Medical tourism's impacts on health worker migration in the Caribbean: five examples and their implications for global justice

Patient care without borders: a systematic review of medical and surgical tourism

BACKGROUND

Medical tourism (MT) is an increasingly utilized modality for acquiring medical treatment for patients globally. This review assimilates the current literature regarding MT, with particular focus on the applications, ethics and economics.

METHODS

A systematic review of MEDLINE and PubMed Central databases for publications relating to MT from 2005 to 2018 yielded 43 articles for this review.

RESULTS

Patients seeking elective bariatric, cosmetic and orthopedic surgery abroad are motivated by significantly lower costs, all-inclusive vacation packages and reduced wait times. Complication rates as high as 56% include infection, poor aesthetic and functional outcome and adverse cardiovascular events. Cross-border reproductive care has steadily increased due to less restrictive policies in select countries; however, the depth of research on outcomes and quality of care is abysmal. Stem cell therapy promise treatments that are often not well researched and offer minimal evidence of efficacy, yet patients are drawn to treatment through anecdotal advertisements and a last sense of hope. Transplant surgery sought to decrease wait times carries many of the similar aforementioned risks and may contribute to the practice of organ trafficking in countries with high rates of poverty. Patients and countries alike are motivated by a plethora of factors to engage in the MT industry but may be doing so without accurate knowledge of the quality, safety or potential for economic gain. Safety is of utmost importance to prevent surgical complications and the spread of treatment-resistant bacteria.

CONCLUSIONS

MT is growing in popularity and complexity. The lack of standardization in its definition and regulation leads to difficulty in epidemiologic and economic analysis and ethical issues of informed consent and health equity. The findings of this review may be used by the stakeholders of MT, including patients and providers, to enhance informed decision-making and quality of care.

"Medical tourism will…obligate physicians to elevate their level so that they can compete": a qualitative exploration of the anticipated impacts of inbound medical tourism on health human resources in Guatemala

BACKGROUND

Medical tourism, which involves cross-border travel to access private, non-emergency medical interventions, is growing in many Latin American Caribbean countries. The commodification and export of private health services is often promoted due to perceived economic benefits. Research indicates growing concern for health inequities caused by medical tourism, which includes its impact on health human resources, yet little research addresses the impacts of medical tourism on health human resources in destination countries and the subsequent impacts for health equity. To address this gap, we use a case study approach to identify anticipated impacts of medical tourism sector development on health human resources and the implications for health equity in Guatemala.

METHODS

After undertaking an extensive review of media and policy discussions in Guatemala's medical tourism sector and site visits observing first-hand the complex dynamics of this sector, in-depth key informant interviews were conducted with 50 purposefully selected medical tourism stakeholders in representing five key sectors: public health care, private health care, health human resources, civil society, and government. Participants were identified using multiple recruitment methods. Interviews were transcribed in English. Transcripts were reviewed to identify emerging themes and were coded accordingly. The coding scheme was tested for integrity and thematic analysis ensued. Data were analysed thematically.

RESULTS

Findings revealed five areas of concern that relate to Guatemala's nascent medical tourism sector development and its anticipated impacts on health human resources: the impetus to meet international training and practice standards; opportunities and demand for English language training and competency among health workers; health worker migration from public to private sector; job creation and labour market augmentation as a result of medical tourism; and the demand for specialist care. These thematic areas present opportunities and challenges for health workers and the health care system.

CONCLUSION

From a health equity perspective, the results question the responsibility of Guatemala's medical education system for supporting an enhanced medical tourism sector, particularly with an increasing focus on the demand for private clinics, specific specialities, English-language training, and international standards. Further, significant health inequalities and barriers to care for Indigenous populations are unlikely to benefit from the impacts identified from participants, as is true for rural-urban and public-private health human resource migration.

What is the financial incentive to immigrate? An analysis of salary disparities between health workers working in the Caribbean and popular destination countries

Background

The continuous migration of Human Resources for Health (HRH) compromises the quality of health services in the developing supplying countries. The ability to increase earnings potentially serves as a strong motivator for HRH to migrate abroad. This study adds to limited available literature on HRH salaries within the Caribbean region and establishes the wage gap between selected Caribbean and popular destination countries.

Methods

Salaries are reported for registered nurses, medical doctors and specialists. Within these cadres, experience is incorporated at three different levels. Earnings are compared using purchasing power parity (PPP) exchange rates allowing for cost of living adjusted salary differentials, awarded to different levels of work experience for the chosen health cadres in the selected Caribbean countries (Jamaica, Dominica, St Lucia and Grenada) and the three destination countries (United States, United Kingdom and Canada).

Results

Registered nurses in the destination countries, across all experience levels, have greater spending power compared to their Caribbean counterparts. Recently qualified registered nurses earn substantially more in the UK (86.4%), US (214.2%) and Canada (182.5% more). The highest PPP salary ($) gap amongst more experienced nurses (5-10 years) is found within the US, with a gap of 163.9%. PPP salary gaps amongst medical doctors were pronounced, with experienced cadres (10–20 years of experience) in the US earning 316.3% more than their Caribbean counterparts, whilst UK doctors (183.5%) and Canadian doctors (251.3%) also earning significantly more. Large salary differentials remained for medical specialists and consultants. US specialist salaries were 540.4% higher than their Caribbean based counterparts, whilst UK and Canadian specialists earned 95.2 and 181.6% more respectively.

Conclusion

The PPP adjusted HRH salaries in the three destination countries are superior to those of comparable HRH working in the Caribbean countries selected. The extent of the salary gaps vary according to country and the health cadre under examination, but remain considerable even for newly qualified HRH. The financial incentive to migrate for HRH trained and working in the Caribbean region remains strong, with governments having to consider earning potential abroad when formulating policies and strategies aimed at retaining health professionals.

Government roles in regulating medical tourism: evidence from Guatemala

Background

Regulation of the medical tourism and public health sectors overlap in many instances, raising questions of how patient safety, economic growth, and health equity can be protected. The case of Guatemala is used to explore how the regulatory challenges posed by medical tourism should be dealt with in countries seeking to grow this sector.

Methods

We conducted a qualitative case study of the medical tourism sector in Guatemala, through reviews and analyses of policy documents and media reports, key informant interviews (n = 50), and facility site-visits.

Results

Key informants were critical of the absence of effective public regulation of the emerging medical tourism sector, noting several regulatory gaps and the importance of filling them. These informants specifically expressed that: 1) The government should regulate medical tourism in Guatemala, thought there was disagreement as to which government sector should do so and how; 2) The government has not at this time regulated the medical tourism sector nor shown great interest in doing so; and 3) International accreditation could be used to augment domestic regulation.

Conclusions

The intersection of domestic and international regulation of medical tourism has been largely unexplored. This case study advances new research in this area. It highlights the need for and dearth of regulatory protections in Guatemala and lessons for other, similarly situated countries. National regulatory models from Israel and Barbados could be adapted to the Guatemalan context. Global governance could help to protect national governments from any competitive disadvantages created by regulation. Underlying the concerns over growth in medical tourism, however, is how it contributes to the ongoing privatization of health care facilities worldwide. This trend risks undermining efforts to reach targets for Universal Health Coverage and exacerbating existing inequities in the global distribution of health and wealth.

What does the development of medical tourism in Barbados hold for health equity? an exploratory qualitative case study

Background

Although the global growth of privatized health care services in the form of medical tourism appears to generate economic benefits, there is debate about medical tourism’s impacts on health equity in countries that receive medical tourists. Studies of the processes of economic globalization in relation to social determinants of health suggest that medical tourism’s impacts on health equity can be both direct and indirect. Barbados, a small Caribbean nation which has universal public health care, private sector health care and a strong tourism industry, is interested in developing an enhanced medical tourism sector. In order to appreciate Barbadians’ understanding of how a medical tourism industry might impact health equity.

Methods

We conducted 50 individual and small-group interviews in Barbados with stakeholders including government officials, business and health professionals. The interviews were coded and analyzed deductively using the schedule’s questions, and inductively for novel findings, and discussed by the authors.

Results

The findings suggest that in spite of Barbados’ universal health care and strong population health indicators, there is expressed concern for medical tourism’s impact on health equity. Informants pointed to the direct ways in which the domestic population might access more health care through medical tourism and how privately-provided medical tourism in Barbados could provide health benefits indirectly to the Barbadian populations. At the same time, they cautioned that these benefits may not materialize. For example, the transfer of public resources — health workers, money, infrastructure and equipment — to the private sector to support medical tourism with little to no return to government revenues could result in health inequity through reductions in access to and availability of health care for residents.

Conclusions

In clarifying the direct and indirect pathways by which medical tourism can impact health equity, these findings have implications for health system stakeholders and decision-makers in Barbados and other countries attempting both to build a medical tourism industry and to protect health equity.