Transnational Health Care:
A Cross-Border Symposium
20-21 June 2013 @ Wageningen (NL) – 25-26
June 2013 @ Leeds (UK)
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.
Conference registration and further logistical information on the
event: http://transnationalhealthcare.leeds.ac.uk/
Day 1 (Thursday, 20 June)
@ Wageningen
10:00-10:35 Registration and coffee/tea - In-house,
Lumen Garden
10:35-10:50 Welcome remarks
Kees Slingerland
(Director General, Environmental Sciences Group, Wageningen University, NL)
Claudio Minca (Cultural
Geography Chair Group, Wageningen University, NL)
Wicher Meijer (Academy
for Tourism, NHTV Breda University of Applied Sciences, NL)
10:50-11:00 Introductory remarks
Event
organisers
11:00-12:00 Keynote
Julie
Feinsilver (American University, USA) - Global Health Diplomacy: Old Wine in New Bottles (or a 53-Year
Retrospective of Cuba’s Medical Diplomacy)
12:00-13:00 Lunch - In-house, Lumen Garden
David Botterill (Oxford Brookes University, UK) - Book presentation in Lumen 1
13:00-15:00 Session 1: Regional Governance,
Development and Cooperation I (Chair:
Irene Glinos)
Tomas Mainil (NHTV Breda
University of Applied Sciences/HZ University of Applied Sciences, NL) - Transnational
Health Care and Sustainable Health Destination Management
Vincent Platenkamp (NHTV
Breda University of Applied Sciences, NL) Habermas,
Transnational Health Care and Cross-Culturalism
Michael Volgger (European
Academy of Bozen/Bolzano - EURAC Research, Italy) - The Governance of Transnational Health Regions: Realizing
Potentials for Health Tourism and
Regional Development
Rita Baeten (European
Social Observatory (OSE), Belgium) -
French Patients in Belgian Hospitals:
Creative Solutions in the Border-Region of the Ardennes
15:00-15:30 Break - In-house, Lumen Garden
15:30-17:00 Session 2: Inward and Outward Medical
Tourism: Results from an NIHR Study Examining Implications for the NHS (Chair:
Tomas Mainil)
Johanna Hanefeld (LSHTM,
UK) – Why
Do UK Patients Travel Abroad for Treatment? Insights
from Interviews with UK Medical Tourists
Neil Lunt (University of
York, UK)
and Ki Nam
Jin (Yonsei University, Korea) - Reflecting on the structure of Medical Tourism in
Europe and Korea
Neil Lunt (University of
York, UK)
– International Patients and the London Health
Economy
17:00-17:30 Wrap-up of Day 1 - Discussant: David Botterill (Oxford Brookes University, UK)
Day 2 (Friday, 21 June) @
Wageningen
10:00-12:00 Session 3: Regional Governance,
Development and Cooperation II (Chair: Rita Baeten)
Irene Glinos (Maastricht
University, NL) - Cross-border Collaboration
between Maastricht and Aachen University Hospitals: European Dreams vs.
Domestic Realism
Arturo Vargas Bustamante
(University of California at Los Angeles, USA) - Healthcare
Access and Utilization in Four Emerging U.S.-Mexico Transnational Healthcare
Markets
Meghann Ormond
(Wageningen University, NL) - Intra-regional Medical Travel
and ASEAN Developmental Regionalism
Jonathan Crush (Balsillie
School of International Affairs, Canada) - The Cross-border Quest for Health in Southern
Africa
12:00-13:00 Lunch - In-house, Lumen Garden
13:00-14:30 Session 4: Regulating
Transnational Health Care Resources (Chair:
Meghann Ormond)
Margaret Walton Roberts
(Wilfred Laurier University, Canada) - Markets,
Migrants and Mediators:
India and the Global Nurse Care Chain
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,
TurkeyAgeing Knowledge Workers’ Propensity to
Engage in Cross-border Living
14:30-15:00 Break - In-house, Lumen Garden
15:00-17:00 Session 5: Regulating Reproduction (Chair: Guido Pennings)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
17:00-17:30 Wrap-up session for Day 2 - Discussant: Andrea Whittaker (Monash University, Australia)
Day 3 (Tuesday, 25 June) @ Leeds
09:15-10:00
Registration and coffee/tea
10:00-10:30 Opening/Welcome
Professor David Hogg (Pro-Vice-Chancellor for Research and
Innovation, University
of Leeds)
10:30-12:00 Session 1: Health Care Provision: Workers’ Experiences and
Patients’ Expectations (Chair: Jacqueline Sanchez Taylor)
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
12.00-13.00 Lunch
13:00-14:30 Session 2: Sun, Sea, Sand and Silicone (Chair: Ruth Holliday)
Ruth Holliday, David Bell, Meredith Jones, Elspeth Probyn, Jacqueline Sanchez Taylor, Olive Cheung, Emily Hunter, Ji Hyun
Cho and Hannah Lewis (University of Leeds, University of Leicester, UK, University of Sydney and
University of Technology Sydney,
Australia)
14:30-15:00 Break
15:00-16:30 Session 3: Examining Equity, Ethical, and Safety Issues in Medical Tourism:
A
Research Programme Overview (Chair: David Bell)
Valorie A. Crooks (Simon Fraser University, Canada) Examining
Equity, Ethical, and Safety Issues in Medical Tourism: A
research program overview
19:00-20:00 Keynote
- At Sculpture Park
John Connell (University of Sydney, Australia) Medical Tourism: On the Road to
Where
Day 4 (Wednesday, 26 June)
@ Leeds
09:30-10:00 Coffee/tea
10:00-10:45 Keynote/Discussion
Deborah Gimlin (University of Aberdeen, UK) Physician associations
and the narrative ‘management’ of cosmetic surgery tourism: A comparison of the US and UK
10:45-11:00 Break
11:00-12:30 Session 4: Methodologies, Fieldwork Experiences and
Positionality
Facilitators:
Valorie Crooks (Simon Fraser University, Canada), Neil
Lunt (University of York, UK),
Meghann Ormond (Wageningen University, NL) and Elspeth Probyn (University of Sydney, Australia)
12:30-13:30 Lunch
13:30-15:30 Session 5:
Transnational Health Care Users - Cross-Border Pursuits and Migration (Chair: Meredith Jones)
Sabina Stan (Dublin City University, Ireland) Transnational
Healthcare Practices of Romanian Migrants in Ireland: Social Mobility and the Marketisation of Healthcare
Services in Europe
Andrea Whittaker (Monash University, Australia) Is It an International
Space? The Experience
of Cross-border Patients in Thailand and
Malaysia
Audrey Bochaton (University of Paris Ouest Nanterre la Défense – Mosaïques UMR Lavue, France) Thai Hospitals at the Crossroad of
New Patient
Flows
15:30-16:00 Break
16:00-17:00 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 University of
Applied Sciences/HZ University of Applied Sciences, NL) and Andrea Whittaker
(Monash University, Australia)
Abstracts
(in alphabetical order by
presentation title)
Ageing Knowledge Workers’
Propensity to Engage in Cross-border Living
Frank M. Go (Erasmus
University, NL) and
Gulcin Bilgin Turna*
(Karadeniz Technical University, Turkey)
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
analyses 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.
Cross-border
Collaboration between Maastricht and Aachen University Hospitals: European
Dreams vs. Domestic Realism
Irene Glinos
(Maastricht University, NL)
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.
Cross-Border Quality and
Safety: Outcome Measures to Establish ‘the Best’
Sharon Kleefield
(Harvard University, USA)
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 traveller. 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.
The Cross-border Quest
for Health in Southern Africa
Jonathan Crush
(Balsillie School of International Affairs, Canada)
Images
and practices of medical tourism to South Africa range from the archetypal
surgical safari to the more sordid kidney exchange case. Ignored in these
representations is the fact that the vast majority of "medical
tourists" come from other African countries. These health-seeking
migrants are of two kinds: middle-class patients who access South Africa's
private system of medical care and poorer patients whose needs are not being
met by severely overburdened public health systems in their own
countries. This paper documents the extent and implications of this
intra-African quest for health and outlines a research agenda for further
exploration of a largely invisible form of medical tourism.
Dutch Patients Looking
for Infertility Treatment in Belgium:
Analysis of Commentaries
on Internet Forums
Wannes van Hoof*,
Veerle Provost and Guido Pennings (Ghent University, Belgium)
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 analysed 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.
Examining Equity,
Ethical, and Safety Issues in Medical Tourism:
A research program
overview
Valorie A. Crooks*,
Jeremy Snyder, Rory Johnston, Vicky Casey and Krystyna Adams
(Simon Fraser
University, Canada)
The
SFU Medical Tourism Research Group 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
on-going studies and our previous analyses.
French and Dutch Patients
Seeking Cross-border Reproductive Care in Belgium:
An Interview Study
Guido Pennings (Ghent
University, Belgium) and
Wannes van Hoof (Ghent University, Belgium)
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.
French Patients in
Belgian Hospitals:
Creative Solutions in the
Border-Region of the Ardennes
Rita Baeten (European
Social Observatory (OSE), Belgium)
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.
Global Health Diplomacy:
Old Wine in New Bottles (or a 53-Year Retrospective of Cuba’s Medical
Diplomacy and Medical Tourism)
Julie Feinsilver
(American University, USA)
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.
The Governance of
Transnational Health Regions: Realizing Potentials for Health Tourism and
Regional Development
Harald Pechlaner,
Michael Volgger* and
Christof Pforr
(European Academy of Bozen/Bolzano - EURAC Research, Italy)
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.
Habermas, Transnational
Health Care and Cross-Culturalism
Vincent Platenkamp*
(NHTV Breda University of Applied Sciences, NL), Tomas Mainil (NHTV Breda
University of Applied Sciences/HZ University of Applied Sciences, NL) and
Herman Meulmans (University of Antwerp, Belgium)
Transnational
health care (THC) is a futuristic, coordinated and professionalised provision
of cross-border health care and medical tourism services. It is an emergent
field (OECD, 2011) with a lot of opportunities, but also has risks. A
conceptual basis is lacking, therefore the application of an established
thought model - Habermas’ action theory - would be beneficial for understanding
the nature and dynamics of THC. The purpose of this paper is to introduce the
legacy of Jürgen Habermas and adapt it to the context of THC, in order to show
the complex cross-cultural dynamics that play a role in THC. Therefore we
introduce the basics of Habermas’ general action theory with its communicative
and strategic actions/life-world and system. Then we link his theory to the
dynamics present in THC with its market/consumer/ethical/professional perspectives.
Furthermore, we focus on a case study in THC, showing at a micro-level how
there are tensions between communicative and strategic actions. The role of
cross-cultural management is introduced to solve these tensions. Finally, the
relationship between cultural management, THC and Habermas’ framework is
discussed.
Healthcare Access and
Utilization in Four Emerging U.S.-Mexico Transnational Healthcare Markets
Arturo Vargas
Bustamante (University of California at Los Angeles, USA)
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 analyses 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.
International Patients
and the London Health Economy
Neil Lunt* (University
of York, UK), Jo Hanefeld* (London School of Hygiene and Tropical Medicine, UK)
and Daniel Horsfall (University of York, UK)
Medical tourism literature
has highlighted the impact of treatment on receiving countries and regions
where typically these are lower middle-income destinations. Globally however
countries are both exporters and importers of patients, and developed economies
within Europe and North America themselves compete to offer high-end services.
This paper examines the health economy of London and identifies the size and
nature of international patient activity within the capital. Our discussion
identifies how such activity is part of a national development
strategy, and how such patient flows may challenge accepted understandings of
medical tourism markets.
Intra-regional Medical
Travel and ASEAN Developmental Regionalism
Meghann Ormond (Wageningen University, NL)
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
explores the influence of ASEAN developmental regionalism on transborder
economies developing around the pursuit of health care in the Malaysian city of
Kuching by patient-consumers from the neighbouring Indonesian province of West
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 a consumer-based regional belonging and
solidarity.
Inward and Outward
Medical Tourism: Results from an NIHR-Study Examining Implications for the NHS
Neil Lunt* (University
of York, UK), Johanna Hanefeld* (London School of Hygiene and Tropical Medicine, UK)
and Daniel Horsfall (University of York, UK)
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.
Is It an International
Space? The Experience of Cross-border Patients in
Thailand and Malaysia
Andrea Whittaker*
(Monash University, Australia) and
Heng Leng Chee
(Universiti Sains Malaysia, 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.
Markets, Migrants and
Mediators: India and the Global Nurse Care Chain
Margaret Walton
Roberts (Wilfred Laurier University, Canada)
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.
Medical Tourism in the
Shadows of the Law
I. Glenn Cohen
(Harvard University, USA)
This
presentation will draw 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.
Medical Tourism: On the
Road to Where?
John Connell
(University of Sydney, Australia)
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.
Medical Tourism Risk
Perceptions: A Preliminary Investigation
Michael Guiry and
Petra Kulasova (University of the Incarnate Word, USA)
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 on-going 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.
Physician associations
and the narrative ‘management’ of cosmetic surgery tourism:
A comparison of the US
and UK
Deborah Gimlin
(University of Aberdeen, UK)
In
makeover programmes, the advertisements of transnational magazines and online
offers for self-improvement ‘getaways’, cosmetic surgery is generally located
in a sphere unconstrained by considerations about the finite nature of medical
resources, healthcare rationing and the struggles of professional groups for
power and authority. Nonetheless, it is also true that national healthcare
structures play a role in determining who has access to cosmetic surgery and
influence its meanings and uses. This presentation first addresses how the
cosmetic surgery industries of the US and UK have taken shape in the context of
these countries’ very different healthcare systems and the interactions of
practitioners and organisations within them. It then turns to the narrower
topic of cosmetic surgery tourism, exploring the distinct responses of US and
UK physicians to its potential threat. It argues that physicians’ public
statements about the ‘risks’ of cosmetic surgery tourism strongly resonate with
the narrative strategies employed by cosmetic surgery consumers, which vary
significantly across cultures. However, while consumers’ accounts seek to align
the practice with nationally-distinctive notions of ‘appropriate’ medical
treatment, physicians’ narratives instead frame cosmetic surgery – when carried
out ‘abroad’ – as ‘illegitimate’ and ‘undeserved’.
Reflecting on the
Structure of Medical Tourism in Europe and Korea
Neil Lunt (University
of York, UK) and Ki Nam Jin (Yonsei University, 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 synergise 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.
Service Expectations of
Medical Tourists
Ki Nam Jin (Yonsei
University, Korea)
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 behaviour (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 behaviour or attitudes of medical tourists. By focusing on
medical tourists, we can develop practical and proactive service strategy.
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, University of Leicester, UK, University
of Sydney and
University of
Technology Sydney, Australia)
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.
Thai Hospitals at the
Crossroads of New Patient Flows
Audrey Bochaton
(University of Paris Ouest Nanterre la Défense – Mosaïques UMR Lavue,
France)
In
today’s world, people move more, move further, and move for increasingly varied
reasons such as work, studies or leisure. Seeking health care away from one’s
home is a part of this trend and many patients do not hesitate to cross
national borders to consult a physician or get a surgical intervention. This
communication will examine this form of mobility towards Thailand from both
global and regional perspectives. This situation involves long-distance
patients travelling from highly industrialized countries and closeby neighbors,
such as Laotians, who may just cross the border to get treated a few kilometers
away from home. Contrasting these scenarios complicates the findings by studies
on “medical travel” as it brings in heterogeneity and variability. There are
significant differences in patients’ motives, in the social implications of
their cross-border health-seeking behaviours, and in the responses by health
infrastructures and authorities in both the host country (marketing, regulation
or even quality of care) and the patients’ lands of origin (policies,
intermediaries, and emerging specialized agencies). This communication will
take this situation as a case study to describe and explain the rise of a new
transnational healthcare paradigm.
Transnational Commercial
Gestational Surrogacy
Kristin Lozanski
(University of Western Ontario, Canada)
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.
Transnational Health Care
and Sustainable Health Destination Management
Tomas Mainil (NHTV
Breda University of Applied Sciences/HZ University of Applied Sciences, NL)
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.
Transnational Health Care
in Malaysia: Input-Output Analysis and its Relation with Factors of Governance
Jeroen Klijs* (Erasmus University, NL), Tomas Mainil (NHTV Breda
University of Applied Sciences/HZ University of Applied Sciences, NL), Meghann
Ormond (Wageningen University, NL) and Wim Heijman (Wageningen University,
NL)
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 impacts 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.
Transnational Healthcare
Practices of Romanian Migrants in Ireland: Social Mobility and the
Marketisation of Healthcare Services in Europe
Sabina Stan (Dublin
City University, Ireland)
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.
Why Do UK Patients Travel
Abroad for Treatment?
Insights from Interviews
with UK Medical Tourists
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)
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.
