Dissertation on medical tourism. Most of the publications on medical tourism are focused on the phenomenon of the trend and its risks and benefits for patients; however, researcher is hoping to study the subject of inequalities that local communities of

University Degree Business and Administrative studies

Chapter 1

Introduction

1.1 The Emergence of Medical Tourism

Medical tourism is described as an emerging trend in tourism industry. Health care systems worldwide are facing privatisation and globalisation and therefore medical industry is becoming more of a business opportunity nowadays. There are several factors influencing the growth of medical tourism – most of them are connected to cheaper costs and long waiting lists for treatments. However, popularity of low cost airlines and better accessibility to information (mainly via Internet) had a significant influence on the popularity of this trend. Medical tourism has a long history. First recorded signs of travelling for medical purposes go back to the 19th century, when French and German Spas were growing in popularity.

General definition of medical tourism indicates that the trend is focused on travel for medical purposes, however the discussion is raised over what kind of treatments should be included in the medical tourism definition. Moreover, there is a debate on whether medical tourism definition should be focused on content of medical services offered or on motivation for treatment abroad. It is crucial to remember close relationship and differences of medical tourism and wellness tourism. While medical tourism is focused on medical treatments, which are often seen as essential health care, wellness tourism is non-invasive and undertaken in order to prevent illness or any medical difficulties rather than treat them; both medical and wellness tourism could be classified as healthcare tourism (Henderson, 2004, pp.111-122).

However, one could argue whether this classification is correct since medical tourism is growing fast and develops different trends within. Cosmetic surgery or fertility treatment could not be classified to either medical or wellness tourism as they are invasive but unnecessary (in objective point of view) treatments. Therefore, the theory presented by Henderson (2004, pp.111-122) is not considerate of all aspects of health tourism.

Smith and Puczko (2009, p.7) demonstrated much more developed classification of health tourism:

Figure 1.1 Classification of health tourism

As presented in the figure 1.1 health tourism is levelled and represents several products that are sometimes not recognised as health tourism (e.g. beauty treatments). It can be easily stated that tourists often do not realise that they are participating in health tourism (that concerns wellness rather than medical tourism where tourists are more aware of the nature of their journey) (Smith and Puczko, 2009, p.8).

There are specific medical tourism destinations established. Those are mostly emerging countries of Eastern Europe and Asia; however it is not always the case. Some of the medical tourism destinations are Costa Rica, Czech Republic, India, Jordan, Malaysia, Saudi Arabia, Switzerland, Thailand, Turkey, and United States of America. As it can be noticed, medical tourism is not focused only on emerging countries but also well-developed destinations; that is due to quality and availability of services in certain countries. Tourism Research and Marketing (2006, p.20) presents an inbound international medical tourism trips by world region:

Table 1.2 Inbound international medical tourism trips by world region

Based on those statistics, it is estimated that medical regions attract around 19 million tourists annually. This data, however, could not be very relevant at this stage, as medical tourism is at the level of constant growth and the numbers are expected to be much higher nowadays. Moreover, India and other Asian countries are actively promoting themselves as medical tourism destinations, therefore balance of inbound international medical tourism trips is likely to be different at the present (Tourism Research and Marketing, 2006, p.20).

Kumar (2009, p.186) reports that tourism is an important source of income for most of the countries worldwide (only in 1999, international tourist arrivals were estimated at 700 million which resulted in $500 billion income within industry and 250 jobs worldwide). Such popularity of tourism resulted in development of different trends in order to meet tourism demand and medical tourism is one of those trends.

India alone is said to attract 150,000 medical tourists in 2004. Its medical tourism market is estimated to be worth US$333 million (in 2004) and the number of medical tourists is said to be growing at the rate of 30% annually. Interesting fact about India’s medical care system is that in 2004 it had very limited health care with four doctors for every 10.000 people (e.g. it is 27 doctors per 10,000 people in United States). This information can raise a discussion on risks and ethical considerations attached to medical tourism. Main ethical concern to be discussed is the issue of patients from wealthy countries travelling to emerging destinations in order to receive healthcare that local community cannot afford. Moreover the aspect of other risks will be discussed, e.g. lack of follow up care (Tourism Research and Marketing, 2006, p.61).

1.2 Medical tourist motivation

One of the most recognised reasons for tourists to travel to foreign countries in order to receive medical treatment is cheaper cost of health care (it is estimated that some treatments in medical tourism destinations are up to 80% cheaper than in the United States). Another factor influencing popularity of the medical tourism is perception of quality of health care. It is considered as sensible to check different health institutions before making decision on important surgery/treatment. On the other hand, it could be argued that making judgments on health institution that patient have not seen or been to before have a high factor of risk included. Other factors influencing international travel for medical purposes are long waiting lists, holiday factor and desire for privacy of a treatment. However, no significant study had been made on the subject yet and those are only general assumptions of medical tourist motivators. At the present, the Guadalajara Convention & Visitors Bureau is undertaking research on the push and pull factors of visitors motivation. It is the first in-depth study on understanding medical tourist motivation. Cormany (2010) reports that ‘Guadalajara is investigating additional motivations such as availability of treatment, cultural roots of the travellers, specialization of treatments, and other factors that may not have been considered yet. In these explorations, traveller demographics are important, and something recognized by nearly all medical destinations, but psychographic dimensions are also being explored by Guadalajara CVB’.

1.3 Aim and objectives

Aim and objectives of this study are to present how the researcher will achieve the research objectives and explain how they will be met.

The aim of the project is:

to investigate into medical tourism trends, tourists motivation and examine the subject of inequalities and ethical considerations within medical tourism.

Objectives of the research are:

To critically analyse literature of medical tourism trends and consumer motivation and define its position in tourism industry.
To undertake research of identifying consumer motivation process in medical tourism.
To study and critically appraise any inequalities and ethical concerns among local communities of emerging countries caused by medical tourism.
To carry out and discuss the results of the primary research and to critically appraise it with information gained from the secondary data.

1.4 Overview of the research project

This research is being conducted in order to learn about medical tourism trend. It is fast growing part of tourism industry and is already considered to be a significant trend in some countries. The researcher aims to seek not only into tourist motivation, trends and destinations of medical tourism but is willing to critically appraise this market’s risks and benefits. Moreover, one of the main interests of the researcher is to study ethical considerations of medical tourism. Most of the publications on medical tourism are focused on the phenomenon of the trend and its risks and benefits for patients; however, researcher is hoping to study the subject of inequalities that local communities of medical tourism destinations could be experiencing. Research will be based on secondary data and supported by primary data (Internet semi-opened survey) in order to provide the reader with the most accurate, up to date information and present an objective point of view on the medical tourism phenomena.

Chapter 2

Literature review

2.1 Literature review outline

Health conscious and ageing population of Western countries accepted medical tourism as a great alternative to failing health care systems in their countries. There are several factors influencing growing popularity of medical tourism including: low air travel costs, holiday factor, long waiting lists in developed countries, expensive healthcare and many others (Tourism Research and Marketing, 2006, p.7). The subject of medical tourism is, however, perceived as a very controversial; not only due to possible risks for the tourist but also major lack of regulations and possible negative effects on local communities. In order to fully understand the medical tourism trend, a multiple research on the areas of sociology, consumer behaviour, sustainability, policies and psychology needs to be undertaken. Information will be gathered from several sources including academic textbooks, journal articles, newspapers and on line resources, which will provide readers with a broad range of opinions and views on this subject area.

2.2 Tourism at the present

Tourism is ‘a major force in the economy of the world, an activity of global importance and significance’ (Cooper et al, 2008, p.3). This statement can easily be proven with the numbers – the travel and tourism industry of world domestic product was 10.3% with turnover of US$6.477.2 billion; it supported 234 million jobs, which is 8.7% of the total world employment (data from 2006) (World Travel and Tourism Council in Cooper et al, 2008, p.3). It is therefore clear that travel and tourism industry is highly developed and due to the demanding nature of the society, new trends are constantly being created. Sometimes it is due to acts of terror or nature (e.g. World Trade Centre Attacks – commonly described as 9/11) which puts a pressure on travel and tourism industry and often results in changes in policies, regulations and health and safety standards, other than that, it is tourists that influence travel and tourism industry.

Cooper et al (2008, pp. 663-664) describes globalisation as a powerful force shaping national and regional economies. It influences all aspects of population’s life. Key drivers for globalisation in tourism are:

‘decreasing costs of international travel allowing access to most markets in the world;
Increasing income and wealth in the generating countries;
Newly emerging destinations and the increased demand for international travel;
Adoption of free trade agreements, removing barriers to international transactions;
Computer and communications technology encouraging ‘e-business’ and
Worldwide acting suppliers utilising global distribution systems.’

Cooper et al (2008, p.664)

Indeed, globalisation has a massive impact on travel and tourism industry and its trends, including emerging trend of medical tourism.

Of course, there are several other factors influencing the growth of medical tourism, those are briefly speaking price, quality, availability and timeliness (Tourism Research and Marketing, 2006, pp.13-14).

It is stated that due to the medical tourism gaining attention from a relatively short time, there are some general data on the subject, however, available figures can often be associated with service providers therefore their credibility, in some cases, may be doubtful. Available data indicates that health-orientated holidays account for about 15% of the total European international holiday market, which brings the number of 37 million trips a year. It is also reported that the total expenditure in European Union for medical reasons accounts for €12 billion a year which is almost a third of the total health travel market in Europe (Tourism Research and Marketing, 2006, p.17).

Due to its big potential and high expenditure, medical tourism is being treated like any other trend within tourism industry. It is being actively advertised and special packages are created in order to attract customers. Not only it is suppliers but also governments that target this area of tourism, e.g. ‘the Singapore government has been actively involved in medical tourism development’ and is ‘aimed at making Singapore’s world-class healthcare services easily accessible to international patients’ (Tourism Research and Marketing, 2006, p.23).

Moreover, medical tourism boosts economy of the other industries, e.g. insurance sector. In a bid to reduce the financial difficulties of employee healthcare, several corporations are now looking into medical tourism. It is also stated that some of the medical facilities in the United States are accepting referrals from medical tourism agencies (Medical Tourism: Globalization of the Healthcare Marketplace, 2007).

2.3 Medical Tourism Trends

Health tourism (medical and wellness tourism), in general, is about increasing one’s health and wellbeing. One of the examples are spas from 18th and 19th centuries in some of the European countries. Over the years, visiting spa had become a popular tourist activity and got to be associated with health tourism. There are several factors that influenced the growth of medical tourism, those are mainly high costs of treatment in well developed countries, long waiting lists, affordability of air travel and favourable economic exchange rates (Medical tourism: Sea, sun, sand and…surgery, 2005). Growth of popularity of Internet has also had an impact on connecting patients with hospital networks. Other than that, the popularity of cosmetic surgeries and other treatments not covered by health insurance, like LASIK eye surgery or cosmetic dental surgery had created demand for cheap treatments abroad.

Asia is well established in medical tourism world with Eastern European countries rapidly entering the market. Nevertheless, countries of Asia are still most recognised on the market, e.g. Thailand got recognized as a medical tourism destination in 1970s due to its specialization in sex change operations and cosmetic surgeries, whilst India is considered as a contemporary global centre of medical tourism. It is said to offer an upgraded technology, well qualified staff and low cost of treatments (Medical tourism: Sea, sun, sand and…surgery, 2005).

In order to promote and develop medical tourism, international events are being held. As stated before, India is one of the most developed medical tourism centres. India Medical Tourism Expo is just one of many successful events in this area of tourism (Tourism Research and Marketing, 2006, p.93).

Medical tourism is a very well developed industry and its segments need to be clearly explained in order to understand the scale of the trend. Medical tourism segments are: illness (medical check-ups, health screening, dental treatment, joint replacements, heart surgery, cancer treatment, neurosurgery and transplants), wellness (acupuncture, aromatherapy, beauty care, facials, exercise and diet, herbal healing, homeopathy, massage, spa treatment, yoga), enhancement (cosmetic surgery, breast surgery, facelifts, liposuction, cosmetic dental work) and reproduction (fertility treatment, birth tourism) (Tourism Research and Marketing, 2006, p.11).

Apart from long waiting lists and high prices of medical treatments in western countries, there are other factors that push tourists towards this trend. The pressure of media creates a self-obsessed and self-conscious society, making those more susceptible an easy target for plastic surgeries companies. Moreover, those who decide to have a plastic surgery often want to keep it private, therefore travelling to other country seems like a perfect option for some of patients. The big advantage of medical tourism is often an exotic location. As this sector is a private-dominated practice, there are hospitals built in the most beautiful locations, which often influences final decision of medical tourist, who is tempted by joining their often painful surgery with a holiday experience (Smith and Puczko, 2009, p.102).

There are several different medical tourism destinations, some of them are already well established and some others are emerging into medical tourism market. Most American tourists would seek treatment in Latin American countries (e.g. Mexico, Brazil or Argentina) which are very popular with plastic surgeries seekers. On the other hand, there are India and Thailand which are marketing themselves with high-tech facilities and well qualified staff and specialise in complicated, more serious surgeries, such as cardiac surgeries or hip or knee replacements. Other popular destinations are Singapore, Belgium, South Africa and Central and Eastern Europe (which is popular with mostly dental services). Herrick (2007) gives readers an insight into the cost of medical procedures in selected countries (in U.S. dollars).

Table 2.1: The cost of medical procedures in selected countries

The difference in costs between United States (U.S.) and medical tourism countries (India, Thailand and Singapore) are astonishing. Looking at heart-valve replacement in U.S. which costs $274.395 at a retail price compared to $9.500 in India saves a patient the total of $265.895 (a medium household income in 2008 in U.S. was $52.029) (U.S. Census Bureau, 2010). Looking at the differences in prices between the countries, it come as a little surprise that medical tourism is growing bigger even though the lack of regulations occurs.

2.4 Tourists motivation

Cooper et al (2008, p.45) highlights the importance of motivation in order to understand tourist behaviour. Maslow’s hierarchy of needs is one of the most popular theories of motivation. It is mostly applied to tourist motivation in general rather than in specific trend of medical tourism. Maslow’s hierarchy of needs consists of five levels. Those are (presented from the lowest to the highest):

‘Psychological – hunger, thirst, rest, activity
Safety – security, freedom from fear and anxiety
Belonging and love – affection, giving and receiving love
Esteem – self-esteem and esteem for others
Self-actualisation – personal self-fulfilment’

Cooper et al (2008, p.45)

Even though, the hierarchy is highly popular and widely used, it is not clear why and how the five basic needs were selected, other than that, in the era of several different trends in tourism industry, when some of them are as extreme as dark or medical tourism, the Maslow’s hierarchy will not be relevant.

There are also different types of tourists. Using Cohen’s classification, those are:

‘The organised mass tourist – low on adventurousness he/she is anxious to maintain his/her ‘environmental bubble’ on the trip. Typically purchasing a ...

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Cooper et al (2008, p.45)

There are also different types of tourists. Using Cohen’s classification, those are:

‘The organised mass tourist – low on adventurousness he/she is anxious to maintain his/her ‘environmental bubble’ on the trip. Typically purchasing a ready-made package tour off-the-shelf, he/she is guided through the destination having little contact with local culture or people;
The individual mass tourist – similar to the above but more flexibility and scope for personal choice is built in. However, the tour is still organised by the tourism industry and the environmental bubble shields him/her for the real experience of the destination;
The explorer – the trip is organised independently and is looking to get off the beaten track. However, comfortable accommodation and reliable transport are sought and, while the environmental bubble is abandoned on occasion, it is there to step into if things get though.
The drifter – all connections with the tourism industry are spurned and the trip attempts to get as far from home and familiarity as possible. With no fixed itinerary, the drifter lives with the local people, paying his/her way and immersing him/her in their culture’.

Cooper at al (2008, p.51)

Looking at the classification above, it is clear that there are several different types of tourists and therefore, one, very simplified model cannot apply to all of them. There is, however, consumer decision-making framework that can give a reader a good insight into decision making process. Kotler et al (2006, pp.217-218) presents buyer decision process that consists of five stages: need recognition, information search, evaluation of alternatives, purchase decision and post purchase behaviour. This model is said to be applied by most of the consumers with every purchase they make (including holidays).
Applying this process to medical tourism, it would start with potential medical tourist recognising a problem or a need (e.g. need for medical treatment that cannot be afforded in the country of origin or long waiting lists for the treatment). Need can be triggered by external stimuli, for example an advert or word of mouth power.

Second stage is information search, once the recognition of a need had occurred, consumer will look into more information on a product from personal, commercial or public sources.

Next stage is evaluation of alternatives. It is very complex stage, where consumer seeks attributes in a product. That could be distance, price, quality of service or even opinions of other customers. Every customer will have a different hierarchy of needs, if someone decided to go abroad to seek medical treatment due to very little money they have, they are likely to go with the cheapest option and not consider any other, maybe more credible destinations, simply because they cannot afford it. However, if the patient will be going abroad due to the long waiting list rather than money issues, it is more likely that they will analyse and consider different options and choose the one that convinced them because of the quality of service or exotic destination rather than affordability.

Another step is purchase decision, which is when consumer will choose the most preferred option. Two factors can influence the decision, firstly, there is consideration of other people (e.g. if medical tourist will go abroad with the family, they are likely to be influenced by their opinion). Purchase decision can also be influenced by an unexpected situation. If any problem, e.g. financial issue occurs, then consumer will need to change their decision and go to the more affordable place which was not their first choice.

Final stage of the process is postpurchase behaviour. Following the purchase, the consumer can be satisfied or dissatisfied. When consumer expectations are not met, it is likely that they will not recommend the product to other customers or ask for refund. Generalising, it can be said that there are two main reasons for seeking treatment abroad – relatively less affluent people seek cost reduction in medical tourism, whereas affluent people seek higher quality which may not be available in the country of their origin.

However, other than classical medical tourism examples, there are several other reasons for medical tourism. Euthanasia, abortion or embryo gender identification are rare but not unknown part of medical tourism. In those cases, there is no specific motivation process, most of the times, medical tourists who seek for euthanasia, abortion or embryo gender identification travel abroad only because those treatments are illegal or not easily accessible in their motherlands. Good example of this kind of medical tourism is a campaign carried by SROM, feminist group based in Poland, where abortion is restricted. It promotes travelling to the United Kingdom in order to receive a free treatment at the cost of NHS. However, there are ethical issues considering this case as it is estimated to cost the NHS £200 million a year (Daily Mail, 2010). In case of euthanasia, one of the most controversial examples in medical tourism is Professor Craig Ewert’s case. As a former university professor with motor neuron disease, he decided to make a footage of his journey from Harrogate in United Kingdom to Zurich in Switzerland in order to commit an assisted suicide at the cost of £3.000. The case is more controversial than any others since it was broadcasted in television in 2008 and was to stimulate national debate on the subject (The Times, 2008). Medical tourism is triggered mostly by lack of money or desire for a better quality of service, however, looking at the examples of medical tourism it is not always a case and several different aspects influence individuals in their decision making process.

2.5 Medical Tourism Destination – India

India is, without a doubt one of the most popular medical tourism destinations. It is being actively promoted through ‘easing visa restrictions, recognising medical tourism as an export and encouraging private health suppliers’ (Medical Tourism: a global analysis, 2006, p.71). The Government of India introduced special medical visas for tourists who come to India for treatment. Until then, patients had to travel on tourist visa (valid for 6 months) which was inconvenience for those who needed long term treatments. Medical visa allows patients to stay in India for one year with the option of extending it for another twelve months and allows them to bring two attendants along. Those changes in visa regulations are to increase the economic benefits of medical tourism due to long term stays of patients and their families. The government of India also actively markets India as a medical tourism destination. In 2005 Government officials of India stated that ‘The formalities for marketing medical facilities to a global audience have already started. We hope to complete the process of price-banding of hospitals in various cities by the third quarter of 2005’ (Medical Tourism: a global analysis, 2006, pp.71-72).

India’s National Health Policy perceives treatment of foreign patients as a way of boosting ‘export earning’ and allows hospitals which specialise in treating medical tourists take advantage of several benefits, such as lower import duties, increase in the rate of deprecation and several various tax benefits. Medical tourism is well established business in India with several private health suppliers all over the country; Apollo Hospital Enterprise, with 53 hospitals and partnerships with other hospitals in e.g. Kuwait, Nigeria or Sri Lanka, is believed to be one of the largest Indian private medical group (Medical Tourism: a global analysis, 2006, p.72). Apollo Hospital Enterprise website is full of information and has a clear layout in order to attract as many customers as possible. Their mission statement is "is to bring healthcare of International standards within the reach of every individual. We are committed to the achievement and maintenance of excellence in education, research and healthcare for the benefit of humanity" (Apollo Hospitals, 2011). Apart from medical treatments, Apollo Hospitals Enterprise operates Apollo Munich Health Insurance. Insurance market is said to be worth $34 billion by now and expected to grow to $280 billion by 2022 (Apollo Hospitals, 2011).

Insurance policies are big part of medical tourism industry. Going abroad to undertake medical treatment can be seen as a risky idea, especially when once patient is aware of the lack of regulations within this industry and it is often insurance policy that help them with the final decision on going abroad to receive treatment.

Mattoo and Rathindran (2006) report that approximately 60%of United States population receives health insurance and most of them do not cover treatment abroad. There are around 40% of Americans without health insurance and prices of the treatments are not affordable for person with average earning and that is where medical tourism destinations step in. Apollo Hospitals chain promotes their services by reporting success rate of 99 percent in around 50.000 cardiac surgeries which is equally good or better than in the best United States clinics. Kumar (2009, pp.251-252) is actively promoting medical tourism (concentrating on India) by putting a lot of attention on holiday factor of it. Author states that ‘thousands of sun-deprived tourists visit India because it incredibly has the most diverse varieties of beaches anywhere in the world […] India offers several hill stations with excellent tourist attractions and facilities […] India offers royal retreats which are nowhere to be seen elsewhere’ (Kumar, 2009, p.252). But how much of a true is it? As far as it is only right to promote destination for leisure reasons, is it appropriate to concentrate on attractions available in India when most likely medical tourist will not get a chance to experience any of those? Kumar (2009, p.51) also states that medical insurance is one of the fastest growing segments in the Indian economy and when it comes to medical tourism itself, the author says that ‘medical tourism in India is one of the best options available to people across the globe’ (Kumar, 2009, p.7). However, it is difficult to find any objective criticism on medical tourism, its lack of regulations and inequalities that may occur in emerging destination in Kumar (2009) publication. The author concentrates on promoting medical tourism, especially in India and forgets to make a relevant evaluation of risks and potential threats therefore it can be difficult to find this publication credible.

2.6 Lack of regulations, potential threats, ethical considerations and inequalities in medical tourism.

Every journey involves certain element of risk, however when it comes to medical tourism it takes potential risks to a different level. Medical tourism is being actively promoted, however, there are major criticisms opinions involved and those are due to several issues connected to medical tourism industry.

Firstly, there are major doubts regarding quality of care. Even though, most of the medical tourism hospitals are internationally accredited, quality of service varies. While affluent patients are likely to receive an outstanding health care, those who are less wealthy are at the risk of getting substandard care. It is a major problem because of little possibility of retaking or continuing treatment if there is a need to do so due to long distances that occur in medical tourism journeys. Lack of international regulations and policies regarding medical tourism industry makes it highly problematic to legally challenge hospital or organisation which took the responsibility for the treatment (Leigh, 2007). Cooper et al (2008, p.581) states that quality ‘involves deciding on quality standards for the product and implementing a method of assurance on the performance level of staff and facilities. The management of quality is becoming an increasingly important management function since it is crucial to create a good reputation for the quality of the product and service offered’. It is likely that western European countries will be attracting well qualified doctors and nurses with better salaries and personal development options whereas, the workforce that will remain in emerging countries like India or Thailand may be less qualified and therefore provide worse quality of service. Going further, most of the hospitals that aim for medical tourists are based in low-cost, emerging destinations that could be experiencing political, social and cultural problems which can influence quality of service. Moreover, travelling long distances (sometimes even up to 14 hours) by airplane is not a good environment for people with health problems, especially with thrombosis or lung disease (McBride, 2010).

Another issue concerning medical tourism world is lack of regulations. The problem had been recognised and it is being discussed on national and governmental level in order to find a solution and create international regulations, it is however in the main interest and focus of India rather than western countries. The Minister of State for Tourism Renuka Chowdhury in India reported that ‘in collaboration with the medical industry, price banding of hospitals has been completed for uniform prices for a particular treatment. Accreditation of hospitals and maintaining required international standards for treatment are now completed in association with the Confederation of Indian Industry and the medical industry’ (Medical Tourism: A global analysis, 2006, p.28). It is, however, not the end of the problem. India is actively promoting medical tourism, therefore the problem had been already recognised in this country but several western European countries still have not identified medical tourism and concerns associated on a wide scale. Any regulations, concerns or ideas regarding medical tourism must be considered on international level in order to meet the highest standard of medical care and solve any problems concerning travelling abroad for medical treatment.

The situation is much less complicated within European Union, where many health authorities already experiment with medical tourism, e.g. in 2002 United Kingdom government developed a scheme to send 190 NHS patients to France and Germany for routine operations. Denmark has similar project where treatments abroad are being covered by insurance companies rather than the patient (Medical Tourism: A global analysis, 2006, p.29). There are regulations that allow patients to be treated in another EU country which are set out in Council Regulation 1408/71, art.22. Under those regulations medical tourism in EU is allowed where:

‘The treatment is amongst those provided for in the patient’s domestic state;
The patient cannot be provided with the treatment within the time ‘normally necessary for obtaining the treatment in question,’ taking into account his or her state of health and the probable course of the disease’.

(Medical Tourism: A global analysis, 2006, p.28)

Moreover, NHS (2011) reports that there are ways to obtain NHS funding when treatment is being undertaken in an EEA country. Patients can use S2 form or go under Article 56 of the Treaty on the Functioning of the European Union. Summing up, undergoing treatment within EEA is significantly less complicated than outside Europe when taking to the consideration regulations aspect, however treatments in countries like India or Thailand are a lot cheaper and in the case when patient do not get NHS funding for the treatment, going to Asia is likely to be more affordable option even though all the potential risks occurs.

Medical tourist is a patient who stays within the medical tourism destination from few days up to few months (there are more complicated cases when patient may stay in the hospital longer) and then, after surgery or treatment they return home. Due to the long distances between country of origin and medical destination (it is often as far away as several thousands miles) once the patient is back home, any complications, side effects and follow up care are patient’s problem. If anything goes wrong, there is a little chance of receiving help from the hospital that patient was treated in (Medical Tourism: A global Analysis, 2006, p.31).

Apollo Hospital in India presents the following massage on their website:

‘A prospective medical tourist should also be aware of possible legal issues. There is presently no international legal regulation of medical tourism. All medical procedures have an element of risk. The issue of legal recourse for unsatisfactory treatment across international boundaries is a legally undefined issue at present’ (Appollo, 2007 cited in Mirrer-Singer, 2007, p.212).

It means that if any difficulties occur, patient may not only loose money (which is often main motivator in getting treatment abroad) but also health. The statement quoted above, clearly shows that medical tourism is unregulated on international level and that if any risk occurs, patient should be aware of any difficulties they may experience.

The issue of lack of regulations in medical tourism brings the subject of medicalisation of healthcare. As reported in People Democracy quoted in Medical Tourism: A global analysis (2006, p.31) ‘a generic problem with medical tourism is that it reinforces the medicalised view of health care. By promoting the notion that medical services can be bought off the shelf from the lowest priced provider anywhere in the globe, it also takes away the pressure from the government to provide comprehensive health care to all its citizens. It is a deepening of the whole notion of health care that is being pushed today which emphasises on technology and private enterprise’. This issue may have a long term negative impact on population of both sending and hosting counties. It should not be a case that patients have to go away in order to receive health treatment (which is sometimes life saving or necessary for every day functioning). Rather than developing the medical tourism trend and letting it grow so rapidly as it does at the moments, the problem of receiving medical care in well developed countries should be identified.

Medical tourism can have highly negative impact on the local communities. Medical tourism works on the basis of the Global Code of Ethics for Tourism. It reports that The Code of Ethics is based on the ‘principles of sustainability that underpin all of UNWTO’s programmes, with special emphasis on involving local communities in planning, managing and monitoring tourism development’ (Kumar, 2009, pp.78-79), On the other hand Cooper et al (2008, p.196) states ‘there is a wide variety in which the development and operation of tourism can create social tensions and impact on integrity of the local culture’. Moreover Cooper et al (2008, p.202) discuss that ‘where the demands of tourism lead to the mutation and sometimes destruction of the meaning of cultural performances and events. Tourists are likely to have different time-frames and expectations from local residents and this may result in religious rituals and traditional ethnic customs and rites being changed to suit the needs and wishes of tourists’ or standardisation – ‘where the tourists’ search for the familiar leads to a loss of cultural diversity’. And even though medical tourism may not occur in crime, sex or other socio-cultural impacts common for ‘regular’ tourism, there are several other negative impacts that should be taken into consideration when it comes to medical tourism. Firstly, ‘international patients tend to use high-end hospital suites - that would only be used by 15—20% of the Indian population anyway. An average 10-min patient consultation in a private hospital in India costs between Rs500 and Rs1000. For many Indians, this would be half or more of their monthly salary’ (Crooks citied in Shetty, 2010). A discussion on the point of having high end hospitals in India should be raised, if they are not only unbeneficial but even detrimental for the local community. Going further, Shetty (2010) reports that ‘countries that see medical tourism as a solution to development of their health-care centres should be cautious because there are a lot of anecdotal stories about how medical tourism can harm health inequity, but without better data it's hard to make the argument that that's always the case or even often the case”.

Medical tourism, without a doubt raises several ethical concerns and is a platform for a discussion on population inequality. It is not only about medical tourists that may experience several problems and complications, but most of all it is host communities that will struggle in long term aspect. Firstly, high end hospitals will attract best qualified staff, creating brain-drain and leaving public hospitals (those affordable by average patient in e.g. India) will have to employ those that are less qualified or experienced, making the quality of service in public institutions fall rapidly. For now on, it is only a theoretical discussion on possible negative impact of medical tourism, it is however highly important to raise this issue, especially when India government heavily tries to establish the country as a main medical tourism destination, without any considerations of importance of risk assessment and possible negative long-term impact medical tourism could have on India’s society (Shetty, 2010).

Moreover, ‘health is fundamental human right indispensable for the exercise of other human rights’ United Nations Economic and Social Council (2000) cited in Smith (2007, p.6). Equal access to the health care should be treated as a social right and not being provided that creates social inequalities where access to health care is judged by social, economic, regional characteristics. Inequality will always occur in one group benefiting over others and creates serious moral and ethical concerns (Farmer, 2002 cited in Smith, 2007, p.6).

Chapter 3

Methodology

3.1 Different approaches to research methods

There are several different approaches to the travel and tourism research methods. For example, there is a business research, which could be described as ‘the systematic and objective process of gathering, recording and analysing data for aid in making business decisions’ (Zikmund, 1991, p.6 cited in Finn et al, 2000, p.2). On the other hand, there is a scientific research which is based on the systematic examination of evidence. It should be possible for it to be replicated by the same or different researchers and for similar findings to emerge (Finn et al, 200, p.2).

In general, three different types of research can be recognized. Those are:

‘Descriptive research – finding out, describing what is
Explanatory research – explain how or why things are as they are (and using this to predict)
Evaluative research – evaluation of policies and programmes’

Veal (1998, p.2).

Descriptive research is common in the leisure and tourism area and it could be described as exploratory – it is about discovery and description. The reason why it is popular in the leisure and tourism area is the subject to constant change of this industry.

Explanatory research is to seek to explain the patterns and trends observed. ‘Why is a particular type of activity or destination falling in popularity? How do particular tourism developments gain approval against the wishes of the local community? Why are the arts patronised by some social groups and not others?’ (Veal, 1998, p.4) Those are typical questions to be answered when doing an explanatory research. Finally, evaluative research is about the need of making judgments on the success of effectiveness of e.g. various trends.

Veal (1998, p.4)

Phenomenology and positivism research approaches

Henderson (1990) cited in Finn et al (2000:6-7) reports that positivist approach relies on:

‘External world determining behaviour
Strives for explanation, prediction and control by dividing into parts and isolating them
Mechanistic process for explaining social behaviour
Researcher is objective and value-free
Truth has to be confirmed with empirical evidence’

Whilst, phenomenologist approach characterise in:

‘Social reality is multiple, divergent and interrelated
Analysis from the actor’s own perspective
Human behaviour is how people define their own world
Reality is the meaning attributed to experience and is not the same for everyone’.

In general, positivism is the type of research that seeks to explain human behaviour through cause and effect, while phenomenology research is based on understanding and interpretation of human actions and behaviour through researcher’s own perspective.

Since the research was initially concerned purely about phenomenon of new trend in tourism industry – medical tourism, its trends, destinations and tourist motivation but was later developed into discussing problem of inequalities and ethical concerns of medical tourism and risks it creates not only for customers but mainly for local communities, triangular research will be carried out – it will allow researcher to use both quantitative and qualitative research methods.

3.3 Primary and secondary data collection

While doing research, it is important to indicate what data collection methods will be the most effective. It should be evaluated whether primary data is essential for the research or if secondary data will be enough to present reliable research results. A lot of the time, information needed for research is already completed and going into expenses of collecting new information may not be necessary. Even if secondary research is not exactly what researches if looking for, it can often provide an interesting facts that will enrich project in general (Veal, 1998, p.33).

Secondary data are ‘those that have already been collected, possibly by some other individual or organisation and for some other purpose’ (Cooper et al, 2008, p.86).

Primary data, on the other hand, is a process of collecting data by researcher. In tourism, the most popular method of collecting data is sample survey (either of visitors or of businesses). There are four main types of survey; those are personal interview, telephone interview, web-based survey and postal survey (Cooper et al, 2008, p.86).

Other than surveys, there is a range of other primary data collection methods. Those are, e.g. qualitative methods, which generally speaking are interviews, and those can be classified as:

‘Informal and in-depth interviews usually involve small numbers of individuals being interviewed at length […]
Group interviews or focus groups apply the informal/in-depth interview approach to groups of people rather than separate individuals
Participant observation involves the researcher becoming a participant in the phenomenon being studied’.

(Veal, 1998, p.71).

Interviews are classified as qualitative methods and the main difference between qualitative and quantitative research methods is that the letter involves numbers, whereas qualitative techniques do not. Qualitative methods do not conclude the research in statistics, which is just opposite to quantitative methods (Veal, 1998, p.71).

Going further, observation techniques could be carried out while doing primary research. The main advantage of this method is its unobtrusive nature. On the other hand, it may raise ethical concerns as most of the time it is carried out without the knowledge of participants (Veal, 1998, p.70).

3.4 Research methods

In order to achieve the aim of this paper, interviews will be carried out. In order to successfully collect primary data, advantages and disadvantages of different types of interviews are being presented below:

Finn et al (2000, p.75).

The researcher decided that the best type of interview for the subject proposed is semi-structured survey. It will not only allow researcher to get general information about people that are interested or involved in medical tourism but also will give a better insight into reasons behind it and more personalised point of view on risk of promoting inequalities among society. The questioners will be distributed via Internet in order to get to specific group of people that are somehow involved with medical tourism.

In this section, the researcher will get into the detail of questioners and explain its purpose as well as present general overview of this primary research and discuss anything that could be a concern, e.g. ethical issues.

3.5 Questionnaire

The main purpose of questionnaires in this research is to provide an accurate data on medical tourists and their opinion on this trend. Questionnaire consists of ten questions and is semi-opened.

PART ONE: Personal Information

In this section, the researcher asks about personal information; questions 1-3 enquire about gender, age and nationality. Researcher found those questions important to be asked in order to find demographic characteristics of medical tourists.

PART TWO: Medical tourism information

In this part, the researcher asks about health insurance, satisfaction of health care in the country of origin. Survey also consist questions on satisfaction level of medical tourism experience, reasons for choosing this type of healthcare and the way that participants found out about medical tourism. The last two questions in the survey ask about any ethical concerns that tourists could have and whether they feel that they positively contributed to economy of local community (those questions were asked in order to find out whether medical tourists are in any way concerned about issues surrounding medical tourism).

3.6 Validity, reliability and ethical issue

Validity is ‘the extent to which the information collected by researcher truly reflects the phenomenon being studied’ (Veal, 1998, p.35). There are many concerns about validity of internet survey research. First of all, the researcher has not have a direct contact with participant and can only assume whether the information given is real. Other than that, personal contact with participant gives greater chance of receiving information that researcher have not even expected (Veal, 1998, p.35). However, as medical tourism could still be classified as emerging trend, it is difficult to get face-to-face interview (expenses of travel and the amount of time being consumed on research would be much greater), therefore researcher decided to base the research on secondary data and only partially support it with primary data (internet survey targeted to medical tourism users) in order to the research be as valid as possible.

Reliability is ‘the extent to which research findings would be the same if the research were to be repeated at a later data or with a different sample of subjects’ (Veal, 1998, pp.35-36). Human beings live in ever-changing social situations, therefore receiving the same data when repeating research at a later date or with different participants is hardly ever possible. It means that researcher has to be very cautious when making statements about the research results (Veal, 1998, p.36).

Ethical issue should always be taken into consideration before applying research. Researcher needs to be open about the aims of the researcher, the way the participants were selected, how long it will take to complete survey as well as what will happen to the results of the research (confidentiality and anonymity of the research) (Finn et al, 2000, p.36).

3.7 Data Analysis

Long (2007, p.19) reports that it is hardly ever that pure description is enough to make a statement. Most importantly, the researcher should consider any implications that the findings may have for thesis stated. In general, data analysis is about altering collected data into information that is useful to the research conducted.

3.7.1 QUALITATIVE DATA ANALYSIS

Qualitative data analysis should result in producing explanations that are generalizable in some way. It concentrates on opinions and views rather than numbers and statistics. Different approaches to analysing qualitative data can be used, depending on the research method that had been undertaken (Veal, 1998, pp.139-142).

3.7.2 QUANTITATIVE DATA ANALYSIS

Quantitative data concerns numbers and statistical data. Surveys can be classified as quantitative data and it should be made clear how the findings have been arrived at; that includes explanation of sample size, respond rate and focus of the survey (Long, 2007, p.55).

3.7.2 TRIANGULATION

Triangulation is described by Veal (2006, p.107) as a research method that use more than one approach in a single study in order to achieve a good understanding of the subject being investigated. It is used so the weakness of one approach is complemented by the strengths of another.

3.8 Research Methodology Summary

Medical tourism researcher will be conducted with the use of triangular research. It will concentrate on analysing society’s opinions and values and will be less concerned about general idea of medical tourism. Medical tourism is emerging trend; however there are several journal articles, books and other secondary data on the subject available. On the other hand, secondary data on medical tourism is mostly concerned about describing the phenomenon in general, rather than looking into bigger detail of potential risks for patients and local communities, therefore the researcher will concentrate on looking into secondary data that describes this aspect of medical tourism. Primary research will be second in hierarchy of data collected and will be mostly used in order to receive information from authentic medical tourists rather than be a tool to make a statement about this trend.

Chapter 4

Data Presentation and Analysis

The research was firstly associated with medical tourism trends and its motivation. However, while researching, the author of the paper analysed secondary data that presented several issues associated to medical tourism - mainly ethical issues and inequalities among local societies of medical destinations. As those issues are not very well known and by many, they are not associated with medical tourism, researcher decided to put a bigger focus on this matter.

4.1 Analysis of the primary and secondary data collection

A semi-opened survey had been designed and distributed via Internet in order to receive response from the target group medical tourists. Therefore, the survey was mainly published on medical tourism forums and websites.

4.2 Survey data and secondary analysis

Conducted survey had 52 responses. The primary research of this project will be based on this sample.

Question 1: Gender

Researcher got response from 24 (46% of all participants) females and 28 (54%) males.

Figure 4.1: Gender

Question 2: Age

Figure 4.2: Age

The most common group among participants of the research is age group of 50-59 year olds (35% of all responders). Going further it is 27% for the group of 60-69; 17% for 40-49 year olds; 11% for 30-39; 6% for 70+ and finally 4% for group of 20-29 year olds.

Questions A and B reveal basic information about the participants of the research. Researcher accepts the fact that medical tourism exists among underage group of people (most likely accompanied by legal guardian), however, due to the ethical considerations, survey is conducted on people above 18 years of age.

Majority of medical tourists in this survey are of age between 40-69 years old. Existence of younger medical tourists (e.g. 18-29 year old) could be explained by popularity of cosmetic surgery rather than specific health problems; however, it is of course not always the case.

Question 3: Country of origin

Figure 4.3: Country of origin

Majority of participants in this research come from United Kingdom – 22 out of 52 participants (42%). Further on, citizens of United States count for 35% (18 participants); population of Germany counts for 6% (3); Belgium – 8% (4) and citizens of other (unspecified) countries accounts for 9% (5) of the whole.

According to Medical Tourism: A global analysis (2006, p.13) medical tourism is about ‘patients going to a different country for either urgent or elective medical purposes’. Basically, it is common to assume that medical tourism is aimed for American and Western European (well developed) countries. One of the main motivators in medical tourism is price and timeliness (Medical Tourism: A global analysis, 2006, p.14) and as prices tend to be much higher in developed than in emerging countries, it explains origin of majority of the participants (United Kingdom – struggles with long waiting list in National Health Service and millions of United States citizens are without health insurance, therefore most of the treatments are costly) (Mattoo and Rathindran, 2006).

Question 4: Health insurance

This question was in relation to whether participants of the survey receive health insurance. 32 (62%) out of 52 (38%) applicants answered positively to this question, however, it is important to state that researcher did not ask on what health insurance covers.

Figure 4.4: Health insurance

Mattoo and Rathindran (2006) claim that there are around 40% of Americans without health insurance and prices of the treatments are not affordable for average citizen of United States, therefore it is easy to assume that majority of responders who answered ‘no’ to this question are citizens of United States or unspecified country with similar situation on health system policies. Lack of health insurance often triggers the need for medical tourism. It is sometimes the only affordable option for potential patient; therefore, even if wary about this way of undergoing medical treatment, any doubts often have to be ignored.

Question 5: Satisfaction of health care system in the participant’s country

Figure 4.5: Satisfaction of health care system

This question was asked in order to see how satisfied medical tourists are with the health care system they receive in their countries. The answer to this question can give a general idea to why (other than price and timeliness) medical tourism exists. Quality is important factor in motivation process. In case of medical tourist looking for superior quality, it is hardly ever that any financial matters were influencing patient’s decision. Most of medical tourism providers realise the importance of quality in customer’s decision making process and they strongly establish that characteristic of their medical centre in their marketing. This part of medical tourism is aimed for wealthy customers and can specifically generate issues on inequalities of patients in medical tourism (Medical Tourism: A global analysis, 2006, p.14)

Question 6: How did medical tourists hear about this trend.

Figure 4.6: How did medical tourists hear about this trend

The most popular way of learning about medical tourism is by friends and relatives (word of mouth) with the result of 52% (27 participants) in this survey. Kotler and Armstrong (2010, p. 439) describe word of mouth as ‘personal communication about a product between target buyers and neighbours, friends, family members, and associates’. Word of mouth is described as one of the most effective marketing tools.

Further on, Internet is very powerful source of information nowadays. As Cooper et al (2008, pp.634-635) states ‘as a result of Internet developments a number of new players have come into the tourism marketplace’. Moreover, tour operators report that up to 25% of their products are sold to a consumer via Internet. When it comes to medical tourism, those numbers would be much higher as most of major leisure tour operators still have not realised the potential of medical tourism, therefore medical tourist looks for information on the subject via Internet or word of mouth.

Question 7: The level of satisfaction from medical tourism service (ranking from 1-dissatisfied to 10-satisfied)

Figure 4.7: The level of satisfaction from medical tourism service

As presented on the figure above, majority of medical tourists who took the part in the survey are satisfied with the quality of the service they received from medical tourism organisation. There are no responders that would be very dissatisfied with the service and as little as 6% that were slightly dissatisfied. It could be down to quality of hospitals that are aimed for medical tourists. Cooper et al (2008, p.581) highlights importance of quality within tourism industry – ‘[quality] encourages a positive image for the company or organisation and a reputation for good quality is a major advantage in reducing the perception of risk in the minds of consumers […] success through quality is often associated with the outcome of the relationship between customer’s prior expectations of service delivery and the perception of the actual service’ (Cooper et al, p.581).

As reported by Shetty (2010) high end hospitals are not affordable for most of citizens in developing countries therefore majority of patients are medical tourists. That is where ethical considerations start to occur. Private organisations are able to pay more than public institutions, hence well qualified doctors and nurses are employed in places like that, leaving local community with less qualified staff and therefore lower quality of the service. Surely, one could argue that developing medical tourism within the emerging country will have positive impact on micro and macro economy as well as employment levels; however, it is at the cost of long term harm that governments will have to recognise and solve at some point. Looking at the high level of satisfaction from services received in medical tourism organisations, it is obvious that the trend will be growing (as mentioned before – mainly thanks to word of mouth and Internet) and as it grows, more and more issues will occur. Connell (2005) argues that ethical issues became significant not only in the aspect of inequality but also in the aspect of more competitive involvement of the market in medical care. Apollo (one of the leaders in medical tourism markets) responds to criticism on medical tourism practice that they provide free beds for those who cannot afford private medical care, however they do not provide any credible evidence of doing so. Moreover, private medical tourism organisations along with government of India state that India is ready for medical tourists and can provide the best quality, however, it remains obvious that population of India is left behind in the trend that turned health care into an excellent business opportunity.

Question 8: Reasons for travelling to other country in order to receive health care.

Figure 4.8: Reasons for travelling to other country on order to receive health care.

Most of the participants of the survey travelled for medical purposes due to cheaper cost of treatment abroad (75% - 39 participants). Other than that long waiting lists in the country of origin were secondary reason for travel (15% - 8 participants); Need for privacy of the treatment (8% - 4 participants) and holiday factor (2% - 1 participant) were the least popular reasons behind medical tourism. Price differentiation between well developed and emerging countries (e.g. India) is significant. Following research carried out by Connell (2005) ‘India has cornered a substantial part of the market because its fees are significantly below those of other possible destinations. Thus bypass operations in India are about a sixth of the cost in Malaysia’.

Leigh (2007) presents risks that are connected to medical tourism. The author highlights lack of regulations occurring in the industry, for instance how wealthy customers have access to the best facilities and health care whilst other medical tourism (although still higher in hierarchy than local community) are at risk of receiving substandard care. There is also a question of why well developed countries such as United States, Canada, United Kingdom and others are struggling with providing decent health care to their populations. One of the indicators of well developed country is their macro economy (‘Macro economy looks at the economy as a whole. The national economy is composed of all the individual market activities added together. Thus macroeconomics looks at aggregates such as national product and inflation’ (Tribe, 2005, p.9)) and part of it is country’s health care system (among other indicators such as infrastructure or inflation). As Leigh (2007) reports ‘delays for medical interventions such as hip and knee replacements, spinal surgery, and ophthalmologic procedures are a serious problem in Canada. Federal and provincial governments are struggling to shorten waiting lists and provide timely care’. Issues like this were significant factors in the creation of medical tourism but is it the best way to resolve the problem of heath care in well developed countries?

Medical Tourism: A global analysis (2006, p.61) indicates that most of the governments have conservative attitude towards medical tourism and are dismissing this trend. It is hardly ever that government is willing to sponsor medical tourism journey therefore this market is very privatised and unregulated. On the other hand, the same publication (Medical Tourism: A global analysis, 2006, p.29) describes the scheme that was developed in United Kingdom and 190 NHS patients were send abroad for routine operations, there are also regulations that allows EU patient to be treated in another European Union country, however, medical tourism within European Union is much more easier to control and monitor (and therefore is considered safer) due to common regulations than medical tourism in e.g. Asian countries (there is no international law regarding medical tourism).

Question 9: As medical tourists – have you got any ethical concerns about travelling to emerging country in order to receive health care?

Figure 4.9: Ethical concerns

100% participants of the survey have not got any ethical considerations when getting involved in medical tourism. It is as, customers are more aware of potential risks and benefits and are not aware about (or are not concerned) potential results it may have on local communities of medical destinations. Medicalised view of health care is not helping in creating equal rights to society. Medical tourism gives an impression that health can be ‘bought’ just like any other product and that attitude is taking the pressure of the governments to improve their health systems and make them available to everyone who is in need for medical treatment (People Democracy cited in Medical Tourism: A global analysis, 2006, p.31).

Ethical considerations are major problem in medical tourism. Kumar (2009, pp.78-79) reports that this trend works on the basis of the Global Code of Ethics for Tourism, however, it could be argues that tourism can lead to the mutation or even destruction of destination’s culture and traditions. When high-end hospitals in India are used by approximately 20% of Indian population, it is first sign of inequality in medical tourism. It cannot be stated that medical tourism contributes positively to the local community if they cannot use facilities that are located within their country. There is no statistical data or even credible government/institutional reports on this matter available at the present; however, the problem needs to be recognised on a global scene (Shetty, 2010).

The fact that 100% responders stated that they have got no ethical considerations about medical tourism is worrying. United Nations Economic and Social Council (2000) cited in Smith (2007, p.6) stated that ‘health is fundamental human right indispensable for the exercise of other human rights’

Local communities are being dismissed when it comes to the medical tourism business and are left with either no or substandard health care. It is social right to have unlimited and equal access to the healthcare and the fact that medical tourism is not only not contributing to improvement of local communities quality of life but is even making the matters worse (e.g. by brain drain – best qualified doctors are more likely to work in high-end hospitals where they can get paid better and by making health care a business opportunity rather than essential right of every citizen and taking the focus away from the issue by promoting it as a trend that will positively influence country’s economy).

Other than that, it is not only local communities that are at risk. Even though, most of the responders of the survey have positive experiences of medical tourism, it has to be taken into consideration that it was a small sample of 52 participants. There are several risks attached to medical tourism and main ones are lack of follow up care and lack of regulations regarding medical tourism (Shetty, 2007).

Question 10: Do you think that medical tourism has a positive impact on emerging countries? Please explain why.

Figure 4.10: Impact of medical tourism on local communities

42 responders (81%) answered ‘yes’ to this question (with 10 – 19% responders who admitted they may not have a positive impact on the local community). The researcher asked participants to explain their point of view in this matter (it was, however, non-mandatory question, in case participants want to keep their opinion to themselves). Majority of anonymous responders said that they believe medical tourism has a positive impact on emerging countries as:

They contribute financially to the local economy and therefore improve employment levels and quality of life of local community
Medical tourism may be the only reason behind visiting medical tourism destination and therefore they contribute to tourism development in the area
Medical tourism lowers the health costs and increases quality.

Other than that, there was an opinion stated that present awareness of both pros and cons of medical tourism:

‘If people are going to emerging countries to take advantage of cheaper medical services, it does improve the financial status of doctors and allows them to afford better equipment, but on the other hand it makes the services dearer and makes it less accessible for the local community. In my opinion medical tourism, has it's pros and cons, which doesn't allow to definitely state whether its impact on emerging countries is positive or negative, what makes it a very controversial matter’ (Anonymous)

In general, average participant that took part in the survey is middle aged citizen from United States or United Kingdom with the access to health care system in their country but considers the service available in their country as average. Typical medical tourist (according to the survey) heard about the trend from friends or relative, eventually learned about it via Internet. The level of satisfaction from the medical tourism service is high and main reason for travel is cheaper cost of treatment (even with health insurance, not every medical treatment is free of charge in the country of medical tourist). Medical tourist is unlikely to have any ethical considerations about the trend and believes that they contribute to the local economy in a positive way.

4.3 Triangulation

Triangulation research method allowed researcher to combine evaluation and analysis in order to present inequalities and ethical considerations in medical tourism. There are two tables presented below and those sums up both primary and secondary finding.

Table 4.1 Secondary research

Table 4.2 Primary research

4.4 Summary

Chapter 4 presented primary and secondary data and analysis with the use of triangulation. Conclusions and recommendations on medical tourism will be presented in chapter 5.

Chapter 5

Conclusion and Recommendations

5.1 Overall conclusion

Medical tourism may appear as cheap and exciting way to undergo medical treatments. From the outside it all looks right – cheaper treatment in private high-end hospital, exotic location and an interesting experience all in one. But does it not sound too good to be true? Medical tourism sometimes is the best or the only option available for some but is that enough of the reason to develop this tourism trend further? Health care should be available at the equal level to everyone and it should not be acceptable that people have to travel abroad in order to obtain medical treatment. Medical tourism associates wide range of risks not only for patients but most of all for local communities and it does spread inequalities and is not ethically appropriate.

When starting research, it was aimed to obtain information on medical tourism trends and tourist motivation but as the research was carried forward, it became clear that the subject of inequalities and ethical concerns should be included in the research. From what researcher learned from the research, it is clear that medical tourism is fast growing trend and for some countries (e.g. India) is the way to establish themselves as an ultimate medical destination. It is thought that medical tourism will provide the country with more tourists, bigger expenditure, better destination image and improvement of local community life. But who is in reality benefiting from the trend? As far as there will be a certain per cent of medical tourists that will return to the destination for leisure reasons and will influence local economy, it is private organisations, tour agents, insurance companies and hospitals that will benefit from medical tourism. Local communities may gain on better employment opportunities but other than that, in long term aspect, they will be the first ones to experience lack of equality that medical tourism causes. Private hospitals designed to service medical tourists from more affluent countries are not willing to treat locals as they hardly ever are able to pay as much as foreign customer can. It may lead to situation where medical tourism destinations will be struggling from problems that are often determinants for medical tourism such as long waiting lists, lack of staff, poor quality of the service and maybe, in extreme situations, health care system crisis in their country. Medical tourists’ main motivators are cheaper cost of treatments, long waiting lists in their countries, holiday factor and sometimes better quality of service or unavailability or difficult access of treatment in their country. But what they often forget to consider is that medical tourism is not only advantages. There are several risks attached to medical tourism and those should be considered before making decision. Medical tourists are at risk of getting substandard service, lack of follow up care, complications after the treatment and difficulties in case they want to legally challenge hospital if there is a need to do so.

5.2 Recommendations

The primary and secondary researched have presented medical tourism trends, tourist motivation as well as ethical concerns regarding this emerging trend in tourism industry. Other than general data and information on the subject, the inequalities among local societies had been shown. Medical tourism is expected to grow rapidly and become more and more popular. However, as stated before, there are several issues that are attached to medical tourism and therefore those should be analysed further. For now on, there is very limited data available on the disadvantages of medical tourism. There are several publications that describe trend in a positive way, whilst issues of it are hardly mentioned. It was the case with Global Trends in Health and Medical Tourism by Kumar (2009). The researcher was struggling to find this book objective and got an impression that it is revolved about promoting medical tourism rather than presenting facts. The reason why there are that little publications on actual threats of medical tourism may be the fact that it is only in recent years that it became more popular. It is expected that with time, the problem will be recognised by a wider audience in case to raise awareness. There will always be supporters and opponents of the trend and as far as it is absolutely acceptable, the researcher finds it essential, for local communities and medical tourists to be aware of both, advantages and disadvantages of the trend in order they can make a reasonable decision based on credible data.
Recommendations for researcher would be to look into this subject area further and investigate what local communities think about this emerging trend.

In relation to make the trend more appropriate from ethical point of view, local communities should have access to the hospitals designed for tourists. It is, however, difficult to achieve – private hospitals are expensive and if locals will be allowed to use it for free then it is some sense kind of inequality again – why does foreigner have to pay for the treatment and local does not? In order to avoid issues like this, international regulations have to be applied. But how to organise it if several countries still have not fully recognised the trend, not even mentioning about the problems that it may cause? Even if it happens; how to control regulations on such a wide level? Creating international regulations regarding medical tourism, applying them and then controlling whether they are being carried out appropriately is expensive and time consuming – in extreme scenario, it may put a strain on international relations. Would it not be easier, cheaper and quicker to recognise the problem within the countries so that patients are not at the must of travelling abroad in order to obtain health care that is, according to United Nations Economic and Social Council (2000), fundamental human right? The answer is, that it probably would, but at the present, with the business of medical tourism and ‘buying health’ developing quicker than ever and surely, there are organisations or even counties (e.g. India – with its government trying to promote it as an ultimate medical destination and goes as far as creating medical visas – Medical Tourism: A global analysis, 2006, p.71) that are determined not to let that happen.

ABBREAVIATIONS

NHS National Health Service

EEA European Economic Area

UK United Kingdom

EU European Union

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Appendix 1