“Best Care on Home Ground” Versus “Elitist Healthcare”: Concerns and Competing Expectations for Medical Tourism Development in Barbados

Introduction Many countries have demonstrated interest in expanding their medical tourism sectors because of its potential economic and health system benefits. However, medical tourism poses challenges to the equitable distribution of health resources between international and local patients and private and public medical facilities. Currently, very little is known about how medical tourism is perceived among front line workers and users of health systems in medical tourism ‘destinations’. Barbados is one such country currently seeking to expand its medical tourism sector. Barbadian nurses and health care users were consulted about the challenges and benefits posed by ongoing medical tourism development there. Methods Focus groups were held with two stakeholder groups in May, 2013. Nine (n = 9) citizens who use the public health system participated in the first focus group and seven (n = 7) nurses participated in the second. Each focus group ran for 1.5 hours and was digitally recorded. Following transcription, thematic analysis of the digitally coded focus group data was conducted to identify cross-cutting themes and issues. Results Three core concerns regarding medical tourism’s health equity impacts were raised; its potential to 1) incentivize migration of health workers from public to private facilities, 2) burden Barbados’ lone tertiary health care centre, and 3) produce different tiers of quality of care within the same health system. These concerns were informed and tempered by the existing a) health system structure that incorporates both universal public healthcare and a significant private medical sector, b) international mobility among patients and health workers, and c) Barbados’ large recreational tourism sector, which served as the main reference in discussions about medical tourism’s impacts. Incorporating these concerns and contextual influences, participants’ shared their expectations of how medical tourism should locally develop and operate. Conclusions By engaging with local health workers and users, we begin to unpack how potential health equity impacts of medical tourism in an emerging destination are understood by local stakeholders who are not directing sector development. This further outlines how these groups employ knowledge from their home context to ground and reconcile their hopes and concerns for the impacts posed by medical tourism

Policy Implications of Medical Tourism Development in Destination Countries: Revisiting and Revising an Existing Framework by Examining the Case of Jamaica

Background: Medical tourism is now targeted by many hospitals and governments worldwide for further growth and investment. Southeast Asia provides what is perhaps the best documented example of medical tourism development and promotion on a regional scale, but interest in the practice is growing in locations where it is not yet established. Numerous governments and private hospitals in the Caribbean have recently identified medical tourism as a priority for economic development. We explore here the projects, activities, and outlooks surrounding medical tourism and their anticipated economic and health sector policy implications in the Caribbean country of Jamaica. Specifically, we apply Pocock and Phua\u27s previously-published conceptual framework of policy implications raised by medical tourism to explore its relevance in this new context and to identify additional considerations raised by the Jamaican context.   Methods: Employing case study methodology, we conducted six weeks of qualitative fieldwork in Jamaica between October 2012 and July 2013. Semi-structured interviews with health, tourism, and trade sector stakeholders, on-site visits to health and tourism infrastructure, and reflexive journaling were all used to collect a comprehensive dataset of how medical tourism in Jamaica is being developed. Our analytic strategy involved organizing our data within Pocock and Phua\u27s framework to identify overlapping and divergent issues.   Results: Many of the issues identified in Pocock and Phua\u27s policy implications framework are echoed in the planning and development of medical tourism in Jamaica. However, a number of additional implications, such as the involvement of international development agencies in facilitating interest in the sector, cyclical mobility of international health human resources, and the significance of health insurance portability in driving the growth of international hospital accreditation, arise from this new context and further enrich the original framework.   Conclusions: The framework developed by Pocock and Phua is a flexible common reference point with which to document issues raised by medical tourism in established and emerging destinations. However, the framework\u27s design does not lend itself to explaining how the underlying health system factors it identifies work to facilitate medical tourism\u27s development or how the specific impacts of the practice are likely to unfold. &nbsp

"I didn\u27t even know what I was looking for": A qualitative study of the decision-making processes of Canadian medical tourists

BACKGROUND:Medical tourism describes the private purchase and arrangement of medical care by patients across international borders. Increasing numbers of medical facilities in countries around the world are marketing their services to a receptive audience of international patients, a phenomenon that has largely been made possible by the growth of the Internet. The growth of the medical tourism industry has raised numerous concerns around patient safety and global health equity. In spite of these concerns, there is a lack of empirical research amongst medical tourism stakeholders. One such gap is a lack of engagement with medical tourists themselves, where there is currently little known about how medical tourists decide to access care abroad. We address this gap through examining aspects of Canadian medical tourists\u27 decision-making processes.METHODS:Semi-structured phone interviews were administered to 32 Canadians who had gone abroad as medical tourists. Interviews touched on motivations, assessment of risks, information seeking processes, and experiences at home and abroad. A thematic analysis of the interview transcripts followed.RESULTS:Three overarching themes emerged from the interviews: (1) information sources consulted; (2) motivations, considerations, and timing; and (3) personal and professional supports drawn upon. Patient testimonials and word of mouth connections amongst former medical tourists were accessed and relied upon more readily than the advice of family physicians. Neutral, third-party information sources were limited, which resulted in participants also relying on medical tourism facilitators and industry websites.CONCLUSIONS:While Canadian medical tourists are often thought to be motivated by wait times for surgery, cost and availability of procedures were common primary and secondary motivations for participants, demonstrating that motivations are layered and dynamic. The findings of this analysis offer a number of important factors that should be considered in the development of informational interventions targeting medical tourists. It is likely that trends observed amongst Canadian medical tourists apply to those from other nations due to the key role the transnational medium of the Internet plays in facilitating patients\u27 private international medical travel

Carbon and nitrogen dynamics: Greenhouse gases in groundwater beneath a constructed wetland treating municipal wastewater

Conference oral presentationConstructed wetlands (CW) act as nitrogen (N) sinks and reactors facilitating a number of physical, chemical and biological processes. The N removal efficiency of through-flowing water in such systems when used to treat municipal wastewater is variable. Their overall removal efficiencies do not specifically explain which N species have been removed by physical attenuation, and by biological assimilation or transformation to other forms. A wider understanding of how N removal occurs would help elucidate how losses of N and associated gases from CW impact on water and air quality. The objective of this study is to investigate the C and N cycling processes in the porewater of soils immediately adjacent, up-gradient and down- gradient to helophyte —vegetated CW cells

What Is Known About The Patient\u27s Experience Of Medical Tourism? A Scoping Review

Background: Medical tourism is understood as travel abroad with the intention of obtaining non-emergencymedical services. This practice is the subject of increasing interest, but little is known about its scope.Methods: A comprehensive scoping review of published academic articles, media sources, and grey literaturereports was performed to answer the question: what is known about the patient’s experience of medical tourism?The review was accomplished in three steps: (1) identifying the question and relevant literature; (2) selecting theliterature; (3) charting, collating, and summarizing the information. Overall themes were identified from this process.Results: 291 sources were identified for review from the databases searched, the majority of which were mediapieces (n = 176). A further 57 sources were included for review after hand searching reference lists. Of the 348sources that were gathered, 216 were ultimately included in this scoping review. Only a small minority of sourcesreported on empirical studies that involved the collection of primary data (n = 5). The four themes identified viathe review were: (1) decision-making (e.g., push and pull factors that operate to shape patients’ decisions); (2)motivations (e.g., procedure-, cost-, 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 formedical care). These themes represent the most discussed issues about the patient’s experience of medical tourismin the English-language academic, media, and grey literatures.Conclusions: This review demonstrates the need for additional research on numerous issues, including: (1)understanding how multiple information sources are consulted and evaluated by patients before deciding uponmedical tourism; (2) examining how patients understand the risks of care abroad; (3) gathering patients’prospective and retrospective accounts; and (4) the push and pull factors, as well as the motives of patients toparticipate in medical tourism. The findings from this scoping review and the knowledge gaps it uncovered alsodemonstrate that there is great potential for new contributions to our understanding of the patient’s experience ofmedical tourism

Medical Tourism Facilitators: Ethical Concerns about Roles and Responsibilities

Within the medical tourism industry are a number of key stakeholders – groups and individuals who champion the development of the industry, provide services within the industry, use the services of the industry, and/or are directly or indirectly impacted by the industry - who contribute to its expansion. One such group is facilitators, private agents who broker medical travel and foreign care arrangements between patients and destination facilities but are not employed by these facilities. Key to this element of the medical tourism industry is the Internet; facilitation companies in many countries have a strong web presence and rely primarily on websites (and secondarily on word-of-mouth) to advertise their services. Medical tourism brokers’ responsibilities toward medical tourists can include securing travel and accommodation needs, suggesting and booking facilities and surgeons abroad, contacting destination clinics, overseeing translation of medical records, arranging for tourist activities, and transferring medical records.These brokers can play an essential role in facilitating communication, providing information, and securing overall quality control by assessing the reputability and reliability of international facilities.It appears, however, that only a fraction of medical tourists actually use the services of brokers

“Do Your Homework…and Then Hope for the Best”: The Challenges that Medical Tourism Poses to Canadian Family Physicians’ Support of Patients’ Informed Decision-Making

Background Medical tourism—the practice where patients travel internationally to privately access medical care—may limit patients’ regular physicians’ abilities to contribute to the informed decision-making process. We address this issue by examining ways in which Canadian family doctors’ typical involvement in patients’ informed decision-making is challenged when their patients engage in medical tourism. Methods Focus groups were held with family physicians practicing in British Columbia, Canada. After receiving ethics approval, letters of invitation were faxed to family physicians in six cities. 22 physicians agreed to participate and focus groups ranged from two to six participants. Questions explored participants’ perceptions of and experiences with medical tourism. A coding scheme was created using inductive and deductive codes that captured issues central to analytic themes identified by the investigators. Extracts of the coded data that dealt with informed decision-making were shared among the investigators in order to identify themes. Four themes were identified, all of which dealt with the challenges that medical tourism poses to family physicians’ abilities to support medical tourists’ informed decision-making. Findings relevant to each theme were contrasted against the existing medical tourism literature so as to assist in understanding their significance. Results Four key challenges were identified: 1) confusion and tensions related to the regular domestic physician’s role in decision-making; 2) tendency to shift responsibility related to healthcare outcomes onto the patient because of the regular domestic physician’s reduced role in shared decision-making; 3) strains on the patient-physician relationship and corresponding concern around the responsibility of the foreign physician; and 4) regular domestic physicians’ concerns that treatments sought abroad may not be based on the best available medical evidence on treatment efficacy. Conclusions Medical tourism is creating new challenges for Canadian family physicians who now find themselves needing to carefully negotiate their roles and responsibilities in the informed decision-making process of their patients who decide to seek private treatment abroad as medical tourists. These physicians can and should be educated to enable their patients to look critically at the information available about medical tourism providers and to ask critical questions of patients deciding to access care abroad

Understanding the Impacts of Medical Tourism on Health Human Resources in Barbados: A Prospective, Qualitative Study of Stakeholder Perceptions

Background Medical tourism is a global health practice where patients travel internationally with the intention of receiving medical services. A range of low, middle, and high income countries are encouraging investment in the medical tourism sector, including countries in the Caribbean targeting patients in North America and Europe. While medical tourism has the potential to provide economic and employment opportunities in destination countries, there are concerns that it could encourage the movement of health workers from the public to private health sector. Methods We present findings from 19 semi-structured interviews with stakeholders across the public health care, private health care, government, allied business, and civil society sectors. These interviews were conducted in-person in Barbados and via phone. The interview transcripts were coded and a thematic analysis developed. Results Three themes were identified: 1) Stakeholder perceptions of the patterns and plans for health human resource usage by current and planned medical tourism facilities in Barbados. We found that while health human resource usage in the medical tourism sector has been limited, it is likely to grow in the future; 2) Anticipated positive impacts of medical tourism on health human resources and access to care in the public system. These benefits included improved quality control, training opportunities, and health worker retention; and 3) Anticipated negative impacts of medical tourism on health human resources and access to care in the public system. These impacts included longer wait times for care and a shift in planning priorities driven by the medical tourism sector. Conclusions Stakeholders interviewed who were connected to medical tourism expansion or the tourism sector took a generally positive view of the likely impacts of medical tourism on health human resources in Barbados. However, stakeholders associated with the public health system and health equity expressed concern that medical tourism may spread inequities in this country. The mechanisms by which observed negative health equity impacts in other countries will be avoided in Barbados are unclear. Continued study in Barbados and comparison with the regulatory frameworks in other countries is needed to help enhance positive and mitigate negative impacts of medical tourism on health human resources in Barbados. These findings will likely have import for other Caribbean nations investing in medical tourism and beyond