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MEDICAL tourism is a term commonly used to describe the travelling abroad to obtain needed medical services. It is often used synonymously with the term “health tourism” which is a part of the same spectrum. The former implies that the individual involved is ill unlike the latter which implies that the person is well.
There are various reasons why an increasing number of people seek healthcare abroad. One of the main reasons is financial.
The quality of healthcare may be variable in different countries and, in some instances, not up to the expectations of medical tourists.
However, the boundary between illness and wellness is often not clearly demarcated. An individual, who is apparently well, may travel abroad as a health tourist and end up as a medical tourist, consequent to findings from health screening or travel associated injury.
Medical tourism is not new. Since the first millennium, the rich and powerful have visited mineral and hot springs, spas and sanatoria located by the sea and in the mountains abroad for treatment of various ailments. Health farms became popular in the 20th century, and after World War II, many sought more sophisticated medical care in the developed countries in Europe, North America, Australasia and latterly, the dragon economies in East Asia.
The marked worldwide increase in tourism in the past two decades has led to the development of the concept of medical tourism. This was created with travel agencies offering traditional travel abroad combined with packaged medical or healthcare in private hospitals and sometimes, private clinics. Potential patients are advised where they should travel to with well organised travel arrangements including communications with hospitals, clinics, doctors and transmission of medical records. Planning a medical tourism trip is similar to planning a vacation.
Many players
Where previously, people have travelled to developed countries to seek more sophisticated medical care, there are also many travelling today from developed to middle income countries, where the level of sophistication in medical care is the same as, or may be better, than that of developed countries. There are also many who travel from one middle income country to another middle income country to seek care.
There are more than 50 countries whose governments promote medical tourism actively. Many of them are in Asia, including India, Thailand, Singapore, Hong Kong, China, Taiwan and South Korea, who are our biggest competitors. One of the fundamental reasons for governmental promotion is that it is a growing source of foreign exchange. Other reasons include prestige and goodwill. Some governments have taken extraordinary measures to get a bigger slice of the market, for example, India issues the M-Visa or Medical Visa specifically for medical tourists.
The growth in medical tourism has not only been in the numbers of patients seeking care but also the types and complexities of the care provided. Dental care is also in on the act!
It is estimated that the annual growth of medical tourism in Asia is between 20 to 30%. According to the Association of Private Hospitals of Malaysia, the number of foreign patients treated in their member hospitals increased from 102,946 in 2003 to 341,288 in 2007, with receipts of RM58.90 million and RM253.84 million respectively, with 72% of the patients coming from Indonesia, 10% from Singapore, 5% from Japan and 4% from India.
The current global financial turmoil may fuel this trend further by increasing waiting lists and exerting pressure on personal finances.
Various reasons
There are various reasons why an increasing number of people seek medical or healthcare abroad. Overburdened health care infrastructure leading to long waiting lists and high costs for life-saving procedures or elective surgery in developed countries are the major drivers. There is increasing pressure on the health care infrastructure in Europe and the United States. There are still long waiting lists for surgery in the National Health Service in the UK despite governmental efforts, which have reduced it somewhat.
The US has more than 50 million uninsured citizens and its health insurance premiums are high, with major impact on affordability. Furthermore, the immigration policies of the US and some European countries after the 9/11 incident have led to an increasing number of medical tourists from the Middle East looking towards Asia.
The costs of comparable treatment are much less in Asia than in developed countries. Various reviews put the cost in Asia at about 12 to 25% that of developed countries. An example is open heart surgery, which can cost up to US$70,000 (RM245,000) in the UK and US$150,000 (RM525,000) in the US compared to US$18,000 (RM63,000) in Malaysia.
Another example is hysterectomy (surgical removal of the uterus), which can cost US$30,000 (RM105,000) in the US and US$8,000 (RM28,000) in Singapore compared to US$4,500 (RM15,750) in Malaysia.
One of the factors contributing to the lower cost in Asia is the premium for medical negligence indemnity, which is around US$100,000 (RM350,000) in the United States compared to the US$7,500 (RM26,250) maximum premium of the only mutual Malaysian medical indemnity organisation.
Aaditya Mattoo and Randeep Rathindran, in a World Bank paper in 2005, compared the prices of 15 surgical procedures and concluded that if 10% of patients in the United States had their treatment abroad, the annual savings would be about US$1.4bil (RM4.9bil).
Another reason is that some treatments are not available or illegal in the patient’s own country, eg the terminally ill have travelled to countries that have legalised assisted suicide like Switzerland and Holland.
A sub-set of medical tourism is assisted reproduction and organ transplantation, both of which pose unique issues that challenge the limits of policy, care, legality and ethics.
The marked growth in medical tourism has enormous implications for both developed and developing countries.
Care issues
Most patients travel abroad for various procedures, eg diagnosis and management of cancer, cosmetic surgery, cardiac surgery, transplant surgery, joint replacement, etc. Yet it is often not appreciated that the very nature of surgery is not always amenable to the constraints of medical tourism.
The epidemiology of infectious diseases in a country is different from that of other countries. Exposure of patients to diseases to which they have limited or no natural immunity can be hazardous, especially those who are weak. The risk of blood clot forming in the legs and lungs (thromboembolism) is increased by long flights and cramped airline cabins, and aggravated by travelling soon after surgical or dental procedures.
The quality of care may be variable and in some instances, not up to the expectations of medical tourists. An example of poor quality care is that encountered by some Malaysians who contracted infectious diseases like hepatitis B and C, and even HIV/AIDS following kidney transplants abroad.
There may be perceptions that a healthcare facility’s complaints policy and procedures are deficient in its ability to address appropriately and fairly the complaints of dissatisfied patients. Of particular concern to doctors is continuity of care as late complications may develop after the foreign patients have returned home. Its management can be challenging especially if the doctors in the patient’s home country have different management approaches.
It must always be remembered that there is no treatment size that fits all even if patients are treated in their home country.
Although there are claims that some aspects of these issues are addressed to some extent by the accreditation of hospitals, much more is needed to maximise patient safety and quality of care, even when patients are treated in their home country.
Legal issues
While there is a legal framework with more than 25 health laws in Malaysia, questions have been raised about its robustness. For example, the Private Healthcare Facilities and Services Act (PHFSA) and its Regulations, which regulate all private hospitals and clinics, prescribe statutory responsibilities for the licensee and person in charge of the facility in respect of all aspects of medical practice.
Although a local residential requirement is implied for both the licensee and person in charge, there is at least one hospital known to have a Malaysian licensee who is ordinarily resident abroad. This raises issues about the accountability of the licensee or person in charge who is a foreigner or a Malaysian who is ordinarily a resident abroad. If something goes amiss, what can the regulators do?
It is accepted that all procedures carry with it risks. If the risks and complications materialise, the insurance coverage of the foreign patient may not be adequate to meet the costs of additional treatment.
The foreign patient may also decide to take legal action for alleged negligence.
The local legal remedies may not appeal to foreign patients for various reasons, eg unfamiliarity and perceived inadequacy of the local doctors’ indemnity and hospitals’ insurance coverage, the local legal process and the magnitude of compensation awards and settlements. Should the foreign patient take legal action in his or her home country, there are issues about jurisdiction and enforcement of awards made. This may even result in the doctors and hospital managers involved encountering problems should they visit the home country of the foreign patient.
Ethical issues
There have been reports of damaging effects on the health systems of countries providing medical tourism. The focus on tertiary care for foreigners, which is inevitably driven by advanced technologies, impact on the provision of healthcare in developing countries like India and Thailand, with suggestions that medical tourism have disadvantaged the local population.
In a World Health Organization (WHO) Bulletin (Vol 85 No 3 2007: 161 – 244) article on medical tourism in India, Dr Manuel Dayrit, director of WHO’s Human Resources for Health, stated: “Although there are no ready figures that can be cited from studies, initial observations suggest that medical tourism dampens external migration but worsens internal migration. It remains to be seen how significant these effects are going to be. But in either case, it does not augur well for the healthcare of patients who depend largely on the public sector for their services as the end result does not contribute to the retention of well-qualified professionals in public sector services.”
In addressing the claim by medical tourism proponents, who argue that medical tourism revenues will find their way into public coffers to help retain staff in the public sector, Dayrit stated “Unless national laws or regulations are set up so that these revenues are taxed explicitly and channelled to the public sector to augment salaries, the likelihood of this happening is very slim.”
Thelma Narayan wrote in the Indian Journal of Medical Ethics (April – June 2005), “The policy of ‘medical tourism for the classes and health missions for the masses’ will only lead to a deepening of the inequities already embedded in our healthcare system.”
It could be argued by medical tourism proponents that the local situation is different from that in India and Thailand. However, only the cavalier would attempt to provide an iota of assurance that the Malaysian public will be spared the ill effects of medical tourism.
A constant complaint of medical tourism proponents is about the perceived stringent guidelines of the Malaysian Medical Council (MMC). The MMC states “…self-advertisement is not only incompatible with the principles which should govern relations between members of a profession but could be a source of danger to the public. A practitioner successful at achieving publicity may not be the most appropriate doctor for a patient to consult. In extreme cases advertising may raise illusory hopes of a cure.”
The MMC permits provision of the doctor’s name, professional qualifications, designation, home, practice as well as e-mail address, telephone and facsimile numbers. However, it does not permit laudatory statements, deprecation of the skills, knowledge or qualifications of others and the canvassing for patients or its abetment.
The MMC’s view is consistent with that of most medical regulatory bodies worldwide. For example, the General Medical Council of the UK, in its guidance on Good Medical Practice states: “If you publish information about your medical services, you must make sure the information is factual and verifiable. You must not make unjustifiable claims about the quality or outcomes of your services in any information you provide to patients. It must not offer guarantees of cures, nor exploit patients’ vulnerability or lack of medical knowledge. You must not put pressure on people to use a service, for example by arousing ill-founded fears for their future health.”
The International Medical Travel Journal’s (IMTJ) advice is: “Once you’ve chosen your destination, your next task is to choose a clinic or hospital, which can be daunting task in an increasingly competitive market place. Your instincts may tell you to go with the clinic with the most impressive website, and while a good website can be a sign of a well-run and professional organisation, make sure you also find out the answers to these crucial questions:
A good hospital or clinic should be happy to provide answers to:
- How many procedures of this type have done over the past year?
- How many required unplanned follow-up treatment?
- To what internationally agreed standards does the hospital or clinic subscribe, and what independent inspection reports are available?
- What happens if something goes wrong?
- How will you ascertain if I’m fit enough to fly (where applicable)?
- If I need routine post-operative care back in my home country, where will this take place and who will arrange and pay for it?
Is there anyone at the clinic who speaks my language?” (www.imtjonline.com/consumer-guide/step-4-find-the-right-clinic Accessed 2 May 2009)
Although an internet search for “medical tourism” yielded 4.6 million results worldwide, including 14,900 from Malaysia, the overwhelming majority are attractive websites of tourism agencies, industry guides or news articles. There is, however, no comprehensive data about the outcomes and complications of various treatments that make comparisons possible.
Such information is vital to decision making in accordance with the IMTJ advice. By comparison, the websites of many public sector hospitals abroad increasingly provide information about the outcomes and complications of specific treatments, eg cardiac surgery.
There are ethical issues galore in organ transplantation and assisted reproduction, some of which involve not only ethics but also religion, morals and culture.
The flourishing market in body parts (especially kidneys) has existed for several years with vulnerable individuals being tricked or coerced into donating their body parts and recipients travelling to countries where donated organs may be purchased legally or illegally.
Guido Pennings, who wrote Ethics Without Boundaries: Medical Tourism in the Principles of Health Care Ethics (Ed: Richard E. Ashcroft, Angus Dawson, Heather Draper, and John McMillan. 2007 John Wiley & Sons) concluded that government regulation and oversight are the only brakes that can be applied to this global economic engine. But can there be political will when economic imperatives are so dominant?
Conclusions
Medical tourism is driven solely by economic considerations and without the benefit of internationally accepted standards, governmental regulation, or ethics review. Whilst there may be global convergence of medical practice, there is almost complete absence of similar agreements with regard to core issues, especially in oversight, care provision, ethics and legal recourse.
Evidence of health systems benefiting from medical tourism has yet to emerge, unlike the damage to healthcare systems and delivery, which are becoming apparent in some countries. As such, economic considerations should not be permitted to be the primary driver of medical tourism. Considerations of care, legal and ethics matters and other issues are just as, if not more, important.
There has to be greater governmental co-ordination in addressing the various associated issues of medical tourism. Stakeholders’ involvement, in this respect, is crucial to assure a win-win situation for the Malaysian public. To do otherwise would court unnecessary tension that would be detrimental to public interest.
Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with.
By DR MILTON LUM
Source: The Star
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Hitesh bansal
said:
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RILEY25Penny
said:
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