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h i g h l i g h t s
< Medical tourism is now seen as relatively short distance, cross border and diasporic.
< Medical tourism is of limited gravity despite cosmetic surgery dominating media discussions.
< Numbers are usually substantially less than industry and media estimates.
< Medical tourism companies integrated into the wider tourism industry.
< Culture, quality and availability of care inuence medical tourism behaviour.
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 3 February 2012
Accepted 21 May 2012
An overview is given of the short history and rapid rise of medical tourism, its documentation, and
current knowledge and analysis of the industry. Denitions of medical tourism are limited hence who
medical tourists are and how many exist are both indeterminate and inated. Denitions often conate
medical tourism, health tourism and medical travel, and are further complicated by the variable
signicance of motivation, procedures and tourism. While media coverage suggests long-distance travel
for surgical procedures, and the dominance of middle class European patients, much medical tourism is
across nearby borders and from diasporas, and of limited medical gravity, conicting with popular
assumptions. Numbers are usually substantially less than industry and media estimates. Data must
remain subject to critical scrutiny. Medical travel may be a better form of overall categorisation with
medical tourism a sub-category where patient-tourists move through their own volition. Much medical
tourism is short distance and diasporic, despite being part of an increasingly global medical industry,
linked to and parallel with the tourism industry. Intermediaries (medical tourism companies) are of new
signicance. Opportunities are diffused by word of mouth with the internet of secondary value. Quality
and availability of care are key inuences on medical tourism behaviour, alongside economic and cultural
factors. More analysis is needed of the rationale for travel, the behaviour of medical tourists, the
economic and social impact of medical tourism, the role of intermediaries, the place of medical tourism
within tourism (linkages with hotels, airlines, travel agents), ethical concerns and global health
restructuring.
2012 Elsevier Ltd. All rights reserved.
Keywords:
Medical tourism
Medical travel
Procedures
Typology
Diaspora
Tourist numbers
Marketing
Multinationals
Thailand
1. Introduction
Medical tourism (MT), primarily a late twentieth century
phenomenon, is said to have recently and rapidly boomed. This
paper assesses the parallel boom in academic analysis. Numerical
data on MT are inadequate and unreliable (e.g. Hopkins, Labont,
Runnels, & Packer, 2010; Johnston, Crooks, Snyder, & Kingsbury,
2010) being based on industry optimism and boosterism rather
than rigorous analysis. Signicant cross border movements for
health care (including diasporas and institutional transfers) are
* Tel.: 61 (0)2 9351 2327.
E-mail addresses: john.connell@sydney.edu.au, jconnell@mail.usyd.edu.au.
0261-5177/$ e see front matter 2012 Elsevier Ltd. All rights reserved.
doi:10.1016/j.tourman.2012.05.009
conated with accidental and expatriate health care, yet developing a rigorous denition of MT poses problems. This paper seeks
to ll this analytical gap and draw attention to those that remain.
The second part analyses recent trends in MT, and the implications
of contemporary change, and argues for greater analysis to be given
to decision-making, the role of intermediaries (medical tourism
companies) and the place of MT within both tourism (linkages with
hotels, airlines and travel agents and tourist performativity) and
global health restructuring.
Travel for medical care (and wellbeing) has long existed.
Destinations, such as Harley Street in London, are famous as
international centres of medical care. Yet in the last two decades
a form of reverse globalisation has occurred with patients from
themselves do, since the term suggests leisure and frivolity [and]
promotes a marketplace model that disregards the suffering that
patients experience, so trivialising the experience. So-called
maternity tourism or citizenship tourism where expectant
mothers cross borders (for example from China to Hong Kong and
Nigeria to the United States) to have anchor babies in more
developed countries (e.g. Erbe, 2011; Gilmartin & White, 2010) have
few touristic characteristics. Long-staying reproductive tourists
and those in search of stem cell cures see their travels as more akin
to exile or pilgrimage, or at least holiday-exile (Inhorn, 2011a,
2011b; Inhorn & Patrizio, 2009; Matorras, 2005; Song, 2010).
Clandestine cross-border and refugee movements for health care,
such as from Papua New Guinea to Australia, and from Burma to
Thailand, are particularly problematic (Connell, 2011a) with
patient-consumers effectively outsourcing themselves, again with
no obvious resemblance to tourism. From this general perspective
Kangas (2010) opts for either medical travel, medical care abroad
or treatment abroad. Yet, though not conventionally seen as MTS,
and sometimes with little individual volition, many such people
engage in somewhat similar travels and experiences.
Some components of the medical industry also regard MT as too
frivolous a term. In the words of one plastic surgeon: While we
appreciate the involvement of the travel and hotel industries we
must never lose sight of the fact that travelling abroad for a medical
procedure is not a vacation, it is surgery (Nahai, 2009: 106).
Destination hospitals focus on high-quality care, reliability and
competence, although other institutions, including the facilitating
MTCs and destination countries, seek to emphasise normal touristic elements, such as shopping, dining and hotel facilities, to stress
that the experience will be pleasurable. Some recuperation is
usually possible, and a journey with a serious purpose can have
a frivolous, pleasurable and celebratory ending. Tourism offers
added value. One industry analyst has argued that the industry
should be working to get medical tourism counted as a niche
tourism sector (Youngman, 2010b). However it is extremely difcult to differentiate MT according to the procedures involved, their
morality and necessity and the social and economic characteristics
associated with them in different national contexts.
4. A detour around diaspora
From a primarily Thai perspective, it has been argued, that even
the idea of medical tourism creates assumptions about race nation
and class, with the emblematic medical tourist a wealthy white
western or East Asian tourist who combines cosmetic surgery with
a beach holiday (Whittaker, 2009: 323). Such assumptions are
enhanced in the generally available statistical data, and much
promotional material (especially websites) within marketing
strategies. Countries and institutions seek afuent patients of
European origin, hence there is a focus on whiteness where
patients appear to be of European origin and, in some destinations
such as Argentina, Mexico and the Philippines, staff too are
depicted as white. However growing recognition of the signicance
of diasporic tourism challenges assumptions about whiteness,
long-distance travel and the meaning of MT. Diasporic tourism is
a widely recognised phenomenon (e.g. Basu, 2004; Coles &
Timothy, 2004) and it has become a distinct component of MT,
although most such returnees probably travel for a multiplicity of
reasons.
Much international medical travel is of overseas diasporic
populations, notably Mexicans in the United States and a more
global Indian and Middle Eastern diaspora. In some countries
return migration for medical care contributed to the genesis of
a wider MT. Patients return home because they are likely to be
comfortable and familiar with the health system, the language and
class, who could no longer pay for private health care, hence private
hospitals lost their customer base and revised their marketing
strategies to target overseas patients, for whom devaluation meant
that prices effectively halved (Turner, 2007b). Malaysia and
Thailand both became involved after 1998. India entered the MT
market rather later than south-east Asia but developed rapidly with
shifts in technology and the development of sophisticated hospital
chains. Entrepreneurial governments have become supporters and
promoters, through national development planning and tourism
campaigns. In India, Malaysia and Thailand, tax concessions were
given to MT providers and tourism ofce campaigns for MT,
alongside subsidies for land purchases and infrastructure (Alsharif,
Labont, & Zuxun, 2010; Chee, 2010; Gupta, 2008; Wilson, 2011).
Asian successes have prompted growing global interest and
competition, with optimism both unbounded and often unfounded.
Difcult political situations, high costs, poor infrastructure,
language differences, unfamiliarity and overstretched medical care
systems are constraints in several countries (Heung et al., 2011).
While MTS ows have become more complex and multidirectional,
Asia is likely to continue to dominate the industry.
MT has parallels with and links to the wider tourism industry.
Marketing is undertaken through websites (of hospitals, national
tourism organisations and MTCs) and distinctive MT guidebooks.
Diaspora tourists are loosely familiar with what is available at
home and many rely almost entirely on word of mouth or good
luck, depending on the gravity of the procedure. Most MT guidebooks were published in the mid and late 2000s and have not been
updated, as the internet has taken over. Although the internet has
become crucial to marketing it only dominates in surveys of groups
of people who are not necessarily intending to be MTS (e.g. Gill &
Singh, 2011) or where a medical tourism industry is being established (Ye, Qiu, & Yuen, 2011). A 2009 survey of an unknown
number of international patients at Bumrungrad revealed that
most learned about medical tourism through friends, and very few
through books and the media, with a quarter of Bumrungrad
patients using the internet for information on country destinations
and hospitals (Anon, 2010). Further studies have shown that the
main inuence on the majority of MTS at Bumrungrad and 60% of
those in Kuala Lumpur hospitals was advice and referrals from
friends and family (Musa, Thirumoorthi, & Doshi, in press;
Veerasoontorn, Beise-Zee, & Sivayathorn, 2011). In a general survey
of MTS, with no information on methodology or sample size, 49%
found out about MT through the internet and 73% sought specic
information on the internet, as opposed to through friends, books
or MTCs (Anon, 2009). In Oman more than 70% of medical tourists
got their information from friends and a further 19% from family
(Al-Hinai, Al-Busaidi, & Al-Busaidi, 2011). Asians (or at least
Chinese, Japanese and Koreans) preferred recommendations from
friends rather than the Internet (Yu & Ko, 2012), and in a large
sample of MTS in four different destinations almost half (45%)
learned of opportunities through friends, relatives and colleagues,
followed by internet advertising (Alsharif et al., 2010). As MT
evolves word of mouth appears to be becoming more important,
with the internet simply a means of checking, corroborating and
booking. How people use the internet, which websites they visit
(whether of MTCs, hospitals or countries) and how they assess the
information is largely unknown. Whether a digital divide
discriminates against potential users in some places is similarly
unknown (Lunt & Carrera, 2010).
The growth of MT has been accompanied and reciprocated by
the rise of medical tourism companies: medical travel agencies
(Sobo, Herlihy, & Bicker, 2011) or virtual brokers (Solomon, 2011).
Rather more scathingly, Turner described them as the car dealerships of the global health-services industry (2007a: 127), beyond
the bounds of ethics or duciary duty, but they are little different
from most travel agents. Indeed MTCs work like specialized travel
agents (Herrick, 2007: 6), some with branches in different countries and with afliations to hospitals, hotels and airlines. Almost all
were established in this century, but most are reticent about their
history, and many have been short lived (Cormany & Baloglu, 2011;
Turner, 2011). Hundreds of MTCs exist in both source and destination countries; Reisman suggests almost 1000 niche facilitators
(2010: 70) while Treatment Abroad has a directory of 820 registered companies.
Most MTCs are small. In the United States MTCs had a mean of
9.8 employers, substantially larger than elsewhere (Alleman et al.,
2011), whereas in Australia, MTCs focused on cosmetic surgery,
were mainly owned by women who had been cosmetic surgery
recipients themselves, hence had personal links with the industry,
promoting their work as a service rather than an industry, and with
few if any employees (Ackerman, 2010; Bell et al., 2011; Jones,
2011). Several larger MTCs have operations spanning the source
country and sometimes multiple destinations. Some MTCs take
a more or less global perspective on the provision of medical
tourism, but most MTCs limit themselves or are limited to particular markets, destinations and procedures e usually about four
destinations e where they claim specialist knowledge, and can
claim to vouch for reputation and experience (Peters & Sauer, 2011).
MTC websites have multiple linkages to countries, hospitals and
clinics, patient stories and testimonials (sometimes in videos),
press reports, virtual tours of particular facilities and interactive
sections for obtaining quotations. All are commercial sites,
complete with advertisements and linkages, for insurance, hotels,
travel companies, sources of nance and related MTCs. Such sites
raise awareness, create a perceived need, offer multiple possibilities, stress benets, emphasise normality, refer to pleasant tourism
components and encourage potential patients to enquire further.
The MTC websites emphasise hospital accreditation and the
pragmatics of international travel, with United States sites
providing more detail on what is likely to be an exceptional experience; all stress affordable, timely, high-quality, reliable care with
the latest technology (Cormany & Baloglu, 2011; Lunt & Carrera,
2011; Sobo et al., 2011; Turner, 2011). Few mention any actual
risks of treatment, although Canadian MTCs were more likely to do
so (Connell, 2011a; Penney, Snyder, Crooks, & Johnston, 2011), but
emphasised patient agency and savvy consumerism. They refer to
medical tourism, perhaps as a purposive strategy to reduce patient
fears (Sobo et al., 2011), so promoting the benets of overseas
treatment while playing down the risks (Mason & Wright, 2011).
Procedures are advertised and promoted in ways that make them
acceptable and not challenging. Gorgeous Getaways in Australia has
packages described as Yummy Mummy, Fabulous Facelift and even
Designer Vagina (Weaver, 2008). Some MTCs encourage contact
between aspiring and former patients, sometimes at forums. A
survey of MTS at Bumrungrad revealed that over half (52%) had
acquired their knowledge of country destinations and hospitals
through MTCs, while as many as 92% claimed to have used an MTC
(Anon, 2010). While that proportion is likely to be particularly high
(since diasporic MT is limited) it emphasises the growing dominance of MTCs within MT. All MTCs stress safety and reliability, by
referring to accreditation, staff credentials and testimonials of
recent patients.
Beyond the ubiquitous focus on price and reliability, the third
focus of MTCs is tourism, often linked into a package. The merits of
particular countries (and their people) as tourist destinations are
usually covered. Thus MedRetreat states: Imagine travelling to
exotic locations like Thailand, Malaysia, India, Argentina and South
Africa in perfect anonymity with a personal assistant at your side
(www.medtretreat.com). As one Indian web site advertisement has
suggested many patients are pleased at the prospect of combining
their tummy tucks with a trip to the Taj Mahal (quoted in Connell,
2008: 232). MTCs, anxious to gain clients, stress tourism possibilities much more than the actual health providers.
Health providers also advertise on the web, and most intending
patients refer to the websites of potential hospitals and clinics.
Their primary focus is on available procedures, reliability, quality
and cost, but the last is somewhat downplayed, except in Asia
(where prices are lower), on the assumption that most potential
patients have already discovered that element. Images of modernity, via technology, cleanliness and apparent efciency are dominant. Mainly English language sites feature the range of possible
procedures, costs, accreditation and afliations, smart and qualied
staff, lavish wards and accommodation, patient testimonials and
diverse language competence. Technological prowess is rarely
ignored in any form of marketing (Crooks, Turner, Snyder, Johnston,
& Kingsbury, 2011). Tourism is less common in hospital websites,
though they often stress comfortable accommodation (and its
facilities, such as internet connections), and links to hotels and
other tourism providers. Websites stress the hotel-like quality and
amenities of the hospitals, like restaurants, and related services
such as airport transfers and visa extensions.
The hospitals at the core of medical tourism have transformed
themselves from the functional and clinical public hospitals that
preceded them, taking on elements of elite hotels, IT ofces and
shopping malls, with an architecture projecting the corporate
hospital as anything but a hospital (Lefebvre, 2008: 102). Foyers
resemble hotels rather than hospitals. In elite hospitals e hospitels
e ve-star rooms have personal VCRs, restaurants provide respite
from hospital food and at Bumrungrad Japanese and Italian
restaurants, McDonalds and Starbucks are all on the rst oor. In
form and function the key hospitals in the medical tourism industry
have come close to luxury hotels, in a transition where consumption and consumerism have been added to cure and care. Rather
like such hotels, they too have become non-places: placeless and
largely indistinguishable (Aug, 1995), and thus more like the basic
elements, the hotel chains, of the international tourism industry.
Some hospitals and hospital chains have become functionally
integrated into the tourist industry. Bumrungrad owns 74 serviced
apartments. The principal hospital group in Singapore, Rafes,
arranges airport transfers, books relatives into hotels and arranges
local tours. Hospitals have also become linked to airlines. Bangkok
Hospital is linked with AirAsia, Bumrungrad has an agreement with
Flight Centre for North American patients. Turkish Airlines
announced that they were working with the major national
medical tourism providers to provide discounted fares for MTS
from the United States and various European countries. Key
hospitals have become more like MTCs, and multinational multiproduct rms, part of integrated systems where, if not owning
components of the travel industry, they are closely integrated into
it, with preferential arrangements with particular hotels, airlines
and related companies. Numerous countries and their tourist
industries, from Jamaica to China (Heung & Kucukusta, in press;
Pearcy, Gorodnia, & Lester, 2012), remain anxious to participate in
every facet of the industry.
No health care sector is as competitive and consumer-oriented
as MT, since some procedures do not need be undertaken, and
most are possible in many countries, usually including home
countries. Beyond obvious information about price differentials and
quality of care, the discourses of marketing MT have taken on
diverse themes that emphasise the ambience and even opulence of
care. Marketing has had the considerable task of convincing
patients to abandon uncertainty and fear, even xenophobia, trust
overseas hospitals and health workers in different cultural contexts
(even though diasporic tourism led the way), at a time of personal
uncertainty and even crisis.
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