Tuesday, 31 December 2013

New project: Elder Care Across Borders

Here's some information on my new study, Elder Care Across Borders (ECAB). More information is available at http://eldercareacrossborders.blogspot.nl/

Researcher (PI):
Meghann Ormond, Cultural Geography Chair Group, Wageningen University, The Netherlands
Email: meghann.ormond [at] wur.nl

Study abstract: 
With more people living longer than ever before, ageing populations’ health and social care needs are increasingly placing a strain on individual and collective resources and capacities. To date, much elder care research has focused on the distribution of health and social care responsibility among individuals, families, communities, voluntary organisations, and public- and private-sector bodies within countries. Yet, as the growing recruitment of foreign health, residential and domestic care workers in many rapidly-ageing countries attests, the management of elder care needs extends already well beyond national borders.

This study examines another emerging yet under-explored facet of this increasingly transnational approach to redistributing elder care: older people remaining in, or relocating to, international retirement destinations as they grow more physically vulnerable. Rather than fully ‘outsourcing’ the fulfilment of older people’s everyday and medical care needs abroad, support is generated and sustained through dynamic cross-border configurations of formal (i.e., state, private and voluntary) and informal (i.e., family and community) care provision. This project therefore contributes novel longitudinal and in-depth perspective into 1) how home and destination countries’ diverse economic, social and political configurations are used to support seniors’ health and quality of life as they age and 2) how practices and policies enable and/or disable cooperation between formal and informal care providers across borders.

To accomplish this, I use a comparative case study approach to explore the health and social care experiences of growing numbers of elderly British settled in Portugal and Singaporeans in Malaysia; their informal care-givers; and the civil society, governmental and commercial entities concerned with them across both home and destination countries. Project output includes the fostering of cross-border networks in Europe and Asia, the co-development of informational tool-kits, student training on the issue and five academic journal articles.

Monday, 25 November 2013

New article: 'En route: Transport and Embodiment in International Medical Travel Journeys Between Indonesia and Malaysia'

My new article just published in Mobilities focuses on what happens in the space and time spent travelling between medical travellers' home countries and their medical destinations. Free access to this article is available for the first 50 users at http://www.tandfonline.com/eprint/teK9an8Gbxguw7HCiqrH/full 

International medical travel is increasingly major business. Using Indonesian patient-consumers’ transport experiences in the pursuit of private medical care in Malaysia, this study explores how transport operators and infrastructure are responding and adjusting to the embodied specificities of the growing market’s access and travel needs. In offering faster and more frequent linkages, they have both expanded the physical and geo-political scope and increased the immediacy of care provision. This underscores the value of examining how the mobile spaces of transport common to international medical travel actively intersect with, blur and re-articulate diverse understandings of ill-health and impairment, care and subjectivity.

Wednesday, 20 November 2013

‘Medical Tourism Resiliency’ - a new research project led by the University of Malaya

‘Medical Tourism Resiliency’ is a study led by the Medical Tourism Research Group, Services Research and Innovation Centre, Faculty of Business and Accountancy, University of Malaya, Malaysia. The overall project, which runs from October 2013 to 2015, has four components: Medical tourism, Islamic medical tourism, Medical tourism communication and Accessible tourism.

Research group: 

  • Ghazali Musa (PI); 
  • Medical tourism: Che Ruhana Isa, Kanagi Kanapathy, Mohd Zulkhairi Mustapha, Jacob John C. Chandy, Sedigheh Moghavammi, Wong Kee Mun and Thinaranjeney Thirumoorthi; 
  • Islamic medical tourism - Suhaiza Hanim Dato Mohd Zailani,  Suhana Mohezar and Mohd Kahalili; 
  • Medical tourism communication - Sheena Kaur a/p Jaswant Singh, Zuraidah Mohd Don, Surinderpal Kaur, Cecilia Cheong Yin Mei, Emily Lau Kui Ling, Ana Tominc and Wang Nan;  
  • Accessible tourism: Azni Zarina Taha; 
  • Meghann Ormond serves as International Research Advisor to the project's four sub-projects.

A website for the project is currently in the process of being set up. For further information, contact Prof Ghazali Musa (ghazalimz [at] um.edu.my). 

Thursday, 31 October 2013

Talk on Singaporean perspectives on retirement migration to Johor, Malaysia - 1 Nov. 2013 - University of Malaya

I'll be giving an impromptu seminar tomorrow (Friday, 1 November) at the Department of Social and Preventive Medicine at the University of Malaya's Faculty of Medicine from 10:30-12:00 on my developing research on retirement villages and residential care facilities in Johor, Malaysia. Many thanks to Prof Chan Chee Khoon for inviting me! 

Saturday, 12 October 2013

Malaysia: Researchers and Stakeholders’ Seminar on Current Issues in Medical Tourism

The University of Malaya's Services Research and Innovation Centre will be hosting a Researchers and Stakeholders’ Seminar on Current Issues in Medical Tourism in Kuala Lumpur on 31 October. I'll be presenting an overview of current research on medical tourism in Southeast Asia at this seminar. And I'm looking forward to meeting up with and working together with colleagues at UM on their new medical tourism project!

Here's the programme:

  • Welcome - Prof Ghazali Musa, Director of ServRI, University of Malaya, Malaysia
  • Medical tourism: A state of the art review - Dr Meghann Ormond, Wageningen University, The Netherlands
  • Factors influencing sustainable performance in the medical tourism industry: A cross-national investigation in Malaysia, Singapore and Thailand - Dr Kanagi Kanapathy and Dr Mohamad Zulkahiri, University of Malaya, Malaysia
  • Travel motivations of Indonesian medical tourists to Malaysia and Singapore: An understanding from push and pull factors - Dr Elaine Chew Yin Teng, Monash University, Malaysia
  • The discursive and visual representations of medical tourism in Malaysia - Dr Sheena Kaur A/P Jaswant Singh, University of Malaya, Malaysia
  • An integrated framework for brand image, healthcare service quality, patient trust, perceived value, patient satisfaction and patient behavioural intention: Evidence from medical tourism of Malaysia - Mr Cham Tat Huei, University Tunku Abdul Rahman, Malaysia
  • Prospects, influential factors and outcomes of Islamic medical tourism industry: Healthcare service providers' perspectives - Prof Suhaiza Hamin Dato' Mohamad Zailani, University of Malaya, Malaysia
  • Marketing promotion strategy of medical tourism in Malaysia - Ms. Izza Harith, Universiti Putra Malaysia, Malaysia
  • Tourism and the disabled community - Dr Azni Zarina Taha, University of Malaya, Malaysia
  • Travel behaviour among health tourists in Kuala Lumpur: How satisfied are medical tourists in Malaysia? A study on private hospitals in Kuala Lumpur - Ms. Thinaranjeney Thirumoorthi, University of Malaya, Malaysia
  • Service quality, patient satisfaction and behavioural intention for medical tourism industry in Malaysia - Dr Eugene Yeoh
  • Medical tourism - Potential and challenges in Malaysia - Mr Wong Kee Mun, University of Malaya, Malaysia

Tuesday, 30 July 2013

Doctors of the World UK weighs in: The truth about “health tourism” to the UK

Source: http://doctorsoftheworld.org.uk/blog/entry/the-truth-about-health-tourism
It seems that hardly a week goes by without reports appearing in the press on how so-called “health tourism” is rampant in the UK. In response, the UK Government is now consulting on proposals to remove access to NHS services for visitors and migrants, while seeking to ensure ineligible patients are charged systematically for the care they receive.
But what is “health tourism” exactly and should we be concerned? The answers are nowhere near as alarming as the panic-mongers suggest…
What is health tourism?
‘Health tourism’ is the idea that people from other countries come to the UK for free NHS care and leave shortly after receiving it. But there's absolutely no evidence it's happening on a significant scale. At the clinic we run in East London, we’ve interviewed migrant patients for the past seven years and found only 1.6% left their country for health reasons. Most migrated to the UK find work or education or escape persecution. 
It’s also important to remember that medical tourism doesn’t just go one way. A January 2013 study in the British Medical Journal found that there are in fact more UK residents who travel abroad for medical treatment than there are international patients who travel to the UK to access treatment (in the NHS and privately). 
But isn’t health tourism costing the UK billions?
Not at all. Estimates vary, but NHS figures suggest the amount lost providing care for foreign nationals in 2012/2013 was £12 million, just 0.01% of the total £108.9 billion NHS budget for the same period. This should also be seen in the context of the £18 billion overseas visitors spend in the UK each year and £3 billion they pay in taxes. Additionally, migrants to the UK contribute £16.3 billion to the UK economy (1.02% of GDP), according to the OECD. And don't forget that all migrants, working or not, contribute to the health service by paying VAT.
Okay, but isn’t the NHS over-generous compared to other European countries?
No. The UK is far from unique in offering healthcare to undocumented migrants with many countries in Europe offering comparable or better care. In France and Belgium, for example, migrants have free access to essential primary and secondary healthcare with medical providers getting reimbursed for treatment. In Portugal, undocumented migrants have full access to healthcare once they have stayed over 90 days. 
That’s all well and good, but what harm is there in charging migrants for the NHS?
Frustratingly, the NHS proposed changes would be costly to put in place and would endanger people’s health needlessly.
Early detection of illness by GPs is the cheapest way of minimizing costs as well as ensuring health conditions can be managed and maintained. If not treated early, patients have a higher chance of presenting at A&E, which costs the NHS three times as much as GP visits. The current system in which visiting a GP is free for anyone who is ‘ordinarily resident’ regardless of their status or ability to pay makes the most sense, in terms of both economics and individual and community well-being.
Why should we provide healthcare regardless of immigration status or ability to pay?
Offering care regardless of immigration status or ability to pay is part of the NHS constitution. As Aneurin Bevan, the Minister for Health when the NHS was introduced, wrote in 1952: 
One of the consequences of the universality of the British Health Service is the free treatment of foreign visitors. This has given rise to a great deal of criticism, most of it ill-informed and some of it deliberately mischievous … However, there are a number of more potent reasons why it would be unwise as well as mean to withhold the free service from the visitor to Britain. How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors?
Healthcare professionals should not have to act as immigration officials and should be allowed to focus on delivering medical care. 
Even if health tourism is not happening on a large scale, doesn’t that open the door for the system to be exploited by some people?
There are already mechanisms in place to deal with individuals who exploit the system. For instance, if debts are run up and the person has left the country, the UKBA will not let them re-enter the UK without paying up.
In short, the claims being made about health tourism are often wildly exaggerated. Correcting these misconceptions is now incredibly important in order to prevent the UK Government’s proposal to introduce costly changes to the NHS that will mean thousands of people will not receive care they’re entitled to. These changes will be bad for individuals’ health, public health, and simply make bad economic sense.
Make your voice heard: tell the Department of Health your opinion in their online survey.
Twitter: #health4all

Sunday, 14 July 2013

ESRC-funded study 'Sun, sea, sand and silicone'

The ESRC-funded project on cosmetic tourism 'Sun, sea, sand and silicone'  has recently wrapped up. The project was undertaken by researchers at the University of Leeds (UK), University of Leicester (UK), University of Sydney (Australia) and University of Technology, Sydney (Australia). 

Study description: (http://www.ssss.leeds.ac.uk/about/)
'This project aims to explore the cosmetic surgery tourism industry from the point of view of tourists, surgeons, care workers, tourist agents and tour guides. There are lots of ‘myths’ about cosmetic surgery tourism, but we want to understand the motivations and experiences of people travelling for surgery and all those who work to provide this service.
Cosmetic surgery tourism is a new and developing industry that incorporates novel forms of labour and organizational structure that straddle national boundaries. For instance, it is possible for a cosmetic surgery travel agent to collect a patient from their doorstep in the UK or Australia, fly them to Spain or Thailand, transport them from the airport to a hotel near the hospital, allocate a nurse/ guide/ interpreter to be constantly at the patient’s side throughout their surgery, recovery and post-surgery tourist ‘experiences’, before returning them once more to their doorstep. Although the ‘credit crunch’ has undoubtedly slowed the growth of the cosmetic surgery industry globally, it has simultaneously swelled the numbers prepared to travel for ‘cut-price’ surgeries made possible by favourable currency exchange rates and lower labour costs outside the richest countries in the world. Little research has yet been conducted on mapping out this new industry and the experiences of those that enter into it. This research aims to broaden our understanding of the modes of operation of the organizations involved, the surgical tourist experience, and the potential implications for a globalized system of healthcare organized around consumption.
The research examines two sites of origin in detail – the UK and Australia – (as well as some tourists from China and Japan) and a number of popular cosmetic surgery tourism destinations including Thailand, Korea, Malaysia, Spain, Poland and Tunisia. The research team is investigating cosmetic surgery tourists, cosmetic surgery tourist agents, care workers, interpreters and tour guides, as well as clinic staff and surgeons. It explores the demand for surgery abroad through individual consumer motivations and charts their experiences and the structure, organisation and experiences of workers in the cosmetic surgery tourism industry. This study represents the first multi-site, empirical and systematic analysis of cosmetic surgery tourism and is being carried out by an internationally renowned research team.
Data from the study will be used to predict some of the key issues facing surgical tourists and healthcare providers in the future, in what will undoubtedly become a more mobile and internationalised market.'

Monday, 17 June 2013

Conference unites world experts on medical tourism

Transnational Health Care: A Cross-Border Symposium – 20-21 June 2013 in Wageningen, The Netherlands, and 24-26 June 2013 in Leeds, United Kingdom. 

Website: http://transnationalhealthcare.leeds.ac.uk/

Today, more and more people are travelling abroad for medical treatment, yet surprisingly little is known about this unique group of tourists.

This week, world experts on medical tourism are gathering at a landmark event to set the agenda for research on this growing global industry. Travelling from around the world for the Transnational Health Care conference, these experts will discuss findings from important international studies that present the key players in medical tourism, what drives tourists abroad, the itineraries tourists take, the places they go, the medical treatments they seek out, the management and promotion of the emerging industry, and the impacts of medical tourism on both sending and receiving countries.

Co-sponsored by the Cultural Geography Chair Group at Wageningen University (The Netherlands), the Academy for Tourism at NHTV Breda University of Applied Social Sciences (The Netherlands), the University of Leeds (UK) and the Economic and Social Research Council (UK), the conference will explore the links between medical tourism and the increasing privatization and commercialization of health in tourists’ home countries and their destinations, the transfer of responsibility for health from the state to individuals, and the limits to the ‘healthy investments’ people can make to their bodies. What does it mean when home health systems get circumvented? Does medical tourism only impose challenges for health systems – such as additional costs and aggravated healthcare inequities – or can it also create opportunities for (sustainable) development within and between countries?

 For further information, in the UK, please contact Ruth Holliday (R.Holliday@leeds.ac.uk) and, in the Netherlands, contact Meghann Ormond (meghann.ormond@wur.nl) or Tomas Mainil (mainil.t@nhtv.nl 

Experts op gebied van medisch toerisme bij elkaar in Wageningen en Leeds

Vandaag de dag reizen meer en meer mensen naar het buitenland voor medische behandelingen. Maar er is verbazingwekkend weinig bekend over deze vorm van toerisme. Dus reizen onderzoekers vanuit alle delen van de wereld nu naar Wageningen voor een conferentie over medisch toerisme met als doel om een onderzoekagenda op te zetten. Tijdens de conferentie zullen relevante internationale onderzoeksresultaten worden besproken zoals: wat zijn de drijfveren van de mensen die als toerist naar een ander land gaan om zich te laten behandelen, hoe gaan ze daar naar toe, waarheen gaan ze en voor wat voor behandelingen? En aan de andere kant: wat zit er achter deze “nieuwe industrie”, hoe vindt de promotie ervan plaats en wat is de invloed van medische behandelingen in het buitenland in zowel dat buitenland als het eigen land?

De conferentie richt zich verder op de relaties tussen enerzijds het toenemende medisch toerisme en anderzijds de toenemende privatisering en vercommercialisering van de gezondheidszorg zowel in eigen land als in de “ontvangende“ landen, de verantwoordelijkheden van overheden en individuen voor de gezondheidszorg in eigen land, en de grenzen van een “gezondheidsinvestering” van mensen in hun eigen lichaam. Wat houdt het bijvoorbeeld in wanneer mensen niet kiezen voor de gezondheidszorg in eigen land maar kiezen voor een behandeling in het buitenland? Brengt dit extra kosten of ongelijkheid tussen patiëntengroepen met zich mee voor behandelingen die wel in eigen land plaatsvinden, of kan het juist bijdragen aan een (duurzame) ontwikkeling van de gezondheidszorg in de diverse landen die hierbij zijn betrokken?

De conferentie ‘Transnational Health Care: A Cross-Border Symposium’ is georganiseerd door de leerstoelgroep Culturele Geografie van Wageningen Universiteit, de Academie voor Toerisme van de NHTV in Breda, de universiteit van Leeds en de Economic and Social Research Council van het Verenigd Koninkrijk. De conferentie vindt plaats in twee delen: op 20 en 21 juni in Wageningen en van 24-26 juni in Leeds.

For further information, in the UK, please contact Ruth Holliday (R.Holliday@leeds.ac.uk) and, in the Netherlands, contact Meghann Ormond (meghann.ormond@wur.nl) or Tomas Mainil (mainil.t@nhtv.nl). Website: http://transnationalhealthcare.leeds.ac.uk/

Sunday, 16 June 2013

Transnational Health Care – A Cross-Border Symposium

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)

(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.