Evidence on global medical travel

Bull World Health Organ 2015;93:785–789 | doi: http://dx.doi.org/10.2471/BLT.14.146027 Policy & practice 785 Evidence on global medical travel Kai Ruggeri,a Ladislav Záliš,b Christopher R Meurice,a Ian Hilton,c Terry-Lisa Ly,d Zorana Zupane & Saba Hinrichsf Introduction Medical travel is projected to expand globally in the next de- cade.1,2 Citizens in the United States of America, for instance, already receive significant volumes of services abroad, both for urgent and elective procedures.3 The growth in medical travel is largely due to improved availability of health technology, de- creasing costs for travel and advertising by companies wishing to attract patients.4,5 Medical tourism has been described as “travel across international borders with the intention of receiving some form of medical treatment. This treatment may span the full range of medical services, but most commonly includes dental care, cosmetic surgery, elective surgery and fertility treatment.”6 Some authors distinguish between medical tourism (travel for wellness, cosmetic or other non-essential procedures) and medical travel (travel with the purpose of receiving treatment that, in the opinion of a health professional, is essential to maintain quality of life). For the purposes of this paper, we define medical travel as including both essential and non- essential treatment. Although it is clear that cost, accessibility and quality are the main motivating factors for medical travel, data are largely limited to anecdotal projects from the perspec- tive of a single country.3,7–12 While some data on transnational health-care practices are available,10,13 current data on the outcomes of medical travel are insufficient and rarely gener- ated using rigorous methods.14 The potential benefits of medical travel include improved care, decreased costs and reduced waiting times.15 Medical travel may increase access to certain treatments for local com- munities through improved infrastructure and higher demand. In India, for example, a two-tiered approach employed in some hospitals resulted in improved services for local patients and tailored services for medical travellers.7,16 Panama and Thai- land have also developed services that were initially intended to attract foreign patients but also resulted in new facilities available for locals.16 A competitive market for health care could help to control medical spending and increase access by introducing patients to new locations and lower costs for care. For developed countries, medical travel may result in small reductions in national health costs.17 Medical travel involves additional risks, compared to obtaining treatment domestically. If complications or adverse outcomes occur, additional expenses are likely, but insur- ance companies may not be willing to cover these costs.18,19 Medical travel may jeopardize the well-being of vulnerable individuals who are ill, in unfamiliar locations or cultures and who lack social support. Factors such as social support, familiarity with language and carers and proximity to home can be important for recovery from clinical procedures.20,21 Medical travel often involves travel from high-income to low- or middle-income countries,5,22 with different standards of clinical practice. The growth in medical travel has implications for health service provision in destination countries. Access to health care for local residents might be adversely affected if local health professionals devote their time to treatment of foreign- ers rather than local communities. The ethical issues raised by medical travel are particularly acute in countries where access to basic medical care may be unaffordable for the local population. Here we review the scientific literature relevant to development of global policy on medical travel. Medical travel needs to be understood in terms of its potential risks and benefits so that it can be evaluated against alternatives. Literature search We carried out a non-systematic literature review. Articles were considered if they were found in any of six databases under the terms “medical tourism” or “medical travel” since the year 2000, with no language restrictions. The databases used were PubMed, EconLit, Google Scholar, the World Bank research database, Europe PubMed Central and EMBASE. We identified primary themes to be reviewed through common arguments used in higher quality sources as well as through common topics in low-quality or potentially very biased material. Papers were included if they provided specific data, policy or practice analyses, or substantial insight to key themes, regarding travel for necessary care. Where available, we extracted estimates of the numbers of medical travellers within the last 10 years. Abstract The potential benefits of travelling across national borders to obtain medical treatment include improved care, decreased costs and reduced waiting times. However, medical travel involves additional risks, compared to obtaining treatment domestically. We review the publicly-available evidence on medical travel. We suggest that medical travel needs to be understood in terms of its potential risks and benefits so that it can be evaluated against alternatives by patients who are seeking care. We propose three domains –quality standards, informed decision-making, economic and legal protection – in which better evidence could support the development of medical travel policies. a Department of Psychology, University of Cambridge, Downing Street, Cambridge, CB2 3EB, England. b Department of Psychology, Masaryk University, Brno, Czech Republic. c North Central College, Naperville, Illinois, United States of America. d Medical Faculty, University of Köln, Köln, Germany. e Department of Psychology, University of Warwick, Coventry, England. f The Policy Institute, King’s College London, London, England. Correspondence to Kai Ruggeri (email: dar56@cam.ac.uk). (Submitted: 20 August 2014 – Revised version received: 21 May 2015 – Accepted: 5 August 2015 – Published online: 18 September 2015 ) Policy & practi Bull World Health Organ 2015;93:785–789| doi: http://dx.doi.org/10.2471/BLT.14.146027786 Policy & practice Global medical travel Kai Ruggeri et al. Available data Most of the available data on medical travel is of poor quality. Sources are often not accessible or do not explain how estimated figures were calculated.10 There are variations in the definition of medical travellers and a lack of agreed methods for data collection.23,24 For example, Singapore collects the data on medical travel using exit polls at the airport, including only travellers who had arrived with a stated primary purpose of obtaining medical care. Thailand counts the number of foreign- ers obtaining medical care at hospitals, including foreign travellers who did not travel primarily to obtain health care. Estimates are framed as medical travel, potentially including visitors coming for beauty treatments using spa and well- ness resorts. These conflate cosmetic and other elective procedures with essential treatments. For example, Hungary is often portrayed as one of the hubs of medical travel in Europe with up to 1.8 million medical travellers annually, yet the majority of those are day visitors on wellness trips or travelling for dental care.25,26 Thailand reports over 1.5 mil- lion medical travellers annually, but it is estimated that only a third travelled specifically for medical treatment.27 The difference between high and low estimates of medical travellers increases if a wider range of timelines, methods and measures are included.28 Without official national data, numbers presented by some countries and hos- pitals may be exaggerated, potentially for the purpose of implying growth and success and encouraging private sector investment and national support.23 Table 1 presents numbers of medi- cal travellers as reported in papers that we reviewed. Considering the limita- tions of the sources, this table cannot accurately reflect the amount and struc- ture of current medical travel, however it does give a basic overview of what is generally reported by researchers. This table reflects publicly-available data and summarizes the kind of informa- tion researchers, policy-makers and health-care professionals may use when making decisions. The data available for different countries and regions indicate a prominent focus on Asian countries, including India, Malaysia, Singapore and Thailand. Additional data, based on narrative and speculative evidence were not included in the table. It does not include reports that required a paid subscription to be accessed. Clear parameters are needed for future work on medical travel, to develop an evidence base for policy development. The existing literature on medical travel emphasizes economic interests.6,17,23,48 Below, we discuss inter- national quality standards, the motiva- tion of medical travellers and the legal and economic situation relevant to medical travel. International quality standards While many different types of national quality-control measures exist, they are not applicable across international borders and this increases the risk of un- informed decision-making by potential medical travellers.49 The lack of interna- tional standards further increases the risk for patients and their local care pro- viders as complications may arise after medical travellers return home.10,18,19 To establish international quality standards, definitions and comparable indicators should be established, with oversight from a major international body. Patient decision-making More data on patient decision-making needs to be collected to ensure the prac- tical value of any evidence generated on medical travel. Existing patient choice models indicate that there are a large number of considerations when decid- ing where to receive care and highly specified measures are needed to evalu- ate this at a global level.10,32,50 The drivers and barriers that precede medical travel need to be assessed beyond general eco- nomic and availability factors. Knowledge of factors involved in patient choices about cross-border care is sparse.10,17 Although evidence is starting to emerge,10 there is an overall deficiency in the literature as to why potential patients travel to specific lo- cations for medical treatment. Future research could build on national stud- Table 1. Reported estimates of medical travellers to receiving countries Receiving country Estimated no. of annual medical travellers Year and reference Australia 13 000 201029 Brazil 49 000–180 000 200517 and 200930 Costa Rica 25 000–150 000 2006,31 200732 and 200833 Cuba 3500 200326 Cuba 200 000 200732 Egypt 68 000–108 000 2003,34 2004,28 200528 and 200635 Germany 50 000–70 000 200828 and 200929 Hungary 1 500 000–1 800 000 200728 and 200927 Hungary 300 000 200830 India 1 000 000–1 180 000 200436 and 200537 India 100 000–150 000 200524,29,38–40 India 300 000–731 000 2006,41 2007,1 20085 and 201039 Israel 35 000 200932 Jordan 120 000–250 000 2002,34 200428 and 200930 Malaysia 300 000–489 000 2006,41 2007,24,29,42 20085 and 201039 Philippines 100 000–250 000 2006,24,41 20092 and 201043 Republic of Korea 60 000 20092,29 Singapore 270 000–450 000 2004,31 2005,24,40 20061,29 and 20085 Singapore 571 000–725 000 2007,42 20082 and 201039 South Africa 330 000 201044 Thailand 450 000–700 000 2004,45 200641 and 200725 Thailand 1 000 000–1 580 000 2004,36,38 2006,46 2007,1 20085,29 and 201039 Tunisia 10 000–42 000 2002,34 200338 and 200728 Turkey 15 000 200728 United Kingdom 52 000 201047 United States of America 250 000–400 000 200616 and 20071,5 Note: Reports were identified by a non-systematic literature review of PubMed, EconLit, Google Scholar, the World Bank research database, Europe PubMed Central and EMBASE. Bull World Health Organ 2015;93:785–789| doi: http://dx.doi.org/10.2471/BLT.14.146027 787 Policy & practice Global medical travelKai Ruggeri et al. ies, which have clearly indicated that cost, quality and availability are critical in the decision-making process.51 Such evidence would make a significant con- tribution, particularly if coinciding with better mapping of the flow of medical travellers.6,7 Finally, if patients, carers, insurers and other stakeholders are to be expected to make informed deci- sions, responsibility for costs needs to be clarified. Understanding the cultural factors that influence patients’ decisions will provide essential background for the development of medical travel policies.51 Frameworks To prevent harm, legal and economic frameworks for medical travel are need- ed.6,52 Existing governance structures and legal frameworks on treatment and care standards need to be harmonized and international quality standards need to be enforced and maintained. The cur- rent lack of regulation in medical travel creates risks for patients due to a lack of oversight and variable standards of practice.33 Economic protection through regulated insurance for patients as well as through local regulation (to avoid negative effects on access to care for local residents) must be in place. This regulation will be critical as some health systems face increased demand from an international market that may result in unwanted increases in costs of care for locals.53 Legal frameworks need to clarify liabilities for adverse events and ensure equality of access for the local popula- tion. Access to health care has implica- tions beyond individual care, including the perception of health-care system quality, which in turn influences indi- vidual well-being.54 Evaluations of medi- cal travel should measure the impact on access to care for local communities, to ensure they are not negatively affected by such changes.55 Conclusion There are considerable gaps in the cur- rent literature concerning the extent to which international health services are consumed and the needs of medical travellers are met. We suggest three key domains (quality standards, informed decision-making, economic and legal protection) for which scientific evidence would support the development of med- ical travel policies. There are challenges to obtaining such data, including barri- ers to accessing up-to-date information in governmental records, in health systems reviews, and in confidential da- tabases kept by insurance firms. It is also difficult to find representative samples of patients who travel for care. There is currently a lack of consistent data on the specific procedures these patients seek, how many patients are involved and how much expenditure occurs. Effective research in medical travel as a global phenomenon requires consideration of all three domains, with the overall goal of improving access, quality of care, and health equity. ■ Acknowledgements We thank Dean Baker, Ingeborg Farver- Westergaard, Bettina Moltrecht, Enikõ Németh, Dimitris Parperis, Pawel Piotr Sleczka and Saša Zorjan, and the Ju- nior Researcher Programme 2011–12 cohort. KR is also affiliated with the Engineering Design Centre, University of Cambridge. Competing interests: None declared. صخلم ةيبط ضارغلأ ةحايسلاب قلعتت ةلدأ لىع لوصحلل لودلا دودح برع رفسلل ةلمتحلما عفانلما لمشت فيلاكتلاو ،ةن َّسحلما ةيحصلا ةياعرلا تامدخ يبطلا جلاعلا نمضتت ،كلذ نم مغرلا لىعو .صرقأ راظتنا تاترفو ،ةضفخلما لوصلحاب ًةنراقم ةيفاضلإا رطاخلما ضعب ةيبط ضارغلأ ةحايسلا لىع ةحاتلما ةلدلأل ةعجارم انيرجأ دقو .لودلا لخاد جلاعلا لىع لىإ يرشنو .ةيبط ضارغلأ ةحايسلاب قلعتي مايف يموكلحا ىوتسلما عفانلماو رطاخلما راطإ في ةيبط ضارغلأ ةحايسلا مهف لىإ ةجالحا ةياعرلا تامدخ نع ينثحابلا ضىرملل نكمي مث نمو ،اله ةلمتحلما روامح ةثلاث حرطن ماك .لئادبلا نم اهيرغب ةنراقلماب اهمييقت ةيحصلا ،تامولعلما لىإ ةدنتسلما تارارقلا ذاتخاو ،ةدولجا يرياعم يهو – معد الهلاخ نم نكمي يتلاو – ةيداصتقلااو ةينوناقلا ةيمالحاو .ةلدلأا لىع اًدماتعا ةيبط ضارغلأ ةحايسلا تاسايس عضو 摘要 全球医疗旅游的证据 跨国医疗旅游的潜在好处包括获得更加优质的护理服 务、更低的花费和更短的等待时间。但是，与在国内 就医相比，医疗旅游存在一些额外的风险。通过审查 现有医疗旅游的证据，我们建议寻求医疗护理的患者 全面了解医疗旅游的潜在风险和好处，以便与其他医 疗方式进行对比评估。我们提议从质量标准、科学的 决策制定、经济和法律保护三个方面入手，这三方面 的良好证据能够为医疗旅游政策的制定提供支持。 Résumé Données scientifiques sur le tourisme médical dans le monde Les avantages potentiels de la traversée de frontières nationales pour recevoir un traitement médical résident notamment dans une meilleure prise en charge, des coûts moindres et des temps d’attente réduits. Il est cependant plus risqué de voyager pour bénéficier de soins médicaux que de recevoir un traitement à l’intérieur du pays. Nous avons analysé les données scientifiques publiquement disponibles concernant le tourisme médical. Il nous apparaît essentiel de considérer le tourisme médical en fonction de ses risques et de ses avantages potentiels afin que les patients qui nécessitent des soins puissent le comparer aux autres solutions possibles. Nous estimons que l’amélioration de la qualité des données scientifiques dans trois domaines – normes de qualité, prise de décision éclairée et protection économique et juridique – favoriserait l’élaboration de politiques relatives au tourisme médical. Bull World Health Organ 2015;93:785–789| doi: http://dx.doi.org/10.2471/BLT.14.146027788 Policy & practice Global medical travel Kai Ruggeri et al. Резюме Свидетельства о фактах медицинского туризма в мировом масштабе Потенциальные преимущества поездки за границу с целью получения лечения включают лучший уход, снижение затрат и меньшее время ожидания лечения. Однако медицинский туризм подразумевает и дополнительные риски в сравнении с лечением дома. Нами были рассмотрены имеющиеся в общественном доступе свидетельства относительно поездок с медицинскими целями. Мы предлагаем рассмотреть медицинский туризм с точки зрения риска и пользы, чтобы пациенты, нуждающиеся в лечении, могли оценить их и сравнить с альтернативными вариантами. Мы предполагаем три области оценки: стандарты качества, принятие информированного решения, экономическую и юридическую защиту, — в которых наличие лучших свидетельств послужит поддержкой при разработке принципов медицинского туризма. Resumen Datos sobre el turismo sanitario a nivel mundial Los posibles beneficios de cruzar las fronteras nacionales para obtener tratamientos médicos incluyen una mejora de la atención, una disminución de los costes y una reducción de los tiempos de espera. Sin embargo, el turismo sanitario implica riesgos adicionales en comparación con obtener el tratamiento en el país. Se revisaron los datos públicos sobre el turismo sanitario. Nuestra sugerencia es que el turismo sanitario se entienda en términos de sus posibles riesgos y beneficios, de modo que aquellos pacientes que busquen atención médica puedan evaluarlos frente a otras alternativas. Proponemos tres ámbitos (normas de calidad, toma de decisiones informada y protección económica y legal) en los cuales unos datos más claros podrían apoyar el desarrollo de las políticas para el turismo sanitario. References 1. Keckley PH, Underwood HR. Medical tourism: consumers in search of value. 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