Medical tourism and policy implications for health systems: a conceptual framework from a comparative study of Thailand, Singapore and Malaysia

Medical tourism is a growing phenomenon with policy implications for health systems, particularly of destination countries. Private actors and governments in Southeast Asia are promoting the medical tourist industry, but the potential impact on health systems, particularly in terms of equity in access and availability for local consumers, is unclear. This article presents a conceptual framework that outlines the policy implications of medical tourism's growth for health systems, drawing on the cases of Thailand, Singapore and Malaysia, three regional hubs for medical tourism, via an extensive review of academic and grey literature. Variables for further analysis of the potential impact of medical tourism on health systems are also identified. The framework can provide a basis for empirical, in country studies weighing the benefits and disadvantages of medical tourism for health systems. The policy implications described are of particular relevance for policymakers and industry practitioners in other Southeast Asian countries with similar health systems where governments have expressed interest in facilitating the growth of the medical tourist industry. This article calls for a universal definition of medical tourism and medical tourists to be enunciated, as well as concerted data collection efforts, to be undertaken prior to any meaningful empirical analysis of medical tourism's impact on health systems.

Introduction

Growing demand for health services is a global phenomenon, linked to economic development that generates rising incomes and education. Demographic change, especially population ageing and older people's requirements for more medical services, coupled with epidemiological change, i.e. rising incidence of chronic conditions, also fuel demand for more and better health services. Waiting times and/or the increasing cost of health services at home, coupled with the availability of cheaper alternatives in developing countries, has lead new healthcare consumers, or medical tourists, to seek treatment overseas [1]. The correspondent growth in the global health service sector reflects this demand. The globalisation of healthcare is marked by increasing international trade in health products and services, strikingly via cross border patient flows.

In Southeast Asia, the health sector is expanding rapidly, attributable to rapid growth of the private sector and notably, medical tourism, which is emerging as a lucrative business opportunity. Countries here are capitalising on their popularity as tourist destinations by combining high quality medical services at competitive prices with tourist packages. Some countries are establishing comparative advantages in service provision based on their health system's organizational structure (table 1). Thailand has established a niche for cosmetic surgery and sex change operations, whilst Singapore is attracting patients at the high end of the market for advanced treatments like cardiovascular, neurological surgery and stem cell therapy [2]. In Singapore, Malaysia and Thailand alone, an estimated 2 million medical travellers visited in 2006 - 7, earning these countries over US$ 3 billion in treatment costs (table 2).

figure 1

The framework facilitated the identification of the following variables for empirical analysis:

Governance: the number and content of GATs health sector commitments, the number and size of medical tourist government committees or agencies, availability of medical tourist visa.

Delivery: number of hospitals in public and private sector treating foreign patients, consumption of health services by domestic and foreign population (hospital admissions).

Financing: medical tourist revenues, type of medical tourist payment (service fee or insurance, level of copayment), foreign direct investment in the health sector.

Human resources: doctor and nurse ratios per 1000 population, proportion of specialists in the public and private sectors, number of specialists treating foreign patients.

Regulation: number of JCI accredited hospitals, number of medical tourist visits facilitated by brokers.

At present there is an acute lack of reliable empirical data concerning medical tourist flows. Most urgently, a universal definition of who counts as a medical tourist (e.g. per procedure or per inpatient) should be agreed on, ideally at the international (WHO) or regional level (amongst Ministries of Health, Trade, Tourism and private hospital associations). Variation in definitions and estimates amongst the three study countries alone are significant. Singapore's Tourism Board estimates medical tourist inflows based on tourist exit interviews with a small sample population, whilst the Association of Private Hospitals in Malaysia collects data only from member hospitals and includes all foreign patients, including foreign residents and those who happen to require medical care whilst on vacation [28]. Thailand's Ministry of Commerce collects data on medical tourist inflows from private hospitals, counting foreign patients as the APHM does, except that definitions between hospitals about numbers vary (some count inpatient admissions, others per procedure) [71]. Standardised data collection will enable researchers to make meaningful cross country comparisons, as well as carry out detailed country specific studies to investigate the benefits and disadvantages of medical tourism's impact on health systems.

Conclusion

The rise of medical tourism in Thailand, Singapore and Malaysia and governments' endorsement of the trend has raised concerns about its potential impact on health systems, namely the exacerbation of existing inequitable resource distribution between the public and private sectors. Nowhere is this more evident than in Southeast Asia, where regulation and corrective policy measures have not kept pace with rapid private sector growth during the past few decades. This paper presents a conceptual framework (Figure 1) that identifies the policy implications of medical tourism for health systems, from a comparative analysis of Thailand, Singapore and Malaysia. This framework can provide a basis for more detailed country specific studies, of particular use for policymakers and industry practitioners in other Southeast Asian countries where governments have expressed an interest in facilitating the development of the industry. Medical tourism can bring economic benefits to countries, including additional resources for investment in healthcare. However, unless properly managed and regulated on the policy side, the financial benefits of medical tourism for health systems may come at the expense of access to and use of health services by local consumers. Governments and industry players would do well to remember that health is wealth for both foreign and local populations.

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Acknowledgements

All analysis and opinions expressed in this paper are the authors' alone. The authors acknowledge the insights on methodology provided by Wu Xun, as well as the detailed and helpful comments from Chee Heng Leng on an earlier version of this draft.

Author information

Authors and Affiliations

  1. Lee Kuan Yew School of Public Policy, National University of Singapore, 469C Bukit Timah Road, OTH Building, Singapore, 259772, Singapore Nicola S Pocock & Kai Hong Phua
  1. Nicola S Pocock