Medical tourism in the Caribbean
Many Caribbean countries have recently demonstrated an interest in pursuing medical tourism as a development strategy [
5,
9,
10]. As tourism dependent states, Caribbean countries are especially vulnerable to fluctuations in the global economy due to their powerful impact on the number of tourists traveling for leisure [
11]. While policies directly supporting medical tourism have historically been limited in the Caribbean (with the exception of Cuba), the sector has recently been promoted by many Caribbean governments as an appealing means of expanding tourism-oriented economies in a way that builds on existing tourism infrastructure [
9,
10]. Demonstrating a regional expansion of interest in exporting health services internationally, many Anglophone Caribbean countries have been involved in the creation of policies, hosting of conferences, and/or development of facilities for medical tourism [
9,
12].
Projects currently being discussed or pursued in the Anglophone Caribbean include the Health City, Cayman Islands development, a 104 bed hospital staffed by international health workers and focused on the American patient market that began operating in early 2014 [
13]. Plans by American doctors to build a new facility in Montego Bay, Jamaica that will primarily treat medical tourists have been well received by the national government, while Turks and Caicos has discussed plans to attract foreign patients by marketing surgical services to international patients at two existing hospitals [
14,
15]. Additionally, governments in Bahamas, St. Kitts and Nevis, and Grenada are all reportedly exploring their options for developing medical tourism industries [
9]. All of these island economies heavily rely on recreational tourism for foreign exchange to fund their public services, including healthcare [
11]. As such, medical tourism has been presented as one particularly appealing avenue for economic development given its reputation for generating large revenues and creating high quality employment [
9,
16]. This dominant discourse, informed by typically inflated projections of the industry’s growth potential and a narrow liberal-economic rationale, regularly neglects to incorporate concerns regarding potential negative impacts of medical tourism on healthcare systems and health equity more generally [
17,
18]. This may be particularly true in the Caribbean region where research has demonstrated the prioritization of tourism policies and limited involvement of local stakeholders in the development of existing tourism infrastructure [
11,
19].
Barbados, the most easterly island in the Caribbean with a population of approximately 280,000 [
20], is an Anglophone Caribbean country actively working to expand its medical tourism sector. Tourism is among the largest economic sectors, with tourism contributing 11% of the country’s total gross domestic product and directly employing approximately 14,500 Barbadians in 2013 [
21]. In contrast, the medical tourism sector in Barbados is currently very small. One facility, the Barbados Fertility Centre, has had great success with recruiting the majority of its patients internationally, primarily from the United Kingdom, Canada, the United States, and other Caribbean countries [
10]. The clinic has served as a proof of concept for medical tourism’s fit with the country and has contributed to the Barbadian government’s plans to develop additional medical tourism facilities [
9]. The largest and most developed of these plans has been the government’s lease of public land home to a long-defunct private hospital (St. Joseph’s Hospital) to the American World Clinics (AWC) company in 2011. AWC plans to build a 105-bed hospital that will be staffed by locally recruited nurses and a rotating roster of visiting American physicians. The facility will be available to local patients with the means to privately pay for their services, but will mostly focus on serving the international market [
22]. This novel approach to healthcare delivery is only the latest of many ‘offshore’ services found in the Caribbean, including the medical education, banking, and gambling sectors [
23,
24]. While construction has yet to begin, the project is reportedly still proceeding and remains the biggest medical tourism proposal to be actively pursued in Barbados and among the largest in the Caribbean to date [
22,
25,
26].
Here we draw on discussions with local citizens and healthcare providers in Barbados in order to better understand the context in which medical tourism is being pursued in the country and local perspectives on its potential impacts, with a focus on their implications for health equity. Barbadian citizens currently have universal access to healthcare, provided through publicly funded and managed facilities that include primary care polyclinics and the Queen Elizabeth Hospital [
20]. This latter facility is the only hospital capable of providing comprehensive tertiary care on the island [
27]. While the universal public system provides a common safety net for all Barbadian citizens, many access care in the private sector [
20]. Private primary care is greatly preferred by citizens with financial means necessary to pay for it, with 50% of all primary care provided delivered through the private healthcare system [
28]. Additionally, there is a small private hospital used by local medical consultants for privately-purchased, non-intensive services [
20]. Despite a strong presence of private medical care for primary care and elective treatments, there are no private providers that offer comprehensive tertiary care, with all emergencies necessitating referral utilizing the public hospital [
20].
While the Barbados Fertility Clinic is the only facility in Barbados currently marketing to international patients outside of the Caribbean, regional patients (typically from smaller, proximate islands) regularly purchase health services at private and public medical facilities in Barbados [
5]. Barbadians also travel throughout the region to access healthcare, both through public cross-border care arrangements and medical trips that are privately financed through insurance or out-of-pocket payments. However, the majority of citizens accessing healthcare off the island do so at extra-regional facilities, often in the United Kingdom or Miami [
27]. Due to the relatively small size of Barbados and resulting limitations to the provision of specialized care, international patient mobility has become a norm in this context. There is also a parallel outflow of health workers, with high levels of nurses in particular emigrating from the country to earn higher incomes elsewhere, resulting in nursing shortages and corresponding challenges in providing effective and efficient health services [
29].
As a tourism-dependent small island state, Barbados provides an example of a country with a vulnerable, service-dependent economy working to diversify its tourism market. As such, the findings of this analysis are likely to be relevant to other countries in similar economic circumstances that are looking to grow their medical tourism sectors, especially other Anglophone Caribbean nations. By seeking Barbadian citizens’ first-hand perspectives on the development of a local medical tourism industry, this paper offers grounded insights into the complicated economic and health equity considerations posed by the growth of medical tourism.