Medical Tourism: Patient’s Perspective

Medical tourism is an emerging concept and becoming popular option for patients who want to receive treatment at various destinations and for undertaking procedures that are not available in their home countries due to lack of affordability, lengthy waiting lines, and for some other reasons(Burkett, 2007&Mudur, 2004). Countries like India, Thailand, Singapore, Malaysia and South Korea are getting 1.3 million medical tourists per year and number is growing annually (Grewal, Daz, Kishore, Nandan, 2010). To define medical tourism it can be said that it is a form of tourism in which a tourist in the form of a patient travels overseas or another destination instead of their home destination for wellness, surgeries, therapies, spas and many health related activities like transplant, reproduction etc. Health Tourism has been defined by Goodrich & Goodrich (1987) as ‗the attempt on the part of a tourist facility or destination to attract tourists by deliberately promoting its health-care service and facilities, in addition to its regular tourist‘s amenities.‘ Consequently, health tourism includes both medical tourism and wellness tourism(spa and relaxation treatment) (Caballero & Mugomba, 2007).

The Place where most of the first-hand accounts of experiences of medical tourists were found is in reports and media sources. The main focus of these accounts was on one of the following three things: (1) positive and negative aspects of medical tourism; (2) sensationalized issues; and (3) reports of post-recovery life. These issues covered quite broad aspects including both positive and negative experience. Negative sides of experience had accounts covering details such as in order to afford access to the care abroad, patients have to borrow heavy amounts from family (Marlowe & Sullivan, 2007) and concerns regarding foreign doctors speaking different language, having different care standards and getting treatment from them(Mudur, 2004). In the topics shared in published accounts of patients relating to medical tourism, the more publicized topics were stories of their own and other‘s presumptions of cleanliness and care quality in the hospitals abroad. While reporting on the care received by him in Thailand a patient said: ―...this is not a straw-village clinic with rusty scalpels!‖ (Operating profit, 2008), also another one who received dental treatment in China reported: ―It was dubious when you looked at it [the clinic], but when you got into the place they were competent, intelligent, and did everything they had to do‖ (Patriquin, 2007).On the other hand, It doesn‘t come as a surprise that patients stressed such issues in their accounts knowing that there were reports to have countered other‘s perceptions of care abroad. Other patient‘s accounts stressed on how care at hospitals abroad was not as sanitary as their assumption (Hewitt, Huston, Dhillon & Haederle, 2006). Reflecting, post-recovery reports were in huge amounts in the reviewed media sources. In these accounts former medical tourists reflect positively on their overall experience and also the positive impact on their health after receiving a procedure abroad. A statement of former medical tourist from Canada who said: ―Life is too precious. I‘m in my early 50s and I have lots of things to do in my life and one of them isn‘t lying at home in pain... I‘m a Victoria fire-fighter. I have been for 29 years and I don‘t want to retire that way, you know, with a disability‖ (Copeland, 2004). Receiving treatment abroad allowed him to continue his employment. Another Canadian patient positively

Asian countries are progressing towards medical tourism.

The issues that were discussed regarding decision making are: (1) push factors (i.e. things that pushed patients to get treatment away from home care at home). (2) Pull factors (i.e. things that attracted patients to other countries). (3) Information sources consulted. Most frequently observed push factors was that of cost. Another factor related to cost that pushes them to approach medical tourism because of high budget health care services and procedures in patient‘s home countries. On the other hand a lack of insurance may also push patients to abroad for more affordable care because some procedures may not be covered by their insurance plans. Long waiting time was also a push factor that drawing patients abroad with proper and timely care. Frequently identified pull factors were also reviewed. The mostly noted pull factor was quality. It has been observed that patients can be attracted towards medical tourism hospitals as such hospitals offer great quality of service, facilities and care. Language is also a constraint that impacts patients decision- making therefore patients prefer hospitals where employees speak their language and follow same religious protocols they do. (Badam, 2005; Perotin, 2004;Olian, 2006) described regarding availability or timely information, while making decision about medical tourism as the patients may need to consider the number of factors, such as the credentials of surgeons or doctors. The internet also becomes an important source of information regarding medical tourism. For example, former medical tourists created various websites to share information and experiences, this serves valuable source for medical tourists. According to the above review it is clear that there are many factors that medical tourists take into consideration while choosing their destination for treatment but their first preference is word-of-mouth and presence of marketing material is favourable as well.

The review not only wanted to address a personal health need through surgery, it also captured three types of factors that motivate patient‘s engagement in medical tourism: (1) procedure-based; (2) travel-based; and (3) cost based. Procedure based motivation for patients noted through several sources is that patients may wish to go for surgery abroad that either are illegal Also, listening to success stories regarding beneficial outcome from others via words-of-mouth or online, can help in motivating potential medical tourists (Kangas, 2002). As stated earlier, patients may consider the potential for travel and tourism while making decisions regarding medical tourism. It thus doesn‘t surprise that final decision making for medical tourism can actually be influenced by certain travel-based factors that include the location of destination. Motivations like these are thought to help in increasing ease and affordability of international travel, the frequency by which flights go to major destinations, the swiftness of visa procedures and hastening up of applications for international patients (Lee, 2007; Jenner, 2008; Bajaj, 2007; Chinai&Goswami, 2007), Arunandondchai& Fink, 2007). The presence of package deals can also serve as a travel-based motivation, as the low price and ease of booking may be appealing to the ones looking for guidance in planning (Saniotis, 2007; Oberholzer-Gee, Khanna &Knoop, 2005; Turner, 2009). Generally, the potential motivations for patients‘ participation in medical tourism were discussed to be cost and affordability. Countries providing public health care coverage, such as Canada, have (often inaccurate) expectation among patients that they may receive a partial or full remuneration for the travel and surgery costs that they incur abroad is thought to motivate some to participate in medical tourism (Eggerston, 2006; Prashad, 2008; Starnes, 2004). It is clear from above that medical tourists are motivated by several factors but the final decision making may be influenced by the location of destination and affordability.

There are many challenges that people can experience when undergoing surgery/operations or travelling for medical purpose. Three types of risk associated with medical tourism concerning these two aspects were discussed. These are: (1) risks to travellers health. (2) Travelling risk. (3) Risks related to pre and post treatment in the home country. According to the (Forgione& Smith 2007; MT, 2007; McQueen, 2008), risks that patients can be exposed may have negative effects on their health contain; post treatment catching infections in the hospitals, inadequate supply of blood in the hospitals when needed to meet the patient‘s needs. (Sen Gupta, 2008)Examined that home countries are not performing operations or surgical procedures that are illegal and medical tourists may be exposed to health risks. According to the (Cheung & Wilson, 2007), there is high cost of some procedures which they

their health. On the other hand, concerning risk associated with travel, there are two risks that are significant to medical tourists were discussed in the literature. The first one relates to airline travel.(Howze, 2007; Law, 2008; Lautier, 2008) discussed another category of travel related risks and mentioned that patients away from their home or country while getting treatment and the recovery period abroad, due to this mental stress of travel can increase the psychological and emotional stress for medical patients/tourists. (Brouwer, van Excel, Hermans& Stoop, 2003) explained another post-operatively risk that may be experienced by patients because many doctors in home countries may be disinclined to treat medical tourists after returning home for anxiety that they will be in some trouble for complications occurring from procedures happened abroad in countries with limited options for legal recourse. From the above discussion it is clear that due to travelling or post treatment care at home the patients may be exposed to serious health risk.

It can be induced from the sources which were reviewed for this review that patients are to hold many responsibilities while practicing medical tourism. As patients mostly have only roles to play in its founding (Crooks & Agarwal, 2008), medical tourists may have specific responsibilities in this regard as it may be expected that they transport hard copy records over vast distances and also ensure their safe arrival to correct people. Of course, there are worries of damaging of records during transit and also of unwillingness of patients to share details regarding their surgery and might choose not to share it abroad with their regular doctor, which threatens the continuity of information of care and its benefits. Another implication for patients is that it is advisable to them to take precautions to avoid risky situations while travelling and also while abroad. Positively, it is understandable that how patients face these challenges will most likely affect their experiences of accessing international medical care via medical tourism directly. It was duly noted in the findings section that word-of-mouth would be important within medical tourism industry: information about facilities and countries providing treatment which might interest others can easily be spread by satisfied patients. In this way, these medical tourists can be considered as ‗ambassadors‘ for countries providing treatment and also for hospitals with time after returning home. Doing this can positively challenge expectations of the health care delivered in some of the countries, thus it helps to overthrow the discussed in the first-hand accounts subsection. Also, negative experiences of the care abroad can very well strengthen these assumptions. Gradual growth of medical tourism has many social and economic benefits both for host and guest community. If medical tourism will grow it will affect many sectors of the economy directly as well as indirectly and will provide a very fertile ground for harmony and social integration. This will develop by performing complex surgical treatments for inbound medical tourists. There are many examples of this and these are:- Some Indian students donated blood for a Pakistani patient liver transplant and surgery was performed by doctors of Shri Ganga Ram Hospital, this showed humanity and compassion for other people. On the other hand, there is a case from Chennai hospital where the life of a Pakistani patient was saved by Indian doctors and Indian donors by performing heart transplant surgery. ―Reflecting its commitment to saving and enriching lives beyond boundaries, a team of cardiac experts at the Centre of Excellence for Advanced Cardiac Care, Fortis Malar, Chennai, led by Dr. K. R. Balakrishnan, Director Cardiac Sciences, performed a lifesaving complex heart transplant surgery on a Pakistani national,‖ (The Express Tribune, 2013). These examples showed that patients country do not matter for doctors, thereby building international relations between two countries.

Arunandondchai, J.,& Fink, C. (2007). Globalization for health: trade in health services in the ASEAN region. Health Promo Int, 21, pp. 59-66. Badam, R.T. (2005). Americans, Europeans head to India for cheap, high-quality medical care. Guardian, B7. Bajaj, K. (2007). Come, Heal Thyself. Business Today (India). Brouwer, W., van Excel, J., Hermans, J.,& Stoop, A. (2003). Should I stay or should I go? Waiting lists and cross-border care in the Netherlands. Health Pol, 63, pp. 289-298. Burkett, L. (2007). Medical tourism: concerns, benefits and the American legal perspective. J L Med, 28, pp. 223-245. Caballero, S., & Mugomba, D. Medical Tourism and its Environmental Opportunities – A conceptual framework for entry into the industry. Available from:

Cheung, I.A., Wilson, A. (2007). Arthroplasty tourism. Med J Aust, 187, pp. 666-667. Chinai, R. & Goswami, R. (2007). Medical visas mark growth of Indian medical tourism.Bull World Health Org, 85, pp. 164-165. Choat, I. (2003). Surgically enhance your wage. Travel Weekly, 1688, pp. 38-39. Connell, J. (2005). Medical tourism: sea, sun, sand and.surgery. Tourism Mgmt, 27, pp. 1093-1100. Copeland, J. Canadian medical tourist in India (2004). CBC News [http://www.cbc.ca/news/viewpoint/vp_copeland/20040920.html]. Crone, R.K. (2008). Flat medicine? exploring trends in the globalization of health care. Acad Med, 83, pp. 117-117. Crooks, V.A. & Agarwal, G. (2008). What are the roles involved in establishing and maintaining informational continuity of care within family practice? A systematic review. BMC Family Practice, 9, p. 65. DiMicco, F., & Centron, M. (2006). Club Medic. Asian Pac Biotech News, 10,527-531, 129. Eggerston, L. (2006). Wait-list weary Canadians seek treatment abroad. CMAJ, 174, pp. 1247-1247. Forgione, D.A. & Smith, P.C. (2007). Medical tourism and its impact on the US health care system. J Health Care Fin, 34, pp. 27-35. Garcia-Altes, A. (2005). The development of health tourism services. Ann Tourism Res, 32, pp. 262-266. Garud, A. (2005). Medical tourism and its impact on our healthcare. Natl Med J India, 18,318-319. Goodrich, J. (1993). Socialist Cuba: a study of health tourism. J Travel Res, 32, pp. 36-41. Goodrich, J.N., & Goodrich, G.E. (1987). Health-Care Tourism –An Exploratory Study: Tourism Management, 8(3), pp. 217-222. Gray, H.H., &Poland, S.C. (2008). Medical tourism: crossing borders to access health care. Kennedy Inst Ethics J, 18, pp. 193-201. Grewal, Indu., Das, J.K., Kishore, J., & Nandan, Deoki. (2010). Satisfaction Levels of International Patient‘s in India, IMJT. Hewitt, B., Huston, A., Dhillon, A. & Haederle, M. (2006). The Doctor is in... INDIA. People, 65, pp. 131-135. Horowitz, M.D.& Rosensweig, J.A. (2007). Medical tourism: health care in the global economy. Phys Exec, 33, pp. 24-30. Howze, K.S. (2007). Medical tourism: symptom or cure? Georgia L Rev, 41, pp. 1013-1052. Hume, L.& DiMicco, F.J. (2007). Bringing hotels to healthcare: a RX for success. J Quality Assurance Hospitality Tourism, 8, pp. 75-84. Importing Competition: globalisation and health (2008). Economist, 388, pp. 12-12. Jenner, E.A. (2008). Unsettled borders of care: medical tourism as a new dimension in America‘s health care crisis. Res Soc Health Care, 26, pp. 235-249.

Kangas, B. (2002). Therapeutic itineraries in a global world: Yemenis and their search for biomedical treatment abroad. Med Anthro, 21, pp. 35-78. Lautier, M. (2008). Export of health services from developing countries: The case of Tunisia. SocSci Med, 67, pp. 101-110. Law, J. (2008). Sun, sand and stitches. Profit, 27, pp. 69-70. Leahy, A.L. (2008). Medical Tourism: the impact of travel to foreign countries for healthcare. Surgeon, 6(5), pp. 260-261. Lee, C. (2007). Just what the doctor ordered: medical tourism. Monash Bus Rev, 3, pp. 10-12. Leng, C.H. (2007). Medical tourism in Malaysia: international movement of healthcare consumers and the commodification of healthcare. Asia Res Inst, 1-32, ART WP No. 83. Lindsay, G. (2008). Medical leave. Fast Comp, 125, pp. 108-119. Marlow, J.,& Sullivan, P. (2007). Medical tourism: the ultimate outsourcing. Hum Resour Plan, 30, pp. 8-10.

health care. WSJ, 252, B9. Medical tourism for insured patients at a glance. (2009). Assoc Press, 312. Medical tourism‘ on the rise (2005). Advert Age, 76, pp. 14-14. Moore, A. (2009). Health tourism: don‘t forget your toothbrush. Health Serv J, 119, pp. 18-20. Mudur, G. (2004). Hospitals in India try and woo patients. BMJ, 328, pp. 1338-1338. Neelakantan, S. (2003). India‘s global ambitions. Far East Eco Rev. Oberholzer-Gee, F., Khanna, T.,&Knoop, C.I. (2005). Apollo-hospitals–first-world health care at emerging-market prices. Harv Bus Sch, HBS No. N9-705-442. Olian, C. (2006). 60 minutes: Medical Tourism. CBS Television [http://www.youtube.com/watch?v=paNRv—Adw]. Operating profit. (2008). Globalisation and health care. Economist, 388. Patriquin, M. (2007). A vacation that‘ll have you drooling. Maclean’s, 120, 68. Perotin, M.M. (2004). Sun, sea and surgery. Natl Post, PT3. Prashad, S. (2008). The world is your hospital. Can Bus, 81, pp. 62-66. Ramirez de Arellano, A. (2007). Patients without borders: the emergence of medical tourism. Int J Health Serv, 37, pp. 193-198. Richards, T. (2008). Border crossing. The medical travellers‘ tale: so far health tourism is a small market, but it is set to stimulate welcome competition. BMJ, 337, pp. 1324-1324. Saniotis, A. (2007). Changing ethics in medical practice: a Thai perspective. Ind J Med Ethics, 4, pp. 24-25. Sen Gupta, A. (2008). Medical tourism in India: winners and losers. Ind J Med Ethics, 5, pp. 4-5. Sen, Gupta. A. (2004). Medical tourism and public health. People’s Dem, 28 [http://pd.cpim.org/2004/0509/05092004_snd.htm]. Canadians help fuel medical tourism boom abroad. CanWest News, 1-1. Termonti, A.M. (2005). The Current. CBC Television[http://archives.cbc.ca/programs/719/]. The Express Tribune. (2013). Accessed on 3 June 2015: http://tribune.com.pk/story/554523/breaking-boundaries-indian-doctors-donor-save-pakistani-mans-life/ The Hindu. (2012). Accessed on 3 june 2015: http://www.thehindu.com/news/indian-doctors-and-students-give-pakistani-patient-fresh-lease-of-life/article3796273.ece Turner, L. (2008). Cross border dental care: ‗dental tourism‘ and patient mobility. Br Dent J, 204, pp. 553-554. Turner, L. (2009). Commercial Organ Transplantation in the Philippines. Cambridge Quarterly of Healthcare Ethics, 18, pp. 192-196.

Research Scholar, Institute of Hotel & Tourism Management, M.D. University, Rohtak