Johnston et al. Globalization and Health (2015) 11:29 DOI 10.1186/s12992-015-0113-0

RESEARCH Open Access

Policy implications of medical tourismdevelopment in destination countries:revisiting and revising an existing frameworkby examining the case of Jamaica

Rory Johnston1*, Valorie A. Crooks1 and Meghann Ormond2

Abstract

Background: Medical tourism is now targeted by many hospitals and governments worldwide for further growthand investment. Southeast Asia provides what is perhaps the best documented example of medical tourismdevelopment and promotion on a regional scale, but interest in the practice is growing in locations where it is notyet established. Numerous governments and private hospitals in the Caribbean have recently identified medicaltourism as a priority for economic development. We explore here the projects, activities, and outlooks surroundingmedical tourism and their anticipated economic and health sector policy implications in the Caribbean country ofJamaica. Specifically, we apply Pocock and Phua’s previously-published conceptual framework of policy implicationsraised by medical tourism to explore its relevance in this new context and to identify additional considerationsraised by the Jamaican context.

Methods: Employing case study methodology, we conducted six weeks of qualitative fieldwork in Jamaicabetween October 2012 and July 2013. Semi-structured interviews with health, tourism, and trade sector stakeholders,on-site visits to health and tourism infrastructure, and reflexive journaling were all used to collect a comprehensivedataset of how medical tourism in Jamaica is being developed. Our analytic strategy involved organizing our datawithin Pocock and Phua’s framework to identify overlapping and divergent issues.

Results: Many of the issues identified in Pocock and Phua’s policy implications framework are echoed in the planningand development of medical tourism in Jamaica. However, a number of additional implications, such as theinvolvement of international development agencies in facilitating interest in the sector, cyclical mobility of internationalhealth human resources, and the significance of health insurance portability in driving the growth of internationalhospital accreditation, arise from this new context and further enrich the original framework.

Conclusions: The framework developed by Pocock and Phua is a flexible common reference point with which todocument issues raised by medical tourism in established and emerging destinations. However, the framework’sdesign does not lend itself to explaining how the underlying health system factors it identifies work to facilitatemedical tourism’s development or how the specific impacts of the practice are likely to unfold.

Keywords: Jamaica, Medical tourism, Health services, Health policy, Qualitative methods, International medical travel,Trade in health services, Caribbean

* Correspondence: Rrj1@sfu.ca1Department of Geography, Simon Fraser University, 8888 University Drive,V5A 1S6 Burnaby, BC, CanadaFull list of author information is available at the end of the article

© 2015 Johnston et al. This is an Open Access article distributed under the terms of the Creative Commons AttributionLicense (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in anymedium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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BackgroundAs international trade in services has become increas-ingly desirable, health services have been identified as apromising export sector by many national governmentsand business consultancies worldwide [1, 2]. Medicaltourism is one form of health services export that hasrecently attracted considerable attention, often reportedas a sector that is quickly growing and immensely valu-able [3, 4]. Most generally, medical tourism describesthe temporary movement of a patient outside the healthsystem of their habitual country of residence for thepurpose of purchasing medical care [5]. Here we con-sider medical tourism to be restricted to patients whointentionally travel to another country primarily formedical care and pay for their care privately. We imposethis restriction in order to exclude ‘cross-border’ patientswho are referred abroad by their home health systemsand thereby face a different profile of health and finan-cial risks than do medical tourists acting on their own[6–8].Southeast Asia provides what is perhaps the best docu-

mented regional example of medical tourism develop-ment and promotion, with numerous hospitals andnational and provincial governments strategically target-ing the sector for investment and further growth in thewake of the 1998 Asian Financial Crisis. Private hospitalsin Singapore, Thailand, and Malaysia are all known to beattracting significant numbers of medical tourists fromboth within and outside the region [9, 10]. These coun-tries’ national governments have been very supportive ofmedical tourism, creating policies and organizations toincrease the export of medical services. The policies andstrategies adopted among these countries commonly in-clude the creation of visas specifically for medical tour-ists [11, 12], the reduction or elimination of taxation onimported medical equipment and supplies [13, 14], in-centives and/or requirements for international hospitalaccreditation [13], and international marketing effortsthat advertise the high quality of medical care available[13, 15]. When taken together, these initiatives demon-strate a regional concentration of similar promotionaland development initiatives among proximate healthcare markets competing for international privately-paying patients.The Caribbean provides another example of region-

wide interest in medical tourism. While Cuba has longsupported its health system by treating medical tourists,its early pursuit of the sector was initiated by the col-lapse of economic support from the Soviet Union [13].St. Lucia, Barbados, the Cayman Islands, and Jamaicaare among the countries in the Caribbean whose gov-ernments and hospitals have more recently identifiedmedical tourism as a strategic priority for economic de-velopment [16–19]. These latter countries and their

health care sectors share similarities in their commondevelopment of facilitative frameworks for private healthsector investment, their formation of national committeesto guide the development of policies that support medicaltourism, their participation in international trade confer-ences promoting medical tourism, and/or their develop-ment of new facilities whose primary purpose is to treatmedical tourists [16, 17, 19]. These activities are an indica-tion of the sustained and widespread interest across manyCaribbean countries in developing their health servicessectors for export. However, little is known about the per-spectives, information, and goals driving these planninginitiatives in the Caribbean or how a medical tourism sec-tor is understood to interact with the existing health sys-tems of these countries. This article provides a case studyof the planning and development activities for the medicaltourism sector in Jamaica using primary qualitative datacollected in on-site fieldwork. This account provides in-sights into how and why the sector is emerging there andthe implications its development for health policies.

Jamaican contextIn the past five years, Jamaica has undertaken all of themedical tourism development initiatives common toCaribbean nations described above [20–24]. A small-island state with a population of 2.7 million, Jamaica isclassified as an upper-middle-income country, althoughthe country is deeply indebted and its economy is char-acterized by long-term stagnancy [25, 26]. Recreationaltourism is one of the country’s largest economic sectors,representing roughly 8 % of direct contribution to thecountry’s gross domestic product in 2013 (26 % of thetotal including indirect and induced effects) and 7 % ofdirect employment [27, 28]. The tourism industry –highly enclavic, dependent on imports, and with signifi-cant levels of foreign investment – is concentrated onthe western and northern coasts, with Kingston, the cap-ital and country’s economic centre, located on thesouth-central coast [29]. Medical tourism has beenframed by local proponents as a viable and lucrative sec-tor that should be developed as a natural extension ofthe country’s existing tourism product [30–32].In spite of the country’s economic difficulties, Jamaica

has a relatively robust, if severely under-resourced,health system. Jamaica’s training programs for both phy-sicians and nurses are internationally respected, thecountry has a strong foundation of primary care deliverythat has secured low rates of communicable disease andinfant mortality, and the country possesses an establishednetwork of secondary and tertiary care centres in urbancentres [33]. This strong provider network and Jamaica’ssmall size have resulted in geographically accessible healthcare throughout the country [34]. Jamaican citizens haveuniversal access to publicly funded primary care clinics

Table 1 Pocock and Phua’s (2011) conceptual framework formedical tourism’s policy implications

Policy Implications

Governance • number and content of health sectorcommitments in multi- and bilateral tradeagreements

(Legislationand Planning)

• regional trade blocs promoting trade inhealth services

• national medical tourism committees oragencies

• creation of medical tourism travel visas

Financing • increase in out of pocket payments

(Fundraisingand Payment)

• increasing interest in internationally portablehealth insurance

Delivery • growth of private health sector

(Service Provision andInfrastructure)

• foreign direct investment in healthinfrastructure

Regulation • public and private sector quality control

(Protocol Creationand Enforcement)

• international accreditation of health facilities(e.g. Joint Commission International)

• number of medical tourist visits facilitated bybrokers

Human HealthResources

• distribution of specialists between public andprivate health sector

(Training and Supplyof Care Personnel)

• future human resource capacity (re: training,availability,professional to population ratios)

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and secondary and tertiary hospitals without user fees, al-though most Jamaicans with private health insurance orthe means to afford out-of-pocket payments prefer to ac-cess primary and secondary care at private facilities due tonegative perceptions of the public system [33, 35, 36]. Thisis a source of inequitable access between poorer andwealthier Jamaicans, with a greater range of care optionsand resources available to the portion of the populationwith a lower burden of poor health because of their highersocio-economic status [37]. Overall, the vast majority ofinpatient services are provided in public facilities whilethe private sector provides roughly half of the total shareof outpatient services [38].While there are few financial barriers facing Jamaicans

seeking public medical care, the country’s weak economyhas proved a major challenge in sustaining adequate fi-nancing for the country’s medical facilities across boththe public and private health sectors [33, 35]. Fundingshortfalls have contributed to major staffing shortagesamong nurses and specialists nationwide, especially asthey face relatively few barriers migrating to the morelucrative health systems of Canada, the United Kingdom,and the United States [39, 40]. These health system fac-tors serve as important context for Jamaica’s developingmedical tourism industry, which is focused on the coun-try’s private health care sector. Jamaica has eight privatehospitals [33], although there is little third party dataavailable on their quality, range of services, or utilization.Reports on Jamaica’s overall health sector capacity donot provide detailed breakdowns of the public/privateshare of the country’s 4,800 hospital beds or its healthhuman resources, nor are there reliable collations of in-formation about the private health sector in general [41].

Study rationale and goalIn this article we seek to contribute to the ongoingscholarly conversation about the impacts of medical tour-ism on health systems, their workers, and their local users(e.g. [10, 42–44]) by documenting and critically assessingthe planning and perceptions surrounding the develop-ment of medical tourism in the Caribbean country ofJamaica. We do this by applying Pocock and Phua’s [45]conceptual framework of the policy implications for des-tination countries posed by the development of medicaltourism. Pocock and Phua previously developed thisframework, published in Globalization & Health, follow-ing a retrospective review of the literature on the well-established medical tourism sectors in Malaysia, Singapore,and Thailand. Their purpose in developing this conceptualframework was not to assess the systemic elements of ‘suc-cessful’ health services exporters, but instead to highlightand organize common health policy implications raised bymedical tourism for destination countries. Table 1 outlinesthe health system impacts and their associated policy

implications identified by the framework, which are struc-tured around core health system elements into the do-mains of governance, financing, delivery, regulation, andhealth human resources.The broad scope of the health system domains and the

high-level considerations identified in Pocock and Phua’sframework encourage its application beyond the originalcontext where it was developed. We use the existingframework to organize our findings from fieldwork inJamaica that seeks to understand how medical tourism isbeing developed there. As Jamaica is prospectively devel-oping a medical tourism sector located outside of the re-gion where the conceptual framework was derived, weextend the framework and its implications outside itsoriginal geographic and temporal scope while also pro-viding the first in-depth account of Jamaica’s plans formedical tourism. This approach explores the wider rele-vance of the framework and its implications in a newcontext and identifies numerous additional system im-pacts and policy implications from the Jamaican experi-ence that refine or are not captured by the existingPocock and Phua framework. These include new policyimplications in every existing domain of the existingframework and the creation of an entirely new domain,that of ‘consumers’. Taken together, we believe our revisedframework, derived from new insights gleaned from

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Jamaica, provides a more comprehensive range of rele-vant policy implications emerging from the develop-ment of medical tourism for monitoring and policydevelopment worldwide.

MethodsBuilding on our existing Caribbean fieldwork [16, 42, 46],Jamaica was identified as a highly relevant site to pro-spectively explore how medical tourism is being pursuedby Caribbean governments and health care providers thatdo not have an existing reputation for health services ex-port. Ongoing monitoring of Caribbean media and onlinemedical tourism promotion outlets such as the MedicalTourism Association and the International Medical TravelJournal indicated Jamaica’s interest in developing a med-ical tourism sector. This was further reinforced by thepresence of Jamaican representatives at the 2011 GlobalHealthcare Congress where the first two authors were inattendance. These initial impressions of Jamaica’s promo-tional activities for medical tourism made it clear that thecountry does not have sizeable existing inflows of inter-national patients but that its government and care pro-viders are working to build a medical tourism sector. Thisindicated that the country would serve as a suitable caseto explore how medical tourism is emerging in a new lo-cation using Pocock and Phua’s framework to identify thehealth policy implications of its development.After receiving ethics approval from Simon Fraser

University’s research ethics board, we travelled to Jamaicain October, 2012, for a two week period of on-site field-work. The first author returned to Jamaica for an add-itional four weeks of fieldwork in June/July, 2013. Theresearch trips were structured within a case study meth-odological framework and employed a range of qualitativemethods to better understand how medical tourism is cur-rently understood and being mobilized in Jamaica. Semi-structured interviews with health system and tourismsector stakeholders; site visits to municipalities, health fa-cilities, and recreational tourism locations; and dailyresearcher group journaling structured around shared re-flective questions were all used to rigorously compile acomprehensive dataset.

Data collection – semi-structured interviewsWhile on-site, we sought to interview key-informantsthat could speak to the planning and development ef-forts for medical tourism in Jamaica as well as the existinghealth and/or tourism sectors. Potential interview par-ticipants were identified based on reviews of publiclyavailable reports and news coverage of medical tourismin Jamaica, contacting individuals and organizationswith roles relevant to medical tourism development,and ongoing referrals from interview participants. We

sought to maximize the diversity of key-informants inorder to capture a breadth of perspectives. Seventy-sixpotential participants and organizations were contactedand asked to follow up by phone or e-mail if they wereinterested in learning more about the study or schedul-ing a face-to-face interview at a time and location oftheir convenience. A letter of information outlining thepurpose and scope of the study as well as its risks andbenefits was provided to participants prior to the inter-view, whereupon consent was obtained. Whenever pos-sible, interviews were digitally recorded. However, sixparticipants declined to be recorded and requested thatonly written notes be taken by the interviewer(s).In total, 18 semi-structured interviews lasting from

30-60 min were conducted with representatives of publicand private hospitals, extant and planned; governmentministries; organizations charged with overseeing profes-sional and regulatory roles in the medical sector; andindividual medical professionals and tourism experts.Interview questions generally inquired about currentstrengths and challenges within the health system, med-ical tourism initiatives, and anticipated impacts of amedical tourism sector, though specific questions weretailored in order to speak to each participant’s expertise.Table 2 provides an overview of the participant numbersand their professional domains. Note that the total num-ber is higher than 18 due to some cross-categorizationof participants.

Data collection – site visitsWe based ourselves in Kingston, the Jamaican capital,during both fieldwork periods in order to facilitate inter-views and visit Jamaica’s core medical infrastructure. Afive-day trip to the country’s recreational tourism hubon the west coast was also conducted to meet withstakeholders and observe tourist and medical facilitiesthere. Site visits were made to five existing medical facil-ities identified in interviews or news reports as potentiallocations for medical tourism, as well as two green-fieldlocations positioned as future locations for medicaltourism facilities. Site visits involved visiting surroundingcommunities where the (proposed) facilities are lo-cated, touring facilities to view infrastructure and seeoperations first-hand, and informal conversations withworkers and users when appropriate. Detailed writtennotes were taken by the researchers during and immedi-ately after site visits and were transcribed and uploaded toour secure shared server for later analysis.At the conclusion of each day during the first field-

work period, we took one hour to write reflectivenotes around a set of common questions in order tocapture our impressions of the site visits. Following writ-ing, we met for an additional hour to discuss the writtenobservations and interpretations of sites visited and

Table 2 Participant overview

Employment Sector Number of participants

Governance 7

Academic and Training 4

Private Health Sector 5

Public Health Sector 3

Trade and Development 2

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debrief about the details shared in interviews during thatday, recording common and divergent issues and interpre-tations. This daily exercise sought to ensure that a com-prehensive range of observations was captured and also toimprove interpretative agreement. During the secondfieldwork period the first author kept an independentjournal that recorded impressions and observations thatwas later shared among the team.

Data analysisFollowing each fieldwork period, all interview transcriptsand field notes were compiled in a secure shared data-base. The database also holds all reports and news arti-cles that were compiled in preparation for and collectedduring the research trips. Using a categorization schemeadapted from Pocock and Phua’s framework of policyimplications emerging from medical tourism, the plans,issues, and actors referred to across the full dataset wereorganized into their respective domains (governance, fi-nancing, delivery, regulation, health human resources)by the first author. Plans, issues, and actors that did notconform to the existing scheme were noted and catego-rized separately. Following this, a synthesis of the cate-gorized and non-conforming findings was circulated tothe second and third authors to confirm their interpret-ation and comprehensiveness and achieve consensus.This process resulted in the most consistent of the non-conforming findings being agreed on as our sixth analyt-ical category of ‘consumers’. Our findings from thisdomain are outlined in the section below following theresults that fall within the existing five health policy do-mains identified by Pocock & Phua’s framework.

ResultsIn this section we organize our fieldwork findings accord-ing to the health system domains outlined in Pocock andPhua’s framework in order to facilitate comparison anddiscussion. Their domains are: governance, financing,delivery, regulation, and health human resources. Table 1(above) provides a summary of how the frameworkcharacterized each domain and its associated policy impli-cations. While we acknowledge the clear interrelationships

between these five domains, we consider each separatelyin order to effectively engage with Pocock and Phua’sframework. Each section in our results briefly notes wherethe implications from the original framework are transfer-able to Jamaica’s experience, however we focus on the is-sues and impacts identified from our Jamaican fieldworkthat were not part of Pocock and Phua’s original policy im-plications framework. We do so given their prominence indiscussions with key-informants and in order to highlightand unpack these new considerations that warrant beingfactored into dialogues and future studies of the healthpolicy implications raised by medical tourism.

GovernanceWith the exception of creating travel visa categories spe-cifically for medical travellers, all of the policy implica-tions resulting from the development of medical tourismoutlined by Pocock and Phua’s conceptual framework arealso found to be relevant to Jamaica’s sector planning. Ourfieldwork revealed two additional impacts relevant to thegovernance domain not included in their original frame-work: 1) the expansion of ministerial responsibilities andconvergence of inter-ministerial relationships; and 2) theinvolvement of international development organizationsin initiating and sustaining interest in medical tourism.We separately expand on these two impacts below.Jamaica’s national government has actively supported

the development of a medical tourism sector in thecountry since at least 2007, with political leaders andgovernment ministers from both main political partiesexpressing their support for specific hospital projectsfocusing on the international patient market and thebroader idea of medical tourism as a viable strategy foreconomic growth. Most recently, the Ministry of Industry,Investment and Commerce, the Ministry of Tourism, andthe Ministry of Health have been jointly involved in layingthe groundwork for a medical tourism sector. JAMPRO,an agency of the Ministry of Industry, Investment andCommerce that is responsible for attracting foreign directinvestment and promoting Jamaican goods and servicesfor export, has been the most active participant in spear-heading sector development. For example, JAMPRO hasrecruited international consultants to assess the viabilityof medical tourism and directly participated in trade showsand conferences organized by the United States-basedMedical Tourism Association and the regional CaribbeanExport Development Agency. It has also convened nationalstakeholder meetings and drafted an incentive frameworkto develop policy and encourage private investment in thehealth services sector. Interview participants made it clearthat JAMPRO has played the key leadership role indeveloping a vision for a Jamaican medical tourismsector and organizing policy development. Participantsalso indicated that the Ministries of Health and Tourism

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and the domestic private health sector, while supportive ofmedical tourism, have participated in a more limited con-sultative role rather than overseeing policy developmentor coordinating private investment in health facilities.Another group of actors involved in medical tourism

sector development and related to health sector govern-ance that were raised in the interviews are internationaldevelopment organizations – a group not considered inPocock and Phua’s framework. In conversations withparticipants, the Canadian International DevelopmentAgency (CIDA) and the Commonwealth Secretariat wereboth identified as having played some role in advancingthe medical tourism sector. These economic develop-ment agencies have been directly implicated in the de-velopment of medical tourism by helping to fundregional Caribbean conferences on health tourism morebroadly and in commissioning and funding the produc-tion of strategic reports that explore how to developmedical tourism in Jamaica. A participant further notedthat funding provided by such agencies earmarked foreconomic development might be used in the future tocommission additional studies or to offset tax incentivesfor growth in the medical tourism sector, demonstrat-ing the potential scope and policy relevance of thisconsideration.

FinancingOur fieldwork found limited consideration of medicaltourism’s likely influences on patterns of care financing.If discussed at all, out-of-pocket payments were under-stood to be the likely source of health care financing forany near-term plans for medical tourism. However, inlight of Jamaica’s proximity to the United States andinterest in attracting American patients and insurers, in-tersections between international hospital accreditationand international health insurance portability not identi-fied in the original Pocock and Phua framework wereregularly raised by participants from the medical sector.Progress on international health insurance portabilitywas reported to be undermined by the lack of local med-ical facilities with international hospital accreditation.This was compounded by the significant financial bar-riers to successfully obtaining international accreditationfacing medical facilities. As such, while accessing foreigninsurance funds was perceived by most participants tobe a long-term goal, out-of-pocket payments are under-stood to be the most likely financing method for inter-national patients seeking care in the immediate future.

DeliveryJamaica’s experience in planning for medical tourismthus far broadly confirms the applicability of Pocock andPhua’s anticipated policy-relevant issues in the deliverydomain. Our fieldwork revealed three new implications

relevant to this domain: 1) the utilization of existing,underutilized private sector supply; 2) an anticipated in-crease in for-profit health care delivery; and 3) the cre-ation of ‘offshore’ medical facilities with deep ties toneighbouring health systems and foreign investment.These impacts are described below.Our fieldwork found two distinct strategic models for

the initial development of the Jamaican medical tourismsector being pursued simultaneously. In the first, med-ical tourism will primarily serve as an additional marketfor the existing stock of private hospitals. Jamaica has anumber of private hospitals located in urban districtswith nearby international airports. Participants reportedthat these existing private hospitals are both locally well-regarded as reputable and having under-utilized capacity.This excess capacity was identified by participants as be-ing well suited to meeting the demands of the inter-national patient market because of the range and qualityof services available. However, it was acknowledged thatthere are few international patients currently accessingthese facilities outside of the Jamaican diaspora. Inter-national hospital accreditation was consistently identi-fied as the largest barrier to immediately accessing theinternational market. This is because accreditation pro-cesses and the costs of the renovations they typically de-mand pose a large and immediate financial barrier.A second project identified by participants as being

spurred by the prospect of medical tourism involves theconstruction of a private wing within Cornwall RegionalHospital, an existing public hospital in Montego Bay.Planning for this new wing intends for it to be closelyintegrated into the infrastructure and operations of theexisting public hospital, but for it to be privately fi-nanced and managed. Although it was noted by one par-ticipant that the primary reason for creating the wing isto both improve the quality of care available to touristswho injure themselves while visiting Montego Bay andto bring in medical tourists, they were careful to explainthat its services would be available to private payingJamaicans as well. It was also emphasized that the add-itional funds generated by private services would directlycross-subsidize a new public children’s hospital affiliatedwith Cornwall Regional Hospital, without which the newfacility could not sustainably operate.In the second model, new hospitals would be built primar-

ily to serve (medical) tourists. This is evidenced in two re-cent projects. In the first project, American Global MD, agroup of American physicians headed by a Jamaican-American, proposes an entirely new 75-bed private hospitalexplicitly framed as a medical tourism destination financedwith foreign investment and built in Montego Bay, the lar-gest city on the west coast. This facility would be staffed byAmerican physicians, while the local population would fillnursing and ancillary positions. The second project is

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spearheaded by a charitable organization in the resort townof Negril, also on the west coast. The Negril InternationalHospital plans to serve as the hub of a larger retirementcommunity that will target foreign and diasporic buyers. Itsstaffing model mirrors American Global MD’s approach,with foreign physicians supplying the specialty labour andmedical tourists comprising the bulk of their cases. Local pa-tients would be served in a charitable capacity with medicaltourists subsidizing their cost of care. This specific exampleof seasonal and year-round retirement migration supportinga medical tourism facility was favoured among numerousparticipants who see the realization of Jamaica’s existingplans to attract foreign and diasporic retirees to the countrycontingent on improving the quality of local medical care.Medical tourism is seen as providing the additional reve-nues required to viably sustain such health systemimprovements.

RegulationOur fieldwork found that the issue of international hos-pital accreditation previously identified by Pocock andPhua’s framework was by far the most prominent regula-tory issue raised in conversations with Jamaican stake-holders. Participants who had engaged with internationalconsultants or workshops/conferences on medical tour-ism reported having the importance of hospital accredit-ation in internationally marketing hospitals emphasizedto them. However, international hospital accreditationwas widely perceived to be a large and costly barrier toattracting international patients, and concerns wereshared that the accreditation might be clinically redun-dant to local standards already in place. This perceptionprompted some participants to raise the possibility ofintra-regional coordination of health care standards andregulation as they relate to medical tourism, an issue notconsidered in Pocock and Phua’s framework. These sameparticipants usually raised the example of harmonizedhealth and safety standards developed for the spa andwellness tourism sector by the Caribbean Spa andWellness Association as a model of how intra-regionalcoordination of the medical tourism sector at the pan-Caribbean scale could occur. With organizational assist-ance from CARICOM and funding from internationaldevelopment organizations, the Caribbean Spa and Well-ness Association organized a committee to identify bestpractices from existing spa standards in North America,Europe, and Asia in order to address an existing regula-tory gap. The result of this extensive review process wasthe creation of up-to-date health and safety regulations forspa and wellness service facilities shared across Caribbeancountries. This case was presented as an example of suc-cessful regional regulation within the wider health tourismsector that could be copied in developing a regional hos-pital accreditation standard.

Health human resourcesDiscussions with Jamaican stakeholders and reviews ofpolicy and media documents revealed that all health hu-man resources-related policy implications identified byPocock and Phua’s framework are relevant to Jamaica’splans for an expanded medical tourism sector. We iden-tified three additional policy-relevant issues pertaining tothe health human resources domain: 1) health workertraining as a marketing tool; 2) the increased overall de-mand for health human resources; and 3) the increasinginternational mobility and altered circulation of healthhuman resources.Jamaica’s health workers were repeatedly referred to by

participants as the country’s greatest asset in developingthe country’s medical tourism sector. This confidencestemmed from the long-standing international ties under-pinning local training practices and standards that haveproduced high quality and culturally familiar medical tra-ditions comparable to other Commonwealth countries.This confidence was also informed by the long history ofJamaican diaspora working as physicians and nurses in thehealth systems of Canada, the United Kingdom, and theUnited States. It was thought that the established familiar-ity of Jamaican health workers in these target medicaltourist markets and their reputable and interpretabletraining backgrounds would serve as a powerful marketingtool for health service exports from Jamaica.Participants were largely unconcerned by the potential

for medical tourism to reduce the availability of physiciansin the public health system due to increased demand. Thisperception was not the same across the two differentmodels of medical tourism being discussed (i.e., domesticservices export versus temporarily importing foreignhealth workers). With regard to the first model where Ja-maican health care facilities and health workers providethe services, participants consistently reported that theexisting arrangement between Jamaican private and publichealth care provides evidence that the two streams of de-livery are not in competition, as most specialists partici-pate in care delivery across both systems and nursingwages are comparable between them. Meanwhile, in thesecond model, facilities plan to recruit foreign physiciansto work in Jamaica on a temporary basis at offshore hospi-tals focusing on medical tourists. This was seen as a wayfor foreign physicians and their families to go on vacation,to generate additional income or, as in the case of theNegril International Hospital, to provide charitable carefor locals as well. Thus, this second model was perceivedas having limited potential to impact the existing Jamaicanhealth system because of these facilities outsourcing muchof their own specialist labour.Given the extreme nursing shortage in Jamaica induced

by extraordinary out-migration, participants generally gavedeep consideration to the potential impacts on nursing

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availability in the public system resulting from additionaldemand for private health care, regardless of staffing for-mats for physicians. Nurse migration from Jamaica waschiefly presented as being motivated by a desire to earnmore income abroad. Medical tourism was generallyunderstood to be a counter-weight that would providehigher wages domestically, incentivizing nurses to remainin Jamaica and ultimately increasing the local availabilityof health workers. This widely shared outlook was con-trasted by a minority who cautioned that the higher wagesthat could be supported by private care provision forinternational patients could serve to attract the mostqualified or senior care providers from the public sector.Altogether, participants demonstrated greater sensitivityto medical tourism’s potential to impact the local availabil-ity of nurses than physicians.

ConsumersThe domain of ‘consumers’ was not identified in Pocockand Phua’s original framework. Our fieldwork inJamaica, however, raised a number of critical policy-relevant questions about how perceptions of the inter-national patient market are compelling policy actionand, in turn, how a larger volume of health service ex-ports might alter the composition of health system usersin medical destinations. Participants demonstrated aconsistent vision of the composition of the internationalpatient market and, consequently, the patients thatJamaican stakeholders are working to attract. There wasa widespread perception that Jamaica will tap into alarge market of under- or un-insured patients from theUnited States. While Canada and the United Kingdomwere sometimes mentioned as additional markets, theUnited States is the predominant target market shapingstakeholders’ current expectations and planning efforts.Participants typically did not identify patients from

within the Latin American and Caribbean region or theJamaican diaspora as potential medical tourists inform-ing current planning. Once prompted, participants gen-erally expressed enthusiasm for attracting patients fromwherever they might come, but it was clear that medicaltourists are commonly interpreted as being patientsfrom high-income settings who are not emigrants withties to the country. This clarifies who are understood tobe medical tourists among sector stakeholders in Jamaicaand therefore which international patients are being mostactively sought and planned for.

DiscussionThe policy implications raised by the planning for med-ical tourism in Jamaica and their significance are dis-cussed below within the domains of Pocock and Phua’sexisting framework. Table 3 provides a synthesis of ouradditional key considerations.

GovernanceIn a departure from Pocock and Phua’s original frame-work, the involvement of Jamaica’s Ministry of Tourism inplanning for medical tourism sector development rein-forces that, regardless of discursive debates around med-ical tourism versus medical travel (e.g. [47, 48]), the framebeing used to develop policy for the sector in emergingdestinations hinges on existing experience with recre-ational tourism. This approach is producing novel inter-sections between government ministries, evident in theinvolvement of both the Ministry of Health and Ministryof Tourism in the consultation and policy planning beingled by Jamaica’s foreign investment and export promo-tion corporation, JAMPRO. These intersections may re-sult in incoherent or competing priorities informing thedevelopment of the sector. This was suggested by theregular conflation among many stakeholders that wereinterviewed between their enthusiasm and plans for a‘health tourism’ product – including wellness retreats,complementary and alternative treatments – with thenarrower, biomedical focus of ‘medical tourism’. TheMinistries involved and their respective roles demon-strate that medical tourism is being pursued primarilyas an economic, not health system, development pro-ject in Jamaica. While the Ministry of Health’s supportfor the sector may result in outcomes that benefit andintegrate with the local health system, its role in devel-oping and regulating an emergent medical tourism sec-tor could also serve as a distraction from its coremandate of overseeing local health (care) concerns.The role of international aid and development agencies

as well as professional medical tourism industry associa-tions observed in the Jamaican context was also not previ-ously captured in Pocock and Phua’s framework. We thinktheir role most coherently fits within the domain of ‘gov-ernance’ given the role that the various groups and institu-tions have played in informing and supporting sectordevelopment. Because of the potential for medical tourismto negatively impact the equitable delivery of healthcare [43], the support of international developmentorganizations for the medical tourism sector raisesimportant questions for both their accountability andoverall coherence of different initiatives’ goals. Any effortsby development organizations to promote medical tourismas an economic development strategy must work to en-sure that health equity is not compromised. This could bethrough concurrent efforts to advance initiatives such asuniversalizing health insurance coverage and transparenthealthcare cross-subsidization schemes in jurisdictionsthat are encouraged to develop medical tourism.

FinancingMedical tourism’s anticipated impacts on health care finan-cing in Jamaica are consistent with those highlighted by

Table 3 Additional policy implications from medical tourism development

Original Policy Implications Additional Implications Identified from Jamaican Case

Governance • number and content of health sector commitments inmulti- and bilateral trade agreements

• expanding/conflicting ministerial responsibilities and novelinter-ministerial relationships

(Legislation andPlanning)

• regional trade blocs promoting • involvement of international

• trade in health services • development organizations and foreign for-profit industryorganizations in developing medical tourism sectors

• national medical tourism committees or agencies

• creation of medical tourism travel visas

Financing • increase in out of pocket payments • intersections between international hospital accreditation andinternational health insurance portability

(Fundraising andPayment)

• increasing interest in internationally portable healthinsurance

Delivery • growth of private health sector • utilization of existing private sector oversupply

(Service Provision andInfrastructure)

• foreign direct investment in health infrastructure • increased for-profit healthcare delivery

• cross-subsidization schemes to explicitly benefit locals

• development of enclavic medical tourism facilities

Regulation • public and private sector quality control • regional development and coordination of healthcarestandards

(Protocol Creation andEnforcement)

• international accreditation of health facilities(e.g. Joint Commission International)

• number of medical tourist visits facilitated by brokers

Human HealthResources

• distribution of specialists between public and privatehealth sector

• health worker training as marketing tool

(Training and Supply ofCare Personnel)

• future human resource capacity (re: training,availability, professional to population ratios)

• increasing international mobility and circulation of healthcarelabour (including importation)

• increased demand for different types of health humanresources with varying supply

Consumers • narrow conceptions of international patient market andinflated projections informing sector development

(Composition andNumber of Patients) • increased utilization of health services by emigrant diaspora

Johnston et al. Globalization and Health (2015) 11:29 Page 9 of 13

Pocock and Phua’s framework, but our results indicate fi-nancing impacts are likely to be staged according to phasesof sector development. While out of pocket payments areperceived to be a matter of necessity, access to an increas-ingly portable American and European health insurancemarket was described as a key long term goal. The originalframework does not capture the relationship betweenaccess to international insurance markets and internationalhospital accreditation that was identified by Jamaican inter-view participants. This widely shared perception helps tofurther explain the growing popularity of international hos-pital accreditation. Instead of only being framed as a marketresponse to individual patient demands for recognizable sealsof quality, international hospital accreditation also positionshospitals as viable participants in an emerging, internation-ally portable insurance environment [10]. Internationalaccreditation may be critical in anticipating current andfuture flows of insured international patients. Should thevolume of international medical travel grow significantly, itwill make it increasingly important to have a clear under-standing of the strengths and limitations of the various inter-national hospital accreditation standards that are being usedto underwrite the risks of international care.

DeliveryThe numerous new private hospital projects being plannedfor in Jamaica that are reliant on foreign patients confirmthe original framework’s general insight that increasinginterest in medical tourism is accompanied by the growthof the private health sector. Our findings further demon-strate that medical tourism is also spurring significantqualitative changes to health services organization anddelivery. For example, medical tourism’s direct role ininforming the planning for a new private wing in a publichospital with the expectation that it will cross-subsidizepublic access to care is not captured by the broad originalconsideration of a growing private health sector. Similarly,in systems such as Jamaica where participants reportedexcess capacity in the private health care sector (a keyelement in narratives explaining the shift towards the inter-national market among Asian hospitals (e.g. [13]), turningto international patients in order to meet existing capacitycan be interpreted as more efficient utilization of existingprivate resources rather than overall growth of the privatesector. This alternate interpretation of how the privatehealth sector might engage in or respond to medical tour-ism raises questions about how under-utilized private

Johnston et al. Globalization and Health (2015) 11:29 Page 10 of 13

hospital beds inform interest in medical tourism amonghospitals and governments.In their plans to focus their services on international

patients, the proposed ‘offshore’ hospitals in Jamaica in-vert the existing model of medical tourism as a nichemarket for established hospitals. These plans are echoedin other Caribbean projects such as Health City in theCayman Islands and American World Clinics in Barbados.These projects raise important health equity concerns forthe health systems that host them [16–19]. In primarilyemploying foreign specialists and treating foreign patients,these facilities would present an especially severe form oftwo-tiered care, particularly if associated with the enclaviccommunities being planned for foreign retirees. The focuson increasing foreign investment in the health sector thatthese offshore hospitals represent is likely to be amplifiedby Jamaica’s weak economic position. Interview partici-pants from the existing private health sector (dominatedby a mixture of not-for-profit hospitals and small, for-profit, physician-owned speciality clinics) clearly articu-lated concerns that they would face difficulty accessingthe financial resources necessary to upgrade their facilitiesto the quality capable of attracting international patients,suggesting immediate future development may be drivenby foreign investment.This above contrast in local versus foreign financial

capacity raises further questions regarding the scale andstructure of foreign investment in health services relativeto domestic ownership, not just an anticipated absoluteincrease. Given Jamaica’s already crowded private hos-pital market, how will new, foreign-owned private hospi-tals impact existing locally-owned ones, especially withtheir attendant for-profit structure? Medical tourism de-velopment strategies that focus on inviting new, foreigninvestment could ultimately diminish domestic owner-ship in the private healthcare market over time and con-solidate foreign ownership of health services. Contextualdynamics such as these demonstrate that while ‘in-creased foreign direct investment in health services’ is afruitful point of departure for considering the impacts ofmedical tourism on a healthcare environment, providingeven a rough outline of the existing private healthcarelandscape prior to the development of medical tourismis critical to unpacking how such an outcome might ac-tually unfold on the ground.

RegulationAs highlighted by Pocock and Phua’s model, inter-national hospital accreditation is closely tied to Jamaica’splans to develop a medical tourism sector. Stakeholderinterviews demonstrated that established medical tour-ism destinations’ experiences with international accredit-ation are informing Jamaica’s policy development for thesector. International consultants and organizations

promoting medical tourism have driven home the im-portance of obtaining international hospital accreditationto Jamaican medical tourism stakeholders by raising suc-cessful examples from Malaysia, Thailand, and Costa Rica.This suggests that international hospital accreditation’sgrowth may have, in part, achieved self-reinforcing mo-mentum as it becomes a core ingredient in the standarddevelopment formula being disseminated by internationalconsultants promoting medical tourism. This requires in-vestigation to determine if its high costs, relative to theeconomic conditions of the destinations pursuing them,are justified by a clinically relevant improvement in servicequality. The Caribbean Spa and Wellness Association’ssuccess in creating their own set of therapeutic standardsdemonstrates that cooperation in regulating emergingeconomic sectors related to health and wellness mostbroadly is a viable route for Caribbean countries. Shouldmedical tourism development follow suit and serve to ini-tiate the development of a regional hospital accreditationscheme, the sector could ultimately standardize and im-prove the quality of hospital care in emerging destinationswithout incurring the costs of more expensive inter-national accreditation regimes. This potential is unlikelyto be realized, however, should marketing considerationsand international insurance portability provide the domin-ant reasons for seeking accreditation.

Human resourcesThe original Pocock and Phua framework focuses onmedical tourism’s influence on specialist behaviour, par-ticularly the potential for a larger private patient mar-ket to further incentivize specialists to reduce theirparticipation in the public healthcare sector. This im-pact was largely interpreted as a non-issue by the ma-jority of interview participants, being explained in threeinterrelated ways. Firstly, the largest medical tourismprojects being pursued in Jamaica plan to rely on for-eign specialist labour, insulating the local health systemfrom losing its own supply of workers. Secondly, thekinds of procedures envisioned as constituting the bulkof medical tourist cases were elective, particularly plas-tic surgery and orthopaedic care, and thereby thoughtto insulate critical care specialities from negative im-pacts. Lastly, there was reported to be a great degree ofexisting participation across the public and private sys-tems among specialists. It was reported that specialistsseek out cases (and thereby payment) wherever avail-able and rarely opt to solely practise in the privatesector.While the paucity of information on public versus pri-

vate sector participation by medical specialists makes itimpossible to independently confirm these perceptionsabove, they illustrate the outlooks driving the acceptabil-ity of medical tourism in emerging destinations. If

Johnston et al. Globalization and Health (2015) 11:29 Page 11 of 13

medical tourism is understood to primarily deal in elect-ive treatments, the kinds of specialist labour in increasedprivate demand are not perceived as a threat to healthequity. Arguably, this dominant outlook understates po-tential health equity impacts by neglecting to engagewith the inevitable linkages between facilities, specialties,and overall health resources that occur in real-worldhealth systems. Participants’ heightened sensitivity to thepotential for medical tourism to place stress on the in-sufficient local supply of nurses demonstrates the rele-vance of these linkages. Their concerns also highlightthe need to differentiate the impacts of medical tourismon different health professions. Whereas Pocock andPhua’s original framework focuses on medical tourism’simpacts on specialists and largely ignores other groupsof health workers, future research examining medicaltourism’s impacts should seek to understand how it in-fluences nurses, specialists, and generalists as they varyboth in supply and in the degree of control they haveover where and how often they work.Lastly, we propose the addition of ‘health worker

training as a marketing tool’ to the ‘human health re-sources’ domain because of both how often participantsemphasized the quality and familiarity of Jamaicanhealth workers as a justification for developing medicaltourism sector and given the discussion of training else-where in the literature as an asset to sector development(e.g., [49, 50]). This consideration is significant in under-standing the factors that initiate and sustain interest indeveloping medical tourism and a key factor driving theperceived viability of the sector in Jamaica. Furthermore,formal and informal connections between health sys-tems, particularly international patterns of health workertraining and employment, are potentially powerful pre-dictive precursors of international patient flows.

ConsumersOur fieldwork demonstrates that the beliefs surroundingwho medical tourists are and the scope of their numbersare critical in understanding the enthusiasm amongcountries seeking to become medical tourism destina-tions. While there is no doubt that there are Americanpatients willing to travel for medical care, the wide-spread uptake among health and tourism sector stake-holders in Jamaica of inflated projections that have beendisseminated by industry promoters and consultantssuch as the Medical Tourism Association and Deloitte’s2008 report on medical tourism [51] is alarming. Thesesources’ wide-ranging estimates and implicit expectationthat the American health system will continue to fail inadequately insuring its own population have been cri-tiqued as overly narrow and inaccurate elsewhere (e.g.[3, 52]). Regardless, articulating who sector stakeholdersare targeting when developing medical tourism is

important in unpacking the likely economic returns andhealth system impacts that the sector will produce. Forexample, recent work from Lunt et al. [53] and otherscholars examining medical tourism (e.g. [52, 54])suggest that the international patient market is most ac-curately understood as relatively small and reliant onexisting social ties between particular ‘source’ and‘destination’ countries, rather than a large, unattachedmarket of atomised patient-consumers with a willingnessto travel anywhere for the care they want. While lesseconomically tantalizing, broadening the popular con-ception of medical tourists beyond the image of the un-insured American patient or wait-listed Canadian orBriton to focus on regional and diasporic populationscould promote the development of health services ex-ports that are likely to have greater uptake while alsobeing more relevant and accessible to the domesticpopulation.

Study limitationsAs researchers with no personal or cultural ties toJamaica, the issues that were raised in interviews and themanner in which they were framed by participants maybe different than those produced by a local researcher.Controversial issues or factors that might negatively im-pact foreign perception of Jamaica (e.g., high crime andviolence rates) may have been omitted by participants,even unintentionally. As our findings emerged from aqualitative case study design, the policy implicationsraised here are not generalizable to all jurisdictions de-veloping medical tourism sectors. This is not a true limi-tation, though, as qualitative research seeks to achievetransferability and not generalizability. Further to this,the considerations identified here and in the originalframework are intended to raise implications for furtherinvestigation rather than serve as a prescriptive account.

ConclusionsThis analysis demonstrates that the domains of Pocockand Phua’s framework for identifying policy-relevant im-plications of the medical tourism sector provide a usefulcommon reference point for exploring the developmentof medical tourism in new contexts. The original frame-work’s inclusion of very specific issues (e.g. ‘creation ofmedical tourism visas’) alongside broad ones (e.g. ‘growthof private health sector’) and the absence of distinctionbetween the drivers and impacts of medical tourism pro-vides great latitude in adapting it to different locationsand stages of development, including Caribbean countrieslike Jamaica. While its basic design does not supply ex-planatory power or trace the relationships between thepre-existing conditions that facilitate medical tourism andthe impacts of the practice, the Pocock and Phua frame-work does provide a useful organizational scheme to

Johnston et al. Globalization and Health (2015) 11:29 Page 12 of 13

identify and compile additional policy-relevant observa-tions. For example, most of the additional policy impli-cations that we identified in the Jamaican context arelogical extensions of the original five domains in theframework. Our addition of ‘consumers’ to the frame-work as a new policy-relevant domain expands Pocockand Phua’s original conceptualization to capture issuesemerging from our work in the Jamaican context. It islikely that the numerous previously unidentified policyimplications and new domain reported in the current ana-lysis hold true for the wider Caribbean and are also rele-vant beyond the region.We believe that future health services research exam-

ining medical tourism can further and meaningfully con-tribute to refining the Pocock and Phua framework byidentifying additional implications emerging from thedevelopment and operation of the sector in other coun-tries and regions beyond those already considered. Suchresearch will assist in assessing the global transferabilityof the framework. Future studies can also advance ourunderstanding of the policy implications of medicaltourism development by undertaking comparative ana-lyses of the implications specific to particular frameworkdomains, which will help us to understand the role thatlocal context plays in shaping how they are occurring inparticular ways in specific places. At the same time, suchresearch will further our understanding of commontrends that are structuring the development of medicaltourism worldwide and the scope of its health systemimpacts and policy implications despite such differences.

Competing interestsThe authors declare that they have no competing interests.

Authors’ contributionsRJ and VAC conceived of original study, and all authors participated in studydesign and implementation. RJ, VAC, and MO participated in identifyingpotential participants, conducting fieldwork, data collection and analysis.RJ drafted the original manuscript, with VAC and MO contributing edits infollowing iterations of writing. All authors have reviewed and approved thismanuscript.

AcknowledgementsWe are very grateful to the interview participants for their generouscontribution of time and knowledge. This study was funded by a PlanningGrant awarded by the Canadian Institutes for Health Research (FRN 122685).RJ holds a Banting and Best Doctoral Award from the Canadian Institutes forHealth Research. VAC is funded by a Scholar Award from the Michael SmithFoundation for Health Research and holds the Canada Research Chair inHealth Service Geographies.

Author details1Department of Geography, Simon Fraser University, 8888 University Drive,V5A 1S6 Burnaby, BC, Canada. 2Cultural Geography, Environmental Sciences,Wageningen University, Wageningen, NL, The Netherlands.

Received: 9 October 2014 Accepted: 15 June 2015

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