The potential for bi-lateral agreements in medical tourism: A qualitative study of stakeholder perspectives from the UK and India

In an increasingly globalised world, countries are assessing their position on trade in health services [1]. Debates on the subject often centre on the World Trade Organisation's General Agreement on Trade in Services [2]. This is removed from the reality, however, where most trade takes place regionally or bi-laterally [3]. In addition, given that there is no systematic collection of data on the quantity of trade in health services that takes place, or the impact it has on the health system [1], discussions on whether to liberalize this type of trade tend to be more influenced by ideology than evidence [4]. Different types of evidence are needed on this debate. These include basic data on trade flows across countries, evidence of the impact of this type of trade on economies and health systems, and a greater understanding of how such trade is perceived, in terms of those involved in it, as barriers or facilitators, and the relative benefits and risks it presents. It is therefore important when seeking to understand and advise a country's position on trade to understand the various perspectives of those involved [5]. To our knowledge, such an analysis of stakeholder perspectives has not been undertaken in the area of trade and health, which this paper seeks to address.

The context for the study is medical tourism, as this is one of the highest profile modes of trade in health services (along with health worker migration) [1]. Medical tourism can be defined as the movement of patients across an international border for the purposes of obtaining healthcare. This is usually motivated by long waiting times, high costs of medical care or unavailability of care in the patients' home country [6, 7]. This definition includes both patients paying out of pocket and the potential scenarios where governments or insurance companies pre-arrange foreign healthcare treatment for patients. Although currently the vast majority of medical tourism occurs from patients arranging and paying for the medical services abroad themselves, arguably the biggest potential for this market lies within governments or insurance companies pre-arranging foreign care for patients. It is therefore the potential for the development of this latter form of medical tourism that this paper concentrates upon. Currently most medical tourism takes place by individuals privately arranging healthcare in a foreign country. Often, medical tourism facilitators play a role in this by providing information on countries, hospitals and services, and sometimes even arranging the care for the patients. This, however, occurs under general regional or global agreements, which are by definition multi-lateral.

There are no agreed figures for the number of people who go abroad for healthcare, and the data available in the literature are wide-ranging (from thousands to millions) [8]. There have been several reports from consultancy firms which are often quoted to portray medical tourism as a market with great potential, but it is often unclear how their data were generated [9‐11]. Medical tourism raises issues of quality of care [12], litigation [13, 14], continuity of care [15], equity [16] and the creation of an internal brain drain, where medical professionals leave the public health service to work for the private hospitals that cater for (more profitable) foreign patients, further exacerbating staff shortages [17]. Countries need to take these issues into account when deciding on whether (and to what extent) to liberalize trade in health services. However, a missing piece in the discussion thus far has been a focus upon what type of trade relationship they may wish to engage in.

The literature concerning medical tourism is expanding, and there have been several recent attempts to synthesise what is already known about this practice [4, 8, 18‐20]. Although these reviews take different perspectives on medical tourism, they all agree on the potential benefits and dangers it can bring to importing and exporting countries. Importing countries (those where the medical tourists come from, as these countries are importing healthcare services) can benefit from lower costs and reduced waiting lists; however, there are concerns regarding quality of services and litigation procedures. On the other hand, exporting countries (those that provide the health services to foreign patients) can bring in foreign exchange and may prevent health professionals leaving their country to work in overseas institutions, but risk creating a two-tiered system, with foreign patients receiving better care than domestic patients. In addition, reviews highlight the dearth of primary data available on medical tourism, both at the national and international level, and call for more empirical research to be carried out to ascertain the numbers of medical tourists and the procedures they undergo, as well as the validity of the claims made for and against this practice. Finally, the literature highlights the need for more and better regulatory frameworks for medical tourism, such as the creation of specific national medical guidelines to guide the provision of services to foreign patients [21], the adoption of equitable buying guidelines to address the impacts of medical tourism on equity [19], and the development of a common international regulatory platform and reporting system, that goes beyond the current regulatory bodies, such as the Joint Commission International [4]. Nonetheless, these alternative frameworks do not address the principle trade-agreement between nation states, and in this respect this paper adds to the literature by explicitly seeking to gain information relating to the potential for a bi-lateral relationship to overcome some of the core concerns raised thus far in the context of multi-lateral trade agreements (e.g. GATS).

To explore the range of issues, risks and opportunities offered to countries when engaging in bi-lateral - rather than multi-lateral - trade in more depth, the authors conducted a systematic literature review, which is reported elsewhere [Smith R, Martínez Álvarez M, Chanda R: Medical Tourism: a review of the literature and analysis of a role for bi-lateral trade, Submitted]. This literature review focussed on the UK and India as a case study of how the issues highlighted by the literature could be addressed from a bi-lateral perspective. The review supported the findings of the wider literature, as reported earlier, regarding the lack of empirical data on medical tourism and the potential benefits and risks that both importing and exporting countries face when engaging in this type of trade.

The review did, however, conclude that most of the issues that arose could be better addressed from a bi-lateral relationship, where a contract can be drawn out between the two countries outlining, for instance, which hospitals would provide the care, what procedures would be followed should something go wrong, what care the patients would receive before and after going abroad, and how this relationship could improve, rather than damage, the healthcare available to the local population. Nonetheless, there are still questions concerning the perception of such a bi-lateral system, and its ability to address concerns associated with medical tourism.

A total of 30 semi-structured interviews were carried out, 20 in India and 10 in the UK. These two countries were chosen because: (i) the UK has some experience with cross-border mobility of patients within the European Union; (ii) India has already made some inroads as an exporter of health services, for instance in the provision of telemedicine services, and is one of the biggest players in medical tourism; and (iii) the two countries have historical ties, a common language, commonalities in the educational system, and there is a large Indian Diaspora population living in the UK, which would facilitate this type of trade. The balance in the number of interviews between the two countries reflects the wider range of stakeholders in India, as a destination for medical tourism, given the variety of the different providers of health services, and the different levels of government and private sector that would be involved in such a decision. The initial participants were selected to represent the key stakeholders likely to be involved in medical tourism as identified through the systematic review mentioned earlier; these were healthcare providers, members of the Department of Health and medical tourists. These stakeholders were accessed through a variety of methods. Healthcare providers and Department of Health officials were selected according to their role. Medical tourists were accessed through personal contacts of the authors. During the interviews, a snowball sampling technique was used to identify others that may have interest and be relevant to the study. The aim of using this type of sampling was to maximise the range of opinions and perspectives and to get as complete a picture on the subject as possible. Recruitment was undertaken until saturation was felt to have been reached (that no new substantive issues were being raised). The stakeholders that took part are listed in table 1. In addition, workshops were held in both India and the UK before and after the interviews took place with officials from the Department of Health, researchers, think tanks, medical professionals and hospital managers. The aim of the workshops was twofold: (i) before the interviews took place, to map out the issues and different perspectives on medical tourism, in order to guide the development of the semi-structured interview schedule; and (ii) after the interviews, to corroborate the findings and obtain any further insights.

The interviews took place between November 2009 and January 2010 and were carried out by one of the authors in the UK (MMA) and another author in India (RC). The interviews lasted approximately one hour, and were semi-structured in nature [22]. This required a qualitative instrument to be designed to guide the interviews; as indicated, this was based on material obtained from the literature review and the first workshops [Smith R, Martínez Álvarez M, Chanda R: Medical Tourism: a review of the literature and analysis of a role for bi-lateral trade, Submitted]. An example is presented in Additional file 1: Appendix A. The instrument was used as a topic guide, but not all questions were covered in all of the interviews, nor were they asked in strictly the order that they are presented. Rather, the instrument was adapted to each participant. The broad themes were: general perspectives, medical tourism-related activities and operations, and policy issues.

The interviews were conducted face-to-face or over the telephone, and the answers recorded by hand, and then typed up. Written consent was obtained from each interviewee before the interview took place.

The interview transcripts were analysed using thematic [23] and directed content analysis [24]. The scripts were reviewed and themes were identified. These were coded based on the results from the literature review and the workshops carried out previously by the authors. Any additional themes that arose from the transcripts were incorporated (see table 2 for a complete list of coding categories). This was carried out by the first author (MMA), and approved by the other authors (RC and RS). No software was used in the analysis of the interviews.

A summary of all the coding categories and the frequency of these by the different groups of stakeholders are shown in table 2. The core findings from this are explored in more detail below.

Of the key themes identified, there was agreement between the stakeholders on the importance of regional travel and proximity, quality, regulation, litigation, continuity of care and the low prospects for a bilateral relationship between India and the UK on medical tourism. However, there were disagreements on the importance of the Diaspora in medical tourism, whether countries like India should concentrate on the local population before offering services to foreign patients or if they should focus on this industry to raise foreign exchange, the status of the three hour 'rule', and what policy changes would be needed for such a relationship to prosper (including the role of government).

These results are subject to two important caveats. First, two different interviewers were involved (one in the UK and one in India), and although the same interview instrument was used there may have been differences in the way questions were asked or answers recorded. Second, the stakeholders approached in India were more willing to participate in the interviews than those approached in the UK. This means that the opinion of those who were not willing to participate from the UK was not represented.

This research supports some of the concerns found in the literature, including quality of care [14], litigation [13, 25], continuity of care [15, 26] and the potentially harmful impact medical tourism may have on the local population [19, 21, 27]. However, as highlighted above, not all stakeholders were in support of these arguments. In addition, this research has shed some light on other issues, such as the uncertainty surrounding three hour 'rule', the importance of the Diaspora and has provided some indication on the amount of foreign patients that Indian private hospitals provide medical treatment to. Although the UK and India were selected as a case study in this research, this is not an exclusive example where this type of trade could take place. The UK has cultural links with many other countries where English is widely spoken that offer medical tourism services, and India attracts medical tourists from across the world.

Nevertheless, when policy makers have to make decisions on whether to engage in this type of trade, this takes place largely in a data vacuum, given that there is no data on the amount of medical tourism that goes on, and what impacts it has on the exporting and importing health system. As this research shows, opinion amongst stakeholders in this field is often divided. These issues cannot be resolved until more and better quality data becomes available.

More research is needed to determine the flows of medical tourism, including the total numbers, what countries they come from and where they get treated. Additionally, it is essential that there is more evidence on the impact medical tourism is having, both on importing and exporting countries, as at present, it is impossible to know whether the concerns outlined in the literature and in these interviews are likely to be realised. Finally, it is of particular importance to examine the effect different types of trade relationships might have. In this respect, whilst the literature review previously carried out by authors suggested that a bi-lateral relationship would be best-placed to address the concerns raised regarding medical tourism, there was scepticism from the analysis provided in this paper based on the over-riding feeling that the political 'cost' involved was likely to be the major impediment. This makes the need for better evidence even more acute, as much of the current policy process could well be based on entrenched ideological positions, rather than secure evidence of impact.

This research can also provide some policy recommendations. The literature suggests that medical tourism can cut costs, improve waiting lists (from the perspective of importing countries) and generate revenue and improve the national healthcare (from the perspective of exporting countries). Given these, policymakers should consider medical tourism as an option to improve their health services. This is particularly important in the current climate where countries are facing budget cuts spurned on by the financial crisis. When evaluating the different options available, policymakers should consider engaging in a bi-lateral relationship, as it has the most potential to ensure the interests of the patients on both countries are prioritised. This could also be addressed through the ongoing EU-India trade negotiations, which also cover services.

In conclusion, there are a wide variety of barriers affecting medical tourism, including restrictions on travel by governments and concerns about quality, regulations and litigation. In order to increase trade, these barriers need to be addressed. The results from the literature review reported elsewhere [Smith R, Martínez Álvarez M, Chanda R: Medical Tourism: a review of the literature and analysis of a role for bi-lateral trade, Submitted] suggests that a bi-lateral relationship is best-placed to tackle these barriers. However, results from the analysis reported here suggest that it is the political sensibility that is the major barrier to be overcome. In this respect, it is worth remembering that policy decisions affecting this type of trade in health services are largely taking place in a data vacuum. It is therefore imperative for more studies and surveys to be carried out and for more empirical data to be collected, in particular data on the size of the medical tourism market, pricing of services, regional breakdown of markets, and the impact of different forms of trade agreement.