David Bell, Ruth Holliday, Meghann Ormond and Tomas Mainil edited a special issue for the journal Social Science and Medicine on transnational health care. This special issue will be released in January 2015 and comprises a collection of papers resulting from the conference we organised in June 2013: Transnational Health Care: A Cross-Border Symposium.
Papers published in the special issue include:
- Bell, David, Holliday, Ruth, Ormond, Meghann and Mainil, Tomas - 'Introduction: Transnational health care, cross-border perspectives' - http://dx.doi.org/10.1016/j.socscimed.2014.11.014
- Growing numbers of people are going abroad in pursuit of healthcare, and the social, political and economic significance of these flows at a range of levels cannot be ignored. This special issue brings together papers from a key international conference held in June 2013, Transnational Healthcare: a Cross-border Symposium – an event that was itself transnational, with hosting shared by institutions in two countries: first in Wageningen, The Netherlands, with delegates then travelling to Leeds, UK, for further presentations and discussion. The aim of this symposium was consider the impacts of ‘medical tourism’ in a range of different contexts, and it brought together scholars involved in cutting-edge empirical and conceptual studies of the transnational pursuit and provision of medical care. It included findings from small-scale as well as large, multi-site research projects. In this introduction, we outline the articles’ main themes and highlight priorities and agendas for the vital shared project of empirically and conceptually investigating the multi-scalar relational geographies -- from the macro/national to the local/embodied – that are currently transforming policies, economies, professions and patient experiences of what some scholars suggest might more appropriately be called ‘international medical travel’ (Kangas 2007) or ‘transnational healthcare practices’ (Stan, this issue) instead of ‘medical tourism’. In recognition of the array of initiatives around the world that challenge and move beyond attempts at self-sufficiency in healthcare at the national level, this special issue draws attention to the breadth of regional capacity-building, forms of governance, relations and identities forged through both high-profile, long-distance pursuits of ‘medical tourists’ and more ‘everyday’ cross-border and intra-regional health-motivated flows (Ormond 2013b). The diversity of case studies presented in the special issue is intended to reflect the many forms of movement that together constitute transnational healthcare practices (though there remains much work to fully map these practices). In the remainder of this introduction, we draw out some of the themes and issues raised in the papers that prompt us to rethink ‘medical tourism’
- Bochaton, Audrey - 'Cross-border mobility and social mobility: Laotians seeking medical treatment along the Thai border' - http://dx.doi.org/10.1016/j.socscimed.2014.10.022
- Drawing upon research conducted on cross-border patients living in Laos and seeking care in Thailand, this paper examines the important role played by social networks in patients' decision-making and on the itineraries they choose to seek treatment on the Thai side of the border. Due to the vastly contrasting situations between the two countries in terms of healthcare supply, and considering Laotians' increasing demand for high quality healthcare, a number of them have managed to satisfy their needs by combining cross-border treatment with the use of the healthcare facilities provided by their own country. This study consisted first of household surveys conducted in five border areas (2006–2007) in Laos in order to quantify and map out cross-border healthcare-related travel patterns. Afterwards, interviews were conducted with cross-border patients (55), Laotian and Thai medical doctors (6), Thai social workers (5), and officials working in public institutions (12). While socioeconomic and spatial factors partly explain cross-border mobility, patients' social networks significantly influence treatment itineraries throughout the decision-making process, including logistical and financial considerations. The social networks existing at different geographical levels (neighbourhood, regional and global) are therefore a powerful analytical tool not only for understanding the emergence of these cross-border movements but also for justifying them in an authoritarian political environment such as Lao PDR's.
- Connell, John - 'From medical tourism to transnational health care? An epilogue for the future' - http://dx.doi.org/10.1016/j.socscimed.2014.11.015
- In the past two decades, medical tourism has seemed to define cross-border travel for medical care. An ebullient expression of late capitalism, in the heady days before the Global Financial Crisis it also seemed remarkably glamorous. Most accounts of medical tourism, certainly in the popular media, centre on cosmetic changes, often dramatic, sometimes problematic, but capable of transforming lives (Jones 2008). Yet, as this special issue has well demonstrated, much of medical tourism is quite prosaic and functional, and transnational health care is very much more than simply medical tourism. These papers have combined to add significantly to collective knowledge of international medical travel, reveal its diversity, and develop an agenda for the future.
- Crush,
Jonathan and Abel Chikanda - 'South-South medical tourism and the quest
for health in Southern Africa’ – http://dx.doi.org/10.1016/j.socscimed.2014.06.025
- Intra-regional
South-South medical tourism is a vastly understudied subject despite its
significance in many parts of the Global South. This paper takes
issue with the conventional notion of South Africa purely as a
high-end “surgeon and safari” destination for medical tourists from the
Global North. It argues that South-South movement to South Africa
for medical treatment is far more significant, numerically and
financially, than North-South movement. The general lack of access to
medical diagnosis and treatment in SADC countries 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. The high demand and large informal
flow of patients from countries neighbouring South Africa has
prompted the South African government to try and
formalise arrangements for medical travel to its public hospitals and
clinics through inter-country agreements in order to recover the
cost of treating non-residents. The danger, for ‘disenfranchised’ medical
tourists who fall outside these agreements, is that medical
xenophobia in South Africa may lead to increasing exclusion and denial
of treatment. Medical tourism in this region and South-South medical
tourism in general are areas that require much additional research.
- Hanefeld,
Johanna, Neil Lunt, Richard Smith and Daniel Horsfall - 'Why do medical
tourists travel to where they do? The role of networks in determining
medical travel' - http://dx.doi.org/10.1016/j.socscimed.2014.05.016
- Evidence on medical tourism, including
patient motivation, is increasing. Existing studies have focused on identifying push and pull
factors across different types of treatment, for example cosmetic or
bariatric surgery, or on groups, such as diaspora patients returning
'home' for treatment. Less attention has been on why individuals
travel to specific locations or providers and on how this decision is
made. The paper focused on the role of networks, defined as linkages
e formal and informal e between individual providers, patients and
facilitators to explain why and where patients travel. Findings are based
on a recently completed, two year research project, which examined
the effects of medical tourism on the UK NHS. Research included
in-depth interviews with 77 returning medical tourists and over sixty
managers, medical travel facilitators, clinicians and providers of
medical tourism in recipient countries to understand the medical
tourism industry. Interviews were conducted between 2011 and 2012,
recorded and transcribed, or documented through note taking. Authors
undertook a thematic analysis of interviews to identify treatment
pathways by patients, and professional linkages between clinicians and
facilitators to understand choice of treatment destination. The
results highlight that across a large sample of patients travelling
for a variety of conditions from dental treatment, cosmetic and bariatric
surgery, through to specialist care the role of networks is critical
to understand choice of treatment, provider and destination. While
distance, costs, expertise and availability of treatment all were factors
influencing patients' decision to travel, choice of destination and
provider was largely the result of informal networks, including web
fora, personal recommendations and support groups. Where patients were
referred by UK clinicians or facilitators these followed informal
networks. In conclusion, investigating medical travel through focus
on networks of patients and providers opens up novel conception of
medical tourism, deepening understanding of patterns of travel by
combining investigation of industry with patient motivation.
- Holliday,
Ruth, David Bell, Olive Cheung, Meredith Jones and Elspeth Probyn - 'Brief
encounters: Assembling cosmetic surgery tourism' - http://dx.doi.org/10.1016/j.socscimed.2014.06.047
- This paper reports findings from a
large-scale, multi-disciplinary, mixed methods project which explores
empirically and theoretically the rapidly growing but poorly understood
(and barely regulated) phenomenon of cosmetic surgery tourism (CST). We
explore CST by drawing on theories of flows, networks and assemblages,
aiming to produce a fuller and more nuanced account of e and accounting
for e CST. This enables us to conceptualise CST as an interplay of
places, people, things, ideas and practices. Through specific instances
of assembling cosmetic surgery that we encountered in the field, and that
we illustrate with material from interviews with patients, facilitators and
surgeons, our analysis advances understandings and theorisations of
medical mobilities, globalisation and assemblage thinking.
- Lozanski,
Kristin - 'Transnational surrogacy: Canada's contradictions' - http://dx.doi.org/10.1016/j.socscimed.2014.10.003
- Transnational
commercial surrogacy represents a form of medical tourism undertaken byintended
parents who seek to hire women in other countries, increasingly often in
the global South, as surrogates. While much of the scholarly
literature focuses on the conditions of surrogacy within
host countries, such as India, there has been limited analysis of
transnational surrogacy focused upon origin countries. In this
article, I build upon the scholarship that explores the impact of host
country structures on transnational surrogacy, with special
attention to the significance of Canadian citizenship policy through
analysis of legislation and policy vis-à-vis transnational commercial
surrogacy. The Canadian case demonstrates clear contradictions
between the legislation and policy that is enacted domestically to
prohibit commercial surrogacy within Canada and legislation and policy
that implicitly sanctions commercial surrogacy through the
straightforward provision of citizenship for children born of such
arrangements abroad. The ethical underpinnings of Canada's domestic
prohibition of commercial surrogacy, which is presumed to exploit
women and children and to impede gender equality, are violated in
Canada's bureaucratic willingness to accept children born of
transnational commercial surrogacy as citizens. Thus, the ethical
discourses apply only to Canadian citizens within Canadian
geography. The failure of the Canadian government to hold Canadian
citizens who participate in transnational commercial surrogacy to
the normative imperatives that prohibit the practice within the
country, or to undertake a more nuanced, and necessarily controversial,
discussion of commercial surrogacy reinforces transnational
disparities in terms of whose bodies may be commodified as a measure
of gendered inequality.
- Lunt,
Neil, Mark Exworthy, Johanna Hanefeld and Richard D. Smith - 'International patients within the NHS: A case of
public sector entrepreneurialism' - http://dx.doi.org/10.1016/j.socscimed.2014.04.027
- Many
public health systems in high- and middle-income countries are under
increasing financial pressures as a result of ageing populations, a
rise in chronic and non-communicable diseases and shrinking public
resources. At the same time the rise in patient mobility and concomitant
market in medical tourism provides opportunities for additional
income. This is especially the case where public sector hospitals
have a reputation as global centres of excellence. Yet, this requires
public sector entrepreneurship which, given the unique features of
the public sector, means a change to professional culture. This
paper examines how and under what conditions public sector
entrepreneurship develops, drawing on the example of international
patients in the UK NHS. It reports on a subset of data from a wider
study of UK medical tourism, and explores inward flows and NHS responses
through the lens of public entrepreneurship. Interviews in the
English NHS were conducted with managers of Foundation Trusts with
interest in international patient work. Data is from seven Foundation
Trusts, based on indepth, semi-structured interviews with a range of
NHS managers, and three other key stakeholders (n ¼ 16). Interviews
were analysed using a framework on entrepreneurship developed from
academic literature. Empirical findings showed that Trust managers
were actively pursuing a strategy of expanding international patient
activity. Respondents emphasised that this was in the context of the
current financial climate for the NHS. International patients were
seen as a possible route to ameliorating pressure on stretched NHS
resources. The analysis of interviews revealed that public
entrepreneurial behaviour requires an organisational managerial or
political context in order to develop, such as currently in the UK.
Public sector workers engaged in this process develop entrepreneurship -
melding political, commercial and stakeholder insights - as a coping
mechanism to health system constraints.
- Ormond,
Meghann – ‘Solidarity by demand? Exit and voice in international medical
travel – The case of Indonesia’ - http://dx.doi.org/10.1016/j.socscimed.2014.06.007
- Globally,
more patients are intentionally travelling abroad as consumers for
medical care. However, while scholars have begun to examine
international medical travel's (IMT) impacts on the people and
places that receive medical travellers, study of its impacts on medical
travellers' home contexts has been negligible and largely
speculative. While proponents praise IMT's potential to make home health
systems more responsive to the needs of market-savvy healthcare
consumers, critics identify it as away to further de-politicise the
satisfaction of healthcare needs. This article draws from work on
political consumerism, health advocacy and social movements to argue
for a reframing of IMT not as a 'one-off' statement about or an
event external to struggles over access, rights and recognition within
medical travellers' home health systems but rather as one of a range
of critical forms of on-going engagement embedded within these
struggles. To do this, the limited extant empirical work addressing
domestic impacts of IMT is reviewed and a case study of Indonesian
medical travel to Malaysia is presented. The case study
material draws from 85 interviews undertaken in 2007-08 and 2012
with Indonesian and Malaysian respondents involved in IMT as care
recipients, formal and informal care-providers, intermediaries, promoters
and policy-makers. Evidence from the review and case study suggests
that IMT may effect political and social change within medical
travellers' home contexts at micro and macro levels by altering the
perspectives, habits, expectations and accountability of, and
complicity among, medical travellers, their families, communities,
formal and informal intermediaries, and medical providers both within and
beyond the container of the nation-state. Impacts are conditioned by
the ideological foundations underpinning home political and social
systems, the status of a medical traveller's ailment or therapy, and the
existence of organised support for recognition and management of
these in the home context.
- Stan,
Sabina - 'Transnational healthcare practices of Romanian
migrants in Ireland: Inequalities of access and the privatisation of
healthcare services in Europe' - http://dx.doi.org/10.1016/j.socscimed.2014.04.013
- This
article deals with the transnational healthcare practices of Central and
Eastern European migrants in Europe, taking the case of Romanian
migrants in Ireland. It explores the implications of
migrants’ transnational healthcare practices for the transformation
of citizenship in Europe, more particularly in terms of access to
free public healthcare. The article places these practices in the larger
perspective of global care chains, seen as including transnational
flows of healthcare seekers and healthcare workers that link distant
healthcare systems in an emerging European healthcare assemblage. The
study adopted a holistic perspective, taking into account both formal and
informal practices, as well as the use of healthcare services in
both the host and the origin countries of migrants. These
were explored during multi-sited fieldwork in Romania and Ireland,
conducted between 2012 and 2013, and combining a variety of sources
and methods (semi-structured interviews, informal
conversations, documentary analysis, etc.). The article
explores the links between migrants’ transnational healthcare practices
and two other important processes: 1) inequalities in access to
healthcare services in migrants’ countries of origin and of
destination; and 2) the contribution of healthcare privatisation to these
inequalities. It shows that Romanian migrants’ transnational
healthcare practices function as strategies of social mobility for
migrants, while also reflecting the increasing privatisation of
healthcare services in Ireland and Romania. The article argues that
these processes are far from specific to Ireland, Romania, and the
migration flows uniting them. Rather, they draw our attention to the
rise of an unevenly developed European healthcare assemblage and
citizenship regime in which patients’ movements across borders are
closely interlinked with diminishing and increasingly unequal access
to public healthcare services.
- Volgger,
Michael, Tomas Mainil, Harald Pechlaner and Ondrej Mitas - 'Health
region development from the perspective of system theory – an empirical
cross-regional case study' - http://dx.doi.org/10.1016/j.socscimed.2014.05.004
- Governments
are increasingly establishing health regions to deal with current
challenges of public health service. These regions are seen as
instruments to balance public and private stakeholders, and
offer health care to regional citizens as well as to medical/health
tourists. However, it is still unclear how the development of such
health regions as well as their governance may be conceptualized. We
apply Luhmann’s system theory approach in the context of a
cross-regional case study that compares health region developments
in the Autonomous Province of Bolzano-South Tyrol (Italy) with particular
regard to the Eastern Dolomites and in the province of Zeeland (the
Netherlands). We suggest that Luhmann’s system theory provides a
useful set of criteria to evaluate and judge health region development.
Fully developed health regions can be understood as auto-poietic
systems. By emphasizing programs, personnel, and communication
channels, these case studies illustrate the suitability of the system
theory toolset to analyze the governance and spatial embeddedness of
health regions. Additionally, the study contributes to literature by
indicating that health regions are closely related to identity issues and
to decision making in regions.
- Walton-Roberts,
Margaret - 'International migration of health professionals and the
marketization and privatization of education in India: From push-pull to
global political economy' -
http://dx.doi.org/
- Health
worker migration theories have tended to focus on labour market
conditions as principal push or pull factors. The role of education
systems in producing internationally oriented health workers has
been less explored. In place of the traditional conceptual approaches
to understanding health worker, especially nurse, migration, I
advocate global political economy (GPE) as a perspective that can
highlight how educational investment and global migration tendencies
are increasing interlinked. The Indian case illustrates the globally
oriented nature of health care training, and informs a broader
understanding of both the process of health worker migration, and how
it reflects wider marketization tendencies evident in India's
education and health systems. The Indian case also demonstrates how
the global orientation of education systems in source regions
is increasingly central to comprehending the place of health workers
in the global and Asian rise in migration. The paper concludes that
Indian corporate health care training systems are
increasingly aligned with the production of professionals orientated
to globally integrated health human resource labour markets, and our
conceptual analysis of such processes must effectively reflect
these tendencies.
- Whittaker,
Andrea and Chee Heng Leng -
'Perceptions of an "international" hospital in Thailand by
medical travel patients: Cross-cultural tensions in a transnational space' - http://dx.doi.org/10.1016/j.socscimed.2014.10.002
- The growing trade in patients seeking health care in other
countries, or medical travel, is changing the forms and experiences of
health care seeking and producing changes to hospitals in terms of their
design, organization and spaces. What is termed in marketing parlance in
Thailand as an ‘international hospital’ oriented to attracting foreign patients, is a
hotel-hospital hybrid that is locally produced through the inflexion of
local practices to make a therapeutic space for international patients.
The paper reports on work undertaken within a Thai hospital in 2012 which
included observations and interviews with thirty foreign in-patients and
nine informal interviews with hospital staff. Although theorized as a
culturally neutral transnational ‘space of connectivity’, we show how cross-cultural tensions affect the
experience of the hospital with implications for the organization of the
hospital and notions of ‘cultural competence’ in care. There is no single universal experience of
this space, instead, there are multiple experiences of the ‘international hospital’,
depending on who patients are, where they are from, their expectations
and relationships. Such hospitals straddle the expectations of both local
patients and international clientele and present highly complex
cross-cultural interactions between staff and patients but also between
patients and other patients. Spatial organisation within such settings
may either highlight cultural difference or help create culturally safe
spaces.
