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Since the Royal Decree was issued on the 22nd August 1970, Oman began to establish healthcare systems based on modern grounds, with governmental support, financing, laws and regulatory frameworks.1 After four decades of continuous improvement and dedicated policies, Oman has a vast network of hospitals, clinics and qualified staff, making it a leader in the whole Gulf Cooperation Council (GCC) for healthcare system in several domains.2,3 In Oman, healthcare is provided with all of its four main components (curative, preventive, promotive and rehabilitative) with cooperative environment for the other health related sectors to synergize the impact on community health.4 All this has resulted in accessibility and distribution of quality healthcare services (accessibility in rural and remote areas is 95% and accessibility in urban areas is almost 100%). W.H.O. ranked Oman’s healthcare system as number 8th among all the member states (191 countries) on the basis of several healthcare related factors.5 Harvard University and other joint commissioned organizations appreciated Oman’s healthcare achievements and considered it as a model for other countries.6
After looking at this wonderful picture of Oman’s healthcare system, it is a point of ponder, why many Omanis travel abroad,7 for medical reasons, why they prefer to get medical services abroad in comparatively sub-standard, less qualitative places, rather than from their own country. This may be due to several reasons, namely; a) long delays, b) fewer competitive private facilities, c) high cost of private medical services and d) the added bells and whistles of medical tourism.
Delays in medical interventions are amongst the reasons for medical travel in Oman. The healthcare system is struggling to shorten waiting lists and provide timely care, but this situation is often difficult to handle for a fully financed governmental system. Here comes the role of private sector, where the waiting time is less but the number of these high quality private hospitals in Oman is limited and their cost is enormous as well. Together, these factors create ample room for hospitals and medical facilities abroad to attract Omanis, where they could save time and cost. Another factor is leisure; medical tourism is not just a trip to the hospital abroad, but in an environment that satisfies patients’ desire for leisure and entertainment as surgery at the beach or having rejuvenation treatment in a natural scenic beauty. Moreover, patients may travel to seek medical procedures, such as injections of stem cells, abortion, organ transplantation, infertility treatment, which are illegal or unavailable domestically.
Medical Tourism is attracting many Omanis; in 2009, an international exhibition was organized in Muscat, Oman; where a large number of medical tourism institutions, from over 17 countries offered their services to Omanis,8 this is a clear indication of international recognition of Omanis as real and potential targets for medical tourism. It is also obvious that international institutions for medical tourism know that a significant number of Omani citizens and residents travel for medical reasons and this number is expected to increase in the coming years. Therefore, it is necessary for medical referrers and general public to be aware of medical tourism and the implications of traveling for medical reasons.
This article provides the foundation in understanding for physicians facing or will in the near future encounter increasing numbers of patients contemplating traveling abroad for care. This is an effort to create awareness of this new trend and related issues rising for physicians and especially family physicians about how they should react to such circumstances. Physicians should be aware of when out-of-country care should encourage or discourage and what help they should provide patients to minimize the risk factors associated with foreign medical treatments. I strongly believe that having answers to such questions might soon become very important.
The general public as an independent decision maker for health related travel must understand the concept of medical tourism and issues related to this practice, although the list is not complete and can never be, but the issues discussed here are major and should be thoroughly considered in order to make an informed and wise decision.
By definition; medical tourism, also known as medical travel, cross-border care, offshore healthcare, health tourism and global healthcare is the practice of patients leaving their country of residence and going abroad, with the core-purpose of getting access to medical care, diagnostic, consultancy and other healthcare services and procedures such as surgery.9,10 The term was coined by travel agencies and mass media to publicize this new form of travel and medical services, but now it is no longer a jargon, it has become a common phrase to describe the rapidly-growing practice of travelling beyond international borders to access healthcare. This concept is not new and has its footprints in history too.10,11 The first recorded event that could be actually referred to as medical tourism was more than a thousand years ago, when Greek pilgrims traveled from all over the Mediterranean to Epidauria, to seek treatment for their health related issues. Another example of medical tourism from history is in eighteenth century, when patients from different places of Europe, come to visit spas which were supposed to treat diseases such as gout, liver disorders and bronchitis.12
Medical travel usually is for non-emergency medical treatment for example; organ transplants, in vitro fertilization, cancer therapies, dental procedures and cosmetic surgeries.13,14
Growing Trend of Medical Tourism
The last few decades were the decades of medical tourism, having tremendous growth and expansion of scope and dimensions. In India alone, records show average 100% growth every year and is expected to maintain this trend in the future (From $310 million in 2005 to $2 billion in 2012).15 Thailand ranks at number 1, and shows more growth in this industry. It is forecasted that global industry for medical tourism will jump 1000% in the next decade.16 Many other countries are considering medical tourism as an important element of their tourism policies. These countries have a large share of medical tourism in their overall healthcare expenditure.
Unprecedented increases in health cost is driving patients to seek treatment on a globally competitive basis, a majority of these patients come from North America, as it provides an alternative, particularly for uninsured or underinsured patients to obtain cheaper treatment. Many countries, supporting medical tourism believe that medical tourism promotes patient choice, gives patients access to treatments not available or not accessible through their local healthcare systems, further medical tourism catalyzes the competitive nature for healthcare systems to provide better, accessible, quality focused and cheap healthcare. It also reduces the extra burden of providing healthcare facilities to their citizens and less pressure from the social group for investing more in the healthcare sector. This is very much true for the developed nations like USA,11 which is why outbound medical travel is becoming popular in many developed countries. The State of West Virginia, USA is considering a legislation to support obtaining, out of country medical services through financial incentives, especially to state employees.17,18 Some US employers have started exploring medical travel programs as a way to cut healthcare cost of their employees.19 Hannaford Bros,20 Blue Shield of California,21 and BlueCross BlueShield of South Carolina,22 are few of the companies to set this trend. Medical tourism is also growing in European countries and according to a recent survey in all member states of the European Union (EU), 53% of the poll expressed a willingness to seek treatment in another country of the (EU).23
Risk Factors Associated with Medical Tourism
As healthcare practices differ among countries, patients seeking offshore treatment are exposed to several risks. Quality of healthcare and patient safety is the most serious issue with medical tourism. Quality of healthcare and standard by which it is measured varies to a great extent around the world. The modest body of scholars on patients traveling to China, India, and Pakistan for organ transplants suggests that financial gain out of transplantation surgeries substantially increases morbidity and mortality rates.24-26
The International Health Accreditation and Quality assurance is a very important means to ascertain the quality of healthcare with medical tourism. It recommends that travellers must choose the hospital and medical facilities that is accredited by health organizations of the first world like USA or the international bodies of quality control such as JCIA.
The different international healthcare accreditation schemes vary in quality, size and cost, as well as intent, skills and the intensity of their marketing.27 The few on top of this list are; (a) Accreditation Canada, formerly known as the Canadian Council on Health Services Accreditation, (b) QHA Trent Accreditation (based in the UK),28 (c) The United Kingdom Accreditation Forum (UKAF), a well known and honoured accreditation network, working towards making medical tourism safer,29 and (d) Joint Commission International (JCI), one of the best known independent accreditation group since 1999.30-32 A report by Deloitte Consulting published in August 2008, clearly indicates that the value of accreditation in ensuring quality of healthcare has given a boost to medical tourism and forecasts increasing confidence for its development.33
Continuity of care is yet another important and serious issue to consider, traveling abroad for treatment is possible but frequent visits for follow-ups may not always be possible, and thus patients resort to their primary physicians for follow-ups and continuity of care. Continuity of care is likely to be disrupted as there are currently no adequate systems in place to enable the transfer of health records between medical tourists and their physicians at home and destination countries. To minimize this issue, medical tourism providers and the concerned hospitals in foreign countries are working together with other international bodies to provide complete documentation in international standard for all treatments and interventions. Therefore, it is important that the travellers ask for proper documentation from their medical tourism providers and should also enquire about the linked follow-up facilities with their local hospitals and clinics. It may be challenging for local healthcare providers to provide follow-up care for procedures they are not familiar with, because in some cases, certain procedures are illegal or unavailable in their own country, therefore physicians may sometimes be reluctant to take clinical responsibility for such patients.
Another issue with medical tourism is based on ethical and moral issues. For example; the Declaration of Istanbul highlighted the ethical issues related to medical tourism for transplantation; illegal purchase of organs and tissues in developing countries is procured through means of exploitation, coercion or through criminal means.34,35 In another example the health services provided through medical tourism in Thailand,36 are at the cost of sacrificing the care and attention their local population needed, this could exacerbate system inequities as doctors are too busy with the foreign patients and the available care resources are consumed by foreign patients, leaving the local population to suffer.37 Subsequently, the conscientious people should study the country and ask their medical tourism provider or the concern country’s embassy to determine whether they follow the ethical issues raised at several forums, so that the patient remains morally healthy after the treatment.
Also, a very common concern related to medical tourism and should be seriously considered before embarking on medical tourism venture, is that patients can be exploited for non-financial aspects by being given false hopes and incomplete information about the procedures, which may be illegal or unavailable in their home countries, owing to their experimental status or to ethical objections, for example stem cell treatments.38,39 Medical malpractice is another important consideration. Therefore it is important to check that the offshore healthcare vendor carries sufficient malpractice insurance.
Amongst the more serious issues for patients traveling abroad for medical purposes is that countries such as India, Malaysia, or Thailand have very different disease epidemiologies. Exposure to these diseases without having adequate immunity can be very hazardous for weakened individuals visiting for medical treatment. There is also a substantial concern about transnational infections. Furthermore, there are increased risks of misdiagnosing diseases by the local doctors during follow-up sessions as disease epidemiology varies from country to country.
With a rise in reproductive tourism and the availability of advanced biomedical fertility technologies, such as in vitro fertilization, egg and sperm donation, surrogate motherhood, there are opportunities for subfertile couples to conceive. However, the availability of such technologies has also lead to commodification and objectification of pregnancy which raises many ethical questions, like whether individuals should have the right to procure a child by every available means; whether the surrogate motherhood and egg donors should receive financial reimbursements, just to name a few. These issues may not be very relevant to Omanis now, but can affect the society in the future due to global dissemination of such technologies.
Conclusion
Although the healthcare system in Oman is commendable, issues such as long waiting times, few and very costly private healthcare services and the idea of leisure with healthcare will always attract a significant number of Omanis towards medical tourism. However, it is necessary to understand that medical tourism is not completely a regulated industry and may lead to risks of varying degree depending on several factors. Given the considerable implications for public health, future research is needed in Oman to further our understanding of cross-border care with the aim of improving public health.
In short, medical tourism has its pros and also its cons, but by taking into account the issues and its solutions discussed in this paper, one can easily minimize the risks of medical tourism. I am hopeful that this paper will significantly help in understanding the concept of medical tourism, its different dimensions, issue and risk factors, but more importantly, it gives guidance on how the risk factors can be minimized to attain a wise and informed decision.
Acknowledgements
The authors reported no conflict of interest and no funding was received on this work. |
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1. United Nations International Children’s Fund (UNICEF) and Ministry of National Economy. Situation Analysis of Children and Women in Oman. Muscat: UNICEF, 2006.
2. United Nations International Children’s Emergency Fund (UNICEF). Progress of Nations 1993. Muscat: UNICEF, 1993.
3. United Nations International Children’s Emergency Fund (UNICEF). Progress of Nations 1997. Muscat: UNICEF, 1997.
4. Ministry of Health. The Seventh Five-Year Plan for Health Development (2006-2010). Muscat: Ministry of Health, Oman, 2006.
5. World Health Organization. World Health Report 2000: Health systems: improving performance Geneva: WHO 2000.
6. Hill GH, Muyeed AZ, AL-Lawati JA. The Mortality and Health Transition in Oman: Patterns and Processes: A study commissioned by the Government of Oman, UNICEF Oman Office, and the WHO Regional Office for the Easter Mediterranean, December 2000.
7. Ministry of Health. Oman Morbidity and Mortality. Muscat: Ministry of Health; 2009. Annual Health Report; pp. 9–92. Ch 9.
8. "MedHealth and Wellness 2009 in Oman to highlight medical tourism" Medical Tourism News, 14th October 2009. http://www.omanexpo.com/medhealth. Accessed Dec 2010.
9. Shaywitz DA, Ausiello DA. Global health: a chance for Western physicians to give-and receive. Am J Med 2002 Sep;113(4):354-357.
10. Johnston R, Crooks VA, Snyder J, Kingsbury P. What is known about the effects of medical tourism in destination and departure countries? A scoping review. Int J Equity Health 2010;9:24.
11. Burkett L. Medical tourism. Concerns, benefits, and the American legal perspective. J Leg Med 2007 Apr-Jun;28(2):223-245.
12. Gahlinger PM. The Medical Tourism Travel Guide: Your Complete Reference to Top-Quality, Low-Cost Dental, Cosmetic, Medical Care & Surgery Overseas. Sunrise River Press, 2008.
13. Jones CA, Keith LG. Medical tourism and reproductive outsourcing: the dawning of a new paradigm for healthcare. Int J Fertil Womens Med 2006 Nov-Dec;51(6):251-255.
14. Jones C. Ethical and legal conundrums of postmodern procreation. Int J Gynaecol Obstet 2008 Mar;100(3):208-210.
15. "Just what the hospital ordered: Global accreditations", by Zeenat Nazir, Indian Express, Sept 18, 2006. Retrieved September 29, 2006, http://www.indianexpress.com. Accessed Dec 2010.
16. Linda A. Johnson, "Americans look abroad to save on health care: Medical tourism could jump tenfold in next decade," The San Francisco Chronicle, August 3, 2008 http://www.sfgate.com. Accessed Dec 2010.
17. Appleby J, Schmit J. Sending patients packing. USA Today 2006 Aug 9. http://www.usatoday.com. Accessed Dec 2010.
18. Anderson J. Hospitals oppose ‘medical tourism’ bill. Charleston Daily Mail 2007 Feb 16.
19. Lindsay G. "Medical Leave" Fast Company, May 2008. Retrieved October 15, 2008. http://www.fastcompany.com. Accessed Dec 2010.
20. McGinley. Laurie, "Health Matters: The next wave of medical tourists might include you", Wall Street Journal, February 16, 2008. http://online.wsj.com. Accessed Dec 2010.
21. Perry, Laura. "New Releases." Blue Shield of California. N.p., 7 June 2000. Web. 15 Nov. 2009.
22. Einhorn B. "Outsourcing the Patients," BusinessWeek, March 13, 2008. http://www.businessweek.com. Accessed Dec 2010.
23. European Commission. Flash Eurobarometer. Cross-border health services in the EU: analytical report. The Gallup Organization, 2007.
24. Turner L. Commercial organ transplantation in the Philippines. Camb Q Healthc Ethics 2009 Apr;18(2):192-196.
25. Canales MT, Kasiske BL, Rosenberg ME. Transplant tourism: Outcomes of United States residents who undergo kidney transplantation overseas. Transplantation 2006 Dec;82(12):1658-1661.
26. Prasad GV, Shukla A, Huang M, D’A Honey RJ, Zaltzman JS. Outcomes of commercial renal transplantation: a Canadian experience. Transplantation 2006 Nov;82(9):1130-1135.
27. "INDIA: Accreditation a must," International Medical Travel Journal http://www.imtjonline.com/news/india-accreditation-a-must. Accessed Dec 2010.
28. "QHA Trent." http://www.qha-international.co.uk/. Accessed Dec 2010.
29. United Kingdom Accreditation Forum http://www.ukaf.org.uk/TAS.htm. Accessed Dec 2010.
30. "Medical Tourism Industry Certifications and Information" http://www.health-tourism.com/medical-tourism/industry-certifications/. Accessed Dec 2010.
31. "Medical Tourism Magazine," Medical Tourism Association, Issue: 2, February 2008
32. "Facts about Joint Commission International." Joint Commission. 2008-12-11. http://www.jointcommission.org/AboutUs/Fact_Sheets/jci_facts.htm. Accessed Dec 2010.
33. Deloitte Report http://www.deloitte.com. Accessed Dec 2010.
34. International Summit on Transplant Tourism and Organ Trafficking. The Declaration of Istanbul on organ trafficking and transplant tourism. Kidney Int 2008 Oct;74(7):854-859.
35. Chopra A. (February 9, 2008). "Organtransplant black market thrives in India." The San Francisco Chronicle. http://www.sfgate.com. Accessed Dec 2010.
36. Medical Tourism Creates Thai Doctor Shortage. NPR http://www.npr.org. Accessed Dec 2010.
37. CSDH: Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health Geneva: WHO; 2008.
38. Lindvall O, Hyun I. Medical innovation versus stem cell tourism. Science 2009 Jun;324(5935):1664-1665.
39. Crozier GK, Baylis F. The ethical physician encounters international medical travel. J Med Ethics 2010 May;36(5):297-301.
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