The Internationalisation of Healthcare and Business Aspirations of Medical Professionals

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    DOI: 10.1177/0038038514535863

    published online 13 June 2014SociologyLila SkountridakiProfessionals

    The Internationalisation of Healthcare and Business Aspirations of Medical

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    The Internationalisation of Healthcare and Business Aspirations of Medical Professionals

    Lila SkountridakiUniversity of Strathclyde, UK

    AbstractInterest in international patient travel and trade in healthcare has grown considerably over the past decade. Whilst the field is under-researched, patients motivation to travel to seek healthcare solutions has attracted significant attention. In contrast, the perspective of the medical doctors (MDs) remains unexplored. This article directs attention to medical professionals as key players in the internationalisation of private healthcare provision. Through the lens of the sociology of the professions, it examines the ongoing initiatives of MDs in Greece to attract patients from abroad. Findings indicate that international patient movement has given an incentive to MDs to exhibit an entrepreneurial approach. Their attitudes portray professionals with business aspirations which go well beyond their role as medics, and stand in contrast to the traditional image of medical professionals. In addition, it fosters competition among professionals at a domestic and international level, threatening the cohesion of the medical community.

    Keywordsinternationalisation of healthcare, medical professionals, medical tourism/travel, professional entrepreneurship

    Introduction

    Interest in international patient travel and trade in healthcare has grown considerably over the past decade. Other than the business interest it attracts, the phenomenon is of importance to a number of academic fields. Whilst the field is under-researched, patients welfare and motivation to travel has attracted considerable attention. In contrast, the perspective of the medical doctors (MDs) involved remains unexplored. This article directs attention to medical professionals as key players in the internationalisation of

    Corresponding author:Lila Skountridaki, University of Strathclyde, 199 Cathedral St, Glasgow G4 0QU, UK. Email: lila@skountridaki.com

    535863 SOC0010.1177/0038038514535863SociologySkountridakiresearch-article2014

    Article

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  • 2 Sociology

    private healthcare. Drawing on an example of MDs in Greece, it suggests that they play a pivotal role in developing and building the new market. This takes place through entre-preneurial tactics and a business approach.

    The sociology of the professions serves as a body of theory that usefully frames the qualitative data. It assumes a dominant position for medics within the healthcare system and examines the changes taking place in healthcare, the economy, and society more broadly. Recent contributions highlight both continuity and change in the professions (Evetts, 2011), but also mutation and adaptation of professionals with respect to the changing environment (Adler and Kwon, 2007). This article focuses on professionals in a private healthcare setting, where MDs work in collaboration but independently from large organisations and avoid bureaucratic control. Within that setting, the professional value of disinterestedness is examined vis-a-vis the perceived opportunity for interna-tional trade in healthcare. Findings indicate that patient travel lays bare entrepreneurial incentives: profit generation and self-interest are not perceived as taboo, while profes-sional success is considered in business terms. Furthermore, it illustrates professionals who advance the commodification of health services through commercial initiatives. The findings show, thus, a case of enterprising professionalism with elements of commercial-ism and entrepreneurship clearly manifested. This does not mean, however, that MDs do not strive to offer the highest quality of care. Nevertheless, it highlights a practising professionalism which isolates expertise from the sense of servicing community (Brint, 1994). Two debates in the sociology of the professions are most relevant here. The first is whether professionalism is mutually exclusive to commercialism and bureaucracy (Freidson, 2001) or whether elements of all three may co-exist (Adler et al., 2008). Evidence presented here suggests that commercialism (expressed through entrepreneur-ship and self-interest) and professionalism (dedication to high-end results) intersect (Hanlon, 2004). In light of this, the contention that disinterestedness comprises the soul of professionalism (Freidson, 2001) deserves re-examination. The second debate revolves around whether professions, over time and amidst socio-economic change, are losing their dominant position. Whilst commercialism may imply loss of public trust, broader trends need to be evaluated before drawing any conclusion.

    Overall, as observed in a number of other countries, MDs entrepreneurship is not unique to the Greek case. Medical doctors appear to be behind medical providers initia-tives to open up services to patients from foreign countries elsewhere; for example, South Africa (Crush et al., 2012), Costa Rica (Ackerman, 2010), or Singapore during the 1980s (Chee, 2010). The contribution of this article is related to MDs initiatives to build the market. Through qualitative interviews it offers insights into the way MDs think and act with regards to the international movement of patients, and discusses potential impli-cations for professional power and the commodification of healthcare.

    The Development of International Patient Travel as an Emerging Opportunity for Business

    In the early part of the new millennium, scholars, mainly from the USA, began to observe a growing trend for patients to go outside their home country for medical care. Media reports provide evidence, for example, of Americans and Canadians moving to Asian or

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    Latin-American countries for cheaper dental care, cosmetic surgery, timely hip replace-ment, accessible fertility treatment, and affordable cardiovascular surgery. Most observ-ers employ the term medical tourism to refer to the phenomenon where patients move to a foreign country with the purpose of receiving medical treatment. According to Carrera and Lunt (2010) it puts an emphasis on clinical, surgical, and hospital provision.

    Patients decide to travel for various reasons. Long waiting lists, high treatment costs, and the need for privacy comprise important push factors. In addition, changes in life-style increase the market demand for cosmetic surgeries, dental care, and wellbeing activities (Garcia-Altes, 2011). Coupled with financial factors such as low-cost airfares, price differences in healthcare services between countries, favourable exchange rates and ease of communication via the internet (Lunt et al., 2009), there has been an increase in the transnational demand for medical services. This trend increases the expectations of business in the private sector, governments and some medical doctors. It gives a financial incentive to invest in new facilities and market services abroad. At an institutional level, transnational organisations make significant efforts to facilitate patient movement. The World Trade Organization promotes opening up trade in services, including the health sector (Labont and Gagnon, 2010; Smith, 2012). At the same time, the European Commission has made clear steps in encouraging patient movement (Jarman and Greer, 2010) with the rationale that patient mobility within the European Union is a citizen right.

    Overall, the expansion of patients travelling to foreign countries is expected to have a significant impact on involved stakeholders and civil society more broadly. It has the potential to affect the national healthcare systems, the life of patients travelling abroad, policy making, medical practices operation, and the hospitality sector. Moreover, schol-ars have voiced concerns over lack of any sort of regulation in terms of patient protection (Cortez, 2010), incidents of malpractice (Barrowman et al., 2010; Birch et al., 2010), and negative effects on the populations of host countries (Sengupta, 2011).

    Academics are paying increasing attention to the emergence of medical tourism with an expanding number of studies exploring its demand, its driving forces, the conse-quences for stakeholders, and the ethical dilemmas involved. Less emphasis is placed on the perspective and role of small medical providers and, in particular, of medical doctors. A central argument of this article is that MDs are not only a key component of the sup-ply-side of global healthcare provision but also a key actor in its emergence. To better understand the argument it is fruitful to consider at this point some basic features of the organisation of international provision (supply-side). It is also important to place Greece within the broader map so as to make the example more illustrative.

    Medical providers servicing the international demand are located in a number of countries. The size of providers, the phase of development of the sector in each country and the government involvement are important elements of this supply. For example, in one group of country-destinations large hospitals concentrate the bulk of inbound patient flows (e.g. Turkey, India, and Thailand). These large organisations may be owned by foreign investors or local entrepreneurs. There is another group of destinations where small providers attract the bulk of inbound patients. These practices are typically run by MDs who carry out the medical procedures but also undertake managerial tasks and marketing initiatives. Their aim is to increase their clientele. Whilst in some countries

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    small providers account for the bulk of inbound flows in the start-up phase, later large providers expand significantly (i.e. Costa Rica and Singapore). The reverse may also hold. According to the vice-president of Thailand Medical Tourism Federation in 2011, there is an interest in encouraging smaller providers to engage with foreign patients. State involvement is also significant. The establishment of special boards and national programmes, the provision of tax incentives, the organisation of marketing campaigns, easing visa restrictions for foreign patients, or relaxing advertising restrictions in the healthcare sector are examples of interventions aiming to boost the sector (Chee, 2010; Crush et al., 2012; Lautier, 2008; Sengupta, 2011).

    In Greece the sector is in its infancy. Small providers led by MDs currently account for the inbound flows. Despite their considerable capacity and strength, large private hospitals have only recently started seeking opportunities in foreign markets. It was also only at the end of 2013 that the state announced that a national programme was under-way. This development presents the group of MDs who have been active in the field for an estimated five to 10-year period as the pioneers. It is notable that the debt crisis has no small role to play in the recent interest of the state, large providers, and medics. Crippled domestic demand has intensified medics interest in the international demand. Larger providers are also increasingly considering agreements with foreign insurance funds as a result of payment delays by local funds. Simultaneously, the government per-ceives medical tourism as a lucrative market worthy of support. The current study research findings suggest that medical doctors in Greece deploy reputational capital, existing cross-border networks, newly established collaborations with intermediaries, and marketing techniques to increase their share in the international market. With regards to the sociology of the professions, the findings de-emphasise the argument that MDs employ a discourse of disinterestedness. Rather, they suggest a changing professionalism and call for an examination of the consequences on professional power.

    The Sociology of Professions: The Case of Medical Doctors

    The professional code of ethics and claim of disinterestedness remain at the centre of sociological discussions over the role and position of professions within society. The ethic of service has been characterised as the soul (Freidson, 2001: 216), or core, of professionalism (Timmermans and Oh, 2010). Freidson (2001) defines professionalism as a mode of production where the producers have control over their work, the labour market, and the production of knowledge in their field. Simultaneously, their work requires discretion, is based on abstract knowledge, and deemed to be dedicated to a higher mission. As a result, it is suggested that the logic of professionalism is distinct from that of bureaucracy and the market. Various schools of thought perceive profes-sional disinterestedness in different terms. Professions have been praised for their traits and service to society (Saks, 2012), even when appraisal has been accompanied with scepticism (Crompton, 1990). Professions have been criticised for using the rhetoric of disinterestedness to advance their own position within society regarding status, influence and financial rewards (i.e. neo-Marxists Johnson, 1972 and Larson, 1977) (Hafferty and Light, 1995). It is...

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