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Medical tourism: The Resentment Factor and the Ripple Effect

ripple effect

Dr Constantine Constantinides suggest how health tourism development can act as a powerful agent of change and force for the general good, highlights the role of the Resentment Factor and the Ripple Effect in medical tourism.

Medical tourism is occasionally associated with unsavoury practices and practitioners. On the whole though, it is unfairly maligned. The hostility directed against it is motivated by narrow interests, short sightedness, scare-mongering and ignorance. 


The Resentment Factor


…not everyone loves Medical (or even Health) Tourism. (Note: health tourism is the “catch-all” term for eight categories or segments of services, related to health and involving some travel. Medical tourism is one of the segments (albeit, the one receiving the lion’s share of publicity and media attention).

Not everyone loves medical tourism.

And this sentiment is not limited to the poorer citizens in developing countries (some of which have surprisingly, become prominent medical tourism destinations), and who see health tourism as “export quality healthcare” (to be enjoyed only by rich foreigners).

It extends to developed countries (such as the USA, Canada and even the United Kingdom), which are currently portrayed (especially by the press) as net exporters of health consumers and view health tourism as a threat to the continued financial well-being of their local healthcare industry.

In the case of developed countries, e.g., the UK and Canada, outbound medical tourism has the additional effect of highlighting that country’s failing National Healthcare System (casting it in a “bad light” – a system shamed). In these countries, even inbound medical tourism can be a cause for resentment , when it is of the “illegal immigrant” and “un-entitled tourist” variety.

Resentment to inbound medical tourism can even be expressed by local healthcare services providers. This happens when “foreigners” come in to invest and run Health / medical tourism Facilities.

And finally, resentment extends even to the “health travelers” themselves, who are obliged to go abroad for treatment (due to personal circumstances and inadequacy of their country’s national system).

Let’s take a closer look at what is resented

We are aware that there is resentment to both, inbound and outbound medical tourism.


Resentment to inbound medical tourism (foreigners coming in)


When it comes to inbound, the following issues cause resentment:

  • Export quality healthcare services (inequality)

  • Subsidizing medical tourism

  • Internal brain drain

  • Healthcare services “free-loading”

  • Unsavoury practices


Export quality healthcar

e services

In practically every country developing and offering medical tourism, Public Sector Services tend to lag behind those of the Private Sector. And medical tourism is offered predominantly by the Private Sector.

The high quality services offered to “foreigners” (often in a lavish setting) are a cause of resentment to the less affluent local population who do not get to enjoy these “export quality” healthcare services. Inequality (in the provision of and access to healthcare services) is a concern expressed in countries known as prominent medical tourism destinations.

There is no doubt that an influx of wealthy foreign patients can siphon the attention, resources, and healthcare professionals of developing countries. The result is a two-tiered system of high quality care for foreigners and sub-par leftovers for citizens.

But the private sector cannot be blamed for the failings of state-run health bureaucracies in developing countries, which neglected the poor long before medical tourists arrived. Besides, a two-tier system exists, anyway, when private and public sector services co-exist.

Some countries, in a move aimed at dealing with inequality and improving the performance of the public sector, are toying with the idea of introducing competition between the two sectors (where both can compete in attracting the private and public sector patient – take Cyprus, for example).


Subsidizing medical tourism


Some countries directly subsidize medical tourism development and promotion

With tax-payer’s money. And of course, it has been pointed out that revenues from medical tourism are unlikely to be fed back into public health systems "unless national laws or regulations are set up so that these revenues are taxed explicitly and channelled to the public sector" (see “Taxing medical tourism”).

Others point to the fact that the state pays for or subsidizes the training of health professionals who then go and work in the private sector (or go abroad), something that does not sit well with the tax payer.

A sensible example of dealing with this “grievance” is provided by the Philippines, which allows nurses to work in the private sector or abroad if they repay their student loans. Other countries allow public sector healthcare professionals to offer their services to the private sector – “after hours”.


Internal brain drain


Some worry that a flood of foreigners into developing countries will divert money and expertise from state health systems (which are already overwhelmed) in what is seen as an “internal brain drain”.

Research by the World Bank does indeed suggest that “internal brain drain” is a worry in some countries, especially those with few doctors and nurses. However, in many huge net exporters of doctors and nurses, such as India and the Philippines, an internal brain drain is hardly much of a worry, because there are plenty of healthcare professionals to go around. And shortages, in countries where they exist, can be alleviated by reforms changing the way healthcare education is funded.


Healthcare services “free-loading”


As far as British politicians are concerned, medical tourism is all about illegal immigrants in Britain making use of free healthcare services (provided by the National Health services) to which they are not entitled. There is much ongoing brainstorming on the subject – aiming to come up with politically correct ways to curb this practice. And of course, British tax payers resent this practice as well.


Unsavoury practices


A practice which is both unsavoury and which gives a medical tourism destination a bad name is that of selling and buying of organs (usually kidneys). There is clear exploitation of poorer and less educated citizens involved. The inevitable publicity has obliged governments to step in to put an end to it, but no doubt, the practice continues.


Resentment to outbound medical tourism (our people going abroad)

  • When it comes to outbound, the following issues cause resentment:
  • Loss of face - a system shamed
  • Loss of business (and outflow of capital)
  • Brain drain
  • By-passing of locally-imposed restrictions


Loss of face - a system shamed


The two countries best known for and proud of their National Health Systems are the United Kingdom and Canada. Yet these two countries are equally well-known for their citizens who seek treatment abroad, because of the inadequacies and inefficiencies of their systems (mainly, long waiting lists for essential medical treatment and poor cover for dental care).

This fact is a blemish on the governments involved with serious political implications. The issue of countries with a national health system not able to adequately cater to the needs of its citizens is a story in itself.


Loss of business (and outflow of capital)


Local healthcare services providers seeing business going abroad cannot be very happy with the loss,  and they too are brainstorming on ways to curb the practice.


Brain drain


It is not difficult to understand that healthcare professionals will tend to move to where career and job opportunities exist (medical tourism destinations). With the competition for clients, destinations also compete for the best healthcare professionals, not a few of whom are nationals of developing countries. And recruitment is not limited to medical personnel. Nurses are also targeted by a number of medical tourism destinations, enticing them with better pay and conditions.


By-passing of locally-imposed restrictions


Some conservative regimes resent the fact that outbound medical tourism allows its citizens to by-pass local restrictions on the provision of certain types of treatment (e.g., IVF, Stem Cell Therapy, Gender Change).


Addressing the Resentment Factor


The resentment directed at medical tourism can only be effectively countered by demonstrating its benefits – its ”Cancelling Out”  and remedial effect on local inadequacies.


Medical tourism as a force for Good


…spreading it around.

We have been observing and documenting how, the development of a medical tourism industry benefits the local population, contributes to the national economy and promotes regional interaction and collaboration.


The  “Ripple Effect” of medical tourism


In considering the Resentment Factor,  we realise  that:

  • In practically every country developing and offering medical tourism, the Public Sector Services tend to lag behind those of the Private Sector

  • The high quality services offered efficiently to “foreigners” (often in a lavish setting) cause resentment amongst the less affluent local population – who do not get to enjoy these “export quality” healthcare services

Having said this, the Private Sector cannot be blamed for the failings of state-run healthcare facilities and services in countries, where the poor were neglected long before medical tourists arrived.

The trickle-down / beneficial ripple effect of medical tourism takes many forms and can affect a broad spectrum of a country’s population. One needs to realise that health tourism (of which medical tourism is a segment) is a lot more than the sum of its two nominal parts (Health and Tourism). Several other industries and industry sectors are likewise stakeholders. Health tourism has a broad stakeholder and beneficiary base.

But let us look more specifically at how medical tourism acts as force for the “General Good”.


Public sector service improvement


We have good reasons to believe and support the view that medical tourism serves as a catalyst in compelling the state to improve the quality of services at public sector facilities by acting as a driver for improvements.

In view of the glaring inequalities (between the private and public sectors), the state can no longer claim that: “this is the best that can be offered in the country”. High-paying and demanding foreign patients provide an incentive for hospitals to upgrade to state-of-the-art technology which also becomes available to the locals.


Motivation to practice what one preaches


One cannot credibly preach and promote health tourism and not stand out as a paradigm (in terms of providing accessible and quality healthcare to its own citizens). “This is the best we can offer” can no longer be an excuse for the poor quality of services in the public sector when next door, “Export Quality Healthcare” is being provided to foreigners.


Appropriate technology , and replacing it with cutting edge technology


The term “Appropriate Technology” (AT) has been used to describe both “low end” and “high end” development and usage of technologies. But as far as the bureaucrats and aid agencies are concerned, the term describes simple (some would say “simplistic”) technologies suitable (or good enough) for use in developing nations or less developed rural areas (using the simplest level of technology that can effectively achieve the intended purpose  at as low a cost as possible).

It reminds one of “Bon pour L'Orient”, (literally “good enough for the East"), an expression coined by the French during the colonial era and applied to below par education and subsequently to services, products and technology.

Appropriate technology is out, cutting edge technology is in

We do not like “appropriate technology”, because we strongly feel it perpetuates under-development and continued under-achievement. We are not, of course, advocating its outright “banishment” but do advocate that it should be regarded, at best, as a stop-gap or “interim” solution whilst plans for introducing “cutting edge technologies” are implemented.

Is this practicable and realistic? Of course it is. We have numerous examples. Do you need to first lay copper wires for “fixed base” telephony before you move on to mobile? Developing countries need to adopt the “leapfrog your way to development and the 21st Century” mindset.


A source of tax revenue


Shoule we tax medical tourism? Generally, we do not like the practice of imposing new taxes “opportunistically”. Nevertheless we need to point to examples of where this has been applied and seems to be having the intended effect.

Certain states in India now impose a Special Tax on health tourism revenue (to be used towards improving and providing public sector services). Of course, this creates an incentive to under-report medical tourism activity to the authorities.

And some cities in Southeast Asia use tax revenue from medical tourism to subsidize hospitals, on condition that these hospitals offer free medical care to that city’s residents.


The effect of competition

Medical tourism can be a catalyst for much needed reforms in the “net exporting” countries. The prospect of losing revenues to competitors abroad is already shocking hospital administrators into looking at “fixes” aimed at raising standards, increasing price transparency and lowering costs. It may even bring the growing political pressure for reform to a head.

Health care abroad is not a substitute for difficult reforms at home. But medical travel could serve as a catalyst for those reforms. Medical travel need not be seen as about “exporting patients” but rather about “importing competition”. Rivalry from top foreign facilities will encourage the introduction of transparency and price competition into a system characterized by inefficiency and plagued by oligopolies and incentives which run contrary to the interests of the health consumer.

By Deloitte’s reckoning, medical travel will represent $162 billion in lost spending on health care in America by 2012. There are signs that American health-care administrators are starting to feel the heat. European hospitals may not be immune from such pressure, either.

We did predict that American hospitals would start cutting prices once they realized how much potential business they were losing. These price cuts, in the USA at least, are now happening.

And we are also seeing healthcare providers in countries such as the UK and Canada clamouring to become more efficient, improve quality and reduce prices, in an effort to stem the outflow of patients. In the process, these same providers are now even soliciting medical tourism. Medical tourism may well prove to be a disruptive market force that improves cost and quality at home.


Population health improvement – by example


Locals often observe and emulate the habits, customs and practices of “foreigners”, especially if these are seen as in some way socially superior and status enhancing. As such, inbound health tourism can act as an influencer, motivating locals towards paradigm shifts. People learn not by what they are told but what they see.

And they see foreigners caring about their health maintaining, restoring or enhancing it, not only through “treatment” (surgical procedures and medical therapies) but also through lifestyle and practices (e.g., sport, diet, regular check-ups).

Can a health tourism destination credibly promote itself as such whilst being populated by unhealthy citizens, oblivious of healthy habits and  lifestyle?


Brain gain and regain …the brain drain in reverse


We are also observing the phenomenon of healthcare professionals (expatriate and foreign) moving to prominent medical tourism destinations to offer their expertise and  services. These often end up also attending to the needs of the local population (whether it be in the private or public sector).

In fact these professionals (Doctors, Nurses, Physiotherapists, Allied Health Workers) often come from the “developed world” where there is often a “glut”. For their part, medical tourism destinations offer incentives to attract these professionals for the prestige and expertise these professionals bring with them. Development of medical tourism motivates and incentivizes prominent and well trained health professionals to stay at home and those amongst the Diaspora, to return.

The World Bank has documented that the rise of high-quality private clinics in Trinidad and other parts of the Caribbean, for example, encouraged highly educated doctors to return home.


Job creation – and new career path development


The hospitals and other facilities that cater to health tourists will of course employ local staff, and create jobs (and not just for doctors and nurses). And with the advent of health tourism studies and the demand for employees with sector-specific executive education and vocational training, new career paths are developing.  Tourism Studies business schools, such as Alpine College in Greece, are now offering University Validated degree courses (including MBA) in health tourism to students from 30 countries, practically all of which are health tourism Destinations.


Investment (internal and foreign direct)


Health tourism is associated with considerable development and investment. Besides individual facilities, several countries have developed or are developing “healthcare cities”. Investors, developers and private equity firms now see the sector as a new and exciting investment prospect.

The issue of investment in health tourism has become a popular agenda item at conferences and more recently, whole events are dedicated to the subject.


Promotion of regional integration, collaboration and trade


Health tourism integration and development on a national level (through the implementation of a purpose designed project) encourages other countries in the region to follow suit – establishing the preconditions for regional integration, collaboration and trade.

Let us not forget that the EU started out as the European Common Market. And, just as we were getting used to globality with regards to healthcare services, we are now (not unhappily) observing the growth and trend of regionality.




Profile of Dr Constantine Constantinides

Dr Constantine Constantinides

Dr Constantine Constantinides runs healthcare Cybernetics, a “think and do” tank that specializes in medical tourism and healthcare consultancy and planning. He lives on the island of Samos in Greece.

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Dr C Constantinides discusses the main issues that serve as feed-forward and feed-back in Medical Tourism.
The author has an ample experience in the field, and his article is nothing short from perfect. Congratulations!
Dr Vic
Bone Marrow Transplant Unit
in Bata, Equatorial Guinea, Africa

Dr Victor(Vic) TOMA, MD PhD (18/10/2009 12:48:43)

I run a HR consultancy specialising in the medical industry here in Dubai, UAE, called Outsourcing Consultants (www.outconsult.com) and feel strongly about medicval tourism.
This article is an excellent presentation of the facts involved in this phenomenon known as medical tourism.
The Dubai government is very keen to get involved in this but is, in my opinion, missing the point and will never be successful at it unless they address the issues at hand.
To be seen as a good destination for this sector you need to be able to offer quality and well governed (accredited internationally) healthcare at a price that is significantly lower price than your home country, along with the ability to be seen quickly and at the convenience of the patient. Other important factors are availability of quality and well priced air travel/hotel rooms. Dubai has a lot but the one thing it cannot compete on is cost both in hospital and hotel costs (although with the current downturn hotel costs have come down dramatically!). This, in my opinion, is crucial in driving a destination forward in this sector. Look at the popular option currently, India, Thailand, Malaysia, South Africa, Eastern Europe and Jordan.
Time will tell if Dubai's ambitious bid to get onto the medical tourism map is successful.
Paul Johnson

Paul Johnson (18/10/2009 08:55:21)

Nice review of the issues. Recognizing that perception is reality, MedVoy has taken some steps to address them. One is to indiretly improve global health as part of our mission through social entrepreneurship. I would encourage others in the industry to do the same.

Arlen Meyers, MD, MBA (16/10/2009 15:28:14)

It is my opinion, after researching the viability of Medical Tourism as a business opportunity, that insurance providers have implimented Medical Tourims options designed for disaster. An intentional deception set forth to undermine the stimulus of Medical Tourism thus maintaining the status quo. My thoughts are based on numerous attempts to obtain factual data as to the cost/benefits provided to employers and consumers through the option of medical tourism. Factual data is non-existant in the insurance provider field and the private sector variants are not reliable thus staving off interested particpants in this most amazing international resource of health and wellness.

Billions could be earned and saved, millions could be healed and countries could be ecomonically united if a vaccine for greed and cronyism were mandatory injections.

Mary Ann Miller (16/10/2009 15:08:26)

I run a British dental clinic abroad in Piestany spa, Slovakia (http://www.dentalholiday.co.uk) and can certainly say that Brits going abroad for dental treatment such as crowns and dental implants is a fast growing trend here in Europe. Not only to save money and time but also to receive access to some of the most experienced dentists within the European Union.

Daniel Shaw (16/10/2009 11:08:30)