New report: Patients without borders: Medical tourism and medical migration in Southern Africa

Crush, J., Chikanda, A. & Maswikwa, B. (2012). ‘Patients without borders: Medical tourism and medical migration in Southern Africa’, Migration Policy Series, 57, Southern African Migration Programme (SAMP), Queen’s University. http://dspace.cigilibrary.org/jspui/bitstream/123456789/33006/1/Acrobat57.pdf?1

Patients without Borders: Medical Tourism and Medical Migration in Southern Africa, 2012

Series Editor: Jonathan Crush
Author: Jonathan Crush, Abel Chikanda and Belinda Maswikwa

Migration Policy Series No. 57

Executive Summary

Medical tourism has become a major focus of research and policy interest in the Global South in recent years. Much of the discussion focuses on the motives and impact of Europeans and North Americans who travel to develop­ing countries for lower-cost medical and health care. One recent over­view of the global medical tourism industry identified three major hubs (Thailand, India and Singapore) and three minor hubs (Costa Rica, Hungary and South Africa) for North-South medical tourists. Medical tourism operators, facilitators and service providers generally advertise South Africa as a cosmetic tourism destination. The most popular pro­cedures for European medical tourists are hip replacements, rhinoplasty, breast augmentation, liposuction, facelifts and tummy tucks. In other words, South Africa is seen as an archetypal medical tourism destination, combining a medical (elective) procedure with related travel and tourism activity. This paper first reviews the operation of the private sector indus­try in South Africa and the role of medical facilitators in particular. It shows that the industry is premised on a highly romanticised and stylised image of South Africa which stresses the quality of the country's private healthcare system and its numerous tourist attractions.

The paper shows that cosmetic surgery is only one small segment of medical tourism to South Africa. A great deal of medical tourism to South Africa is not from the North at all, but from other African coun­tries. The number of medical migrants to South Africa increased from 327,000 in 2006 to over 500,000 in 2009. Around 4.5% of total entries were for medical treatment which, became relatively more important over time (rising from 3.9% in 2006 to 5.0% in 2010). The Global North generated a total of 281,000 medical travellers over this time period while the Global South was the source of over 2 million The South African case therefore offers an important opportunity to examine the dynamics of South-South and intra-African travel for medical treatment. Just as South-South migration has generally been ignored, there is a danger that the same will happen to South-South medical tourism. This is unfortunate as South-South medical migration is growing rapidly and challenges conventional notions of medical tourism. This paper aims to reinstate intra-African medical tourism and migration as an important topic worthy of further research and policy attention. 

South-South movement to South Africa for medical treatment is far more significant, numerically and financially, than North-South move­ment. Two major forms of South-South medical migration (or medical travel) to South Africa from the rest of Africa are identified. The first is the growth in medical travel from East and West Africa to South Africa. These travellers spend more in South Africa than any other traveller (including those from the North) and are generally middle-class Africans seeking specialist diagnosis and treatment. The second, making up over 80% of the total medical travel flow to South Africa, are formal and informal movements from countries neighbouring South Africa (especial­ly Lesotho, Swaziland, Mozambique and Zimbabwe). Very little is known about this movement beyond the basic dimensions of the flow.

Public health systems in countries neighbouring South Africa are in a state of crisis, under-resourced, understaffed and overburdened. The problem is exacerbated by the ongoing brain drain of doctors and nurses to South Africa and overseas. The countries neighbouring South Africa have much worse patient to doctor and nurse ratios than South Africa or the recommended WHO minimum. Southern Africa is also the epicentre of the global HIV and AIDS pandemic, which has increased the burden of disease on health systems by increasing the demand for treatment and palliative care, imposing heavier workloads on health care workers, reducing the workforce by infecting health care workers and imposing psychological stress on health workers who have to administer palliative care, leading to low morale, burn-out and absenteeism.

The general lack of access to medical diagnosis and treatment in SADC has led to a growing temporary movement of people across bor­ders to seek help at South African institutions in border towns and in the major cities. These movements are both formal (institutional) and infor­mal (individual) in nature. In some cases, patients go to South Africa for procedures that are not offered in their own countries. In others, patients are referred by doctors and hospitals to South African facilities. But the majority of the movement is motivated by lack of access to basic health­care at home. An analysis of exit survey data reveals the following about the movement:

• The proportion of medical travelers from neighbouring states as a proportion of total entries was around 6% in 2010. However, there is considerable country variation with medical travellers amounting to 17% of total entrants from Mozambique and 12% of those from Angola. The proportion for most countries neigh­bouring South Africa is much lower: Botswana (4%), Lesotho (4%), Zimbabwe (3%) and Swaziland (2%). This is because cross-border traffic with these countries is so large that medical travel is relatively insignificant as a proportion of the whole.
• The actual number of medical travellers is currently 300-350,000 per annum. Lesotho is the source of the greatest numbers (140,000), followed by Botswana (55,000), Swaziland (47,000), Mozambique (38,000) and Zimbabwe (17,000). The flow has been increasing fastest from Mozambique: from 8,000 in 2003 to 147,000 in 2008.
• The average length of stay for medical tourists from Europe is 8 nights. The average length of stay for medical travellers from countries neighbouring South Africa, on the other hand, is lower than 4 nights and as low as 1 night in the case of Botswana and Lesotho. This is consistent with a pattern of short-term cross-border movement to access routine medical services or treat­ment in South African towns close to the border between the countries.
• The total annual spend by medical travellers in South Africa amounts to over R1.5 billion. Of this, over 90% is generated by South-South medical travellers from the rest of Africa, powerfully illustrating the overall economic importance of this form of medi­cal travel. 

The high demand and large informal flow of patients from countries neighbouring South Africa has prompted the South African govern­ment to try and formalize arrangements for medical travel to its public hospitals and clinics through inter-country agreements. South Africa has entered into bilateral health agreements with eighteen African countries. Bilateral agreements can be seen as an effort to formalise and manage these movements and obtain payment from governments for the cost of treating non-residents. Some SADC governments have set up special funding mechanisms (such as the Phalala Fund in Swaziland) to pay the medical costs of patients who go to South Africa for approved treatment. However, these special funds have been plagued by corruption on both sides of the border to the detriment of patients. 

Medical tourism and South-South medical travel are areas that require much additional research and policy formulation. SAMP has recently embarked on a major research project on South-South medical travel to examine the following issues:

• Drivers of Cross-Border Medical Migration. The reasons for the growth of medical travel to South Africa require investigation. Possible “push” factors include the crisis of detailed public health care systems in most SADC countries; lack of access of patients to diagnosis, drugs and care; inequitable distribution of health care resources that disadvantage rural populations; growth in the burden of disease and care accompanying the HIV and TB pan­demics; lack of access to ART for PLHIV; and the comparative costs of treatment at home versus in South Africa. Possible “pull” factors include South Africa’s better-resourced and staffed public health system; the existence of world-class medical facilities in the private system for those who can afford to pay; easier access to diagnosis, treatment and care; and greater ART coverage and accessibility.
• Health Seeking Behaviour by Medical Migrants. Beyond aggregate statistical information on the numbers involved, their length of stay in South Africa and their expenditure patterns, little is known about the medical reasons why residents of neighbour­ing countries seek treatment and care in South Africa and the ways in which they seek to access medical treatment in South Africa. What kinds of medical conditions prompt people to cross borders for treatment? Have HIV and AIDS and TB played a role in inducing more people to cross borders and, if so, what do they hope to achieve by going to South Africa? What role does the quest for maternal and child health play in prompting migra­tion? Do people cross borders in order to access ART and how is their treatment regime affected by the fact that they have to travel regularly to access the drugs? Do medical migrants tend to go to hospitals and clinics in border towns or do they go to the larger centres? How do they decide which clinics and hospitals to attend and how do they actually get to these centres? What kinds of follow-up do they receive and, in particular, do they continue on prescribed drug regimens after leaving South Africa? This could be a crucial issue in the context of the emergence of drug-resistant strains of TB and other conditions.
• Treatment of Medical Migrants in South Africa. There is consider­able evidence that migrants living in South Africa are regularly denied their constitutional right to medical treatment and care by personnel at hospitals and clinics. Studies of foreign residents of South Africa have clearly demonstrated the difficulties faced in getting medical attention from the public health system. Clearly, given the scale of the movement involved, medical migrants are somehow able to access treatment or they would not come. The fundamental question, then, is whether the barriers to access and human rights violations experienced by foreign residents are also experienced by medical migrants and what strategies they adopt to try and overcome these barriers. Are patients denied access to clinics and hospitals on the grounds of origin, citizenship and language? How are they treated by South African health workers and physicians? Do they receive the same kinds of care as South African patients? What kinds of payments are they asked to make for treatment? What happens to them if admission is considered medically advisable? Are they admitted and under what condi­tions or are they sent home?
• Policy Responses to Medical Migration. The 1999 SADC Health Protocol has amongst its objectives “to facilitate the establish­ment of a mechanism for the referral of patients for tertiary care” and “to coordinate regional efforts on epidemic preparedness, mapping, prevention, control and where possible the eradication of communicable and non-communicable diseases.” Bilateral agreements can be seen as an effort to formalise these movements and obtain payment for the cost of treating non-residents who cannot afford to pay for expensive, specialised medical treat­ments in South Africa. Recent press reports from Botswana and Swaziland suggest that these agreements are not functioning well, to the detriment of patient care. For example, 500 Swazi can­cer patients undergoing chemotherapy were recently sent home because the Swazi government had not paid their hospital bills. A critical analysis is needed of the functioning of the bilateral agreements and the extent to which they facilitate or obstruct the rights of patients.

New special issue: Transnational Health in Asia - Patients, Knowledge, Praxis

The European Journal of Transnational Studies has released a special issue on Transnational Health in Asia. The full text is available in PDF at http://www.transnational-journal.eu/5_1_2013/EJOTS2013_01.pdf

• Laurent Pordié: Spaces of connectivity, shifting temporality: Inquiries in transnational health
• Mika Toyota / Chee Heng Leng / Xiang Biao: Global track, national vehicle: Transnationalism in medical tourism in Asia
• Andrey Bochaton: The rise of a transnational healthcare paradigm: Thai hospitals at the crossroads of new patient flows 
• Junko Iida: Holism as a whole-body treatment: The transnational production of Thai massage
• Roman Sieler: From lineage transmission to transnational distance education: The case of siddha varmam medicine

New book: Medical Tourism and Transnational Health Care

Medical Tourism and Transnational Health Care (David Botterill, Guido Pennings and Tomas Mainil, eds., Palgrave MacMillan, May 2013) 

Medicine and tourism have become separated in contemporary popular consciousness. The former implies anything but a pleasurable experience and the latter presumes a healthy disposition for participation. We argue that this popular conception of the separation of tourism and medicine ignores an historical continuity of lineage from the 18th century pursuit of a 'cure' at resorts and spas, to 20th century notions of holidays as worker welfare through to global patient mobility in the quest for cutting-edge medical interventions in so-called 'untreatable' conditions. Disciplinary divisions within the academy have reinforced the separation between medicine and tourism in popular culture, but there is now an emergent challenge to re-think the medicine/tourism nexus. Under the influence of transnational health care consumption, two very contrasting traditions of Western thought are now confronting one another. This book provides a comprehensive landscape of diverse research communities' attempts to capture its implications for existing bodies of knowledge in selected aspects of medicine, medical ethics, health policy and management, and tourism studies.

New book: The Globalization of Health Care: Legal and Ethical Issues

The Globalization of Health Care (I.Glenn Cohen, ed., Oxford University Press, April 2013) offers a comprehensive legal and ethical analysis of the most interesting and broadest reaching development in health care of the last twenty years: its globalization. It ties together the manifestation of this globalization in four related subject areas - medical tourism, medical migration (the physician "brain drain"), telemedicine, and pharmaceutical research and development, and integrates them in a philosophical discussion of issues of justice and equity relating to the globalization of health care. The time for such an examination is right. Medical tourism and telemedicine are growing multi-billion-dollar industries affecting large numbers of patients. The U.S. heavily depends on foreign-trained doctors to staff its health care system, and nearly forty percent of clinical trials are now run in the developing world, with indications of as much of a 10-fold increase in the past 20 years. NGOs across the world are agitating for increased access to necessary pharmaceuticals in the developing world, claiming that better access to medicine would save millions from early death at a relatively low cost. Coming on the heels of the most expansive reform to U.S. health care in fifty years, this book plots the ways in which this globalization will develop as the reform is implemented.

CFP: Theorising mobilities in/from Asia

CALL FOR PAPERS (DEADLINE: 14 JUNE 2013)
THEORISING MOBILITIES IN/FROM ASIA

Date	:	14-15 November 2013
Venue	:	Asia Research Institute, National University of Singapore
Website	:	http://www.ari.nus.edu.sg/events_categorydetails.asp?categoryid=6&eventid=1425

Asia’s rapid ascension to become a beacon of 21st century development has ostensibly rendered the region that much more dynamic and fluid. In particular, the continent now seems abuzz with activities involving the circulation of large numbers of people and goods between and within countries and urban centers. While mobilities have long been a staple in Asian societies and a force of social transformation throughout history, a greater need/desire for mobility in recent years has impelled new ways of being on the move in Asia. Of note, fresh outlooks have emerged in relations to the organisation of. as well as people's aspirations for, migration and transport mobilities—at times resulting in new innovations and phenomena, and at others, seeing the importation and re-circulation of different models.

Shifting the focus to these themes inevitably plugs Asian social research to literatures subscribing to the mobilities turn. Of note, there is growing awareness among scholars that societies are principally loose formations shaped and reshaped by the very condition of flux and restlessness, rather than stable, self-evident entities. From how urban rhythms alter the city’s fabric to how international travel is governed, scholars have outlined the disparate ways in which places are animated, made meaningful, and moulded out of mobile ideologies and practices. The resulting scholarship is also one that does not seek to locate stasis, but one that tries to unfix apparent, but misleading, 'fixities'.

Despite this newfound emphasis, the mobilities literature has remained rooted in the Anglo-American context within which it first gained prominence. Its disposition, it seems, remains to valorise, even universalise, ‘western’ theories, terminologies and perspectives about moving, so much so that 'Other' expressions of mobilities have been silenced or excluded. This conference thus invites scholars to explore ways of retrieving these lost knowledges of mobilities through a deliberate (re)turn to ‘Asia’. In particular, the region is taken as a collective of centres for re-understanding and re-theorising mobilities in their plurality and, especially, how migration and transport have compelled new social outlooks and modes of organisation in ‘Asian’ contexts. In building such a cosmopolitan case, participants are encouraged to engage with the following questions:

• What do mobilities (and mobile subjects) mean in the region, and how are they expressed through migration and transport?
• How have mobilities in Asia developed over time and through disparate historical pathways?
• What are the impetuses for mobilities in Asia, particularly where organised movements are involved?
• How do different forms of mobilities intersect and to what extent have they challenged regulatory regimes in Asian contexts?
• How do we theorise mobilities in Asia vis-à-vis other regions?

SUBMISSION OF PROPOSALS
Paper proposals should include a title, an abstract of 300 words maximum and a brief personal biography of 150 words for submission by 14 June 2013. Please send all proposals to Mr Weiqiang Lin at weiqiang.lin.2011@live.rhul.ac.uk.Click here for the Paper Proposal Submission Form. Successful applicants will be notified by 14 July 2013 and will be required to send in a completed draft paper (5000 - 8000 words) by 14 October 2013.

Based on the quality of proposals and the availability of funds, partial or full funding will be granted to successful applicants. Participants are therefore encouraged to seek funding for travel from their home institutions. Full funding cover air travel to Singapore by the most economical means, plus board and lodging for the duration of the conference.

CFP: International Conference: Practising the Good Life/The Good Life in Practices

The Call for Papers is now open for the International Conference: Practising the Good Life/The Good Life in Practices, to be held at the Universidade Nova de Lisboa (Lisbon, Portugal) on October 17th/18th 2013.

This will be the first conference in Portugal solely dedicated to Lifestyle Mobilities. The conference is free of charge, but is limited to a maximum of 24 paper presentations, to be delivered in plenary sessions over two days.

Privileged forms of mobility have not only become increasingly evident in the past few decades but they are also attracting growing attention as an area of enquiry within social sciences research across various disciplines. These mobilities are driven by the pursuit of ideals loosely and subjectively defined as leading to a better quality of life. Playing on the tensions and interactions between tourism and migration, such forms of movement and settlement are theorized as  'lifestyle migration', 'amenity migration', 'counter-urbanization migration', 'international retirement migration' and ‘residential tourism’.

Notably, while the various ways of perceiving this type of movement and reterritorialization signal a striking diversity concerning the various actors involved – whether expatriates, global nomads, counter-culture dropouts, highly skilled professionals or retirees – the phenomenon seems to be at once clearly identified and loosely characterized. The motivations, circumstances, life trajectories, expectations, outlooks and material conditions of individuals may vary widely, since these types of migratory projects are largely individualistic, designed on a voluntary basis and supported by sufficient resources to pursue a better quality of life. In essence, their particular relation to place(s) questions notions of 'home' and suggests singular ways of constructing belonging.

While much is already known about these mobilities, more systematic and textured analysis is necessary to move forward. Previous work flags directions to explore such as the specificities of destination contexts (that range from rural areas to holiday resorts and include sites of spiritual relevance); the ambivalences of dwelling between 'local' and 'outsider' categories; and the entanglements of privileged living conditions, infrastructures and policies geared to tourism and the second-home market as well as the negative impacts for local populations and their environments. In this conference, we suggest delving into these and other aspects of lifestyle oriented mobilities by taking a practice-based approach. Exploring how people, in practice, live out “the good life” implies considering how mobilities materialize in people’s everyday engagements, institutional articulations and international dynamics. Among the practices that could be considered are:

• Transnational Practices – approaches drawing on a transnational lens to reflect on the particularities of the lifestyle driven mobilities at stake such as perspectives grounded in material culture; transnational families; production of locality or other aspects of transnationalism;
• Modalities of reterritorialization – approaches focused on the symbolic investments shaping the construction of belonging(s), such as practices of solidarity and community-making at a local level; commitments to citizenship; reinforcements and reworkings of ethnicity; engagement with place through spirituality; appropriations of new settings sought by lifestyle migrants; language learning and language practices;
• The role of the senses – approaches centered on the senses and sensory based practices, including the construction of meaning through art, leisure, performance, sports in lifestyle migration’ contexts; the importance of landscapes and environments in the relationship with place; the production and appropriation of the domestic space;
• Mediations of lifestyle migration – approaches exploring the role of (broadcast, “new” and/or “small”) media in the promotion and construction of lifestyle migration, such as research exploring how people resort to media for the negotiation of cultural identities in a lifestyle migration context; their relationships to “home” and the production of (local, diasporic, or other) imagined communities; the promotion of destination-images; specificities of media made by, for, with and/or about lifestyle migrants;
• Structuring practices: approaches that critically reflect on the inter-relations between Lifestyle Migration fluxes and policy making as well as economic activity, such as international retirement programs attracting migrants; real estate industry dynamics impacting on fluxes; environmental activism deriving from investments on residential tourism infrastructures; entrepreneurial activities and other modalities of work; the internationalized fluxes relating to the care giving market;
• Areas of Friction: approaches exploring how the presence of conflict sheds light on the contours of lifestyle migrants lived experience (e.g. textured relations between autochthones and foreigners; tensions between the perspective of the context of settlement and the context of origin; strategies of integration; ambivalent positionings and strategies particular to second-generation lifestyle migrants, etc.)

Please send your abstracts (max. 300 words) by June 1st to: goodlifepractices@gmail.com

Participants will be notified of acceptance by June 15th.

Full papers are to be submitted by October 1st for circulation among participants. Please keep papers under 6000 words.

For more information, please visit: http://goodlifepracticescria.wordpress.com

AAG 2013 - Politics of global health care offerings

Here's a list of sessions to attend at the 2013 AAG in Los Angeles (9-13 April) if you're interested in politics of global health care:

• Tuesday
• GeoHumanities and Health I is scheduled on Tuesday, 4/9/2013, from 12:40 PM - 2:20 PM in Laguna Parlor 3068, Westin, 30th Floor -- Session Description: These session/sessions call for papers both conceptual and empirical that explore the interface between the GeoHumanities and Health - the interface between geographical interests in health, illness and medicine and the interests of the humanities.
• GeoHumanities and Health II is scheduled on Tuesday, 4/9/2013, from 2:40 PM - 4:20 PM in Laguna Parlor 3068, Westin, 30th Floor
• Wednesday
• Feminist Engagements with Health, Capitalism, and the Body I is scheduled on Wednesday, 4/10/2013, from 8:00 AM - 9:40 AM in Santa Barbara A, Westin, Lobby Level -- Session Description: Feminist geographers have a long history of engagement with theories on the body.  As "the geography closest in" (Rich, 1986), the body is a key site of struggle in which we not only experience oppression but also work toward the construction of new and better alternatives.  Theorizations of the body have, necessarily, crossed disciplinary and sub-disciplinary boundaries.  Feminist economic geographers have contributed a large body of research on the gendered nature of capitalism, while feminist medical/health geographers have made significant inroads in the theorization of health, difference, and the body.  While bodies are never completely determined by their economic contexts, this session seeks to unite these literatures in an attempt to theorize how interventions of patriarchy and capitalism on the body produce particular experiences of health and disease in the twenty-first century.
• Feminist Engagements with Health, Capitalism, and the Body II is scheduled on Wednesday, 4/10/2013, from 10:00 AM - 11:40 AM in Santa Barbara A, Westin, Lobby Level 
• SOCIAL CITIZENSHIP, LANDSCAPES OF CARE AND HEALTH GEOGRAPHIES is scheduled on Wednesday, 4/10/2013, from 12:40 PM - 2:20 PM in Mediterranean, Biltmore, Mezzanine Level -- Session Description: Recent geographical studies of heath care have demonstrated the contested nature of place in understanding socio-spatial inequalities as a result of neoliberal discourses and governance. As indicated by Milligan and Wiles (2010) the complex relationship between people, places and care is largely unexplored especially within the context of social justice.  This session intends to bring together those scholars who are interested in understanding this complex relationship within the context of democracy, social citizenship, justice and health geographies. 
• Thursday
• Ecologies of Well-Being I is scheduled on Thursday, 4/11/2013, from 8:00 AM - 9:40 AM in Santa Monica C, Westin, Level 3 -- Session Description: Well-being has attracted significant academic and political attention in recent years. Researchers in psychology, economics, public health and development studies have sought to conceptualize, measure and explain variations in well-being between individuals and groups. In the political arena, several western governments have commissioned reports on well-being, including France, Canada and Britain, and some countries are seeking to develop national well-being accounts. Geographers are also engaging with well-being, both conceptually and through empirical investigation. To date, this work has included relatively extensive, quantitative investigations as well as local, more qualitatively oriented studies. A common thread has been an interest in the ecological determinants of individual and collective well-being. This is about how the 'natural', built and social environments as well as the cultural and spiritual context in which people are situated shape their happiness, flourishing, health and capabilities. This session is part of a larger series in which the organizers and speakers continue the conversation regarding how best to understand and investigate the environments which support human well-being using qualitative and quantitative methods and GIS. They will also consider the connections between geographical work on well-being and critical thought on equity, governmentality and related concerns. The session is part of the symposium 'Geography, GIScience, and Health: Spatial Frontiers of Health Research and Practice'.
• Ecologies of Well-Being II is scheduled on Thursday, 4/11/2013, from 10:00 AM - 11:40 AM in Santa Monica C, Westin, Level 3
• Ecologies of Well-Being III is scheduled on Thursday, 4/11/2013, from 12:40 PM - 2:20 PM in Santa Monica C, Westin, Level 3
• Ecologies of Well-Being IV is scheduled on Thursday, 4/11/2013, from 2:40 PM - 4:20 PM in Santa Monica C, Westin, Level 3
• Saturday
• Questioning Generosity in the Golden Age of Philanthropy is scheduled on Saturday, 4/13/2013, from 4:00 PM - 5:40 PM in Mediterranean, Biltmore, Mezzanine Level -- Session Description: This is the golden age of philanthropy. Over the 55 year period 1998 to 2052, bequests to charity in the United States are estimated to be between $109 and $454 billion per year. Heightened demand for philanthropy has been promoted by forty years of privatization and curbed spending on social services and compounded recently by government budgets straightened as a result of the Global Financial Crisis. And philanthropic donations will need to be used more efficiently than ever before, so there will be a heightened need for more 'businesslike' approaches to philanthropy. More than this, because philanthropists now find celebrity status and new forms of philanthropy are emerging rapidly, it is increasingly important to understand what is going on. This special session is intended to encourage geographers to give critical attention to these and some of the other less-than-charitable consequences and significance of philanthropy. Papers for the session may approach issues surrounding philanthropy conceptually or empirically and from any of a variety of methodological stances.

Transnational Health Care – A Cross-Border Symposium

 An international event co-sponsored by the Academy for Tourism at NHTV Breda University of Applied Sciences (NL), the Cultural Geography Chair Group at Wageningen University (NL), the Economic and Social Research Council – ESRC (UK), and the University of Leeds (UK)

At a moment in which the provision and regulation of health care within national boundaries is profoundly shifting, the growing numbers of people going abroad in pursuit of health care mean that the social, political and economic significance and impacts of these flows at a range of levels cannot be ignored. This symposium provides those involved in cutting-edge empirical and conceptual studies of the transnational pursuit and provision of medical care the opportunity to share their work, explore emerging research agendas and to encourage and foster future research collaborations.

Venues: Wageningen University, NL (20-21 June 2013) & Leeds University, UK (24-25 June 2013)

Conference fees: GBP 100 (for participation in both Wageningen and Leeds), GBP 50 (for participation in either Wageningen OR Leeds)

Conference registration and further logistical information on the event: http://transnationalhealthcare.leeds.ac.uk/

Preliminary Schedule (subject to change)

(abstracts are below the schedule)

Wageningen University - Day 1 (Thursday, 20 June 2013)

• Welcome/Introductory remarks
• Keynote
• Julie Feinsilver (American University, USA) - Global Health Diplomacy:  Old Wine in New Bottles (or a 53-Year Retrospective of Cuba’s Medical Diplomacy)
• Lunch
• Book presentation by David Botterill (NHTV Breda, NL) in Lumen 1
• Session 1:  Regional Governance, Development and Cooperation I
• Michael Eshiemokhai (University of Montreal, Canada) - Experiences with the Southern African Development Community (SADC) Health Protocol
• Harald Pechlaner, Michael Volgger and Christof Pforr (European Academy of Bozen/Bolzano - EURAC Research, Italy) - The Governance of Transnational Health Regions: Realizing Potentials for Health Tourism and Regional Development
• Tomas Mainil (NHTV Breda/Hogeschool Zeeland, NL) - Transnational Health Care and Sustainable Health Destination Management
• Break
• Session 2: Regional Governance, Development and Cooperation II
• Irene Glinos (Maastricht University, NL) - Cross-border Collaboration between Maastricht and Aachen University Hospitals: European Dreams vs. Domestic Realism
• Arturo Vargas Bustamante (UCLA, USA) - Healthcare Access and Utilization in Four Emerging U.S.-Mexico Transnational Healthcare Markets
• Meghann Ormond (Wageningen University, NL) - Everyday Economies of Regional Healthcare Consumption in Malaysia
• Rita Baeten (European Social Observatory (OSE), Belgium) - French Patients in Belgian Hospitals: Creative Solutions in the Border-Region of the Ardennes
• Group dinner

Wageningen University - Day 2 (Friday, 21 June 2013)

• Session 3: Regulating Reproduction
• Guido Pennings (Ghent University, Belgium) - French and Dutch Patients Seeking Cross-border Reproductive Care in Belgium: An Interview Study
• I. Glenn Cohen (Harvard University, USA) - Medical Tourism in the Shadows of the Law
• Kristin Lozanski (University of Western Ontario, Canada) - Transnational Commercial Gestational Surrogacy
• Wannes van Hoof (Ghent University, Belgium) - Dutch Patients Looking for Infertility Treatment in Belgium: Analysis of Commentaries on Internet Forums
• Lunch

• Session 4: Regulating Transnational Health Care Resources
• Margaret Walton Roberts (Wilfred Laurier University, Canada) - Markets, Migrants and Mediators: India and the Global Nurse Care Chain
• Primah Kwagala (Centre for Health, Human Rights and Development, Uganda) - Medical Tourism in Uganda: Regulating Traditional Medicinal Knowledge and Practices
• Jeroen Klijs (Erasmus University, NL) - Transnational Health Care in Malaysia: Input-Output Analysis and its Relation with Factors of Governance
• Frank M. Go (Erasmus University, NL) and Gulcin Bilgin Turna (Karadeniz Technical University, Turkey) - Ageing Knowledge Workers’ Propensity to Engage in Cross-border Living
• Break

• Session 5: Inward and Outward Medical Tourism: Results from an NIHR Study Examining Implications for the NHS
• Neil Lunt (University of York, UK) - Reflecting on the Structure of Medical Tourism in Europe and Korea
• Johanna Hanefeld (London School of Hygiene and Tropical Medicine, UK) - Why Do UK Patients Travel Abroad for Treatment? Insights from Interviews with UK Medical Tourists
• Daniel Horsfall (University of York, UK)

• Wrap-up session
• Group activity - TBA

Leeds - Day 1 (Tuesday, 25 June 2013)

• Opening/Welcome
• Session 1: Health Care Provision: Workers’ Experiences and Patients’ Expectations
• Napaphat Satchanawakul (Asian Institute of Technology, Thailand) - Gender Analysis of Mobility of Nurses Under ASEAN Economic Community in Thailand
• Sharon Kleefield (Harvard University, USA) - Cross-Border Quality and Safety: Outcome Measures to Establish ‘the Best’
• Ki Nam Jin (Yonsei University, Korea)  - Service Expectations of Medical Tourists
• Michael Guiry and Petra Kulasova (University of the Incarnate Word, USA) - Medical Tourism Risk Perceptions: A Preliminary Investigation
• Lunch

• Session 2: Sun, Sea, Sand and Silicone

• Ruth Holliday, David Bell, Meredith Jones, Elspeth Probyn, Jacqueline Sanchez Taylor, Olive Cheung, Emily Hunter, Ji Hyun Cho and Hannah Lewis (University of Leeds, UK, and University of Sydney, Australia)
• Break
• Session 3: Examining Equity, Ethical, and Safety Issues in Medical Tourism: A Research Programme Overview
• Valorie A. Crooks (Simon Fraser University, Canada)

• Keynote - At Sculpture Park
• John Connell (University of Sydney, Australia) - Medical Tourism: On the Road to Where?
• Group dinner

Leeds - Day 2 (Wednesday, 26 June 2013)

• Keynote/Discussion
• Deborah Gimlin (University of Aberdeen, UK) - Physician Associations, Medical Sovereignty and the Management of Cosmetic Surgery Tourism: A Comparative Analysis
• Break
• Panel Session 4: Methodologies, Fieldwork Experiences and Positionality
• Facilitators: Elspeth Probyn (University of Sydney, Australia), Neil Lunt (University of York, UK), Meghann Ormond (Wageningen University, NL).
• Lunch
• Session 5: Transnational Health Care Users - Cross-Border Pursuits and Migration
• Sabina Stan (Dublin City University, Ireland) - Transnational Healthcare Practices of Romanian Migrants in Ireland: Social Mobility and the Marketisation of Healthcare Services in Europe
• Robert McLaughlin (Stanford Cancer Institute, USA) and Theresa Alfaro-Velcamp (Sonoma State University, USA) - The Transnational Case of Breast Cancer among Latinas/Hispanics in California
• Andrea Whittaker (Monash University, Australia) - Is It an International Space? The Experience of Cross-border Patients in Thailand and Malaysia
• Break
• Open Discussion Session 6: Medical Travel Research Agenda-Setting
• Facilitators: John Connell (University of Sydney, Australia), Valorie Crooks (Simon Fraser University, Canada),  Tomas Mainil (NHTV Breda, NL) and Andrea Whittaker (Monash University, Australia)

Abstracts 

(alphabetical order)

• Rita Baeten (European Social Observatory (OSE), Belgium) - French Patients in Belgian Hospitals: Creative Solutions in the Border-Region of the Ardennes
• The area in the North of France around the Meuse River, with the town of Givet in its centre, is surrounded by Belgium. In this enclave, the activity of two local hospitals has, for economic reasons, been drastically reduced since 2002, which resulted in the nearest French hospital being at a distance of 60 kilometres. Under pressure from the local population, policy makers and field actors looked for innovative solutions to compensate for the lack of care provision on the French side. Successive agreements have been developed to allow French citizens who are socially insured in the Botte de Givet to be treated across the border, in the nearby Belgian hospital of Dinant.  This resulted in important and almost one-way patient flows from France to Belgium. We will look at these developments and analyse why the initial hospital collaboration, instigated and controlled by the French health authorities, transformed into collaboration between health insurers across the border, where hospitals became competitors and health authorities are only involved at the margin.  We will analyse the stakes of the actors involved and explore the role of the EU. Whilst the rationale of this collaboration is to ensure access to proximity healthcare services for the local population, we show how the incentives for the stakeholders created a dynamic in which the legal frameworks are applied in a very creative way. Practical arrangements, negotiations and tacit agreements were concluded between field actors, often before any legal basis existed or in spite of existing ones.

• I. Glenn Cohen (Harvard University, USA) - Medical Tourism in the Shadows of the Law
• This presentation will draw from from various chapters of my forthcoming book, Patients With Passports: Medical Tourism, Law, and Ethics (under contract Oxford University Press) related to the medical tourism for services legal in the patient’s home country but illegal in the patient’s destination country (what I call “circumvention tourism”) as well as medical tourism for services illegal in both the patients home and destination countries. I will discuss the current state of medical tourism for a subset of the following services of this kind: stem cell tourism, transplant tourism, fertility tourism, travel for abortion, and travel for assisted suicide. I will discuss the existing domestic and international law pertinent to these kinds of medical tourism, potential home and destination country regulatory interventions, international cooperation, and the normative arguments underlying the regulation of these trades.

• John Connell (University of Sydney, Australia) - Keynote: Medical Tourism: On the Road to Where?
• In its present incarnation medical tourism has barely passed adolescence. It should therefore be rapidly changing - but it is not changing as far as its proponents would like. Why is that? But – are we sure we are agreed on what it is (and whether wellness, refugees etc have anything to do with it) and what the numbers may mean? We need better data, better definitions and less boosterism. How will ‘Obamacare’ and EU directives shape future trends? Will Psy redirect East Asian cosmetic surgery? What does a globally ageing population mean for the industry?  Will defensive investment reverse trends? Is strategic investment anything more than desperation stakes that will prove disastrous? Will ‘new’ destinations emerge? Will new technologies and treatments shape the face – literally and metaphorically – of medical tourism? Is there an integrated transnational tourist future? Is it all an ethical disaster and should be discouraged? Much remains to be seen but some emerging trends are now apparent.

• Valorie A. Crooks, Jeremy Snyder, Rory Johnston, Vicky Casey and Krystyna Adams (Simon Fraser University, Canada) - Examining Equity, Ethical, and Safety Issues in Medical Tourism: A Research Program Overview
• The SFU Medical Tourism Research Group (www.sfu.ca/medicaltourism) is focused on undertaking non-hypothesis testing qualitative research that provides insight into equity, ethical, and safety issues associated with the practice of medical tourism. We explicitly conceptualize medical tourism as involving patients’ intentional travel across national borders for private medical care. Although our group is based in Canada, a number of our studies have an international focus – wherein we currently have funded research activities in Mexico, Guatemala, Barbados, India, Jamaica, and Belize. In this presentation we will provide an overview of our current program of research, including major studies focused on: (1) the health equity impacts of medical tourism in destination nations, (2) the practice of informal caregiving by medical tourists’ friends and family members, and (3) the development of an ‘ethical buying guideline’ for Canadian medical tourists. In doing so we will characterize the international networks of collaborators involved in these studies and also make explicit connections between these ongoing studies and our previous analyses.

• Michael Eshiemokhai (University of Montreal, Canada) - Experience with the Southern African Development Community (SADC) Health Protocol
• There is no denying the fact that many of the most challenging global health problems are found in developing countries. Many of these problems such as HIV/AIDS, malaria, tuberculosis, maternal mortality, and malnutrition, amongst others are located in sub-Saharan Africa. While global initiatives to address them have intensified in the last decade, regrettably, progress has been slow in many countries. In 1999, as part of efforts to find solution to regional problems, the Southern African Development Community (SADC) Health Protocol was initiated. It facilitated the establishment of a mechanism for the referral of patients for tertiary care, address and coordinate regional epidemic preparedness, prevention, control, as well as diseases eradication. The increase in patient flow from neighboring countries as a result of this protocol recently made the government formalize inter-country arrangement for medical travel to its public health facilities with over a dozen African countries. The paper discusses the impact of this bilateral agreement and the extent to it facilitates or obstructs the patients flow. It also addresses the challenges this could have on public health facilities in South Africa and suggests lessons that other regional bodies such as in the Economic Community for West Africa States (ECOWAS) can draw from the SADC experience.

·         Julie Feinsilver (American University, USA) - Global Health Diplomacy:  Old Wine in New Bottles (or a 53-Year Retrospective of Cuba’s Medical Diplomacy)

• Global health diplomacy has become an important part of foreign policy over the past two decades and, more recently, a popular subject of academic research and debate.  However, much recent scholarly work in this field has overlooked past research on medical diplomacy—the provision of medical assistance to simultaneously produce both health benefits and improve government-to-government relations.  For example, it is little known that medical diplomacy has been a key instrument of Cuba’s foreign policy since the beginning of its 1959 Revolution.  Better known is its most famous medical tourism case, that of Venezuela’s President Hugo Chavez.  Nonetheless, Cuba first provided disaster-relief assistance to Chile after the earthquake of May 1960.  In the fifty-three years since then, Cuba has become a major provider of health care and medical education to developing countries. Cuba’s medical diplomacy provides a comprehensive package of assistance from short-term emergency aid to long-term health-system development, which has aided tens of millions of people in 107 countries throughout the world. To contribute to the sustainability of this medical assistance, since 1961 Cuba also has provided free medical education for tens of thousands of foreign students. In 1999 Cuba even established a medical school specifically to train foreign students from the developing world, and in 2010 alone, began training more than 50,000 future doctors there and in their home countries. This paper will discuss why and how Cuba has conducted medical diplomacy, provide a longitudinal view of Cuba’s experience in the provision of transnational health services (including medical tourism) and medical education, discuss the enabling factors underlying this endeavor, specific cases, the costs, risks, and benefits of Cuba’s medical diplomacy; and delineate a typology of medical diplomacy activities. Finally, the conclusion will summarize the political, economic, health, and symbolic results, and suggest some lessons that could be learned from this case study.

·         Irene Glinos (Maastricht University, NL) - Cross-border Collaboration between Maastricht and Aachen University Hospitals: European Dreams vs. Domestic Realism

• This is a story of two university hospitals too close to ignore each other.  In the border-region between the Netherlands and Germany, the Maastricht Universitair Medisch Centrum (MUMC+) and the Universitaetsklinikum Aachen (UKA) have been collaborating since the 1990s and formalised their exchanges with the signing of an agreement in 2004.  Soon after, negotiations were initiated with the intention of creating a ‘European University Hospital’ through a hospital merger and building a new joint centre of excellence. In parallel, medical teams and researchers have been working across the border in various fields. Over the past 20 years, the collaboration has evolved in content, scope, intensity and ambition but now is at the crossroads. We explain the complex mix of parameters which led UKA and MUMC+ to collaborate, and analyse the stakes of the local actors. Contrary to any arguments of geographical determinism, the case-study reveals that only few aspects of cross-border collaboration are determined by border-region circumstances. The technical difficulties which MUMC+ and UKA faced boil down to the tremendous differences between the two health systems they are part of. As opposed to other examples of cross-border collaboration, this case is not driven by the need of local patients to access care, but rather by the strategic considerations of the two partners.  Drawing on business administration literature we show how collaboration is interest-driven similar to the corporate world, and how the two hospitals have used discoursive legitimation to justify their actions. Ultimately, however, unrealistic discourses, the lack of an objective need and overconfidence in the project have contributed to the cancellation of plans and to undermining the collaboration.

• Frank M. Go (Erasmus University, NL) and Gulcin Bilgin Turna (Karadeniz Technical University, Turkey) - Ageing Knowledge Workers’ Propensity to Engage in Cross-border  Living
• During the next two decades thousands of European scientists, educators and academics will be retiring. Many of these professionals will be in search for activities and health care that they perceive as relevant to their personal development and well-being. In the wake of the financial crisis and the projected decline of pensions a question of great import arises whether and to what extent values set/worldview on the one hand health and well-being on the other might influence knowledge workers to opt for taking up temporary residence across borders from their native country. The focus of this work, aging knowledge workers’ propensity to engage in cross-border living, learning and transition, is highly complex, yet under researched, at a time when businesses and government are in search of inclusive solutions to retain the skills of experienced workers whose life expectancy is lengthening. Transnational health care providers have been developing and marketing medical travel as an industry for a long time to attract the attention of many people who do not hesitate to cross borders to benefit from a high-quality health care service. This paper analyzes how attractive Turkey would be in the perception of retiring knowledge workers (especially academics) as a country to take up temporary residence in the pursuit of a combination of research/publishing, work, leisure activities, and health care in comparison to other Mediterranean countries such as Greece, Italy, France, and Spain.

• Michael Guiry and Petra Kulasova (University of the Incarnate Word, USA) - Medical Tourism Risk Perceptions: A Preliminary Investigation
• Crooks, Kingsbury, Snyder, and Johnston (2010) noted that most of what is known about the patient's medical tourism experience, including the risks of being a medical tourist (MT), “is, in fact, speculative, idea-based, or anecdotal in nature” (p. 9). Given the importance of perceived risk in the consumer purchase decision process and the lack of empirical research on medical tourism risk perceptions (MTRP), the purpose of this ongoing study is to investigate consumers’ MTRP. Data are being collected via an online survey of U.S. adults, 18 years of age and older. Preliminary results show that experienced medical tourists (EMT) view traveling abroad for medical care as having significantly more social risk than non-medical tourists (NMT) do. Interestingly, EMT who were satisfied with their experience believe being a MT has significantly higher overall, physical, psychological, performance, financial, and time risks than EMT who were not satisfied with their experience do. Likewise, EMT likely to travel abroad again for medical care think being a MT has significantly higher overall, physical, psychological, performance, financial, and time risks than EMT not likely to travel again for overseas medical care do. Concerning NMT, those who are interested in being a MT have significantly lower overall, physical, psychological, social, performance, financial, and time risk perceptions than NMT who are not interested in being a MT do. This ongoing study provides new insights on consumers’ attitudes towards medical tourism. Further analysis will investigate the relationship between EMT and NMT personality traits/psychographic characteristics and MTRP.

• Johanna Hanefeld (London School of Hygiene and Tropical Medicine, UK), Daniel Horsfall (University of York, UK), Richard Smith (London School of Hygiene and Tropical Medicine, UK) and Neil Lunt (University of York, UK) - Why Do UK Patients Travel Abroad for Treatment?  Insights from Interviews with UK Medical Tourists
• Background: While there are increasing reports in popular media and studies exploring the phenomenon of medical tourism, understanding of why patients travel is still limited. Evidence suggests that a growing number of patients from the within publicly funded universal health care systems such as the UK National Health Service (NHS) travel abroad to access (and pay for) medical treatment. Methods: This paper presents findings resulting from a two year research project undertaken by researchers at the London School of Hygiene and Tropical Medicine and the University of York, which focused on understanding the impact of medical tourism on the UK NHS. As part of the study a total of 77 patients who had travelled abroad for treatment were interviewed to better understand factors determining patient motivation to travel. Results: Patients interviewed fell into one of the following categories: bariatric, fertility, dental, cosmetic or diaspora travellers. Thematic analysis of the interviews revealed a complex interplay of different factors motivating patients to travel. This included cost, and extended to greater perceived expertise and availability of treatment abroad. Distance, cultural affinity and initial experience of the NHS also were factors determining travel. Motivation varied according to the treatment for which patients travelled. Analysis also revealed that for some patients the ability to go and ‘take action’ in the form of travel seemed important. Conclusions: Motivation of medical tourists’ is complex, in part determined by their personal circumstances and the condition for which they travel. Where patients travel abroad for conditions routinely offered for free on the NHS this may be an indicator of unavailable or unacceptable services. The complex, differing motivations for patient travel affect where they go, the providers they choose, and the risks their medical travel may entail. Understanding patient motivation is therefore important for policies and interventions aimed at minimising complications from treatment abroad.

• Ruth Holliday, David Bell, Meredith Jones, Elspeth Probyn, Jacqueline Sanchez Taylor, Olive Cheung, Emily Hunter, Ji Hyun Cho and Hannah Lewis  (University of Leeds, UK, and University of Sydney, Australia) - Sun, Sea, Sand and Silicone
• This panel will present research findings from a major ESRC project 'Sun, Sea, Sand and Silicone' which explores the cosmetic surgery tourism business for patients travelling from the UK, China and Australia. In particular the panel addresses key differences in patient experiences according to social class and geographical location. We also explore discourses of cosmetic surgery and transnational healthcare from the point of view of surgeons, agents and other key actors. We find that cosmetic surgery is an uneven practice and that patients travel sometimes for low cost and sometimes for high skill. The ways in which cosmetic surgery is supported or condemned in different national discourses is also central to how it is perceived by patients and discussed by surgeons. As part of this study we explore regional, expatriate and 'return' medical tourism as well as the role of online resources in promoting cosmetic surgery tourism and protecting patients. Finally, we also explore qualitative methodologies and some of the affective dynamics at the heart of explorations of cosmetic surgery tourism.

• Wannes van Hoof, Veerle Provost and Guido Pennings (Ghent University, Belgium) - Dutch Patients Looking for Infertility Treatment in Belgium: Analysis of Commentaries on Internet Forums
• The internet is a very important source of information for cross-border patients. Internet forums are a virtual place where patients can help each other with practical, emotional and even medical issues. There are several Dutch internet forums where patients share their experiences with cross-border reproductive care (CBRC) or ask questions about treatments abroad. We analyzed all the threads on CBRC from eight forums that were active in a fifteen-month period (October 2010 - December 2011) using inductive thematic analysis. Eight themes emerged after data analysis: medical expertise and testing, costs, feelings and experiences, trying out different clinics, travel and waiting times, treatments in the Netherlands, cooperation between clinics/physicians and laws and regulations. Internet forums offer an easy way for patients to share practical information such as which health insurer offers the best care package for IVF or where drugs are the cheapest. In all eight Dutch forums, the general message about fertility treatment in Belgium is very similar: Belgium offers better quality of care. The most important markers of good quality care are high medical skill (effectiveness), cost-effectiveness (efficiency) and respect for patients’ feelings and experiences (patient-centeredness). According to the forum users, the main difference between IVF treatment in Belgium and the Netherlands is the central position of the patient: in Belgium, more tests and treatments are possible and patients are seen as persons rather than numbers.

• Ki Nam Jin (Yonsei University, Korea) - Service Expectations of Medical Tourists
• Asia has become the most popular destination of medical tourists in the world. Asian medical tourism market was expected to be worth US$4 billion by the year 2012. The South Korean Government used a lot of resources for promoting medical tourism industry. The restriction on medical tourism marketing was loosened to vitalize this new industry by the modification of medical law. Hence the number of medical tourists increased from 27,480 to 122,297 during 2008-2011 period. The purpose of this study is to examine the service expectations of medical tourists who visited Korea. For this purpose, we will survey 200 medical tourists by using questionnaire. We will examine the pre-trip behavior (e.g., reason for visit, information source, trip arrangement, worry) of medical tourists. We will examine the service expectations of medical tourists. For measuring expectations, we will use SERVQUAL scale. There have been few studies on the actual behavior or attitudes of medical tourists. By focusing on medical tourists, we can develop practical and proactive service strategy.

• Sharon Kleefield (Harvard University, USA) - Cross-Border Quality and Safety: Outcome Measures to Establish ‘the Best’
• The Economist Intelligence Unit (EIU) published a first study on medical tourism entitled Traveling for Health in 2011.  The report highlights the fact that developing markets are becoming more pronounced because of the continued rise of costs in the US and Europe, and the increasing number of ‘baby boomers’ moving toward retirement, causing additional strain on  health care systems in the West.  Reduced health care services and longer waiting times for patients continue to drive people to look outside their communities for faster and cheaper care.  However, identifying hospitals and physicians who provide ‘the best’ care remains challenging. Currently 50 countries have identified ‘medical tourism’ as a strategic national industry; but not every country will succeed in becoming a medical tourism ‘hub’. Accreditation provides one view of the quality and safety of hospitals. The Joint Commission International (JCI) has accredited 375 hospitals to date, with most of these located in the Middle East, Southeast Asia, Turkey, Brazil and China.  The JCI has the longest international experience, but the number of JCI accredited organizations is small, as compared to the total number of hospitals offering treatment to the medical traveler.  It is difficult to find outcomes data that reflect the quality of patient care and safety, with no cross-border consensus on defining and benchmarking such data.  Governments, insurers and patients are rightfully hesitant to support cross-border medical travel, given the lack of quality data. I am proposing a set of outcome measures for measuring quality across borders.  These measures will be presented.  The utilization of quality data will serve the medical travel industry by providing: 1) transparency of key quality data in a standardized, evidence-based approach;  2) address concerns about quality by payors and employers;  3) establish global consensus (and competition) to be ‘the best’;  4) allow patients to make informed decisions about safety and standards of care.

• Jeroen Klijs (Erasmus University, The Netherlands), Tomas Mainil (NHTV Breda, The Netherlands), Meghann Ormond (Wageningen University, The Netherlands) and Wim Heijman (Wageningen University, The Netherlands) - Transnational Health Care in Malaysia: Input-Output Analysis and its Relation with Factors of Governance
• Intro: The present dynamics of transnational health care are explained.  In a second motion we elaborate on the specific status of transnational health care in the region of Malaysia.  Furthermore the application of input-output analysis as a tool is exemplified as a way to analyze the economical streams generated in Malaysia by means of transnational health care.  Finally, as a developed research problem the relationship between IO analysis and existing factors of governance is assessed. Methods: In this article we apply an extended IO model, which has been further developed to allow for (price induced) substitution between inputs. We explain the difference with the basic IO model, in which substitution does not play a role. Furthermore, we will apply the IO model not only on a national – but also on a regional level. We will therefore explain the technical details of the regionalization – which information is required and what are the assumptions involved. Results: Based on this model, 3 scenarios are displayed, one based on the current number of visitors / spending patterns, and two other scenarios: a more negative (less visitors / less spending) and a more positive outcome (more visitors / more spending). Also the impact on the national level is compared with regional levels. Results could be that transnational health care has a substantial economic impact, not only in the sector directly related to health care but also in the wider economy. The impact differ per region. The use of the extended model enables us to make a more realistic calculation (leading to a lower impact), although the calculation does depend strongly on the (arbitrary) choice of the elasticity of substitution. Discussion: It is certain that economic effects are created by transnational health care in Malaysia.  However, in this paper the relationship between these effects and the performance of the national health system is assessed.  The role of the government in promoting transnational health care is being framed onto these effects.  It is questioned if these effects relate to possible benefits for local populations. Finally, consumer and citizenship frames are being embedded in the rationale of the IO analysis.

• Primah Kwagala (Centre for Health, Human Rights and Development, Uganda) - Empirical and Conceptual Studies of Medical Tourism in Uganda: Regulating Traditional Medicinal Knowledge and Practices
• Medical travel is a common way of life for rich persons and highly positioned public servants and their relatives in Uganda. This is however not the case when considering people living in high income countries like the US where medical expense costs are quite high and people seek to obtain better medical services in cheaper places like Thailand, China and Singapore to pay a fifth of what they would pay at home. Medical tourism is as such a blossoming trade in the west but has lately infiltrated Uganda. The main attraction in Uganda has been hot springs like Ihimba hot springs found in the western part of Uganda. These Hot springs have become a popular tourist destination and location for rehabilitation clinics for those with disabilities. Herbal medicine in Ugandan forests also have a granary of herbal medicinal leaves, backs and roots to resource from, cosmetic surgery, availability of cheap women's fertility services and advanced HIV/AIDS research and management programmes. These and other factors are drawing patients to the country. It should be noted however that Provision and use of herbal medicine, traditional knowledge and Intellectual Property rights of communities in the case of hot springs is not regulated in Uganda, as such, we are investigating these issues through participatory reflection and research methodology as well as engaging in community consultations so as to inform legal, regulatory plans, strategies and policy reform in Uganda.

• Ki Nam Jin (Yonsei University, Korea) - Service Expectations of Medical Tourists
• Asia has become the most popular destination of medical tourists in the world. Asian medical tourism market was expected to be worth US$4 billion by the year 2012. The South Korean Government used a lot of resources for promoting medical tourism industry. The restriction on medical tourism marketing was loosened to vitalize this new industry by the modification of medical law. Hence the number of medical tourists increased from 27,480 to 122,297 during 2008-2011 period. The purpose of this study is to examine the service expectations of medical tourists who visited Korea. For this purpose, we will survey 200 medical tourists by using questionnaire.We will examine the pre-trip behavior (e.g., reason for visit, information source, trip arrangement, worry) of medical tourists. We will examine the service expectations of medical tourists. For measuring expectations, we will use SERVQUAL scale. There have been few studies on the actual behavior or attitudes of medical tourists. By focusing on medical tourists, we can develop practical and proactive service strategy.

• Kristin Lozanski (University of Western Ontario, Canada) - Commercial Gestational Surrogacy
• Commercial gestational surrogacy is emerging in countries such as India and Ukraine as means of providing surrogacy to Western clients (amongst others) for whom this service is unavailable in their home countries, due either to prohibitive cost (as in the USA) or prohibitive legislation (as in Canada and the UK). In this paper, I will consider the ways in which transnational surrogacy—as a form of reproductive tourism or transnational reproductive care—represents a form of global mobility that disrupts assumptions of both kinship and state-recognized citizenship. Surrogacy involves medical practices and procedures that challenge norms of biological reproduction and kinship. In transnational contexts, these challenges are further complicated by potential inconsistencies with respect to the norms of political eligibility for citizenship. With focused attention to the context within which Canadian parents commission babies overseas, but also situating Canada in comparison to the UK and the USA, this analysis will consider transnational surrogacy from a range of perspectives, including policy and legislation of both parental and surrogacy countries; websites for organizations offering or mediating surrogacy; and pilot interview data. Additionally, I will explore the global forces driving women within some countries to turn to surrogacy as a means of income, as well as the formal and informal transnational relationships that underscore the practice of surrogacy. Thus, this analysis of transnational surrogacy will situate the practice at the intersection of (post)colonialism, gender, family, citizenship, and global political economy.

• Neil Lunt (University of York), Jo Hanefeld (LSHTM ) and Daniel Horsfall (University of York) - Inward and Outward Medical Tourism: Results from an NIHR-Study Examining Implications for the NHS
• This session presents findings from a recently completed NIHR-funded study on the implications of medical tourism for the UK NHS. On behalf of the wider project team the session will focus on three particular strands of empirical data from the 18-month study. First, the numbers who travel into and out of the UK for treatment. Here we draw upon analysis of the International Passenger Survey and offer a critical interrogation of the data. Exploring trends from over the last decade our discussion examines the wider challenges of collecting accurate information on numbers of medical travellers and their destinations/origins. Second, we discuss the motivations of outward medical patients who travel from the UK to Europe and beyond. Drawing on in-depth interviews with medical tourists we compare and contrast drivers for different treatment groups including: bariatric, cosmetic, dental and fertility. Third, we examine the evidence around patients from overseas who book and plan treatment within the UK health system. Focusing on the NHS sector we explore referral processes, how treatment is delivered, and the broader implications, risks and opportunities facing the NHS in its treatment of these international patients.
• Reflecting on the structure of Medical Tourism in Europe and Korea - Background: We need to know more about medical travel within regional settings in terms of demand (consumer flows, decision-making, and experiences) and supply (range of providers and marketing strategies, business models and suchlike). UK patients travel to Europe, India and Thailand. Korea serves the Korean Diaspora, and targets neighbouring East Asian countries. Whilst the UK and Korea do not have bilateral patient flows between themselves, there is nonetheless real value in examining each country's knowledge-base and experience of medical tourism (for patients travelling inwards/outward). They are also inextricably linked to an emerging global industry. Methods: This discussion allows two existing programmes of work to syngergise European and East Asian insights drawing on (1) UK knowledge and empirical research, including a national NIHR funded-study and a British Council study (2) a series of empirical studies undertaken within Korea. Results: Commercialisation is at the heart of the growth in medical tourism and includes the influence of advertising on consumer decisions. Countries seeking to develop medical tourism have the options of growing their own health service or inviting partnerships with large multinational players. Countries have sought to promote their comparative advantage as medical tourism sites, with official support for activities as part of their economic development and tourism policy.  We will seek to understand patterns of demand and drivers of choice and decision-making, and begin to examine supply-focused questions including: 1) the regulatory framework (including the lack of one); 2) state and regional support for medical tourism development; 3) professional bodies support and involvement within medical tourism; 4) the structure of health care provision; 5) cultural and ethical standpoints of providers on offering particular treatments; 6) market opportunities, niches and potential for profit; 7) economic position, exchange rate and comparative advantage; 8) policy traditions and trajectories; 9) health care reform and existing capacity within systems; 10) the role of national/international quality frameworks.

• Tomas Mainil (NHTV Breda/Hogeschool Zeeland, The Netherlands) - Transnational Health Care and Sustainable Health Destination Management
• We introduce a refined terminology of transnational health care with cross-border access searchers (CBASs), trans-border access seekers (TBASs), sending context actors (SCAs) and receiving context actors (RCAs) and create a linkage with regional development.   In arguing in terms of regional development  for transnational health care, we construct the idea of a destination management framework for transnational health care.  In doing so we present the building blocks of destination management, specifically stakeholder, ethical and branding theories.  This leads to importance of a network of stakeholders, ethical principles towards the local populations and necessary efforts to visualize the region as a transnational health region.  The role of the regional government seems important when observing 4 regions in the European Union.  We tend to assess if the theoretical framework of a transnational health region is present or possible in the EU context.   Finally we formulate a combination of the practice of bi-lateral agreements in transnational health care and sustainable health destination management as a mode to enhance governmental sustainability between developed and developing countries.

• Robert McLaughlin (Stanford Cancer Institute, USA) and Theresa Alfaro-Velcamp (Sonoma State University, USA) - The ‘Hispanic Paradox’
• Medical migrations may be defined as temporary or permanent relocations motivated by  the pursuit of health care and/or departure from contexts of vulnerability to disease, inadequate care, or inaccessible care.  They relate to patterns of health disparities.  They may also shape or distort how disease incidence, traditionally assessed through population-based disease surveillance, is understood.  For example, cancer epidemiologists in California have recently identified a trend termed the "Hispanic Paradox," that suggests Latina/Hispanic immigrants born in Mexico have reduced breast cancer incidence relative to Latina/Hispanic women who were both born and continue to reside in California. This paper reconsiders this idea, noting that cancer incidence among Latinos/Hispanics may bear an association with immigration, the politics of status, the fear of medical repatriation, and perceptions of relative opportunities for care across the US-Mexican border. Cancer incidence thus poses a variety of transnational implications for health economics and regional development. While there may, in fact, be attributes of lifestyle and environmental exposures that impact cancer among Latinos born on separate sides of the border, this paper draws on evidence of medical migration and estimates of the undocumented population to question the completeness of the data on which the "Hispanic Paradox" depends. The paper argues that a transnational and multidisciplinary approach to public health is key to understanding disease incidence in places like California that are highly connected to other places yet also structurally disconnected through the politics of status and mobility.

• Meghann Ormond (Wageningen University, The Netherlands) - Everyday Economies of Regional Healthcare Consumption in Malaysia
• There is a disjuncture between Malaysia’s growing desire for foreign patient-consumers from high-income countries and the corresponding governmental and private sector investments in spectacular medical tourism infrastructure, on the one hand, and the essential yet relatively invisible role that everyday intra-regional medical travellers from nearby lower-income countries – who comprise the bulk of medical travellers to Malaysia – actually play in constituting and sustaining the country’s principal medical travel destinations, on the other. Seeking to bring attention to the relevance and realities of these more everyday medically-motivated mobilities, this paper draws on recent fieldwork that explores transborder micro-economies developing around the pursuit of health care in the Malaysian city of Kuching, where private hospitals actively court and receive high numbers of patient-consumers from neighbouring Indonesian Kalimantan. The paper argues for greater consideration of the political, economic and social ties fostered by these everyday medical mobilities and their potential for fostering regional development at the micro-level.

• Harald Pechlaner, Michael Volgger and Christof Pforr (European Academy of Bozen/Bolzano - EURAC Research, Italy) - The Governance of Transnational Health Regions: Realizing Potentials for Health Tourism and Regional Development
• South Tyrolean (North Italian) hospitals located close to the Italian borders are facing the risk of being shut down due to national budgetary constraints. On the other hand, the materialization of new transnational possibilities based on the European Directive on patient mobility, which must be implemented within October 2013, as well as an increasing demand in health tourism products open new scenarios and prospects. The creation of transnational health regions is deemed to be an approach capable of exploiting the outlined potentials to cope with the risk of hospital closure. Generally, health regions develop around primary health care providers or actors specialized in provisioning subsidiary services of the health economy (Pforr et al., 2011). Their competitive advantage is based on quality and cost advantages due to spatial proximity (Smeral 1998; Porter, 1993) of complementary actors, resources and competencies (Pechlaner et al., 2006). Health regions are able to combine therapeutic landscapes (Gesler, 1992) with primary health care providers, subsidiary services as well as accommodation business and the offering of healthy food. The question arises how to manage and organize such a cross-border health region in order to generate benefits for residents, tourists as well as medical institutions and companies involved? First, the paper discusses opportunities for and potential outcomes of the creation of a transnational health region in the Italian-Austrian cross-border region of the Eastern Dolomites. Among the potential benefits may figure ensuring residents a high quality medical service, increasing the attractiveness of the region as a health tourism destination as well as promoting a cross-border identity. Second, the paper discusses the compatibility of some governance approaches adopted in similar European cases with the local peculiarities of the case study region.

·        Guido Pennings (Ghent University, Belgium) and Wannes van Hoof (Ghent University, Belgium) - French and Dutch Patients Seeking Cross-border Reproductive Care in Belgium: An Interview Study

• Belgium is a popular destination country for cross-border reproductive care (CBRC). The most common reasons why people cross borders for infertility treatment is because they want to evade restrictions in their own country or because they believe the quality of care to be higher abroad. The main reason why French women come to Belgium is to evade restrictions on access to assisted reproduction for single women and lesbian couples. Dutch couples mainly visit Belgium for the assumedly better quality of care, although their motivations are often more complicated. For our study, we purposefully sampled 40 Dutch patients (20 couples) and 26 French women (4 single women and 11 lesbian couples) to be interviewed about their opinions on and experiences with CBRC. Surprisingly, both groups of patients reported feeling abandoned by their home country. The Dutch patients felt abandoned by the health care system, while the French women felt a lack of respect for their identity. Both groups report difficulties when they need to find a local clinic or physician to help them. For the Dutch patients, these were mostly practical difficulties, whereas French physicians sometimes support the restrictive law or fear prosecution if they help a lesbian or single woman. The negative attitudes towards the home country stand in stark contrast to the positive experiences in Belgium, where patients felt welcomed, in capable hands and well accommodated with regard to practical arrangements.

• Napaphat Satchanawakul (Asian Institute of Technology, Thailand) - Gender Analysis of Mobility of Nurses Under ASEAN Economic Community in Thailand
• As the ASEAN Economic Community (AEC) will be officially launched in 2015, the free flow of skilled labor  - a key element for being the single market and production base of the AEC, seem create an attractive condition for medical personnel in Thailand. This paper analyzed the possibility of Thai nurses to change their workplace – from rural to urban and from urban to overseas – and the implication of such change to the health services in rural Thailand. Thai nurses suffer from low status. Thai registered nurses have been distinctly inferior to other medical professions in terms of working conditions compared with compensations, especially in the last 10 years when the government refused to consider new generation of registered nurses as civil servants. Although the protest by nurses made the government to promise improvements, in reality, the situation has not changed. Such bad working condition and status would encourage nurses to seek better jobs outside the province and outside the countries. This will leave the most vulnerable population in the country to be deprived of health services from adequate number of health personnel. At the same time, family obligation and/or family and other community support might retain the nurses to stay in the provinces and in the country. It is important for the government to understand the needs of the nurses to provide support from various aspects.

• Sabina Stan (Dublin City University, Ireland) - Transnational Healthcare Practices of Romanian Migrants in Ireland: Social Mobility and the Marketisation of Healthcare Services in Europe
• Following the last two waves of European enlargement, east-west European migration was perceived as posing significant challenges at policy and societal levels. In particular, both host and origin countries raised the issue of the burden East European migrants might represent for their health and welfare systems. By taking the case of Romanian migrants in Ireland, this paper addresses the question of migrants’ use of health care systems in host and origin countries by placing it in the context of migrants’ transnational health care practices in their entirety. This means taking into account both formal and informal practices, as well as the use of healthcare services in both the host and origin countries. The study seeks to explore the links between two important areas: 1) the manner in which migrants’ transnational healthcare practices contribute to the transformation of host and origin countries’ social landscape; and 2) the impact European integration has on health care services in both host countries and in countries of origin. The study adopts an encompassing perspective that sees access to healthcare services as a constitutive part of both social positioning and social citizenship. Moreover, in order to deal with transnational practices in a holistic perspective, the study is based on multi-sited ethnographic fieldwork in both Romania and Ireland. The paper argues that Romanian migrants’ transnational healthcare practices function as strategies of social mobility for migrants, while also contributing to the increasing marketisation of healthcare services across Europe.

• Arturo Vargas Bustamante (UCLA, USA) - Healthcare Access and Utilization in Four Emerging U.S.-Mexico Transnational Healthcare Markets
• Background: The 12.4 million Mexican migrants in the United States (U.S.) face considerable barriers to access health care, with 45% if them being uninsured. To address some of the barriers to care in the US, some Mexican immigrants in the US travel across the border to Mexico in order to utilize health services due to financial, cultural, and personal factors. Objective: This study investigates the main determinants of healthcare access and utilization among four different types of Mexican populations in the U.S. that are more likely to utilize transnational health services: i) employees working for self-insured employers, ii) the uninsured, iii) the elderly and iv) those living close to the U.S.-Mexico border. The study analyzes how changing immigration patterns, population ageing and public policies in the U.S. and Mexico are likely to change current patterns of transnational healthcare utilization. Methods: U.S.-born Mexican-Americans and Mexican immigrants (>18 years) from the 2005-2009 California Health Interview Survey are the study population. Healthcare access and utilization measures are the outcomes of interest. Explanatory variables include socioeconomic and demographic characteristics, citizenship/nativity status, time of U.S. residence, health-related factors, among others. We implement a means comparison and multivariate analyses to identify the main predictors of healthcare access and utilization in each sub-population of interest. Results: This study portrays high heterogeneity in healthcare access and utilization across Mexican immigrants sub-population mostly determined along the lines of socioeconomic, demographic, health status and health insurance coverage. Overall, U.S.-born and naturalized Mexican Americans are more likely to access and utilize health care compared to non-citizen Mexican immigrants. Conclusions: Declining Mexican immigration to the U.S., population ageing and the implementation of healthcare reforms in the U.S. and Mexico are likely to impact the transnational utilization of health services by the Mexican diaspora living in the U.S.

• Margaret Walton Roberts (Wilfred Laurier University, Canada) - Markets, Migrants and Mediators: India and the Global Nurse Care Chain
• India’s growing presence in the global care nurse chain is fuelled by the rise of private educational establishments and entrepreneurial migration intermediaries and recruiters. This private sector driven process suggests a number of important policy considerations for Indian health care delivery, especially those related to human health resources, debt-financed migration of skilled health professionals, status realignment of the nursing profession internationally and domestically, and the continued growth of private health care systems. Examining how the phenomenon of India’s nurse emigration is connected to these elements of domestic health policy, this paper attempts to unravel the complex transnational threads that comprise the current health policy and global migration landscape.   This paper is based on research conducted in both south and north India over the last 5 years on India’s changing role in the global nurse care chain.  

• Andrea Whittaker (Monash University, Australia) and Chee Heng Leng (Universiti Sains Malaysia, Malaysia) - Is It an International Space? The Experience of Cross-border Patients in Thailand and Malaysia
• Cross border health care involves the interaction of people from remote sites, forced to negotiate a range of cultural differences, values, practices, histories and regulations. Yet it is usually promoted as providing ‘international’ health care indistinguishable from health care elsewhere. It points to the degree to which biomedicine can be described as a ‘global form’—one that is able to be transported and recontextualised to produce similar results in disparate places. Based upon interviews with cross border patients and their medical companions  in Thailand and Malaysia, this paper explores the extent to which hospitals involved in this trade are able to negate local cultural and social differences and create globalised spaces through the familiar routines and spaces of biomedicine. We interrogate how different in-patients responded to a question about the nature of the hospital space as international or localised.  What is considered ‘international’ depends on the country of origin of the patient and the organisation and standards of health care in that country, their experience of other countries and their own expectations. For some, an ‘international’ space was equated to a hospital being like hospitals back home, in contrast to ‘local’ (distinct to back home). For other patients, being ‘international’ was to be distinctly different to hospitals ‘back home’.  Patients and their companions often spoke of epiphanies in which local  cultures and values intruded upon their experience to remind them that they were not back home.