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Medical tourism and national health care systems: an institutionalist research agenda

Daniel béland.

Johnson Shoyama Graduate School of Public Policy, 101 Diefenbaker Place, Saskatoon, SK S7N 5B8 Canada

Amy Zarzeczny

Although a growing body of literature has emerged to study medical tourism and address the policy challenges it creates for national health care systems, the comparative scholarship on the topic remains too limited in scope. In this article, we draw on the existing literature to discuss a comparative research agenda on medical tourism that stresses the multifaceted relationship between medical tourism and the institutional characteristics of national health care systems. On the one hand, we claim that such characteristics shape the demand for medical tourism in each country. On the other hand, the institutional characteristics of each national health care system can shape the very nature of the impact of medical tourism on that particular country. Using the examples of Canada and the United States, this article formulates a systematic institutionalist research agenda to explore these two related sides of the medical tourism-health care system nexus with a view to informing future policy work in this field.

In this era of globalized medicine, when international travel and access to online health information are readily accessible, medical tourism is an important issue both for national health care systems and from a global health perspective [ 1 – 3 ]. Patients from countries around the world are exercising increasing degrees of autonomy over their health care options by obtaining information from sources other than their regular health care providers and, in some cases, by electing to pursue care alternatives outside their domestic medical system. Medical tourism is a broad and inclusive term that captures a wide range of diverse activities [ 3 ]. It has been defined as “the practice of travelling to another country with the purpose of obtaining health care (elective surgery, dental treatment, reproductive treatment, organ transplantation, medical checkups, etc.),” and is generally distinguished from both care sought for unplanned medical emergencies that occur abroad and from formal bi-lateral medical trade agreements [ 4 , 5 ]. Individual motivations for engaging in medical tourism vary widely and may include imperatives such as avoiding wait times, reducing costs, improving quality, and accessing treatments not available or legal in the home jurisdiction, or for which the individual is not eligible [ 5 – 8 ].

While medical tourism is far from new, shifting patient flow patterns and a growing recognition of the complex ethical, social, economic, and political issues it raises are underscoring renewed efforts to understand this phenomenon and its future [ 3 , 9 , 10 ]. Some of the current attention focused on medical tourism concerns its implications and potential risks for individual patients and health care systems [ 11 – 13 ]. Medical tourism impacts both importing and exporting health care systems, albeit in different ways [ 14 ]. Various terms exist to describe trade in health services [ 15 ]. For the purpose of this discussion, we will use importing or destination to describe systems whereby patients come from other jurisdictions to receive care, and exporting to describe the departure of individuals from their domestic medical system to pursue health services elsewhere. Recognizing that there are important knowledge gaps and a need for definitional clarity and further empirical work to understand the effects of medical tourism on the countries involved [ 16 ], concerns for importing or destination systems include, though are not limited to, ethical questions about inequity of access for local residents versus high paying visitors and about the “brain drain” of local talent into private, for-profit organizations focused on non-resident care [ 15 ]. Conversely, the issues exporting systems face often revolve around implications for domestic health care providers, the potential for patients to avoid domestic wait lists, and the costs of follow-up care upon patients’ return [ 12 ]. For example, research from Alberta, Canada, suggests that the financial costs associated with treating complications from medical tourism for bariatric surgery are substantial, and complication rates are considerably higher than similar surgeries conducted in Alberta (42.2–56.1% versus 12.3% locally) [ 6 ].

Although a growing body of literature has emerged to study medical tourism and address the policy challenges it creates for health systems [ 3 , 16 ], the comparative scholarship on medical tourism remains too limited in scope, a remark that should not hide the existence of a number of recent comparative studies in the field [ 17 – 19 ]. These studies demonstrate that comparative research is helpful in identifying both the unique and the most common policy challenges facing each country [ 20 ] and can, if done appropriately, offer learning opportunities [ 21 ]. Indeed, this process can facilitate policy learning (related terms include lesson drawing, policy transfer, diffusion, and convergence) whereby ideas, policies, or practices (e.g., regulatory tools) in one jurisdiction inform or shape those in another [ 22 , 23 ].

With a view to ultimately informing policy related to medical tourism, this article discusses the value of a comparative research agenda about medical tourism that stresses the multifaceted relationship between medical tourism and the institutional characteristics of national health care systems. On the one hand, these characteristics may shape the content of the demand for medical tourism among the citizens of a particular country [ 24 ]. From this perspective, as argued, existing typologies of health care systems can shed light on the varying features of the demand for medical tourism across countries. In other words, different types of health care systems are likely to produce different configurations of demand for medical tourism, which influences the range of policy instruments available to governments and other actors seeking to influence decision-making and behavior within their particular context [ 25 ]. On the other hand, the institutional characteristics of each national health care system may also shape the very nature of the impact of medical tourism on that system. Accordingly, the institutional characteristics of health care systems, such as insurance structures [ 26 ], may impact both citizens’ demand for medical tourism and the ways in which medical tourism affects each country. Obtaining a better understanding of these relationships may inform new ways of thinking about both the challenges and opportunities medical tourism presents. As medical tourism markets continue to grow and diversify, and as domestic health care systems increasingly feel the stress of limited resources, this kind of work will be critical to support policymakers and health system leaders in their efforts to mitigate the potential harms of medical tourism while, at the same time, responding to the needs of the citizens they serve [ 3 ].

Using the examples of Canada and the United States (US), this article proposes the use of an institutionalist research agenda to explore these two related sides of the medical tourism-health care system nexus as a central element of future policy strategies. We first take a comparative perspective on medical tourism and present what we see as key aspects of the issue from a policy perspective. Drawing on current evidence and leading literature in the field, we highlight ways in which national health care systems shape the demand for medical tourism and then, in turn, how medical tourism impacts national health care systems. From this discussion, we identify four key lines of enquiry that we suggest are of critical importance in the medical tourism policy landscape and propose an agenda for future comparative research on medical tourism and national health care systems that could play an important role in informing future policy decisions in this area.

Medical tourism in comparative perspective

Although gathering robust data on the magnitude of medical tourism continues to be a challenge and more empirical work in this area is needed [ 3 , 5 , 10 , 12 ], a strong body of literature addresses different aspects of the issue. For example, research is improving understandings of how medical tourism impacts destination and departure jurisdictions [ 16 , 27 ], affects relationships with domestic health care providers [ 28 ], relates to economic factors including health system costs [ 29 ], and impacts clinical outcomes for patients [ 30 ], among other important lines of enquiry. However, much of this valuable scholarship focuses on particular forms of medical tourism in specific contexts (bariatric surgery [ 31 ], dental care [ 32 ], reproductive services [ 33 ], etc.) or on the policy and health system implications for individual jurisdictions [ 13 ]. There is an increasing amount of comparative research exploring how different features of health care systems may in some cases help drive demand for medical tourism and in other cases constrain it (i.e., push/pull factors), and how they relate to the impact of medical tourism [ 24 ], but more work remains to be done in this important area [ 4 , 10 ]. The potential value of data on the impact of medical tourism in one jurisdiction to structurally- similar systems (e.g., other universal public health care systems) has already been recognized [ 34 ]; we agree and suggest that going further with an associated analysis considering the role of their institutional features is critical. This approach is particularly valuable from a policy perspective, especially when it comes to maximizing opportunities for policy learning from other jurisdictions and to identifying and evaluating the respective strengths and limitations of different policy options for decision-makers seeking to, for example, discourage particular forms of medical tourism (e.g., organ transplant tourism [ 35 ]).

The governance of medical tourism in its various forms is complex and highly fragmented given its broad range of influential stakeholders (both state and non-state, individual and institutional), its international market-based nature, and its engagement of vastly different and often competing priorities and interests (e.g., profit-driven, patient care, autonomy, ethics, etc.). As a result, policy makers and health system leaders face considerable challenges when it comes to seeking to influence medical tourism markets, whether by encouraging their development or restricting access to them. Obtaining a better understanding of the institutional forces that shape the demand for, and impact of, medical tourism—and connecting those forces to the policy context—may help identify a broader range of tools and options decision- makers can employ to achieve their particular objectives with respect to medical tourism.

Looking at Canada and the US is an appropriate starting point for this comparative work and we use this comparison to ground our analysis of the value of an institutional research agenda as a policy strategy for addressing potential concerns and opportunities associated with medical tourism. While these neighboring countries are similar in many ways, there are dramatic differences in important institutional features of their respective health care systems, including funding and delivery models. The US is both an established importer and exporter of medical tourists, the latter supported in part by insurers offering medical tourism coverage in an effort to reduce the high costs associated with domestic health care services [ 11 , 36 ]. In contrast, the structure of Canada’s largely publicly-funded, single-payer medical system limits foreign access to non-emergent care and makes it challenging for Canadians to be reimbursed for care received abroad via medical tourism [ 7 ]. It also makes the current involvement of Canadians in medical tourism [ 37 ] a public policy issue because of its implications for the public purse.

How national health care systems shape demand for medical tourism

Because health care systems can be understood as relatively stable institutional settings that shape human behavior [ 38 , 39 ], their features are likely to impact the demand for medical tourism in a particular country or even, in the case of decentralized health care systems subject to considerable regional variation, in a particular region. Health care systems can vary greatly from one country to the next, or even from one region to the next within the same country. Accordingly, what citizens might be looking for when they seek medical treatment abroad is likely to fluctuate based on the nature of health care coverage, financing, and regulation they have at home. Research about these and other drivers is growing but important gaps in knowledge remain [ 5 ]. In other words, alongside factors like geographical mobility and travel costs, the institutional configurations of health care systems likely shape, at least in part, the types of services people are looking for based on what health services they can access in their home country, with what degree of quality and timeliness, and at what cost [ 24 ].

A comparison between Canada and the US is illustrative here. Starting with the Canadian context, universal coverage has existed in Canada since the early 1970s [ 40 , 41 ]. Under this framework, regardless of the province or territory in which they live, Canadian citizens and permanent residents are entitled to medically necessary health care services with no user fees, which are strictly prohibited under the 1984 Canada Health Act (CHA). Yet, although the CHA mandates comprehensive coverage for “all insured health services provided by hospitals, medical practitioners or dentists,” many services do not fall under this umbrella and the Canadian health care system has long waiting lists for many non-emergency surgeries like hip replacement [ 40 , 42 ]. Wait times vary from province to province but they are a source of frustration for many Canadians, some of whom elect to go abroad to get their non-emergency procedure done faster, even if they have to pay for it themselves, instead of relying on the slower public system back home [ 7 ]. Gaps in coverage within the single-payer system in important areas such as prescription drugs [ 43 ] and dentistry [ 44 ] also sometimes push Canadian citizens and permanent residents to go elsewhere for care to reduce costs. There are also a wide variety of medical treatments and health-related interventions offered in private markets that are either not available or not publicly funded in Canada. There are a variety of reasons for this lack of public funding, including those related to evidence (or, more precisely, the lack thereof) regarding safety and efficacy. For example, there is a large international market for unproven stem cell interventions that are not part of the approved standard of care in Canada or available in the publicly funded health care system [ 45 ]. Therefore, key motivations underlying the pursuit of Canadian medical tourism often relate to a desire to access care faster, to reduce out of pocket costs for care not covered by provincial health insurance, and/or to access options that are not available in Canada [ 7 ].

In the US healthcare system, where about 9% of the population remains uninsured despite the enactment of the Affordable Care Act (ACA) in 2010 [ 46 ], people who lack insurance coverage but who face a medical need might go abroad to seek cheaper treatment. In fact, the high cost of care in the US has been recognized as a major factor pushing Americans to seek care at lower cost outside the US, an option that is facilitated by health care globalization [ 2 ]. For example, there is research documenting the strong market in the Mexican border city of Los Algodones for Americans seeking dentistry, optometrist, and pharmacy services [ 47 ]. Others may be motivated to return to systems with which they are more familiar, as is the case with the Mexican diaspora [ 24 ]. In the US, in contrast to Canada where universal coverage prevails, the lack of health care coverage is likely to be a key factor driving the demand for medical tourism. At the same time, waiting times are much less likely to drive the demand for medical tourism in the US, where waiting lists are less of an issue [ 40 ].

These brief remarks highlight how key institutional features in both Canada and the US shape patterns in the demand for medical tourism in these two countries, creating both similarities and differences between them. At the same time, regional differences in health system institutions within the two countries can also shape the demand for medical tourism within their borders. For instance, in states like Texas, where elected officials have thus far refused to expand Medicaid as part of the ACA [ 48 ], more people live without health care coverage than elsewhere (about 18% of the population as of March 2016 [ 49 ]), which may push them to look to Mexico for cheaper health care. Here the institutional characteristics of a state’s health care system and the geographical proximity to Mexico, coupled with the presence of a large population of Mexican descent who speak Spanish, are likely to favor cost-saving medical tourism from Texas to Mexico. This example highlights how geographical and even ethno-cultural factors can shape medical tourism alongside and even in combination with the institutional features of a particular health care system. This is also the case when we deal with issues such as dental care and cosmetic surgeries, which are not covered by many US public and private insurance plans [ 50 ].

How medical tourism impacts national health care systems

At the most general level, existing national and sub-national institutions may mediate the impact on particular countries of transnational processes stemming from globalization [ 20 , 51 ]. This general remark also applies to global medical tourism, which is unlikely to affect all national health care systems in the same way. Put bluntly, systems will react differently to external pressures, based in part on their own institutional characteristics. Those same institutional characteristics also form part of the policy matrix that shapes the options available to decision makers.

There are two central aspects to this story. First, we can look at how domestic health care institutions are specifically impacted by inbound medical tourism (i.e., destination countries at the receiving end of medical tourism). Research suggests that the way in which health care systems cope with foreign users, and what impact those foreign users have on the system, will vary according to the institutional characteristics of that system [ 16 ]. For instance, countries that attract many medical tourists could witness price increases and the diversion of services away from their less-fortunate citizens [ 1 ]. At the same time, the institutional features of national health care systems can explain why some countries attract more medical tourists than others. The comparison between Canada and the US is particularly revealing here. On the one hand, although some provinces have considered alternate approaches that would encourage inbound medical tourism as a source of revenue generation [ 52 ], at present the limited scope of private health care in Canada restricts the availability of medical tourism opportunities for wealthy foreigners seeking treatments. On the other hand, the large scope of private health care in the US makes that country an obvious target for wealthy medical tourists who can afford its high medical costs.

Second, and more important for this article, national health care institutions may also shape the way in which each country is affected by outbound medical tourism. For example, in a single-payer health care system such as Canada’s, both routine follow-up care and complications resulting from medical acts performed abroad are typically dealt with within the public system, engendering direct costs to taxpayers and potentially impacting access for others in the system (i.e., if physicians’ time is diverted to attend to emergent issues) [ 6 ]. The extent of these concerns varies depending on the urgency of the issue and whether it falls within hospital and physician services covered by the universal system (versus, for example, dental care where public coverage is more limited) [ 52 ]. By comparison, within the fragmented public-private US health care system, public programs may only absorb a fraction of the costs of complications related to outbound medical tourism, thus reducing their direct negative impact on taxpayers, whereas private insurance companies or individuals themselves might bear the majority of these costs.

The potential savings for outbound countries medical tourism generates are also likely to depend on the institutional features of each national or sub-national health care system [ 16 ]. In Canada, for instance, people who decide to go abroad for non-emergency surgeries might help reduce the length of waiting lists, although this positive impact might be limited by the fact that some of these surgeries are simply not available in Canada or, at least, not available to the individuals who seek treatments abroad (e.g., because of their age or health status). Because waiting lists are much less of an issue in the US [ 40 ], this potential benefit of medical tourism to domestic health care systems may be less relevant there.

Conversely, the prospect of affordable medical tourism may convince people in the US who do not have access to Medicaid, Medicare, or employer-based coverage that they do not need coverage at all, because they can always go abroad and save money should they need medical treatment. In this context, global medical tourism could interact with the question of whether people will seek coverage or not. At the same time, to save money, “US companies, such as Anthem Blue Cross and Blue Shield and United Group Programs, are now exploring the idea of including medical tourism as a part of their coverage,” a situation that could increase their administrative burden and create further complications along the road [ 53 ].

Policy implications

Our aim with the preceding high-level overview was to draw on existing knowledge to highlight not only that national health care institutions may shape the demand for medical tourism in a particular country or region, but also that the consequences of such tourism for national health care systems are likely similarly mediated by the institutional features of these systems. These connections have a number of important potential implications for health system governance of medical tourism and, more specifically, for the options available to policy makers seeking particular objectives. For example, depending on the jurisdiction, efforts to reduce demand for medical tourism could include a range of options such as investing resources targeted at reducing domestic wait times, expanding public health insurance, limiting public coverage for follow-up care needs, or educating the public about the potential risks associated with medical tourism [ 2 ], among other options. Conversely, efforts to encourage the development of a medical tourism industry within a particular jurisdiction might involve regulatory change to expand options for private system offerings and targeted marketing campaigns, again among other possibilities [ 5 , 17 ].

In fact, it has long been recognized the governments have a variety of tools or policy levers at their disposal when they seek to influence behavior [ 54 ]. Identifying which tool (or combination of tools) is likely to be most effective in a particular set of circumstances, such as medical tourism, requires a nuanced understanding of relevant institutional characteristics and situational factors. Accordingly, we propose that a comparative research agenda should be a key element of future analysis and decision-making efforts in this field. Such an agenda would not only help empirically test the above hypotheses about the institutional-medical tourism nexus, it could also help facilitate lesson drawing between jurisdictions that have attempted different approaches by helping pinpoint salient commonalities and points of difference between the systems that might initially explain, and ideally ultimately even predict, the likely results of particular policy initiatives.

Research agenda

We propose a comparative research agenda that aims to explore the relationship between medical tourism and key institutional features of national health care systems. Although some aspects of our research agenda are already present in the existing literature, we think studying these elements together and with a comparative policy lens would be of tremendous value to health system decision -makers seeking to navigate different objectives including, for example, avoiding “brain drain” from public to private health care, minimizing added costs to publicly funded systems, protecting vulnerable individuals, and facilitating patient autonomy.

Drawing on our review of the health care systems in Canada and the US, we have identified three key institutional features that we suggest are particularly relevant to medical tourism and its broader policy context. These key features are health care funding models, delivery structures (e.g., public/private mix, provider payment models, role of user choice, and competition between providers), and governance systems (e.g., location of authority, health care provider regulation, liability systems). Future empirical research may identify other more salient features and certainly an iterative approach may be valuable. Nonetheless, we suggest that these features would provide a useful starting point for the next step, which we propose be an exploration of how these institutional features relate to the following areas:

• (i) Patient flow patterns – e.g., inbound versus outbound, treatment destinations, types of treatment sought.
• (ii) Patient motivations – e.g., cost reduction, wait list avoidance, pursuit of quality, circumvention tourism.
• (iii) Health system interactions – e.g., costs and options for follow-up treatment, roles of domestic health care professionals.
• (iv) Existing policy levers – e.g., public and private insurance structures, incentive schemes, information campaigns, regulation.

These four areas are not intended to serve as a comprehensive list of all relevant lines of enquiry. However, they present a valuable starting point, particularly because of their relevance to policy instrument selection processes. Having said that, and although it is beyond the scope of this piece to go further than laying a foundation for this proposed research agenda, we suggest that future research take a broad and scoping approach to draw on existing data and information and, where possible, conduct new empirical work addressing these critical areas. With a view to identifying patterns and generating hypotheses, researchers will likely need to continually refine the initial assumptions, outlined above, about the relationships between different institutional features and aspects of medical tourism. Doing so will require careful thought regarding the selection of an appropriate scientific paradigm, with a view to research validity and reliability [ 55 ].

We also anticipate that end-users and important stakeholders, including elected officials, civil servants, health care providers, and patients and families, would have an important contribution to make to the research design and with respect to interpreting the findings, particularly as they relate to the identification and evaluation of policy options. One important limitation in this type of work will relate to data availability. We expect that comparative work of this nature and any future empirical analyses it includes will highlight gaps in knowledge and potentially trigger future research agendas. Overall, the research envisioned here should complement and augment ongoing efforts in the field to improve understandings of important factors including patient flows, expenditure trends, system impacts, and individual decision-making determinants, among others.

Conclusions

This article discussed the relationship between medical tourism and key institutional aspects of national health care systems with a view to highlighting the value in a comparative research agenda focused on identifying and evaluating policy options. First, we argued that these characteristics directly affect the demand for medical tourism in each country. Second, we suggested that such institutional characteristics shape the actual impact of medical tourism on that particular country . This discussion led to the formulation of an institutionalist research agenda about medical tourism. It is our hope that this proposed agenda will trigger discussion and debate, help develop future research, and inform new ways of thinking about medical tourism in the global landscape. Medical tourism is a complex phenomenon and we suggest that applying a comparative, institutional lens will shed new light on its drivers, constraints, and impacts and, in so doing, ultimately help inform policy development in this area.

Acknowledgements

The authors thank Rachel Hatcher for the copy-editing support and anonymous reviewers for their helpful suggestions. DB acknowledges support from the Canada Research Chairs Program, and AZ funding from the Canadian National Transplant Research Program.

Authors’ contributions

DB wrote the theoretical paragraphs and AZ the paragraphs focusing more directly on medical tourism. Both authors read and approved the final manuscript.

Authors information

DB has published extensively on institutionalism and on health care systems, and AZ has published extensively on health law and policy issues, including topics related to medical tourism.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Competing interests.

The authors declare that they have no competing interests.

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Contributor Information

Daniel Béland, Phone: 306 966-1272, Email: [email protected] .

Amy Zarzeczny, Email: [email protected] .

• Empirical article
• Open access
• Published: 12 September 2018

Medical tourism: focusing on patients’ prior, current, and post experience

• Soonae Hwang 1 ,
• DonHee Lee   ORCID: orcid.org/0000-0003-2799-8547 2 &
• Chang-Yuil Kang 3  

International Journal of Quality Innovation volume  4 , Article number:  4 ( 2018 ) Cite this article

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This study empirically examines the effects of medical tourists’ experience of the decision-making process through a patient’s prior, actual, and post experience after having received the medical services. The research model and associated hypotheses were tested using a structural equation modeling based on data collected from 188 medical tourists who received care in Busan, South Korea. The findings of the study indicate that patients’ experience in medical tourism pre-search (reputation, searching information, and communication) has a partially positive effect on their experience (costs, care quality, and supporting system and/or information) and patients’ current experience during the medical tour process has a positive effect on post-experience (relationship building, recommendation, and feedback). The results of this study provide new insights about how key players (e.g., hospitals, medical travel agencies, hotels, and the medical tourists themselves) in medical tourism can effectively help managers identify medical tourists’ needs based on the decision-making process of prior, current, and post-experience of medical tourists.

Medical tourism has emerged as a result of consumers being exposed to a wider range of choices of medical services and exponential growth in global healthcare market [ 1 ]. A combination of the terms “medical” and “tourism” [ 1 ], its main target is patients who visit other regions or countries for medical treatment. Therefore, the medical tourism industry is geared toward significant efforts to meet people’s desire for a better wellness with quality medical treatment [ 2 , 3 ]. According to the Allied Market Research [ 4 ], the net worth of the medical tourism market worldwide is estimated at $61.172 billion as of 2016 and is expected to increase to $165.3 billion by 2023.

The global growth of the medical tourism industry is most prominent in Asia, with Singapore, Thailand, South Korea, and India being well known as medical tourism countries. In a report “Estimates of the South Korea Medical Tourism Market and Expenditure to 2020,” Orbis Research [ 5 ] presented that highly skilled professionals, advanced medical devices, and well-established infrastructures are the factors that contribute to the rapid growth of medical tourism in South Korea.

Customers opting for medical tourism visit local hospitals in other countries and/or regions, where they use this opportunity to relax and enjoy cultural activities in addition to seeking medical treatment, maintenance, and recovery. Increased promotions of a wide range of one-stop medical services and advancements in medical technology have made traveling for treatment a rather convenient and attractive prospect for medical tourists [ 2 , 5 , 6 ]. Information retrieval for overseas medical care is one of the components in the decision-making process for medical tourism [ 6 ]. The quality of medical services and expertise of institutions in other countries may also be important factors since they influence patients’ access to medical information [ 1 ]. Therefore, the industry should extend greater efforts in this area to attract more patients.

Medical services create value-generating activities through an effective interaction of human resources (service providers and recipients), processes, technologies, and/or material resources. Interaction activities reflect consumer needs, and these activities can lead to improvements in medical services delivery [ 1 , 7 , 8 , 9 ]. Therefore, the interaction at each service encounter is very important. Also, patient experience upon receiving medical services will influence future decision-making of patients, as has been shown in previous studies on the importance of experience [ 10 , 11 ]. The customer experience consists of multiple independent service encounters throughout the exchange process [ 11 ]. As a matter of fact, customer experience is becoming significantly more important as itself has become the target customer, and ideas proposed by customers can generate a value proposition, which can lead to a newer and improved revenue model [ 12 , 13 ].

Patients’ evaluation of a hospital’s medical services is based on his/her own experience or others’ recommendation influences not just the local population but also potential customers from overseas [ 14 ]. Ofir and Simonson [ 15 ] suggested that customer brand perceptions through purchase evaluations of experience have a significant effect on the customer’s experience. Thus, to obtain favorable customer reviews, healthcare organizations provide patient-oriented medical services mainly by interacting with their patients at each service encounter. This is why it is imperative to build processes that focus on delivering better, customer-oriented medical services for positive customer experience.

A process is a set of activities for creating value for the customer through input–process–output, so the process can vary depending on the requirements of the customer. Medical services are provided only when patients and medical staff meet in a service encounter. Therefore, various processes can be set up depending on the type and severity of the disease and the patient’s health condition. A more comprehensive approach may be needed as patient outcomes are a result of not just one process but a combination of processes before, during, and after the overall process of medical service. While customers search healthcare providers before their visit, their revisit intention is dependent on the institutions’ care processes and outcomes [ 9 , 11 ]. However, due to the nature of medical care, patients may not be able to easily switch medical institutions, their experience will nevertheless have a direct or indirect bearing on other prospective patients’ decisions [ 9 ].

While previous studies already have and continue to examine the importance of experience, they have focused largely on customer experience from arrival to departure rather than comprehensive processes [ 1 , 3 , 6 , 10 , 13 ]. As such, it is necessary to take a more holistic approach to studying customer experience through before, during, and after service provision. This study focuses on the decision-making process in customer experience. More specifically, it aims to examine the patient’s pre-experience of researching medical services abroad, the actual experience during their trip, and the post-experience after having received the medical services.

This study thus attempts to answer the following two basic research questions: (1) Does the experience of those who pre-searched for medical tourism impact their current experience in medical tourism? (2) Does patients’ experience during medical tour impact post-experience? A research model is proposed to answer these questions. The result of the study is expected to contribute to both theory and practice of medical tourism regarding customer experience through the decision-making process of prior, current, and post medical tours.

The rest of the paper is organized as follows: Section “ Review of relevant literature ” reviews relevant literature and proposes conceptual development, section “ Research methodology ” develops the hypotheses; section “ Results ” presents the research methodology is presented, section “ Discussion and conclusions ” reports the results of analysis and concludes the study by articulating the results, implications, and limitations of the study, and future research needs.

Review of relevant literature

• Medical tourism

The definition of medical tourism varies among researchers depending on the choice of place and location (domestic or foreign) of medical tourism, the method and procedure applied, application, and/or processes. Generally, it is referred to as tourism activities related to medical treatments or activities to improve tourists’ well-being. The Medical Tourism Association [ 16 ] defines medical tourism as “where people who live in one country travel to another country to receive medical, dental and surgical care while at the same time receiving equal to or greater care than they would have in their own country, and are traveling for medical care because of affordability, better access to care or a higher level of quality of care.” Wongkit and Mckercher [ 17 ] defined medical tourism as “the travel of people to specific destinations to seek medical help that forms the primary purpose of their trip.”

The Tourism Research and Marketing [ 18 ] presented treatment of illnesses, enhancement/cosmetic surgery, wellness, and fertility-related treatments as types of medical tourism. Lunt et al. [ 19 ] described the range of treatments in the medical tourism sector, focusing mainly on the common factors suggested in many previous studies: “cosmetic surgery (breast, face, liposuction); dentistry (cosmetic and reconstruction); cardiology/cardiac surgery (bypass, valve replacement); orthopedic surgery (hip replacement, resurfacing, knee replacement, joint surgery); bariatric surgery (gastric bypass, gastric banding); fertility/reproductive system (IVF, gender reassignment); organ, cell and tissue transplantation (organ transplantation; stem cell); eye surgery and diagnostics and check-ups.”

The quality of medical services is one of the factors that potential customers consider most important [ 18 ]. This implies that the quality of medical service and its costs are the most important influencers in their decision on the destination for their medical tourism [ 20 ]. Lunt et al. [ 19 ] emphasized that customers should be informed of the potential benefits of medical tourism regarding credible evidence of quality care and safety of their stay. In particular, when compared to other service industries, where word-of-mouth plays a big role, the medical industry is relatively slow in adopting a business model focused on customer satisfaction. With the right focus on quality and outcomes of the medical service processes, including customer interaction with service providers, healthcare organizations should try to improve patient satisfaction. This will have a positive effect on attracting potential future customers, thus promoting medical tourism [ 21 ].

Ehrbeck et al. [ 22 ] suggested five factors that promote medical tourism through a survey of 49,980 patients: most advanced technology (40%), better-quality care for medically necessary procedures (32%), quicker access to medically necessary procedures (15%), lower-cost care for medically necessary procedures (9%), and lower-cost care for discretionary procedures (4%). Crook et al. [ 23 ] presented the following as the most frequently discussed topics on patient experience: (1) decision-making (e.g., push-and-pull factors that shape patients’ decisions); (2) motivations (e.g., procedure, costs, and travel-based factors motivating patients to seek care abroad); (3) risks (e.g., health and travel risks); and (4) first-hand accounts (e.g., patients’ experiential accounts of having gone abroad for medical care). Thus, we consider combining the factors suggested by Ehrbeck et al. [ 22 ] and Crook et al. [ 23 ] to devise new strategic measures for medical tourism.

Few potential medical tourists are aware of what products or services are available through medical tourism. Some may have misconceptions and fear of various situations, including anxiety about traveling possible dangers, culture shock, and language barriers. In addition, it is very difficult for medical tourists to search for healthcare providers with accurate information in different countries individually for the treatment of diseases and for finding relevant wellness/sightseeing information.

In general, unlike making a decision to buy commercial products or services, the decision-making process for medical tourism is very complicated as it also involves emotional aspects that lead to multidimensional behaviors [ 24 ]. A variety of factors can affect decision-making of medical tourism because it influences not only physical (medical services) but also mental (tour) health conditions during and after activities [ 22 , 23 ].

Medical tourism advertisements tend to focus too much on treatment results and outcomes rather than quality improvements and safety [ 25 ]. When customers base their decisions on over- or underestimated advertisements, there tends to be a gap between the expected and actual outcomes. The increasing media interest in medical tourism has made it popular on a global platform, and today, we can obtain information on medical tourism destinations through various channels, including newspapers, magazines, radio, and television programs [ 25 ]. Online marketing efforts via web help publicize medical tourism [ 26 , 27 ]. Ormond and Sothern [ 28 ] analyzed five medical tourism guide books and found that a common factor among the books was to encourage potential customers to tour rather than introduce destinations and international choices for medical services. Thus, a sufficient preliminary investigation in advance is necessary for medical tourism. Customers can make the final decision through proper search of a variety of information and comparing them with services offered by providers in other regions or countries. It is suggested that a synergistic approach is more effective when it is done in a comprehensive way than in a piecemeal information survey [ 29 ].

Medical services comprise those put into the service (patients and medical staff), organization (service providers, service or products), treatment procedures, and outcomes [ 30 ]. As each process generates activities for medical treatment through interaction with patients, Lee [ 12 ] divided the process of value creation into preprocessing, responding process, and resulting processes. The preprocessing refers to a set of preparative activities in advance of care services, the responding process as the one to respond to interactions during treatment, and the resulting processes as related to the prevention and outcome of disease. Thus, sufficient information should be provided to customers about the entire process rather than at the time of experiencing each process. Once customers achieve their goal of getting the desired outcome, they will go back home and may come back for further treatments for better quality of life or wellness (repurchase or any positive activities) or the other way around (negative activities). Customers make their decisions based on what they searched before selecting the destination. It means that they would first experience medical tourism through Googling; feedback from colleagues, friends, or family; or direct communication with the hospital.

Medical tourism is a major decision problem for the patient; it is much more involved than deciding to visit a local healthcare provider. The customer’s experience of medical tourism is the main factor that influences his/her satisfaction which in turn would influence revisit intention. Thus, it should be a major strategic priority for medical tourism hospitals and their administrators to develop a system that can provide positive experience to customers. Many tourism hospitals have a one-stop service system for their customers that may include such services as government documents (visa service), transportation (air flight reservations, airport pickup, shuttle service, etc.), language help, local hotel reservations, insurance processing, financial arrangements, local tour attractions, and the like. For example, Bumrungrad Hospital in Bangkok, Thailand, which is ranked ninth in the top ten hospitals in the world, provides a very efficient one-stop service to foreign customers (VIP airport transfers, interpreters, concierge services, embassy assistance, international insurance arrangements, and medical coordinators, see http://www.bangkok.com/hospitals-private-hospitals.htm ).

Experience of customers

Since customers’ overall satisfaction may be subjective, recent studies have emphasized the importance of customer experience and strategic approaches to improve the quality of medical services [ 12 ].

Merlino and Raman ([ 31 ], p.113) suggested that patient experience is a strategic priority and provided a broad definition: “The patient experience was everyone and everything people encountered from the time they decided to go to the clinic until they were discharged.” Meyer and Schwager ([ 7 ], p.118) defined customer experience as “the internal and subjective response customers have to any direct or indirect contact with a company”, and De Keyser et al. ([ 8 ], p.23) also suggested customer experience as “comprised of the cognitive, emotional, physical, sensorial, spiritual, and social elements.” These definitions imply that patient experience includes cognitive activities (e.g., checking reputation and searching other relevant information) before going to the hospital to the post-discharge behaviors (e.g., recommendation and feedback) with patient’s own emotional and subjective judgments.

In particular, medical tourism needs to be investigated thoroughly prior to the travel, because it focuses not only on information of medical institutions but also on the region or country where they will receive treatment. New advanced technologies can earn positive reviews from consumers and succeed only if they are unique in terms of their functions, convenience, and attractiveness. The positive images created from this could generate favorable responses from customers as they make comparisons based on actual use or indirect experience. In other words, customers’ direct or indirect experiences can affect their future repurchase intention.

The direct and indirect experience gained during the preliminary investigation will affect the process of receiving the actual medical service [ 12 ]. Further, if the gap between expectation and reality increases, there will be a decline in satisfaction. It will also affect revisit intention. In addition, since the medical services provided to patients with various diagnoses and administration services that are multidimensional, it is difficult to directly measure patient experience. As customer satisfaction might be improved based on their experience, customer satisfaction should also be included in the behavior of the customers’ preparation before arriving at the destination [ 12 ].

Verhoef et al. [ 11 ] suggested customer experience as “the total experience, including the search, purchase, consumption, and after-sale phases of the experience.” The prior experience occurs before purchase and consumption, and the purchase and consumption represents current experience, and after-sale/consumption experience represents post-experience. Therefore, in this study, the patient experience in medical tourism can be divided into prior experience for deciding on medical tourism, current experience during the treatment and/or medical tour, and post-experience after treatment and/or tour.

The prior experience includes the direct or indirect experience of customers during various activities before actually experiencing the main service, medical tourism. Patients can search various information, such as reputation, specialized treatment, and interesting tour destinations, directly or indirectly before choosing a hospital for the best possible treatment and service. Since the customer’s decision-making is based on a thorough prior investigation [ 7 ], sufficient communication with the customer is necessary. Patients can of course directly consult with the medical staff or service personnel of a hospital via video chatting (e. g., Skype or FaceTime) or telephone. In this study, the prior experience was categorized into checking reputation, searching information, and communication.

Through prior experience, customers make their final decisions for medical tourism, receive actual medical services, and have various other experiences. They are involved in direct communication with service providers, direct engagement in the service provision processes, and witnessing a gap between what they expected and the service actually received. Therefore, the current experience in this study refers to customer experience while engaging in various activities at the hospital, including interaction with service providers or other customers, use of information and comminutions technology (ICT), and enjoying the service environment. The current experience was categorized into checking costs, care quality, and supporting system and other relevant information.

Customers come to evaluate their own experience based on expectations, current experience, and other activities. Their experiences may generate either positive or negative impact on others. From the customers’ perspective, the post-experience influences the intention to repurchase or has a positive word-of-mouth. Service providers, on the other hand, may search for new ways to retain customers and improve their satisfaction through their post-experience (i.e., surveys or social networking). Sridhar and Srinivasan [ 32 ] suggested that the reviews customers read in advance actually influence purchase intention or encourage them to share their own feedback online after purchase and encouraged organizations to work hard to create positive customer experiences for “leaving good memories.” Thus, the post-experience of customers extends the processes continuously as it affects their prior, current, and post experience [ 10 ]. Consequently, the post-experience in this study refers to experiences that will influence patients’ decision on what to do after service provision. The post-experience includes relationship building, recommendation, and feedback.

As discussed earlier, decision-making for medical tourism can be determined with a variety of patient experiences. Thus, this study examines the effects of experience of medical tourists on the decision-making process. The proposed research model is shown in Fig.  1 .

Proposed research model

Hypotheses development

Prior and current experience.

As it is difficult to set clear standards on hospital selection, which is the most critical factor of medical tourism, and vacation spots, most patients make decisions based on their own experience, information technology, and prior patients’ feedback [ 10 ]. In recent years, with the advent of smart devices and ICT, both patients and providers can access the information they want directly or indirectly and can easily make their own decisions. The decision process is also influenced by the changing business environment as well as purchase patterns of patients [ 33 , 34 ].

Hospital reputation is an important factor in patients’ decision-making [ 18 ]. Ferguson et al. [ 35 ] argued that medical service providers can enforce patient loyalty and maximize word-of-mouth effect efficiently. Based on a study of hospitals in Taiwan, Cheng et al. [ 36 ] suggested that recommendations made by patients form an important factor in attracting patients for medical tourism. Therefore, recommendations from family, friends, or colleagues become a critical factor in hospital selection [ 36 ].

Prior experience begins with customers searching for, reviewing information, or asking someone about key services. Many customers seek information from online reviews, asking medical staff questions, or going through onboarding processes [ 10 ]. For instance, in prior experience, a customer may communicate with physicians by filling out documents before making an appointment, review information about hotels in the destination area, or use a Twitter before the trip. As mentioned above, current experience includes experiences during service delivery through meeting physicians, using hospital facilities, staying at a hotel, or visiting tourist attractions in the selected region [ 10 , 37 , 38 ].

Patients’ positive or negative perceptions are based on the quality of service they received at the hospital. They come to build these positive or negative images after comparing their expectations with what they actually experienced at the selected hospital at the time of getting the medical treatment. Since medical services are delivered through interaction between patients and physicians, patients show mixed responses depending on the kind of services they received at the hospital. Such variations in response result in from the gap between what they expected based on prior experience and their evaluation of the actual services, which will ultimately affect their future decision [ 12 ]. Therefore, prior experience should be considered to have an effect on current experience. The following hypothesis is proposed.

Hypothesis 1: Patients’ experience in medical tourism pre-search has a positive effect on their current experience.

H1-1: Reputation gained through the prior experience of a hospital has a positive effect on costs related with medical tourism.

H1-2: Reputation gained through the prior experience has a positive effect on care quality.

H1-3: Reputation gained through the prior experience has a positive effect on supporting system and/or information.

H1-4: Searching information gained through the prior experience has a positive effect on costs related with medical tourism.

H1-5: Searching information gained through the prior experience has a positive effect on care quality.

H1-6: Searching information gained through the prior experience has a positive effect on supporting system and/or information.

H1-7: Communication gained through the prior experience has a positive effect on costs related with medical tourism.

H1-8: Communication gained through the prior experience has a positive effect on care quality.

H1-9: Communication gained through the prior experience has a positive effect on supporting system and/or information.

Current and post experience

When a customer chooses a service through the evaluation of available information or word-of-mouth and dissatisfied with the service received, he/she may switch to another service provider. Even though patients themselves may not be able to change hospitals easily, owing to the nature of the medical service, their dissatisfaction can have a direct or indirect effect on others. For instance, patient “A” was discharged from hospital “B” after undergoing a surgery. Even if patient A is not satisfied with hospital B, he/she may be compelled to visit hospital B for a follow-up service. However, patient A may discourage potential patients from visiting hospital B through negative word-of-mouth based on his/her own experience. Therefore, to provide medical services with positive effects on other patients, hospital should recognize that the patient has selected a particular hospital after carefully considering and searching hospitals directly or indirectly. Especially, patients choose hospitals for medical tourism abroad because they are not satisfied with their current care providers. Consequently, provision of diverse and accurate information is necessary for medical tourism [ 2 , 3 ].

Previous studies suggest that patients make decision based on their cognitions about something ➔ evaluation and emotions ➔ acting for outcomes [ 10 ]. de al Hoz-Correa et al. ([ 2 ], p.208) pointed out that the key factor to be considered by the medical tourism industry in the future should be the “consequences of commodification in healthcare pressures for privatization of health in departure and host countries.” This means that hospitals should take measures for more effective communication and provide adequate explanations during the medical treatment and try to relieve patient dissatisfaction by offering follow-up options. In addition, hospitals should offer patients guidance regarding medical insurance before treatment so as to prevent any conflict after the treatment. Therefore, medical tourism hospitals should provide all the pertinent information to potential patients so that they can make intelligent decisions in selecting the best hospital for their unique needs with quality care and positive experience. By doing so, they can create positive outcomes. Such activities could encourage patients to have positive experiences, share their satisfaction with others, and make more visits in the future.

Revisit intention is based on patients’ overall experience of the service, which will influence their future decisions. Polluste et al. [ 39 ] stated that revisit intention can be positively influenced by respecting and reflecting patient demands and opinions, and striving to improve patient experience through direct interaction with patients. Therefore, the current experience during treatment or at a tourism spot influences post-experience and encourages multiple visits and positive word-of-mouth effects [ 40 ]. Thus, the following hypothesis is suggested.

Hypothesis 2: Patients’ current experience during the medical tour process has a positive effect on post-experience.

H2-1: Costs related with medical tourism gained through the patients’ current experience has a positive effect on relationship building.

H2-2: Costs related with medical tourism gained through the patients’ current experience has a positive effect on recommendation.

H2-3: Costs related with medical tourism gained through the current experience has a positive effect on feedback.

H2-4: Care quality gained through the current experience has a positive effect on relationship building.

H2-5: Care quality gained through the current experience has a positive effect on recommendation.

H2-6: Care quality gained through the current experience has a positive effect on feedback.

H2-7: Supporting system and/or information gained through the current experience has a positive effect on relationship building.

H2-8: Supporting system and/or information gained through the current experience has a positive effect on recommendation.

H2-9: Supporting system and/or information gained through the current experience has a positive effect on feedback.

Data collection

Data was collected from medical tourists who were in stable enough conditions for this survey and were willing to participate. Hospitals in this survey participated on a voluntary basis. The main reason for using this sampling approach was that South Korea represents a major country with highly skilled professionals, advanced medical devices, and well-established infrastructures for medical tourism [ 5 ]. The target population of this study was the international medical tourists traveling to seeking medical services in selected hospitals in Busan, South Korea during April 2018–May 2018. The researcher was assisted by the hospitals’ administration team, and the hospital staff assisted in finding medical tourists at the time of research and provided the responses to the researcher.

A survey questionnaire was developed using the double translation protocol [ 41 ]. The questionnaire was developed in English first and then translated into Korean by two bilingual operations management faculty in Korea. The Korean version was translated back into English by two American operations management experts who are also bilingual. The two English versions of the questionnaire had no significant difference.

The initial questionnaire was tested in a pilot survey involving 30 participating medical tourists in a Korean hospital. The reasons for this pilot test were to ensure the participating medical tourists clearly and fully understood the questionnaire items. After the pilot study, the number of measurement items of each variable was reduced as some items suggested by managers were difficult to measure precisely. The final questionnaire is shown in Table  1 and provides the measurement items for prior, current, and post experience of medical tourists.

To collect data, we were helped by the medical staff and medical consultants since patients were from various countries (Japan, China, Russia, Mongolia, and others) and the participating hospitals in this study were all medical tourism hospitals. Out of 500 questionnaires that were distributed to medical tourists, subsequently, 188 (37.6%) responses returned useable questionnaires. The respondents’ demographics and their hospitals’ characteristics are summarized in Table  2 .

As shown in Table  2 , majority respondents’ nationality is Japanese (53.7%), Chinese (16.5%), and Russian (10.6%),

Of respondents, 92% traveled to Korea for the first time, and another 18% were here for the second time. Majority of the respondents are going to stay more than 15 days to less than 22 days in Korean (70.4%). A total of 80.9% of respondents’ primary purpose of this visit is to receive medical service, while not medical service was 19.1%. About 30.3% of medical tourist wanted to cosmetic/plastic/reconstructive surgery, and 26.1% wanted to dental treatment during their trip in Korea. Almost (96.3%) of respondents made their decision based on word-of-mouth information and 3.7% on their experiences. More than half (53.7%) of the respondents chose medical tourism because of medical costs, and then quality of care service (24.5%).

Variables of the model

The questionnaire utilized 5-point Likert scales to measure the constructs. The data was analyzed by SPSS 23.0 and AMOS 23.0 programs. Structural equation modeling (SEM) was chosen because it provides all the tools necessary to test the hypotheses.

Reliability was tested based on Cronbach’s alpha value (Table  3 ). In the reliability test, Cronbach’s alpha value of relationship building on post-experience was highest (.945), and supporting system and/or information on current experience was lowest (.736). All of the coefficients of reliability measures for the constructs exceeded the threshold value of .70 for exploratory constructs in basic research [ 42 ].

For validity test, the principal component analysis (PCA; minimizes the sum of squared perpendicular distance to the component axis) and the confirmatory factor analysis (CFA) were used to identify the most meaningful basis and to examine similarities and differences of the data based on Brown’s [ 43 ] recommendation. Eigen values and percent of variance explained for each construct are shown in Table  3 . The cumulative percentages of explained variance were exceeded 70% for the each constructs on statistics of PCA. The loading values of each factor ranged from .566 (CQ5) to .957 (RB4) as shown in Table  3 .

The results of CFA can provide evidence of the convergent and discriminant validity of theoretical constructs [ 44 ]. This measurement model consisted of nine components of reputation, searching information, communication, costs, care quality, supporting system and/or information, relationship building, recommendation, and feedback. The standardized factor loadings and t values for measurement variables, results of CFAs to test the measurement model for all construct using the AMOS 23 program, are presented in Table  3 . The values of standardized regression weight and all variables proposed by the study exceeded .5 and were statistically significant at the .05 level.

The results of goodness of fit test for the measurement model are summarized and shown in Table  4 . Compared to the recommended values for the goodness of fit tests, the values of CFI, RMR, RMSEA, TLI, and χ2/d.f. were satisfactory, while the value of GFI was not. Deepen [ 44 ] suggested that GFI is desired to be over 0.9; however, “this must not automatically require the model to be rejected.” In our model, the majority of fit indices showed good acceptance measures and only GFI and AGFI were below the required thresholds.

To identify whether a single factor does account for the majority of the total variance of all the measurements, common method variance (CMV) was tested. Tehseen et al. [ 45 ] suggested Harman’s single-factor test and controlling for the effects of an unmeasured latent methods factor by Podsakoff et al. [ 46 ] for CMV test. For Harman’s single-factor test, an exploratory factor analysis (estimates factors which influence responses on observed variables in the data) employed the unrotated factor to account for the variance in the variables. Nine factors with an eigenvalue greater than one were identified and that the largest factor accounted for 36.404% of the total variance, less than 50% of the total variance is acceptable as per Harman’s single factor test. For controlling for the effects of an unmeasured latent methods factor, we added a single common latent factor on measurement model to connect it to all observed variables in the measurement model of the study [ 46 ]. As shown in Table  4 , the results indicated that the original measurement was similar to that of the extended model with an inclusion of the common latent factor. It means that common method bias would not be of concern [ 47 ].

Table  5 provides the square roots of average variance extracted (AVE) of latent variables, while the off-diagonal elements are correlations between latent variables. Campbell and Fiske [ 48 ] suggested that the construct validity is tested by discriminant and convergent validity. For discriminant validity, the square root of the AVE of any latent variable should be greater than the correlation between this particular latent variable and other latent variables [ 49 ]. For convergent validity of the measurement model, Fornell and Larcker [ 50 ] recommended that AVE measures the level of variance captured by a construct versus the level due to measurement error, values above .7 are considered very good, and the level of .5 is acceptable. The acceptable value of critical ratio (CR) is .7 and above.

Statistics shown in Table  5 satisfied this requirement, leading to discriminant validity. As the values of AVE and CR of reputation, searching information, communication, costs, care quality, supporting system and/or information, relationship building, recommendation, and feedback were all greater than .6 and .8, respectively, thus convergent validity met the threshold. Statistics shown in Table  5 therefore satisfied this requirement, lending evidence to construct validity as discriminant and convergent validity.

This section presents the results of hypotheses testing, including the standardized coefficient of each path in the model. As a result of the goodness of fit test, compared to the recommended values, in this model the values of GFI (.857), CFI (.929), RMSEA (.058), RMR (.068), TLI (.920), and χ 2 /d.f (1.639) were good for fit. In our model, the majority of fit indices showed good acceptance measures and GFI (.857) and RMR (.068) were below the required threshold.

Table  6 presents the results of the significance test for the proposed research model as well as the summary of the hypotheses test. For H1-1, H1-2, and H1-3 tests, patients’ experience of their decision-making process before care, the standardized path coefficient between reputation and costs related with medical tourism (H1-1), care quality (H1-2), and supporting system and/or information (H1-3) were .030, .112, and .094, respectively. H1-2 was statistically significant at the .05 level, while H1-1 and H1-3 were not significant. Thus, H1-2 ( β  = .112) was supported, while H1-1 ( β  = .030) and H1-3 ( β  = .094) were not supported.

With a well-known hospital for medical tourism, patients seek to ensure a positive experience with quality care by engaging in activities before care to ensure their satisfaction [ 19 ]. Thus, before making a final medical tourism decision, patients research the reputation of a particular hospital in advance, ensure that the hospital’s communication enables them to achieve what they desire, and locate information through various media. Among the pre-care activities for medical tourism examined in the study, the hospital’s reputation was shown to have a positive impact on the quality of care [ 35 , 36 ], but not on the costs related with medical tourism or on the supporting system and/or information within a hospital.

For H1-4, H1-5, and H1-6 test, the standardized path coefficients between searching information on medical tourism and costs related to medical tourism (H1-4), care quality (H1-5), and supporting system and/or information (H1-6) were .519, .796, and .297, respectively, and statistically significant at the .05 level, supporting H1-4, H1-5, and H1-6.

The results of this study supported previous studies [ 6 , 10 , 25 ], which found that searching medical tourism has shown a positive impact on costs related with medical tourism, care quality, and supporting system and/or information. This means that researching for information in advance leads to a positive experience while visiting the hospital abroad. New digital devices provide opportunities for searching for accurate information through easy access to technology systems [ 51 , 52 ].

For H1-7 test, the standardized path coefficient between communication about medical tourism and costs related with medical tourism (H1-7) was .377 and statistically significant at the .001 level, supporting H1-7. For H1-8 and H1-9, the standardized path coefficient between care quality (H1-8) and supporting system and/or information (H1-9) were .108 and .259, respectively, and not statistically significant at the .05 level. The result of H1-7 test was supported, while H1-8 and H1-9 were not supported. From these results, the following can be summarized.

No matter how well-coordinated decisions between a patient and a provider are, what patients expect based on prior experiences does not have a positive impact on care experiences. Some patients did not expect that high-quality care and a good supporting system and information would be provided in advance of the care. When medical tourists have good communication with a potential hospital provider, they positively weigh that communication in making medical tourism decision [ 53 ]. Thus, hospitals should honor the medical costs quoted and provide the quality of care and information that were promised in communications, both before and during care.

For H2-1, H2-2 and H2-3 tests, patients’ current experience during their trip in Korea, the standardized path coefficient between cost related to medical tourism and relationship building with the hospital (H2-1), recommendation for medical tourism (H2-2), and feedback for the hospital (H2-3) were .147, .423, and .372, respectively, and statistically significant at the .05 level. Thus, H2-1, H2-2, and H2-3 were supported.

For H2-4, H2-5, and H2-6, the standardized path coefficients between care quality and relationship building with the hospital (H2-4), recommendation for medical tourism (H2-5), and feedback for the hospital (H2-6) were .800, .732, and .545, respectively, and statistically significant at the .001 level. Thus, H2-4, H2-5, and H2-6 were supported.

For H2-7 and H2-8 tests, the standardized path coefficient between supporting system and/or information to patients and relationship building with the hospital (H2-7) and recommendation for medical tourism (H2-8) were .589 and .165 respectively, and statistically significant at the .05 level. Thus, H2-7 and H2-8 were supported. For H2-9, the standardized path coefficient between supporting system and/or information to patients and feedback for the hospital (H2-9) was .036, and not statistically significant at the .05 level; thus, H2-9 was not supported.

The results of the study are similar to those of previous studies [ 36 , 54 ]. Costs related with medical tourism had a positive impact on the relationship building with the hospital, recommendation for medical tourism, and feedback for the hospital. Thus, costs associated with medical tourism are a key factor that supports a thriving medical tourism industry.

Heung et al. [ 55 ] suggested that key players in medical tourism as hospitals, medical travel agencies, hotels, and the medical tourists themselves. As with previous studies [ 36 , 54 ], the importance of care quality must be acknowledged by service providers because most medical tourists’ expectations exceeded their perceptions of the quality of care provided. Therefore, healthcare facilities with medical tourism should be provided high standards of care quality and be permitted to facilitate cross national travel to improve healthcare services.

Based on the result of this study, medical travel facilitators should consider providing supporting systems and/or information to patients as a one-stop service offering integrated knowledge of medical care services and travel [ 56 ]. Hospital management could actively focus on achieving better care outcomes if supporting systems and/or information were provided by medical travel facilitators in advance.

Discussion and conclusions

Medical tourism industry has drawn attention from international patients, travel agencies, governments, and the international accreditation sector [ 1 , 4 , 5 ]. Medical tourism can be arranged by the patients themselves by researching and booking on the internet, as well as by medical travel agencies [ 24 , 29 ]. Therefore, medical tourists have information on the best and most well-known healthcare providers and travel arrangements before embarking on medical tourism (pre-experience), and then the medical tourism experience (current experience) affects whether the tourist will recommend the medical provider to other potential customers (post-experience). Thus, this paper advances the idea that all three stages of a patient’s experience affect the medical tourism industry.

In this empirical study, we collected data to examine pre-experiences (e.g., reputation, searching information, and communication), current experiences (e.g., cost, care quality, and supporting system and/or information), and post-experiences (e.g., relationship building, recommendation, and feedback) in the medical tourism industry. The results of this study provide new insights about how key players (e.g., hospitals, medical travel agencies, hotels, and the medical tourists themselves) in medical tourism can effectively help managers identify medical tourists’ needs based on medical tourists’ decision-making process of pre, current, and post experience of medical tourism. In addition, the study sheds light on the perception of medical tourists on care quality and costs, as well as their future intention to obtain healthcare in the same hospital or country. Patient experience based on their interaction with medical staff and/or coordinators should be given as much importance as accuracy of diagnosis, treatment, and procedures.

The most important service attributes, which are highly attractive to international patients, will help medical travel agencies improve the information provided and develop innovative ideas among key players in medical tourism. As a variety of information retrieval functions grow and digital devices spread [ 52 ], medical tourism will gain a competitive edge by providing medical tourism information. Consumers will also have more opportunities to access information using comparative searches through different media.

Academically and practically, this paper provides several implications. First, developing and expanding a well-developed medical travel procedure based on patients’ experiences is a prerequisite for successful medical tourism. Such decision-making process could be measured by integrating three types of customer experience to enhance customer satisfaction. Because many hospitals and travel agencies are striving to develop new protocols using advanced technologies, the proposed model should be easy to access and the reservation process should be simple. For example, a one-stop service system can help with travel arrangements, arrange airport pick up and local transportation, hotel recommendations, ancillary services at the hospital, scheduling tours to selected destinations, coordinating with insurance companies, and assisting with other paper work. To build an effective medical travel process for patients, healthcare facilities and travel facilitators must fulfill their promises. In other words, the promised services and costs should be provided without fail. For example, policymakers should ensure that the standard model of medical tourism include internationally accepted standardized care processes and insurance. The qualification criteria for medical tourism agents/brokers should be developed and enforced globally. Since customers from various countries visit a hospital, to overcome barriers to global medical tourism, the use of standardized communication devices should be available for customer convenience.

This study has several limitations that should be considered when interpreting its findings, and future studies should also consider these limitations. First, the study assumed that hospitals visited by medical tourists have the same medical environments. Second, to collect data, we did not consider personal experiences and preferences for researching information. Third, data was collected from medical tourists in Korean hospitals located in Busan, South Korea, without considering the number of beds in the hospitals. Thus, the generalizability of this study’s results may be limited. There are several potential future research opportunities considering these limitations. For example, as there are many different hospital sizes, a comparative study of small and large hospitals in terms of care quality and costs might yield interesting results. In addition, there are many different data characteristics based on the type of patients, disease conditions, and demographic characteristics (e.g., personal experience researching information with different media used, personal income, gender, etc.) that could be studied.

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Medical tourism and national health care systems: an institutionalist research agenda

• Daniel Béland 1 &
• Amy Zarzeczny 1  

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Although a growing body of literature has emerged to study medical tourism and address the policy challenges it creates for national health care systems, the comparative scholarship on the topic remains too limited in scope. In this article, we draw on the existing literature to discuss a comparative research agenda on medical tourism that stresses the multifaceted relationship between medical tourism and the institutional characteristics of national health care systems. On the one hand, we claim that such characteristics shape the demand for medical tourism in each country. On the other hand, the institutional characteristics of each national health care system can shape the very nature of the impact of medical tourism on that particular country. Using the examples of Canada and the United States, this article formulates a systematic institutionalist research agenda to explore these two related sides of the medical tourism-health care system nexus with a view to informing future policy work in this field.

In this era of globalized medicine, when international travel and access to online health information are readily accessible, medical tourism is an important issue both for national health care systems and from a global health perspective [ 1 , 2 , 3 ]. Patients from countries around the world are exercising increasing degrees of autonomy over their health care options by obtaining information from sources other than their regular health care providers and, in some cases, by electing to pursue care alternatives outside their domestic medical system. Medical tourism is a broad and inclusive term that captures a wide range of diverse activities [ 3 ]. It has been defined as “the practice of travelling to another country with the purpose of obtaining health care (elective surgery, dental treatment, reproductive treatment, organ transplantation, medical checkups, etc.),” and is generally distinguished from both care sought for unplanned medical emergencies that occur abroad and from formal bi-lateral medical trade agreements [ 4 , 5 ]. Individual motivations for engaging in medical tourism vary widely and may include imperatives such as avoiding wait times, reducing costs, improving quality, and accessing treatments not available or legal in the home jurisdiction, or for which the individual is not eligible [ 5 , 6 , 7 , 8 ].

While medical tourism is far from new, shifting patient flow patterns and a growing recognition of the complex ethical, social, economic, and political issues it raises are underscoring renewed efforts to understand this phenomenon and its future [ 3 , 9 , 10 ]. Some of the current attention focused on medical tourism concerns its implications and potential risks for individual patients and health care systems [ 11 , 12 , 13 ]. Medical tourism impacts both importing and exporting health care systems, albeit in different ways [ 14 ]. Various terms exist to describe trade in health services [ 15 ]. For the purpose of this discussion, we will use importing or destination to describe systems whereby patients come from other jurisdictions to receive care, and exporting to describe the departure of individuals from their domestic medical system to pursue health services elsewhere. Recognizing that there are important knowledge gaps and a need for definitional clarity and further empirical work to understand the effects of medical tourism on the countries involved [ 16 ], concerns for importing or destination systems include, though are not limited to, ethical questions about inequity of access for local residents versus high paying visitors and about the “brain drain” of local talent into private, for-profit organizations focused on non-resident care [ 15 ]. Conversely, the issues exporting systems face often revolve around implications for domestic health care providers, the potential for patients to avoid domestic wait lists, and the costs of follow-up care upon patients’ return [ 12 ]. For example, research from Alberta, Canada, suggests that the financial costs associated with treating complications from medical tourism for bariatric surgery are substantial, and complication rates are considerably higher than similar surgeries conducted in Alberta (42.2–56.1% versus 12.3% locally) [ 6 ].

Although a growing body of literature has emerged to study medical tourism and address the policy challenges it creates for health systems [ 3 , 16 ], the comparative scholarship on medical tourism remains too limited in scope, a remark that should not hide the existence of a number of recent comparative studies in the field [ 17 , 18 , 19 ]. These studies demonstrate that comparative research is helpful in identifying both the unique and the most common policy challenges facing each country [ 20 ] and can, if done appropriately, offer learning opportunities [ 21 ]. Indeed, this process can facilitate policy learning (related terms include lesson drawing, policy transfer, diffusion, and convergence) whereby ideas, policies, or practices (e.g., regulatory tools) in one jurisdiction inform or shape those in another [ 22 , 23 ].

With a view to ultimately informing policy related to medical tourism, this article discusses the value of a comparative research agenda about medical tourism that stresses the multifaceted relationship between medical tourism and the institutional characteristics of national health care systems. On the one hand, these characteristics may shape the content of the demand for medical tourism among the citizens of a particular country [ 24 ]. From this perspective, as argued, existing typologies of health care systems can shed light on the varying features of the demand for medical tourism across countries. In other words, different types of health care systems are likely to produce different configurations of demand for medical tourism, which influences the range of policy instruments available to governments and other actors seeking to influence decision-making and behavior within their particular context [ 25 ]. On the other hand, the institutional characteristics of each national health care system may also shape the very nature of the impact of medical tourism on that system. Accordingly, the institutional characteristics of health care systems, such as insurance structures [ 26 ], may impact both citizens’ demand for medical tourism and the ways in which medical tourism affects each country. Obtaining a better understanding of these relationships may inform new ways of thinking about both the challenges and opportunities medical tourism presents. As medical tourism markets continue to grow and diversify, and as domestic health care systems increasingly feel the stress of limited resources, this kind of work will be critical to support policymakers and health system leaders in their efforts to mitigate the potential harms of medical tourism while, at the same time, responding to the needs of the citizens they serve [ 3 ].

Using the examples of Canada and the United States (US), this article proposes the use of an institutionalist research agenda to explore these two related sides of the medical tourism-health care system nexus as a central element of future policy strategies. We first take a comparative perspective on medical tourism and present what we see as key aspects of the issue from a policy perspective. Drawing on current evidence and leading literature in the field, we highlight ways in which national health care systems shape the demand for medical tourism and then, in turn, how medical tourism impacts national health care systems. From this discussion, we identify four key lines of enquiry that we suggest are of critical importance in the medical tourism policy landscape and propose an agenda for future comparative research on medical tourism and national health care systems that could play an important role in informing future policy decisions in this area.

Medical tourism in comparative perspective

Although gathering robust data on the magnitude of medical tourism continues to be a challenge and more empirical work in this area is needed [ 3 , 5 , 10 , 12 ], a strong body of literature addresses different aspects of the issue. For example, research is improving understandings of how medical tourism impacts destination and departure jurisdictions [ 16 , 27 ], affects relationships with domestic health care providers [ 28 ], relates to economic factors including health system costs [ 29 ], and impacts clinical outcomes for patients [ 30 ], among other important lines of enquiry. However, much of this valuable scholarship focuses on particular forms of medical tourism in specific contexts (bariatric surgery [ 31 ], dental care [ 32 ], reproductive services [ 33 ], etc.) or on the policy and health system implications for individual jurisdictions [ 13 ]. There is an increasing amount of comparative research exploring how different features of health care systems may in some cases help drive demand for medical tourism and in other cases constrain it (i.e., push/pull factors), and how they relate to the impact of medical tourism [ 24 ], but more work remains to be done in this important area [ 4 , 10 ]. The potential value of data on the impact of medical tourism in one jurisdiction to structurally- similar systems (e.g., other universal public health care systems) has already been recognized [ 34 ]; we agree and suggest that going further with an associated analysis considering the role of their institutional features is critical. This approach is particularly valuable from a policy perspective, especially when it comes to maximizing opportunities for policy learning from other jurisdictions and to identifying and evaluating the respective strengths and limitations of different policy options for decision-makers seeking to, for example, discourage particular forms of medical tourism (e.g., organ transplant tourism [ 35 ]).

The governance of medical tourism in its various forms is complex and highly fragmented given its broad range of influential stakeholders (both state and non-state, individual and institutional), its international market-based nature, and its engagement of vastly different and often competing priorities and interests (e.g., profit-driven, patient care, autonomy, ethics, etc.). As a result, policy makers and health system leaders face considerable challenges when it comes to seeking to influence medical tourism markets, whether by encouraging their development or restricting access to them. Obtaining a better understanding of the institutional forces that shape the demand for, and impact of, medical tourism—and connecting those forces to the policy context—may help identify a broader range of tools and options decision- makers can employ to achieve their particular objectives with respect to medical tourism.

Looking at Canada and the US is an appropriate starting point for this comparative work and we use this comparison to ground our analysis of the value of an institutional research agenda as a policy strategy for addressing potential concerns and opportunities associated with medical tourism. While these neighboring countries are similar in many ways, there are dramatic differences in important institutional features of their respective health care systems, including funding and delivery models. The US is both an established importer and exporter of medical tourists, the latter supported in part by insurers offering medical tourism coverage in an effort to reduce the high costs associated with domestic health care services [ 11 , 36 ]. In contrast, the structure of Canada’s largely publicly-funded, single-payer medical system limits foreign access to non-emergent care and makes it challenging for Canadians to be reimbursed for care received abroad via medical tourism [ 7 ]. It also makes the current involvement of Canadians in medical tourism [ 37 ] a public policy issue because of its implications for the public purse.

How national health care systems shape demand for medical tourism

Because health care systems can be understood as relatively stable institutional settings that shape human behavior [ 38 , 39 ], their features are likely to impact the demand for medical tourism in a particular country or even, in the case of decentralized health care systems subject to considerable regional variation, in a particular region. Health care systems can vary greatly from one country to the next, or even from one region to the next within the same country. Accordingly, what citizens might be looking for when they seek medical treatment abroad is likely to fluctuate based on the nature of health care coverage, financing, and regulation they have at home. Research about these and other drivers is growing but important gaps in knowledge remain [ 5 ]. In other words, alongside factors like geographical mobility and travel costs, the institutional configurations of health care systems likely shape, at least in part, the types of services people are looking for based on what health services they can access in their home country, with what degree of quality and timeliness, and at what cost [ 24 ].

A comparison between Canada and the US is illustrative here. Starting with the Canadian context, universal coverage has existed in Canada since the early 1970s [ 40 , 41 ]. Under this framework, regardless of the province or territory in which they live, Canadian citizens and permanent residents are entitled to medically necessary health care services with no user fees, which are strictly prohibited under the 1984 Canada Health Act (CHA). Yet, although the CHA mandates comprehensive coverage for “all insured health services provided by hospitals, medical practitioners or dentists,” many services do not fall under this umbrella and the Canadian health care system has long waiting lists for many non-emergency surgeries like hip replacement [ 40 , 42 ]. Wait times vary from province to province but they are a source of frustration for many Canadians, some of whom elect to go abroad to get their non-emergency procedure done faster, even if they have to pay for it themselves, instead of relying on the slower public system back home [ 7 ]. Gaps in coverage within the single-payer system in important areas such as prescription drugs [ 43 ] and dentistry [ 44 ] also sometimes push Canadian citizens and permanent residents to go elsewhere for care to reduce costs. There are also a wide variety of medical treatments and health-related interventions offered in private markets that are either not available or not publicly funded in Canada. There are a variety of reasons for this lack of public funding, including those related to evidence (or, more precisely, the lack thereof) regarding safety and efficacy. For example, there is a large international market for unproven stem cell interventions that are not part of the approved standard of care in Canada or available in the publicly funded health care system [ 45 ]. Therefore, key motivations underlying the pursuit of Canadian medical tourism often relate to a desire to access care faster, to reduce out of pocket costs for care not covered by provincial health insurance, and/or to access options that are not available in Canada [ 7 ].

In the US healthcare system, where about 9% of the population remains uninsured despite the enactment of the Affordable Care Act (ACA) in 2010 [ 46 ], people who lack insurance coverage but who face a medical need might go abroad to seek cheaper treatment. In fact, the high cost of care in the US has been recognized as a major factor pushing Americans to seek care at lower cost outside the US, an option that is facilitated by health care globalization [ 2 ]. For example, there is research documenting the strong market in the Mexican border city of Los Algodones for Americans seeking dentistry, optometrist, and pharmacy services [ 47 ]. Others may be motivated to return to systems with which they are more familiar, as is the case with the Mexican diaspora [ 24 ]. In the US, in contrast to Canada where universal coverage prevails, the lack of health care coverage is likely to be a key factor driving the demand for medical tourism. At the same time, waiting times are much less likely to drive the demand for medical tourism in the US, where waiting lists are less of an issue [ 40 ].

These brief remarks highlight how key institutional features in both Canada and the US shape patterns in the demand for medical tourism in these two countries, creating both similarities and differences between them. At the same time, regional differences in health system institutions within the two countries can also shape the demand for medical tourism within their borders. For instance, in states like Texas, where elected officials have thus far refused to expand Medicaid as part of the ACA [ 48 ], more people live without health care coverage than elsewhere (about 18% of the population as of March 2016 [ 49 ]), which may push them to look to Mexico for cheaper health care. Here the institutional characteristics of a state’s health care system and the geographical proximity to Mexico, coupled with the presence of a large population of Mexican descent who speak Spanish, are likely to favor cost-saving medical tourism from Texas to Mexico. This example highlights how geographical and even ethno-cultural factors can shape medical tourism alongside and even in combination with the institutional features of a particular health care system. This is also the case when we deal with issues such as dental care and cosmetic surgeries, which are not covered by many US public and private insurance plans [ 50 ].

How medical tourism impacts national health care systems

At the most general level, existing national and sub-national institutions may mediate the impact on particular countries of transnational processes stemming from globalization [ 20 , 51 ]. This general remark also applies to global medical tourism, which is unlikely to affect all national health care systems in the same way. Put bluntly, systems will react differently to external pressures, based in part on their own institutional characteristics. Those same institutional characteristics also form part of the policy matrix that shapes the options available to decision makers.

There are two central aspects to this story. First, we can look at how domestic health care institutions are specifically impacted by inbound medical tourism (i.e., destination countries at the receiving end of medical tourism). Research suggests that the way in which health care systems cope with foreign users, and what impact those foreign users have on the system, will vary according to the institutional characteristics of that system [ 16 ]. For instance, countries that attract many medical tourists could witness price increases and the diversion of services away from their less-fortunate citizens [ 1 ]. At the same time, the institutional features of national health care systems can explain why some countries attract more medical tourists than others. The comparison between Canada and the US is particularly revealing here. On the one hand, although some provinces have considered alternate approaches that would encourage inbound medical tourism as a source of revenue generation [ 52 ], at present the limited scope of private health care in Canada restricts the availability of medical tourism opportunities for wealthy foreigners seeking treatments. On the other hand, the large scope of private health care in the US makes that country an obvious target for wealthy medical tourists who can afford its high medical costs.

Second, and more important for this article, national health care institutions may also shape the way in which each country is affected by outbound medical tourism. For example, in a single-payer health care system such as Canada’s, both routine follow-up care and complications resulting from medical acts performed abroad are typically dealt with within the public system, engendering direct costs to taxpayers and potentially impacting access for others in the system (i.e., if physicians’ time is diverted to attend to emergent issues) [ 6 ]. The extent of these concerns varies depending on the urgency of the issue and whether it falls within hospital and physician services covered by the universal system (versus, for example, dental care where public coverage is more limited) [ 52 ]. By comparison, within the fragmented public-private US health care system, public programs may only absorb a fraction of the costs of complications related to outbound medical tourism, thus reducing their direct negative impact on taxpayers, whereas private insurance companies or individuals themselves might bear the majority of these costs.

The potential savings for outbound countries medical tourism generates are also likely to depend on the institutional features of each national or sub-national health care system [ 16 ]. In Canada, for instance, people who decide to go abroad for non-emergency surgeries might help reduce the length of waiting lists, although this positive impact might be limited by the fact that some of these surgeries are simply not available in Canada or, at least, not available to the individuals who seek treatments abroad (e.g., because of their age or health status). Because waiting lists are much less of an issue in the US [ 40 ], this potential benefit of medical tourism to domestic health care systems may be less relevant there.

Conversely, the prospect of affordable medical tourism may convince people in the US who do not have access to Medicaid, Medicare, or employer-based coverage that they do not need coverage at all, because they can always go abroad and save money should they need medical treatment. In this context, global medical tourism could interact with the question of whether people will seek coverage or not. At the same time, to save money, “US companies, such as Anthem Blue Cross and Blue Shield and United Group Programs, are now exploring the idea of including medical tourism as a part of their coverage,” a situation that could increase their administrative burden and create further complications along the road [ 53 ].

Policy implications

Our aim with the preceding high-level overview was to draw on existing knowledge to highlight not only that national health care institutions may shape the demand for medical tourism in a particular country or region, but also that the consequences of such tourism for national health care systems are likely similarly mediated by the institutional features of these systems. These connections have a number of important potential implications for health system governance of medical tourism and, more specifically, for the options available to policy makers seeking particular objectives. For example, depending on the jurisdiction, efforts to reduce demand for medical tourism could include a range of options such as investing resources targeted at reducing domestic wait times, expanding public health insurance, limiting public coverage for follow-up care needs, or educating the public about the potential risks associated with medical tourism [ 2 ], among other options. Conversely, efforts to encourage the development of a medical tourism industry within a particular jurisdiction might involve regulatory change to expand options for private system offerings and targeted marketing campaigns, again among other possibilities [ 5 , 17 ].

In fact, it has long been recognized the governments have a variety of tools or policy levers at their disposal when they seek to influence behavior [ 54 ]. Identifying which tool (or combination of tools) is likely to be most effective in a particular set of circumstances, such as medical tourism, requires a nuanced understanding of relevant institutional characteristics and situational factors. Accordingly, we propose that a comparative research agenda should be a key element of future analysis and decision-making efforts in this field. Such an agenda would not only help empirically test the above hypotheses about the institutional-medical tourism nexus, it could also help facilitate lesson drawing between jurisdictions that have attempted different approaches by helping pinpoint salient commonalities and points of difference between the systems that might initially explain, and ideally ultimately even predict, the likely results of particular policy initiatives.

Research agenda

We propose a comparative research agenda that aims to explore the relationship between medical tourism and key institutional features of national health care systems. Although some aspects of our research agenda are already present in the existing literature, we think studying these elements together and with a comparative policy lens would be of tremendous value to health system decision -makers seeking to navigate different objectives including, for example, avoiding “brain drain” from public to private health care, minimizing added costs to publicly funded systems, protecting vulnerable individuals, and facilitating patient autonomy.

Drawing on our review of the health care systems in Canada and the US, we have identified three key institutional features that we suggest are particularly relevant to medical tourism and its broader policy context. These key features are health care funding models, delivery structures (e.g., public/private mix, provider payment models, role of user choice, and competition between providers), and governance systems (e.g., location of authority, health care provider regulation, liability systems). Future empirical research may identify other more salient features and certainly an iterative approach may be valuable. Nonetheless, we suggest that these features would provide a useful starting point for the next step, which we propose be an exploration of how these institutional features relate to the following areas:

Patient flow patterns – e.g., inbound versus outbound, treatment destinations, types of treatment sought.

Patient motivations – e.g., cost reduction, wait list avoidance, pursuit of quality, circumvention tourism.

Health system interactions – e.g., costs and options for follow-up treatment, roles of domestic health care professionals.

Existing policy levers – e.g., public and private insurance structures, incentive schemes, information campaigns, regulation.

These four areas are not intended to serve as a comprehensive list of all relevant lines of enquiry. However, they present a valuable starting point, particularly because of their relevance to policy instrument selection processes. Having said that, and although it is beyond the scope of this piece to go further than laying a foundation for this proposed research agenda, we suggest that future research take a broad and scoping approach to draw on existing data and information and, where possible, conduct new empirical work addressing these critical areas. With a view to identifying patterns and generating hypotheses, researchers will likely need to continually refine the initial assumptions, outlined above, about the relationships between different institutional features and aspects of medical tourism. Doing so will require careful thought regarding the selection of an appropriate scientific paradigm, with a view to research validity and reliability [ 55 ].

We also anticipate that end-users and important stakeholders, including elected officials, civil servants, health care providers, and patients and families, would have an important contribution to make to the research design and with respect to interpreting the findings, particularly as they relate to the identification and evaluation of policy options. One important limitation in this type of work will relate to data availability. We expect that comparative work of this nature and any future empirical analyses it includes will highlight gaps in knowledge and potentially trigger future research agendas. Overall, the research envisioned here should complement and augment ongoing efforts in the field to improve understandings of important factors including patient flows, expenditure trends, system impacts, and individual decision-making determinants, among others.

Conclusions

This article discussed the relationship between medical tourism and key institutional aspects of national health care systems with a view to highlighting the value in a comparative research agenda focused on identifying and evaluating policy options. First, we argued that these characteristics directly affect the demand for medical tourism in each country. Second, we suggested that such institutional characteristics shape the actual impact of medical tourism on that particular country . This discussion led to the formulation of an institutionalist research agenda about medical tourism. It is our hope that this proposed agenda will trigger discussion and debate, help develop future research, and inform new ways of thinking about medical tourism in the global landscape. Medical tourism is a complex phenomenon and we suggest that applying a comparative, institutional lens will shed new light on its drivers, constraints, and impacts and, in so doing, ultimately help inform policy development in this area.

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The authors thank Rachel Hatcher for the copy-editing support and anonymous reviewers for their helpful suggestions. DB acknowledges support from the Canada Research Chairs Program, and AZ funding from the Canadian National Transplant Research Program.

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Béland, D., Zarzeczny, A. Medical tourism and national health care systems: an institutionalist research agenda. Global Health 14 , 68 (2018). https://doi.org/10.1186/s12992-018-0387-0

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Medical tourism today: What is the state of existing knowledge?

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• Volume 31 , pages 185–198, ( 2010 )

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One manifestation of globalization is medical tourism. As its implications remain largely unknown, we reviewed claimed benefits and risks. Driven by high health-care costs, long waiting periods, or lack of access to new therapies in developed countries, most medical tourists (largely from the United States, Canada, and Western Europe) seek care in Asia and Latin America. Although individual patient risks may be offset by credentialing and sophistication in (some) destination country facilities, lack of benefits to poorer citizens in developing countries offering medical tourism remains a generic equity issue. Data collection, measures, and studies of medical tourism all need to be greatly improved if countries are to assess better both the magnitude and potential health implications of this trade.

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After reviewing data, claimed benefits, and risks the authors conclude that global implications of medical tourism remain largely unknown–and ask if the ability of elites to benefit imposes costs on access for less affluent groups.

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Hopkins, L., Labonté, R., Runnels, V. et al. Medical tourism today: What is the state of existing knowledge?. J Public Health Pol 31 , 185–198 (2010). https://doi.org/10.1057/jphp.2010.10

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Published : 10 June 2010

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DOI : https://doi.org/10.1057/jphp.2010.10

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Medical Tourism

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Lin H. Chen, Mary E. Wilson, Medical Tourism, Journal of Travel Medicine , Volume 22, Issue 3, 1 May 2015, Page 218, https://doi.org/10.1111/jtm.12190

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To the Editor in Chief:

The review by Hanefeld and colleagues nicely summarized some aspects of medical tourism based on the published literature from September 2011 to March 2012 and brings attention to an important area. 1 We would like to alert the readers to additional perspectives that are relevant to travel medicine practitioners. 2 In addition to the papers published in the medical literature, a number of recent books explore some of the broader issues related to medical tourism. 3,4

Other critical issues include cross‐border movement of infections, particularly multidrug‐resistant microorganisms, associated with medical tourism. 2 Challenges also include the lack of regulation of medical tourism companies, inconsistent accreditation of care providers, and the absence of a system to document the flow of medical tourists and to assure informed follow‐up care. 2

Medical tourism is complicated by financial, legal, and ethical issues, as well as by health‐related risks. Obtaining a medical procedure or treatment abroad that lacks scientific evidence clearly raises ethical concern. Lack of communication from providers to the medical tourist's home health care system results in fragmented care. Lack of oversight is associated with poor standards regarding patient privacy and confidentiality, suboptimal care, lack of liability/recourse for poor outcome, and low likelihood to effect improvement. Finally, medical tourists may not be sufficiently prepared for diseases that are endemic in the destination countries, for example, vaccine‐preventable diseases, travelers' diarrhea, malaria, and other vector‐borne diseases. 5,6

As Hanefeld and colleagues have illustrated, a large number of articles on medical tourism have been published in the last several years. There is clearly much interest on the topic among health care providers as well as consumers. The lower cost and ease in travel, aggressive marketing, availability of online information, and globalization of the training of the health care workforce have all contributed to its enormous growth. More research is needed to define the magnitude of this trade and its impact on individual patients, countries of patient origin, and countries providing medical services.

Finally, portability of health care in the European Union as noted by Hanefeld and colleagues supports further formalization of cross‐border medical care. Given the globalization of health care, a better integrated surveillance system that includes data about medical tourists is long overdue.

Hanefeld J Smith R Horsfall D Lunt N . What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system . J Travel Med 2014 ; 21 : 410 – 417 .

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Chen LH Wilson ME . The globalization of healthcare: implications of medical tourism for the infectious disease clinician . Clin Infect Dis 2013 ; 57 : 1752 – 1759 .

Cohen IG . Patients with passports: medical tourism, law, and ethics . New York : Oxford University Press , 2014 .

Hodges JR , Turner L , Kimball AM , eds. Risks and challenges in medical tourism: understanding the global market for health services . Santa Barbara, CA : Praeger , 2012 .

Sadlier C Bergin C Merry C . Healthcare globalization and medical tourism . Clin Infect Dis 2014 ; 58 : 1642 – 1643 .

Chen LH Wilson ME . Reply to Sadlier, Bergin, and Merry . Clin Infect Dis 2014 ; 58 : 1643 – 1644 .

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