Abstract

 

 

Background

Medical tourism is understood as travel abroad with the intention of obtaining non-emergency medical services. This practice is the subject of increasing interest, but little is known about its scope.

 

Methods

A comprehensive scoping review of published academic articles, media sources, and grey literature reports was performed to answer the question: what is known about the patient's experience of medical tourism? The review was accomplished in three steps: (1) identifying the question and relevant literature; (2) selecting the literature; (3) charting, collating, and summarizing the information. Overall themes were identified from this process.

 

Results

291 sources were identified for review from the databases searched, the majority of which were media pieces (n = 176). A further 57 sources were included for review after hand searching reference lists. Of the 348 sources that were gathered, 216 were ultimately included in this scoping review. Only a small minority of sources reported on empirical studies that involved the collection of primary data (n = 5). The four themes identified via the review were: (1) decision-making (e.g., push and pull factors that operate to shape patients' decisions); (2) motivations (e.g., procedure-, cost-, and travel-based factors motivating patients to seek care abroad); (3) risks (e.g., health and travel risks); and (4) first-hand accounts (e.g., patients' experiential accounts of having gone abroad for medical care). These themes represent the most discussed issues about the patient's experience of medical tourism in the English-language academic, media, and grey literatures.

 

Conclusions

This review demonstrates the need for additional research on numerous issues, including: (1) understanding how multiple information sources are consulted and evaluated by patients before deciding upon medical tourism; (2) examining how patients understand the risks of care abroad; (3) gathering patients' prospective and retrospective accounts; and (4) the push and pull factors, as well as the motives of patients to participate in medical tourism. The findings from this scoping review and the knowledge gaps it uncovered also demonstrate that there is great potential for new contributions to our understanding of the patient's experience of medical tourism.

Background

 

Medical tourism is becoming an increasingly popular option for patients looking to access procedures (typically via out-of-pocket payment) that are seemingly unavailable to them in their home countries due to lack of affordability, lack of availability, and/or lengthy waiting lists, among other reasons [1, 2]. In its broadest conceptualization, medical tourism refers to "travel with the express purpose of obtaining health services abroad" (p.193) [3]. People wishing to access procedures such as cardiac, orthopaedic, dental, and plastic surgeries are going to key destination countries known to provide care for international patients [4]. For example, countries such as India, Singapore, and Thailand have become global leaders in the industry, providing services for patients from around the world. Brochures, websites, and other marketing materials promote the services of hospitals in these countries wanting to attract international patients [5]. Facilitators/brokers specializing in medical tourism further promote the practice, and offer services such as making travel bookings, assisting with selecting hospitals and surgeons abroad, and helping with completing paperwork to potential medical tourists [6].

The practice of medical tourism does not exist without criticism, particularly when involving patients from developed nations going to developing nations for procedures. It is thought to contribute to the commodification of health and health care by allowing those with the financial means to do so to purchase care that may be unavailable to other citizens [7]. The practice can also lead to international patients receiving a higher standard of care than residents of the country where it is being given [8]. Another criticism is that health service providers trained in countries with publicly-funded education systems who are involved in privately treating international patients are misdirecting the public funds that contributed to their training [9]. It has, however, been suggested that if the industry is properly regulated, medical tourism can provide a viable means by which developing countries can gain access to needed revenue and developed countries can lessen 'bottlenecks' in their health systems [10]. The presence of medical tourism hospitals in developing nations is also thought to lessen the international brain drain of health human resources by providing surgeons and others with access to advanced, high technology work environments [3].

Although estimates of the number of patients engaging in medical tourism each year vary widely, ranging from millions to tens of thousands, there has been speculation that growth in the industry will continue in the coming years [11, 12, 13]. Given the prominence of this global industry, research and media attention focused on it will also surely continue to grow. With projections of growth in the industry and the existence of significant criticisms about the practice, it is an opportune time to undertake knowledge syntheses to assess what exactly is known about medical tourism so as to ultimately inform research, government, and industry agendas alike. In the remainder of this article we take on this task, presenting the findings of a scoping review that addresses the question: what is known about the patient's experience of medical tourism? This article serves as the first attempt to draw together what is known about this issue, and thus is a valuable contribution to the burgeoning literature on medical tourism. In an attempt to be as comprehensive and inclusive as possible, multiple types of sources are included in the review, including: academic articles, newspaper and magazine articles, industry reports, and law reviews. Such inclusivity is central to the scoping review process in general, where the aim is to appreciate the breadth of knowledge that is available on a particular topic [14].

While there is no singular definition of medical tourism that has gained wide acceptance, in this article we place some widely acknowledged parameters on what it is understood to be in order to focus the scoping review. People who become ill or injured while traveling abroad and require hospital care are not thought to be medical tourists, nor are expatriates accessing care in the countries or regions in which they live. A survey run by the Thai government to assess the scope of its domestic medical tourism industry distinguished between international patients who were medical tourists, ill vacationers, and expatriates living in Thailand or a neighbouring country, which confirms the distinctions being used here [15]. Established cross-border care arrangements between countries are not forms of medical tourism. This is because out-of-pocket payments for the accessed care are not typically made under such arrangements, as is the case for medical tourists, and because these arrangements typically require referrals to be given for care that is not available locally based on collaborative arrangements between hospitals or care systems. Meanwhile, medical tourists can choose to go abroad for care without the referral of a physician. These distinctions are made elsewhere. For example, a World Health Organization report on cross-border care within Europe distinguishes between patients travelling independently (i.e., without referral) for care internationally, those who are sent abroad by their home systems in order to access specialized care that is not available locally, and those who live in border regions with traditions of sharing care across borders [16]. Further, the pursuit of complementary and alternative care abroad is not medical tourism; instead, it falls under the even broader rubric of health tourism. When taken together, these parameters result in achieving a focused understanding of medical tourism, whereby it occurs when patients intentionally leave their country of residence outside of established cross-border care arrangements in pursuit of non-emergency medical interventions (namely surgeries) abroad that are commonly paid for out-of-pocket. This typically includes staying abroad for at least part of the recovery period, whereby such post-discharge time can be spent at tourist resorts that cater to international patients [17, 18, 19].

Methods

 

Broadly speaking, knowledge syntheses aim to collect and evaluate the current state of knowledge on a particular issue [14]. The scoping review is a knowledge synthesis technique that is most commonly used when: it is difficult to identify a narrow review question; studies in the reviewed sources are likely to have employed a range of data collection and analysis techniques; no prior synthesis has been undertaken on the topic; and a quality assessment of reviewed sources is not going to be conducted [14]. In this article the findings of a scoping review that meets all of these criteria is presented. The review poses the broad question: what is known about the patient's experience of medical tourism? The synthesis presented in this article follows the scoping review protocol set out by Arksey and O'Malley [14]. In the remainder of this section we outline the steps undertaken to complete the review.

Identifying the Question and Relevant Literature

The first step was to develop the scoping question, which was done by holding a research team meeting to identify a potentially fruitful and also useful issue to focus on within the area of medical tourism. Next the team moved to delineate a search strategy that would lead to the identification of relevant literature. To do this, keywords were first identified based on review of relevant literature and ultimately team consensus. As depicted in Table 1, keywords probed five main categories: (1) focus; (2) what; (3) who; (4) why; and (5) where. Eight types of rationale were identified for the why category, as shown in Table 1. Known destination and departure countries were used to populate the where category.