional features of national health care systems. Although some aspects of our research agenda are already present in the existing literature, we think studying these elements together and with a comparative policy lens would be of tremendous value to health system decision -makers seeking to navigate different objectives including, for example, avoiding “brain drain” from public to private health care, minimizing added costs to publicly funded systems, protecting vulnerable individuals, and facilitating patient autonomy.

Drawing on our review of the health care systems in Canada and the US, we have identified three key institutional features that we suggest are particularly relevant to medical tourism and its broader policy context. These key features are health care funding models, delivery structures (e.g., public/private mix, provider payment models, role of user choice, and competition between providers), and governance systems (e.g., location of authority, health care provider regulation, liability systems). Future empirical research may identify other more salient features and certainly an iterative approach may be valuable. Nonetheless, we suggest that these features would provide a useful starting point for the next step, which we propose be an exploration of how these institutional features relate to the following areas:

• (i) Patient flow patterns – e.g., inbound versus outbound, treatment destinations, types of treatment sought.
• (ii) Patient motivations – e.g., cost reduction, wait list avoidance, pursuit of quality, circumvention tourism.
• (iii) Health system interactions – e.g., costs and options for follow-up treatment, roles of domestic health care professionals.
• (iv) Existing policy levers – e.g., public and private insurance structures, incentive schemes, information campaigns, regulation.

These four areas are not intended to serve as a comprehensive list of all relevant lines of enquiry. However, they present a valuable starting point, particularly because of their relevance to policy instrument selection processes. Having said that, and although it is beyond the scope of this piece to go further than laying a foundation for this proposed research agenda, we suggest that future research take a broad and scoping approach to draw on existing data and information and, where possible, conduct new empirical work addressing these critical areas. With a view to identifying patterns and generating hypotheses, researchers will likely need to continually refine the initial assumptions, outlined above, about the relationships between different institutional features and aspects of medical tourism. Doing so will require careful thought regarding the selection of an appropriate scientific paradigm, with a view to research validity and reliability [ 55 ].

We also anticipate that end-users and important stakeholders, including elected officials, civil servants, health care providers, and patients and families, would have an important contribution to make to the research design and with respect to interpreting the findings, particularly as they relate to the identification and evaluation of policy options. One important limitation in this type of work will relate to data availability. We expect that comparative work of this nature and any future empirical analyses it includes will highlight gaps in knowledge and potentially trigger future research agendas. Overall, the research envisioned here should complement and augment ongoing efforts in the field to improve understandings of important factors including patient flows, expenditure trends, system impacts, and individual decision-making determinants, among others.

Conclusions

This article discussed the relationship between medical tourism and key institutional aspects of national health care systems with a view to highlighting the value in a comparative research agenda focused on identifying and evaluating policy options. First, we argued that these characteristics directly affect the demand for medical tourism in each country. Second, we suggested that such institutional characteristics shape the actual impact of medical tourism on that particular country . This discussion led to the formulation of an institutionalist research agenda about medical tourism. It is our hope that this proposed agenda will trigger discussion and debate, help develop future research, and inform new ways of thinking about medical tourism in the global landscape. Medical tourism is a complex phenomenon and we suggest that applying a comparative, institutional lens will shed new light on its drivers, constraints, and impacts and, in so doing, ultimately help inform policy development in this area.

Acknowledgements

The authors thank Rachel Hatcher for the copy-editing support and anonymous reviewers for their helpful suggestions. DB acknowledges support from the Canada Research Chairs Program, and AZ funding from the Canadian National Transplant Research Program.

Authors’ contributions

DB wrote the theoretical paragraphs and AZ the paragraphs focusing more directly on medical tourism. Both authors read and approved the final manuscript.

Authors information

DB has published extensively on institutionalism and on health care systems, and AZ has published extensively on health law and policy issues, including topics related to medical tourism.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

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Contributor Information

Daniel Béland, Phone: 306 966-1272, Email: [email protected] .

Amy Zarzeczny, Email: [email protected] .