Kristen D Smith Research Fellow School of Population & Global Health University of Melbourne, Australia

Medical tourism

and bioethics: Imprints left by

the global neoliberalisation

of health

What is medical tourism?

Medical Tourism (MT) is generally used as an

umbrella term (Connell, 2012) – defined as

travel with an aim to improve health.

Focus on biomedical procedures as

opposed to Complementary and

Alternative Medicines.

• Changing trends and greater complexity in

patient origins & destinations alongside

motivations.

• Shifts in types of health services sought

abroad.

Global Health inequalities and the

‘market’

In past 40 years, health status disparities between

Developed and Developing countries have been linked

to:

(1) The relationship between the reduction of the

role of the public sector in health systems and the

correlating commercialisation of health.

(2) The conduct and influence of international

organisations on health.

(3) Market led health care models and health

protection for vulnerable groups.

The World Bank: late 80s

World bank 1987 report ‘Financing Health

Services in Developing Countries’ heralded

health reform movement

Moved away from public funding model for

health service provision

Consolidated links between population health

status and economic development of nations

Argued that curative services should be provided

& regulated by market.

Medical Tourism and the WTO

General Agreement on Trade in Services (GATS)

Under the GATS, health is one of 12 listed services provided for.

Within the GATS medical tourism falls under the second mode as “consumption abroad”

The GATS have drawn critique the secrecy of the negotiations

Human Rights and Health

• The view of health as a human right has evolved alongside other human rights discourses

• The Alma Ata Declaration (1978) expressly states that health is a human right

• Farmer (2002) contends equal access to medical care is a social and economic right

An ethnography of

medical tourism in

Mumbai

5 private hospitals in Mumbai.

Observations in hospitals waiting rooms, board

meetings, administrative meetings, hospital wards,

waiting rooms and consultancy rooms.

Semi-structured, in-depth interviews with healthcare

professionals (consultant surgeons, medical directors,

hospital management personnel).

Health care System Shifts in India 1980 – 1990

•1980s saw a major shift in policy direction as seen in seen in the

National Health Policy 1982.

•Over the decade 1980s external foreign debt doubled.

•1991, a Structural Adjustment Program (SAP) was introduced

•Soon followed by the New Economic Policy.

•The NEP directly impacted on health sector through reduction of grants

to state public health and disease control programs.

• Growing demand for medical services saw the proliferation of health

services within the private sector throughout the 1990s.

Wards in two Public

Hospitals in Mumbai

The Rise of the Corporate Hospital in India

First corporate hospitals emerged in early 1980s

>150 private tertiary healthcare conglomerates.

Growth of corporate hospitals puts pressure on Trust (not for

profit) Hospitals.

Financial Director of Hospital B in study claimed only options

for Trust hospitals:

1. Transform core ideals towards a market based ethos;

2. Outsource management to the larger health care

conglomerates to attain sufficient funding;

3. Submit to the inevitability of closure.

“Turning around sick hospitals has become the latest rage in

the healthcare industry”(Sharma, 2007 )

Scenes from two Private Hospitals

in Mumbai

Medical tourism: healthy for

the health system?

Public discussion framed by three central claims:

Claim 1: MT will increase export earnings through

attracting foreign exchange into the country, lowering

fiscal deficit and assisting the economic development.

“…well it’s like this, we had the boom in the IT industry. Now

there’s a boom in healthcare industry. Healthcare in the same

way, government are spending lots of money on the

infrastructure. You know the government, the next goal for the foreign exchange is the healthcare industry.”

(Dr. Nair: Mumbai Interviews 2009)

Medical tourism: healthy for the health system

cont.…

Claim 2: Promotion of medical tourism will raise the

national standards of health care through competitive

market practices (also translating to an increase of

the standards in the public sector).

Movements towards national and international

accreditations, but increasing the standards is likely

to increase costs for local patients.

Is medical tourism healthy for the health system

cont.….

“Yes, if I focus a lot on medical tourism obviously I’ll

increase my charges. That means my local people, if I don’t have a dual billing, will have to pay more. Okay. And

the infrastructure costs, to match up to international

standards, which I feel is required, will increase the costs

again and the local population will not be able to afford it.

The health insurance has not reached to its optimal level

yet. Where, you know, people cannot afford the

healthcare in a, in a facility like, our hospital. So the

facility that can be afforded by this hospital is more of a middle, middle upper class population”

(Dr Rao: Interviews, Mumbai 2010)

Region Public Private

Rural 35.8 42

Urban 43.4 53.7

Total 39.9 49.1

Increase in Medical Cost of Hospitalisation

between 1994-95 and 2004 (%)

Source: data adapted from NSSO 2006

Is medical tourism healthy for the health system

cont.….

Claim 3: The economic growth medical tourism

generates would result in an overall increase of

national income, thus creating equity in access

through allowing more of the population access to

private care.

Employs the widely critiqued notion of the trickle-

down concept, but is thinly veiled.

“Improving the lives of billions of people at the bottom of

the economic pyramid is a noble endeavour. It can also be a lucrative one.” (Prahalad & Hammond, 2002)

“It will put us on the world map, I think. The

world has considered us as a Third World

Country, we still are. Let’s face facts. This can

change things. Definitely. But the message is,

we will now go to work, in all departments, in

all faculties of medicine. Very good, well

trained doctors. Very well educated, not

generally the backward class I’m talking. By

on large the bulk of us are a very good lot.”

(Dr Patel, Mumbai interviews, 2010)

Conclusions

Still very little empirical knowledge on

volume, nature and broader practices of MT

MT provides a window through which to

identify & analyse broader issues relating to

the health care internationally.

Global rise of market-led healthcare: MT one

of many bi-products.

Highlights need for more critical analysis of

dominant discourses.

References Cummins. (2003). A mysterious conversion: How Escorts made a 'for-profit' company out of a charitable society. Businessworld Online.

India.

Directorate-General of Health Services India Ministry of Health & Family Welfare (DGHS). (1983). National Health Policy 1983. New Delhi:

Government of India.

Ehrbeck, T., Guevara, C., & Mango, P. D. (2008). Mapping the market for medical travel. The McKinsey Quarterly, May.

Evans, R. G. (1997). Going for the gold: the redistributive agenda behind market-based health care reform. Journal of health politics, policy

and law, 22(2), 427.

Geest, S. v. d., & Finkler, K. (2004). Hospital ethnography: introduction. Social Science & Medicine, 59.

The Globalization of Health Care: Can Medical Tourism Reduce Health Care Costs? (2006). Special Committee on Aging pp. 109-659).

Washington, DC: U.S. Government Printing Office.

Henderson, J. C. (2004). Healthcare tourism in Southeast Asia. Tourism Review International, 7, 111-121.

Kangas, B. (2010). Traveling for Medical Care in a Global World. Medical Anthropology: Cross-Cultural Studies in Health and Illness, 29(4),

344 - 362.

Lefebvre, B. (2009). 'Bringing World-class Health Care to India': The rise of corporate hospitals. In A. Vaguet (Ed.), Indian Health Landscapes

under Globalization. New Delhi, India: Manohar Publishers & Distributors.

National Health Accounts Cell (NHAC). (2005). National Health Accounts India 2001-2002. New Delhi: Ministry of Health and Family Welfare,

Government of India.

Rao, K. S., Selvaraju, S., Nagpal, S., & Sakthivel, S. (2006). Financing of Health in India. Background Papers: Financing and delivery of

Health Care Services in India. New Delhi: National Commission on Macroeconomics and Health, Ministry of Health and Family Welfare,

Government of India.

Smith-Morris, C., & Manderson, L. (2010). The Baggage of Health Travelers. Medical Anthropology: Cross-Cultural Studies in Health and

Illness, 29(4), 331 - 335.

Teh, I. (2007). Healthcare Tourism in Thailand: Pain Ahead? Asia Pacific Biotech News (APBN), 11(8), 493-497.

Turner, L. (2007). 'First World Health Care at Third World Prices': Globalization, Bioethics and Medical Tourism. BioSocieties, 2(303-325).

Whittaker, A., & Speier, A. Cycling Overseas•: Care, Commodification, and Stratification in Cross-Border Reproductive Travel. Medical

Anthropology: Cross-Cultural Studies in Health and Illness, 29(4), 363 - 383.

Winter, T., Teo, P., & Chang, T. C. (2009). Asia on tour : exploring the rise of Asian tourism. New York: Routledge.

Yamey, G. (2001). World Bank funds private hospital in India. BMJ: British Medical Journal, 322(7281), 257.