Pharmaceutical Education

Medical Tourism: Ethics, Risks and Benefits

Nur Syafiqah Abd Mutalib1, Long Chiau Ming1,2*, Siew Mei Yee3, Poh Lee Wong3, Yee Chang Soh1*
1
Department of Pharmacy Practice, Faculty of Pharmacy, Universiti Teknologi MARA, Puncak Alam, Selangor, MALAYSIA.
2
Vector-borne Diseases Research Group (VERDI), Pharmaceutical and Life Sciences CoRe, Universiti Teknologi MARA, Selangor,
MALAYSIA.
3
Department of Pharmacy Practice, Faculty of Pharmacy & Allied Health Sciences, SEGi University, Selangor, MALAYSIA.

ABSTRACT
Background: Despite of the global increase of medical tourism, there is no review done to examine the motivation
leads to the practice of medical tourism, opportunities and risks with the practice of medical tourism and the
ethical issue of medical tourism. Objectives: This review aims to highlight the issues associated with medical
tourism and its facilitators and barriers by evaluating literature of the development and types of medical tourism in
these countries. Methodology: We reviewed the relevant articles that were searched using Embase, Medline, Pub
Med and CINAHL databases. Risks and benefits as well as ethical issues emerged from the practice of medical
tourism were identified. Results: Pull factors that make patients having medical treatment, therapy and services
abroad are language familiarity, the need for privacy, quality, bioethical legislation, food, cultural and tourist
attractions at their destination. Affluent medical tourists from countries such as Indonesia, Brunei, Singapore and
Bangladesh also are likely to practise medical tourism for both purpose of cheaper and reliable medical therapy
and tourist vacation. Thus, the countries that have certain attractions associated with cheaper healthcare cost
will be the most preferred place for them to practise medical tourism. Conclusion: This review can be useful for
the patients who want to practise medical tourism, for nations which has already practised medical tourism to
improve their quality in medical tourism and aware of ethical concerns that arise from this practice, as well as for
the references of the countries which want to practice medical tourism in the future.
Key words: Medical tourism, Hospital care, Health care quality, Access and evaluation, Cross-border medical
tourism, Push and pull factors.

INTRODUCTION Submission Date : 15-07-2015

Medical tourism can be traced back to the Revised Date : 30-11-2015
care sought by patient at another country
Accepted Date : 16-02-2016
1980s when several Latin American coun- is organ transplantation, reproductive treat-
tries offering cheaper dental, cosmetic and ment and dental treatment.5 Despite the raw DOI: 10.5530/ijper.50.2.6
Correspondence Address
surgical procedures to patients from United definition of medical tourism described as Dr. Long Chiau Ming,
States (US) and Europe. Since the past few the movement of patients abroad for medi- Department of Pharmacy
decades, the rapid growing of international cal therapy intention, the applicability and Practice, Level 11, FF1,
Faculty of Pharmacy,
trade and economy has influenced the rise usage of ‘tourism’ terminology in medical Universiti Teknologi MARA,
of many other sectors especially healthcare tourism is continuously reviewed.6-11 42300 Puncak Alam,
Selangor, MALAYSIA.
sector. The concurrent ease of global travel, Carrera (2006) defined medical tourism as Tel: +603 32584775;
seeking for cheaper healthcare cost, desire the enhancement or restoration of the indi- Email: [Link]@[Link],
syc_chris@[Link]
for high technology of medical facilities, vidual’s health through medical intervention
lack efficiency and effectiveness of public by organized travel outside one’s natural
health services has increased healthcare sector healthcare jurisdiction.12,13 Medical tourism
more through the art of practicing medical is recognized as the act of tourists who are
tourism.1-4 people that travelling abroad for the pur-
Medical tourism is a practice of travelling pose of seeking medical services or treat-
to other country for the intent of attaining ment. Generally, travellers who have stayed
[Link]
healthcare services. Such popular health- away and travelled for more than 24 h from
Indian Journal of Pharmaceutical Education and Research | Vol 50 | Issue 2 | Apr-Jun, 2016 261
 Abd Mutalib et al: Review of medical tourism

their home country and often used any form of accom- METHODOLOGY
modation facility is considered as tourists while those Inclusion Criteria
who act in this way but does not meet this 24 h cri-
terion are often determined as visitors. Thus, patients Studies were considered to be included in the review
travel abroad for medical purpose is considered as medi- if the following criteria were met: (1) randomized
cal tourists. They can be grouped into a special inter- controlled trials, (2) non-randomized controlled trials,
est tourist and since they main motivation of travelling (3) longitudinal studies, (4) cohort studies, (5) case–control
abroad is for a specific purpose, which are attaining studies, (6) descriptive studies, (7) reviews, (8) letters,
healthcare.14 (9) conference papers, (10) opinions, (11) reports,
(12) editorial papers that reported medical tourism,
Medical tourism is not a new phenomenon and his- (13) studies focusing in Malaysia and India medical
torically, the instance of medical tourism has started tourism,and (14) no gender restriction placed on sample
since thousands years ago to when Epidauria, a place participants. Studies were excluded if: (1) they were
in the Saronic Gulf where the healing god, Asklepios review studies and (2) studies in other languages than
resides, reached by Greek pilgrims after travelling English language.
all over Mediterranean. Thus, Epidauria has been
recorded as the original destination of medical tour- Search Strategies
ism in medical tourism history. Spas and sanitariums A narrative literature search was performed using
also recognized as an early type of medical tourism databases provided by UiTM Library: Embase (starting
and popular among England people in 18th century, 1980), Medline (starting 1948), PubMed, and the Cumu-
as the high mineral water provided by spas treated a lative Index to Nursing and Allied Health Literature
lot of diseases including psoriasis.15 Cuba, being one (CINAHL) (starting 1982). The search strategy included
of the known country practising medical tourism has articles published till March 2015 and written in English
actively practised and advertised medical tourism in language. References from eligible articles were hand-
their country since 1990s by the Cuban government searched in order to identify additional relevant papers.
which offered a package known as ‘sun and surgery’ Keywords and their synonyms including “air travel”,
package. This package included cardiac transplant and “expeditions”, “medical tourism”, “health tourism”,
organs transplant.9 “clinic tourism” or “hospital tourism” were used in the
In recent years, medical tourism has been practiced search strategies. The Boolean logic terms “or” and
broadly and interchangeably in many countries. India, “and”, truncation, citation tracking and chaining were
Thailand, Korea and Malaysia are among the countries also applied to combine searches.
where the development of medical tourism increases
aggressively.6,16-22 This trend or practice becomes Review Procedure
increasingly common because of the affordability and Studies of medical tourism have been found to be
ease of global travel. In 2008 estimation, there were heterogeneous, as they are conducted in different coun-
about 2 million Americans travelled internationally for tries used different definitions and different methods
the purpose of improving their health. Over 30 countries to collect data. For this reason we did not analyze the
already have high technology of healthcare facilities that data from a statistical viewpoint, but the results were
offered medical services to international patients. Patients summarized according to the type of medical tourism
can choose from a large variety of required procedures and its relevant issues.
of prevention, screening and health maintenance by this A total of 578 titles and abstracts were identified by
rises in technology of medical worldwide that provides three authors from electronic searches of the 5 data-
numerous options for healthcare on the global market.23 bases and search engines, and wherever possible, a
Despite of the global increase of medical tourism, there review of the reference lists. Of these, 539 titles and
is no review done to examine the motivation leads to the abstracts not related to medical tourism perspective
practice of medical tourism, opportunities and risks with and duplicated citations were examined and excluded.
the practice of medical tourism and the ethical issues The full text of 39 articles was retrieved and distrib-
of medical tourism especially in Asian countries.24-26 uted among the authors for further assessment. All
This review aims to highlight the issues associated authors agreed that 21 of the 39 manuscripts did
with medical tourism and its facilitators and barriers not fulfill the inclusion criteria and were excluded.
by reviewing studies of the development and types of The PRISMA flow chart for our reviewing process is
medical tourism in these countries. shown in Figure 1.

262 Indian Journal of Pharmaceutical Education and Research | Vol 50 | Issue 2 | Apr-Jun, 2016
 Abd Mutalib et al: Review of medical tourism

Figure 1: PRISMA flow chart of the reviewing process

RESULTS AND DISCUSSIONS countries to search for sophisticated and high quality
One of the significant products of globalization is the of medical tourism. Recently, the trend has changed
where involving ordinary group of people from more
rises of economic integration and interdependence
developed countries searching treatments in developing
of nation’s state and region. Concurrent events of
countries because of the price of medical treatments and
free exchange of products and people and the rise of
services required for developing countries is far cheaper.
cross-border movement are facilitated by this strong
Phua (2010) characterized cross border medical tourism
international connection between countries which has
into two different typologies which are quality sensitive
successfully increased the growing of international medical tourism and price sensitive medical tourism.
market rapidly. This includes the market of healthcare Quality sensitive medical tourism involved affluent peo-
products, services as well as consumers and one of the ple of a small group of wealth people searching medi-
growing healthcare market.27 cal treatment abroad for a sophisticated and high quality
Medical tourism is not a new phenomenon, what is new medical treatment and services which rarely provided in
is actually the trend of practising medical tourism. Pre- their home country while price sensitive medical tourism
viously, medical tourism was practised by elite group involved less affluent people travelling out of country to
from developing and third world countries to developed seek for affordable medical treatment price.28
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 Abd Mutalib et al: Review of medical tourism

Ethical issue on medical tourism hospital and private medical service center will be
The inequity of healthcare distribution among the local provided with best medical facilities, high technology
population and foreigner patients is the major negative of medical equipment as well as well-trained physician
effect seen in the practice of medical tourism.11,19,29,30 compared to public healthcare sector.
Since medical tourism gives a great benefit to nation’s Low import duties of medical facilities and land have
economy sector, there is a possibility for the develop- been subsidized by government for private sectors.
ment of two tiered health system where medical tourist For example, the intervention of government in the
enjoying the conducive medical facilities, well-trained regulation of private sector in India is minimal. The
physicians and high technology medical equipment practice of medical tourism could further rule out their
while the local underprivileged patients would only have demands and pressure state to give them even more
basic medical facilities and lack of source of medication subsidy. This eventually causes the country’s budget in
and medical services. Besides that, better salaries and healthcare sector will go less for public healthcare sector
work opportunities offered to healthcare providers may and more to private sector. All these implications will
cause them leaving the health public sector to work with put the pressure on local patients who have severe and
private hospitals that capitalizing on medical tourism. chronic disease or illness and do not have the affordability
These will definitely affect the quality of public health- to having abroad medical therapy and fully depend on
care sector as well as the ratio of healthcare providers- public healthcare provided by their government.35
to-patients.6,31,32 Another ethical issue is related to cross-border repro­
One of the major reasons of long waiting times or poor ductive. For example, legal restriction of fertility treat-
services delivery in public healthcare sector is due to ment in France has motivated French citizens to have
the inadequate skilled and well-trained public healthcare reproductive care treatment in Belgium. Fertility treat-
professional. India having low numbers of healthcare ment for transgender couple or single mothers and
personnel of 1 million nurses, 200 000 dental surgeons homosexual are not allowed in France due to the
as well as 600 000 physicians according to the report absence of medical evidence on its sterility. In contrasts,
of India Planning Commission in 2008.33 A shortfalls Belgium has not legally restricted this practice towards
of healthcare specialist manpower at community health these groups and many centers can provide reproductive
care treatment to them. Furthermore, the prohibition
centers in India and their availability is worrying.34 This
of egg donator in France from patient’s nieces or sisters
is due to the brain drain and migration of skilled health-
has motivated patients from France to seek this treat-
care personnel to private sector inside or outside the
ment in Belgium in contrast with legal restriction of
country that provide international medical services
Netherland that prohibited anonymous egg gametes to
which offer more competitive salaries and better oppor-
be used in reproductive care treatment, which eventually
tunities. While the public health sector is overburdened
motivated their citizens to seek their desired treatment
with inadequate resources and physicians, the majority
in Belgium.36
of advanced technology of medical equipment and vast
medical facilities are in private sectors. Social impact to the local population
Furthermore, considerable large sum of money were Despite prior benefits of medical tourism, a number of
taken away from the local population to develop this studies have found the significant impact of practising
medical tourism industry by focusing on the construc- medical tourism. The most important impact is inequity
tion of medical facilities at the urban areas; away from of health distribution towards local patients especially
the rural areas for the local population needs. This is not those who are fully dependent on the public healthcare
justified for local citizens that live in rural areas to seek provided by government. Although the market of medical
for medical treatments and services. This is one of the tourism is driven by private health sector, the profit
sentiments raised by local Brazilian when the country obtained from this practice towards nation’s revenue
prepares for World Cup 2014 and the coming Olympic has urged nation to engage in this sector by investing
Game.5 The argument are the market of medical tourism the limited fund allocated for public healthcare sector
is driven by private health sector. Nevertheless, the profit into private sector especially in countries with no policy
obtained from this practice towards nation’s revenue has for the regulation of private healthcare sector. Private
urged nation to engage in this sector by investing the hospital and private medical service center will be
limited fund allocated for public healthcare sector into equipped with good quality medical facilities, high tech-
private sector especially in countries with no policy for nology of medical equipment as well as professionally
the regulation of private healthcare sector. Private trained physician compared to public healthcare sector.
264 Indian Journal of Pharmaceutical Education and Research | Vol 50 | Issue 2 | Apr-Jun, 2016
 Abd Mutalib et al: Review of medical tourism

Furthermore, the medical centers tend to focus more saving factors even for publicly-funded patients that
on urban areas as to meet the demand for medical tourist seeks alternative abroad to avoid long waiting times in
of ease of mobility to medical centers but unfair to their home country if their country refuse to pay for
patients in rural areas to access those facilities. Besides healthcare therapy abroad and this scenario happened
that, this growing of medical tourism led to brain drain often. Therefore, the strongest motivation for patients
since the private sectors which practicing medical tourism of developed country having medical services or therapy
are likely to offer more salary and best opportunity to to developing countries via the industry of medical
skilled healthcare professionals which encourage them tourism is the cost-saving. Anyhow, there are critics arise
to leave public healthcare sector. from this motivation stated that this low cost of medical
In addition, there are other impacts that arise from this therapy and services in particular nations is due to the
practice such as the quality care issue, infection acquired limitation malpractice insurance paid by healthcare
during medical procedure especially in third world country professionals while patients have likely at risk when
and complication of travelling for medical tourist.37 receiving this low cost medical therapy and services.6,39
Previous study has shown that in India, the costs of
Patients’ decision-making in terms of push and comparable medical services are on average of 1/8 to
pull factors
1/5 of those in other countries. A cardiac procedure
Push and pull factors can affect patient’s decision-making only costs about 3,000 to 6,000 US dollar in India
to practise medical tourism. Push factors are any forces compared to 30,000 US dollar in Singapore and 40,000
or factors that drive people away from particular place to 60,000 US dollar in US. Thus, with this cheaper
and pull factors are any factors that drive people to a medical services cost and availability of high technology
particular location. In other words, push factor hap- medical facilities as well as well-trained physician in
pened due to non-availability of one’s desired things in India has made India among the most favorable countries
particular places that makes people seeks those things to practice medical tourism. Based on this study, the
is another place while pull factors are desired things major ratio of healthcare growth is attributed to the
that are present in particular place that attract people to growth in the market of medical tourism. Medical tourism
move to that particular places.38 has made healthcare sector hits a place among the other
International literature has recorded two different moti- sectors in term of contribution to nation’s revenue and
vations that commonly cause patients from high income employment rate. In 2012, India’s health sector has
countries practising medical tourism to other nations, grown nearly to 40 billion US dollar from 34 billion US
specifically the developing one. The most crucial factor dollar in 2009. According to Confederation of India
in encouraging people to travel long distance just to seek Industry (CII), over the past few years, medical tourism
medical therapy is thought to be cost-saving in searching in India has gained momentum which approximately
affordable medical cost for patients without universal 150,000 medical tourist arrived in India in 2005 and
medical insurance that come from privately funded the number of medical tourist that choose India as
healthcare system such as US. According to push and medical tourism destination is expected to increase by
pull factor theory, this might be due to the high medical 15% annually.35
therapy cost required in their own country that causes For example, price advantage is the pull factor that
them to seek therapy at another country regardless the makes India a well-known country in receiving patients
quality of therapy as well as non-availability of needed all over the world for the medical therapy and services
healthcare in their home or more cheaper medical purpose. While India offering world class treatment in
therapy cost required in particular country that provided it huge number of hospitals, the cost of medical
same quality of therapy with their own country has services and therapy is much cheaper whereas the cost
motivated them to having medical therapy there. Mean- differential between India and in West countries is huge
while, for patients from Canada and much of Europe and this makes India one of the favorite destination for
countries that their home system have an access to medical tourism although it entrance in medical tourism
publicly-funded medical therapy, practised medical tour- industry mere recently. Industry observers predicted
ism due to the long waiting list for healthcare therapy in that for the each year of the next 6 years, India health-
their countries as well as looking for alternative abroad care sector that had boosted up by healthcare tourism
due to the unavailable services or treatment procedures could grow up to 30% from 17 billion dollar per year
in their own country or particular healthcare services that healthcare market due to its price advantage. A study
illegal locally. However, the huge interest of patients on Indian healthcare carried out by Confederation of
seeking medical services abroad are due to the cost- Indian Industry (CII) stated that 50-69 billion US
Indian Journal of Pharmaceutical Education and Research | Vol 50 | Issue 2 | Apr-Jun, 2016 265
 Abd Mutalib et al: Review of medical tourism

dollarcan be contributed by medical tourism alone as an In addition, the unavailability of specialized cardiac
extra profit for tertiary hospitals by 2012 that account surgery in several African countries is the reason of
for about 6.2% to 8.5% of gross domestic product.40 those patients having treatment in India. Even though,
There is an enormous and intact market for curative the desired treatments are locally present in these coun-
treatment of medical tourism as well as therapeutic tries, there is high proportion of patients from Malaysia
medical tourism such as Ayurveda. This new entrance and African countries that received the sponsor by their
in the industry of medical tourism has made India as a government to undergo medical tourism in India.15
chosen destination for medical therapy asides from the
Promotion of medical tourism
traditional fact that India, being the oldest country prac-
tice medical tourism where tourists come for Ayurveda The effective promotion of medical tourism is one of
and other therapies. Since India has great technologies the factors that lead to the growth of practising medical
and huge pool of skill healthcare professionals, India is tourism. According to the Malaysian Tourism and
estimated to be a leader in medical tourism industry.41 Culture Ministry Malaysia and Ministry of Health, the
Asian countries such as Thailand, India, Malaysia and promotions of medical tourism that has been con-
Singapore are among the most famous medical tourism ducted and implemented by them has attracted 770,000
destinations which remarked by medical tourism industry. and 790,000 medical tourists to choose Malaysia as
These countries can attract more tourists because of the destination country for having services and treatments
medical treatments or services provided are less expen- in 2013 and 2014, respectively which in turn bring profit
sive than those of other part in the world like US or for about 191.80 million US dollar to the country.44
European countries.42 Medical tourist or international The growth rate of income in the medical tourism
patients can save up to 40% to 60% due to the lower industry had exceeded the Malaysian national plan
labor cost in most of Asian countries which cause lower (2010-2015) target by 10% every year, and for the
cost for medical treatment and services.43 Malaysian national plan period (2016-2020), the income
was expected to grow by 15% annually, generating
Another important pull factor is the credibility and
revenue of about RM2 billions by 2020.
professionalism of healthcare providers in Malaysia,
India and Thailand. The good English-proficiency and Medical tourism facilitators or agents that are responsi-
well-trained medical staffs is a plus point when deciding ble in disseminating information about medical tourism
the destination for medical tourism.35 In one study that to prospective patients, advertising its availability and
seeks the reasons of patients from particular countries overseeing follow-up care has contributed to the pro-
practising medical tourism in India for congenital heart motion of medical tourism by using the internet and
disease treatment shown that the number of interna- popular social media to advertise possible and promising
tional patients having cardiac treatment in India is 1 in medical procedures and destinations.6 For example,
10 of every cardiac admission. This indicated that India private hospitals in Malaysia engage foreign agents in
has a stable position among countries that frequently several key markets overseas who help patients selecting
visited for the best quality of treatment. Surprisingly, Malaysia as destination of medical tourism. These
patients from a country with good medical and surgical agents then work closely with the health tourism team
services like Malaysia took the highest percentage number of the hospital to arrange every aspect of our foreign
of cardiac admission in India hospitals. This might be visitors stay at treatment in the hospital. Meanwhile, a
due to several reasons such as long waiting list, insuf- study about promoting medical tourism in India found
ficiency of specialized cardiac surgery center in public that the hospitals, clinics and medical service centers in
hospitals, geographically near to India as well as low India play a big role in attracting international patient
transportation cost in India. Besides that, medical tourists for medical tourism in India through advertisement
from South Africa is the second highest patients likely with a variety of messages and images that promoting a
to have cardiac surgery in India although the culturally broad range of specialized medical services offered to
and physical proximity of South Africa to India is quite international patients, which emphasize on best quality,
far. The main reason is due to the cost competiveness advanced technology of medical equipment and facili-
advantage of India over other US and Europe countries. ties, competent and professional healthcare providers
In India, 7500 US dollar has already covered the cost and best quality of medical care. Nevertheless, overall
of travel, surgery and 3-week stay in India for surgery cost of this practice is rarely mentioned in those adver-
of ventricular septal defect which merely 10% cost of tisements as they are often carried out by tour operators
surgery of open heart in London, United Kingdom. or agents.6,39

266 Indian Journal of Pharmaceutical Education and Research | Vol 50 | Issue 2 | Apr-Jun, 2016
 Abd Mutalib et al: Review of medical tourism

Financial Implication of medical tourism condition of citizens which can produce more productive
Exporting countries workers or citizens.
Exporter countries in medical tourism in context of To certain extent, importing countries have financial
medical cost advantage which commonly low income benefit by sending patients to have medical treatments
countries could gain benefit tremendously from the and services abroad to countries that offering low medical
dividend they make through medical tourism as the cost treatment. There are one study claimed that, overall
foreign exchange is the prime financial source of medi- US annual savings would be 1.4 US billion dollar if
cal tourism. The Tourism Research and Marketing 1 in 10 patients from US who suffered from one of
Group reported that each year there are 27 millions of fifteen conditions having medical treatments or services
trips related to health which generating about 33 billion abroad. Furthermore, if bilateral trade relationship
Euros. Medical tourism in most countries occur not between countries is applied, cost of medical treat-
mere through the private sector but the government ments abroad can be directly negotiated and savings
also investing in private hospitals indirectly (i.e. through from this low cost of medical treatment of abroad can
incentives of tax) and directly. Since the government be included in nation’s budget to be used for developing
also benefited from this practice, they participate in other sectors.5
promoting medical tourism actively. For instance, India Risk exposure to medical tourists
through leaflet of medical services offered in theairport
and the campaign of ‘Incredible India’.45 Furthermore, There are risks associated with the practice of medical
the revenue from this practice is increased not only for tourism which arise from the surgery procedure or
the medical services or treatment provided but also travelling abroad. Three broad categories have been
during the healing period as well as the accomodation identified: risk of travel, risk post-operative procedure
of accompanying person. in patients own country as well as risk that might affect
the health of patients during the procedure.47
The expansion of medical tourism in particular countries
has been used to bring back their healthcare providers Medical tourism comes with two main risks that are
who had emigrated by offering better opportunities broadly discussed in the context of in terms of psychol-
and competitive salaries. Typically, abroad patients are ogy and physiology. Psychologically and emotionally, being
more likely to trust the healthcare providers such as away from the closest people such as family, spouse, and
physicians, pharmacist, reflexologist and etc. who being parents may lead to acquired stress to medical tourist.
trained in their home country. Thus, this will converse Such health risk related to travel is due to the mental
the brain drain and emigration of skilled workers from burden and particularly during the healing period
particular countries.5 The traveller may travel alone or abroad. Besides that, physiological risk that may be
for those who undergo serious medical procedure that developed during airline travel is the major concern that
needs companion for the ease of mobility and safety for the medical tourist before and after having medical
such as cancer treatment and cardiac surgery may travel treatment or services). Potential health conditions using
with one or more support person such as parent, siblings, long haul flight are more susceptible to travelers’ throm-
friends or spouse. In this case the medical tourism bosis which also known as deep vein thrombosis (the
destinations will benefit in their monetary inflow from swelling of deep vein due to the clotting of blood in
the stay of patients and their companions aside from those particular areas).48 It is more likely to occur for
medical treatment cost itself. The close proximity of restricted and lack of movement during the flight which
luxury accommodations to private medical centers or causes lack of blood flow to the areas of the legs.
facilities which provide medical tourism services also Furthermore, there might be a possibility of blood
aim to benefit from this industry.46 clotting occurs in the lungs which lead to pulmonary
embolism.49,50
Importing countries The risks of medical tourism are not restricted only
Patients from importing countries (the original countries when patients neither are abroad nor ended after patients
of the medical tourist) would have high confidentiality check out from the hospital. Lack of information flow
and privacy of medical treatment, increase personal between abroad physician and home country is another
care level as well as high medical services and treatment negative impact of medical tourism as the continuity of
options by practicing medical tourism. Importing coun- care towards patients is broken. This might arise from
tries can reduce the waiting list and waiting time by prac- inadequate follow up care after the medical treatment is
tising medical tourism. This will reduce the number of received abroad by the patients. There are no transfer
mortality in importing countries and increase the health of health information from foreign hospital to home
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 Abd Mutalib et al: Review of medical tourism

country which might lead to several consequences such With the above mentioned limitation, a mixed methods
as inability to screen complication from the treatment or studies are recommended to uncover issues such as
surgery abroad, toxicity arise from administered medi- perception, facilitator and barrier of general public in
cation. If any complication arises, patients are more developed countries about medical tourism. It is hope
susceptible to severe condition as the local physicians that the recommended findings would provide much
have little knowledge on what is going on during abroad needed information on the key issues identified, and
treatments or medical procedures.51 knowledge gaps that exist about medical tourism.
However, these problems can be avoided by requesting
their medical report from the attending doctors. CONCLUSION
Destination countries that have poor medical care
The main forces that encourage patients to practise
laws enforcement might lack legal remedial procedure
medical tourism to particular countries is due to the
if complications of treatments arise. This would be a
relatively low cost required for medical services com-
problem to medical tourists are further separated geo-
parable with its quality, more inflow of patient to that
graphically from their home country. Furthermore,
particular countries will help to increase their economic
some physicians in home countries may refuse to treat
patients who having medical treatment abroad due to sector through this practice. However, inequity of health
the fear of being accused or sued for complication distribution towards local patients especially those who
arising from treatment abroad for those countries with are fully depend on the public healthcare provided by
little legal recourse for procedures or treatments.47 government do occur.
Besides that, patients exposed to post-operative infec- This review can be useful for the patients who interested
tion in the hospitals, lack of blood supply available at in medical tourism, for nations which has already prac-
the hospitals of destination countries as well as travel- ticed medical tourism to improve their quality in medical
ling during healing period clearly have negative impact tourism and aware of ethical concerns that arise from
of patients’ condition and health. Decision making of this practice, as well as for the references of the countries
practicing medical tourism based on cost advantage is which want to practise medical tourism in the future.
thought to be risky and gives bad impact on patients’
health.52 Furthermore, unknown health risks may be ACKNOWLEDGMENTS
exposed to medical tourist that having medical treat- This work was supported by LESTARI Grant Scheme:
ments or services which are illegal in patients’ home 600-RMI/DANA 5/3/LESTARI (42/2015). The
country.39 Study showed that a kidney transplant patient authors would like to express their gratitude to Min-
might contract tuberculosis, pneumonia, HIV, urinary istry of Higher Education and Universiti Teknologi
tract infection, wound infection as well as hepatitis B MARA, Malaysia for financial support for this research.
from kidney transplant procedure through medical tour- The funders had no role in study design, data collection
ism. There are only 69.2% patients with one year average and analysis, decision to publish, or preparation of the
graft survival and 75% of patient’s survival rate based on manuscript.
previous medical tourist having this procedure abroad.53

CONFLICTS OF INTEREST
LIMITATION AND RECOMMENDATIONS
The author declare no conflict of interest.
Apparently, the finding of this review is geographic
restricted to India where the ethical issues discussed are
mainly focusing in this country which may not reflect REFERENCES
the same in other countries like Thailand and China 1. Johnston R, Crooks VA, Ormond M. Policy implications of medical tourism
development in destination countries: revisiting and revising an existing
that practice medical tourism. The review also mainly framework by examining the case of Jamaica. Global Health. 2015;11(1):29.
focuses on motivation which leads to the practice of 2. Chen LH, Wilson ME. Medical tourism. J Travel Med. 2015;22(3):218.
medical tourism, opportunities, risks and the ethical 3. Leggat P. Medical tourism. Aust Fam Physician. 2015;44(1):16-21.
4. Connell J. From medical tourism to transnational health care? An epilogue for
issue associated with medical tourism. Other issues such the future. Soc Sci Med. 2015;124(Jan):398-401.
as types of medical tourists, decision making process, 5. Smith R, Martínez Álvarez M, Chanda R. Medical tourism: a review of
branding, positioning, competitive differentiation are the literature and analysis of a role for bi-lateral trade. Health Policy.

not discussed. Besides, only English written studies are 2011;103(2):276-82.

6. Crooks VA, Turner L, Snyder J, Johnston R, Kingsbury P. Promoting medical
included in this review which has limited the relevant tourism to India: messages, images, and the marketing of international
data from other non-English written studies. patient travel. Social Sci Medicine. 2011;72(5):726-32.

268 Indian Journal of Pharmaceutical Education and Research | Vol 50 | Issue 2 | Apr-Jun, 2016
 Abd Mutalib et al: Review of medical tourism

7. Pocock NS, Phua KH. Medical tourism and policy implications for health 30. Ramskold LA, Posner MP. Commercial surrogacy: how provisions of
systems: a conceptual framework from a comparative study of Thailand, monetary remuneration and powers of international law can prevent
Singapore and Malaysia. Global Health. 2011;7(1):12. exploitation of gestational surrogates. J Med Ethics. 2013;39(6):397-402.
8. Kumar S, Breuing R, Chahal R. Globalization of health care delivery in the 31. Deonandan R, Green S, van Beinum A. Ethical concerns for maternal surro­
United States through medical tourism. J Health Commun. 2012;17(2):177- gacy and reproductive tourism. J Med Ethics. 2012;38(12):742-5.
98. 32. Snyder J, Crooks VA, Adams K, Kingsbury P, Johnston R. The ‘patient’s
9. Smith K. The problematization of medical tourism: a critique of neoliberalism. physician one-step removed’: the evolving roles of medical tourism
Dev World Bioeth. 2012;12(1):1-8. facilitators. J Med Ethics. 2011;37(9):530-4.
10. Guiry M, Scott JJ, Vequist DGt. Experienced and potential medical tourists’ 33. Planning Commission GoI. Eleventh Five-Year Plan 2007–12. Volume II:
service quality expectations. Int J Health Care Qual Assur. 2013;26(5):433- Social Sector. New Delhi: Oxford University Press. 2008.
46. 34. Bhat R. Characteristics of private medical practice in India: a provider
11. Ozan-Rafferty ME, Johnson JA, Shah GH, Kursun A. In the words of the perspective. Health Policy Plan. 1999;14(1):26-37.
medical tourist: an analysis of Internet narratives by health travelers to 35. Hazarika I. Medical tourism: its potential impact on the health workforce and
Turkey. J Med Internet Res. 2014;16(2):e43. health systems in India. Health Policy Plan. 2010;25(3):248-51.
12. Carrera P, Lunt N. A European perspective on medical tourism: the need for 36. De Sutter P. Considerations for clinics and practitioners treating foreign
a knowledge base. Int J Health Serv. 2010;40(3):469-84. patients with assisted reproductive technology: lessons from experiences
13. Carrera PM, Bridges JF. Globalization and healthcare: understanding at Ghent University Hospital, Belgium. Reproductive Biomedicine Online.
health and medical tourism. Expert Rev Pharmacoecon Outcomes Res. 2011;23(5):652-6.
2006;6(4):447-54. 37. Bies W, Zacharia L. Medical tourism: Outsourcing surgery. Mathematical and
14. Douglas N, Derrett R. Special interest tourism: John Wiley and Sons Computer Modelling. 2007;46(7):1144-59.
Australia, Ltd; 2001. 38. Sridhar KS, Reddy AV, Srinath P. Is it push or pull? Recent Evidence from
15. Maheshwari S, Animasahun B, Njokanma O. International patients with Migration into Bangalore, India. J Int Migr Integr. 2013;14(2):287-306.
congenital heart disease: what brings them to India?. Indian Heart J. 39. Crooks VA, Kingsbury P, Snyder J, Johnston R. What is known about the
2012;64(1):50-3. patient’s experience of medical tourism? A scoping review. BMC Health Serv
16. Solomon H. Affective journeys: the emotional structuring of medical tourism Res. 2010;10(1):266.
in India. Anthropology and Medicine. 2011;18(1):105-18. 40. Medhekar A. Indian Government Policy to Support Trade in Medical Tourism
17. Gupta V, Das P. Medical tourism in India. Clinics in laboratory medicine. Services, in Emmett D (ed.), Proceedings of the Seventh International
2012;32(2):321-5. Conference on Healthcare Systems and Global Business Issues, Jaipur
18. Mamun MZ, Andaleeb SS. Prospects and problems of medical tourism National University, Jaipur, India (3-6 Jan 2013),205,209.
in Bangladesh. Int J Health Serv : planning, administration, evaluation. 41. Medhekar A, Australia Q, editors. Indian Government Policy to Support Trade
2013;43(1):123-41. in Medical Tourism Srevices. Message From the Conference Program Chair;
19. Qadeer I, Reddy S. Medical tourism in India: perceptions of physicians in 2013.
tertiary care hospitals. Philosophy, ethics, and humanities in medicine: Philos 42. Abd Manaf NH, Hussin H, Jahn Kassim PN, Alavi R, Dahari Z. Country
Ethics Humanit Med. 2013;8(1):20. perspective on medical tourism: the Malaysian experience. Leadersh Health
20. Finch S. Medical tourism driving health care disparity in Thailand. CMAJ. Serv (Bradf Engl). 2015;28(1):43-56.
2014;186(1):E11. 43. Sultana S, Haque A, Momen A, Yasmin F. Factors Affecting the Attractiveness
21. Oh KM, Jun J, Zhou Q, Kreps G. Korean American women’s perceptions of Medical Tourism Destination: An Empirical Study on India-Review Article.
about physical examinations and cancer screening services offered in Iran J Public Health. 2014;43(7):867-76.
Korea: the influences of medical tourism on Korean Americans. Journal of 44. Malaysia Health Tourism Council. Malaysia Your Healthcare Destination.
community health. 2014;39(2):221-9. Available from [Link]
22. Ormond M, Mun WK, Khoon CC. Medical tourism in Malaysia: how can [Link]. Acessed on 11 May 2015. 2015.
we better identify and manage its advantages and disadvantages?. Global 45. Wikipedia. Incredible India. Avaialble from: [Link]
Health Action. 2014;7(Sep):25201. Incredible_India. Accessed online 10 Dec 2014. 2014.
23. Eissler LA, Casken J. Seeking health care through international medical 46. Lee C, Spisto M, editors. Medical tourism, the future of health services.
tourism. J Nurs Scholarsh. 2013;45(2):177-84. Proceedings of the 12th International Conference on ISO; 2007.
24. Jun J, Oh KM. Framing risks and benefits of medical tourism: a content 47. Turner LG. Quality in health care and globalization of health services:
analysis of medical tourism coverage in korean american community accreditation and regulatory oversight of medical tourism companies. Int J
newspapers. J Health Commun. 2015;20(6):720-7. Qual Health Care. 2010:mzq078.
25. Snyder J, Byambaa T, Johnston R, Crooks VA, Janes C, Ewan M. Outbound 48. Johnston RV, Hudson MF. Travelers’ Thrombosis. Aviat space Environ Med.
medical tourism from Mongolia: a qualitative examination of proposed 2014;85(2):191-94.
domestic health system and policy responses to this trend. BMC Health Serv 49. Iqbal O, Eklof B, Tobu M, Fareed J. Air travel-associated venous
Res. 2015;15(1):187. thromboembolism. Med Princ Pract. 2003;12(2):73-80.
26. Ho KT. Medical tourism: new strategies for the health care industry in Taiwan. 50. Carabello L. A medical tourism primer for US physicians. J Med Pract
J Formos Med Assoc. 2015;114(2):99-101. Manage. 2008;23(5):291-4.
27. Lunt N, Carrera P. Medical tourism: assessing the evidence on treatment 51. Carrera P, Lunt N. A European perspective on medical tourism: the need for
abroad. Maturitas. 2010;66(1):27-32. a knowledge base. 2010;40(3):469-84.
28. Phua KL. Cross-Border Medical Tourism: A Typology and Implications for 52. Idowu EO, Adewole OA. Spectrum of neurosurgical complications following
the Public and Private Medical Care Sectors in the South-East Asian Region medical tourism: challenges of patients without borders. Afr Health Sci.
2010. Available from: [Link]/super4/3301134001/[Link]. 2015;15(1):240-5.
29. Bustamante AV. Globalization and medical tourism: the North American 53. Anker AE, Feeley TH. Estimating the risks of acquiring a kidney abroad: a
experience Comment on “Patient mobility in the global marketplace: a meta-analysis of complications following participation in transplant tourism.
multidisciplinary perspective”. Int J Health Policy Manag. 2014;3(1):47-9. Clin Transplant. 2012;26(3):E232-E41.

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 Abd Mutalib et al: Review of medical tourism

PICTORIAL ABSTRACT SUMMARY

• The pull factors that make patients having medi-
cal treatment, therapy and services abroad are
language familiarity, the need for privacy, quality,
bioethical legislation, food, cultural and tourist
attractions at their destination.
• The push factors includehigh medical therapy
cost required in their own country, long waiting
time or unavailability of the treatment procedures
in home countries
• Affluent medical tourists from countries such as
Indonesia, Brunei, Singapore and Bangladesh also
ABBREVIATIONS USED are likely to practise medical tourism for both pur-
pose of cheaper and reliable medical therapy and
US: United States; CINAHL: Cumulative Index to
tourist vacation.
Nursing and Allied Health Literature; UiTM: Universiti-
Teknologi MARA; CII: Confederation of Indian Industry.

About Authors

Nur Syafiqah Abd Mutalib: A Bachelor of Pharmacy (Honours) student in Faculty of Pharmacy,
UiTM, Malaysia. She is the receiver of scholarship award from Public Service Department of Malay-
sia and Dean List Award from UiTM in her first and seventh semester.

Ms. Esmee Yee SM: A clinical pharmacy academic and practicing pharmacist in Malaysia. She
has more than 5 years of teaching experience in leading Universities and practicing experience in
both hospital and community pharmacy setting in Malaysia. She teaches clinical pharmacy and
pharmacy practice modules and also supervises undergraduate students on research projects. Her
area of research includes quality use of medicines in community and hospital setting, adverse drug
reaction and pharmacy education.

Soh Yee Chang, RPh, BCPS: Has been a clinical pharmacy lecturer at the Universiti Teknologi
MARA (UiTM), Malaysia since 2007. She received a first-class honour degree in Pharmacy from the
University of Malaya, Malaysia in 2005 and earned her Master in Clinical Pharmacy degree from
University of Science, Malaysia in 2009 with scholarship. Prior to joining the Faculty of Pharmacy,
she worked as a clinical pharmacist in Malaysian public hospitals for three years. She led the oncol-
ogy pharmacy team and supported the HIV/AIDS clinic. She is the American Pharmacist Association
certified pharmacotherapy specialist (BCPS) and Good Clinical Practice certified clinical researcher. Her area of
research includes clinical pharmacy, pharmacy practice and pharmacy education. She has published many articles
in international and national reputable journals. She has also received several research grants at international and
national levels.

270 Indian Journal of Pharmaceutical Education and Research | Vol 50 | Issue 2 | Apr-Jun, 2016