Pocock and Phua Globalization and Health 2011, 7:12

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REVIEW Open Access

Medical tourism and policy implications for

health systems: a conceptual framework from a
comparative study of Thailand, Singapore and
Malaysia
Nicola S Pocock* and Kai Hong Phua

Abstract
Medical tourism is a growing phenomenon with policy implications for health systems, particularly of destination
countries. Private actors and governments in Southeast Asia are promoting the medical tourist industry, but the
potential impact on health systems, particularly in terms of equity in access and availability for local consumers, is
unclear. This article presents a conceptual framework that outlines the policy implications of medical tourism’s
growth for health systems, drawing on the cases of Thailand, Singapore and Malaysia, three regional hubs for
medical tourism, via an extensive review of academic and grey literature. Variables for further analysis of the
potential impact of medical tourism on health systems are also identified. The framework can provide a basis for
empirical, in country studies weighing the benefits and disadvantages of medical tourism for health systems. The
policy implications described are of particular relevance for policymakers and industry practitioners in other
Southeast Asian countries with similar health systems where governments have expressed interest in facilitating
the growth of the medical tourist industry. This article calls for a universal definition of medical tourism and
medical tourists to be enunciated, as well as concerted data collection efforts, to be undertaken prior to any
meaningful empirical analysis of medical tourism’s impact on health systems.

Introduction In Southeast Asia, the health sector is expanding

Growing demand for health services is a global phenom- rapidly, attributable to rapid growth of the private sector
enon, linked to economic development that generates ris- and notably, medical tourism, which is emerging as a
ing incomes and education. Demographic change, lucrative business opportunity. Countries here are capita-
especially population ageing and older people’s require- lising on their popularity as tourist destinations by com-
ments for more medical services, coupled with epidemiolo- bining high quality medical services at competitive prices
gical change, i.e. rising incidence of chronic conditions, with tourist packages. Some countries are establishing
also fuel demand for more and better health services. Wait- comparative advantages in service provision based on
ing times and/or the increasing cost of health services at their health system’s organizational structure (table 1).
home, coupled with the availability of cheaper alternatives Thailand has established a niche for cosmetic surgery
in developing countries, has lead new healthcare consu- and sex change operations, whilst Singapore is attracting
mers, or medical tourists, to seek treatment overseas [1]. patients at the high end of the market for advanced treat-
The correspondent growth in the global health service sec- ments like cardiovascular, neurological surgery and stem
tor reflects this demand. The globalisation of healthcare is cell therapy [2]. In Singapore, Malaysia and Thailand
marked by increasing international trade in health products alone, an estimated 2 million medical travellers visited in
and services, strikingly via cross border patient flows. 2006 - 7, earning these countries over US$ 3 billion in
treatment costs (table 2).
Carrera and Bridges (2006) define medical tourism as
* Correspondence: [email protected]
Lee Kuan Yew School of Public Policy, National University of Singapore, 469C “the organized travel outside one’s natural healthcare
Bukit Timah Road, OTH Building, Singapore 259772, Singapore

© 2011 Pocock and Phua; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
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reproduction in any medium, provided the original work is properly cited.
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Table 1 Health systems in comparison [3]

Country Thailand Malaysia Singapore
Organizational Pockets of excellence in some private Growing private health sector with Balanced public-private mix,
structure Bangkok hospitals movement of qualified workforce corporatized public sector

National strategy Regional health hub Industrial strategy to develop tourism Economic growth strategy to develop
biomedical industries
Extensive tourism infrastructure Regional service hub
Medical R&D support

Policy impact Issues of growing inequity and urban- Public-private divide Narrow income gaps of public and
rural divide private sectors
Racial inequities between public and private
sectors

jurisdiction for the enhancement or restoration of the inexpensive air travel to reach destination medical [9].
individual’s health through medical intervention”, using The impact of medical tourism on health systems is as
but not limited to invasive technology. The authors yet unknown due to a dearth of data and empirical ana-
define medical tourism as a subset of health tourism, lysis of the phenomenon.
whose broader definition involves “the organized travel Governments are noticeably playing a strong market-
outside one’s local environment for the maintenance, ing and promotional role in the emerging medical tour-
enhancement or restoration of the individual’s wellbeing ism industry. This is a clear trend in Southeast Asia,
in mind and body”. Importantly, their definition of med- especially in Thailand, Singapore and Malaysia, the main
ical tourism takes into account the territorially bounded regional hubs for medical tourism, where medical tourist
nature of health systems, where access to healthcare is visas are available and government agencies have been
often but not always limited to national boundaries [6]. established with the mandate to increase medical tourist
Medical tourism constitutes an individual solution to inflows [10]. Governments in Indonesia, the Philippines
what is traditionally considered a public (government) and Vietnam have also expressed interest in promoting
concern, health for its citizens, who at the micro level the industry. The potential economic benefits of medical
are responding to market incentives by seeking lower tourism make it an attractive option for governments.
cost and/or high quality care overseas that cannot be Medical tourism can contribute to wider economic
found at home. These tourists may be uninsured or development, which is strongly correlated with improved
underinsured. Travelling overseas for medical care has population health status as a whole, e.g. increased life
historical roots, previously limited to elites from devel- expectancy, reduced child mortality rates [11]. Encoura-
oping countries to developed ones, when health care ging foreign direct investment in healthcare infrastruc-
was inadequate or unavailable at home. Now however, ture and medical tourist inflows with correspondent
the direction of medical travel is changing towards revenue can create additional resources for investment
developing countries [7], and globalization and increas- in health care [12]. Furthermore, medical tourism may
ing acceptance of health services as a market commodity slow or reverse the outmigration of health workers, par-
[8] have lead to a new trend; organized medical tourism ticularly of specialists [13].
for fee paying patients, regardless of citizenship, who However, health systems in some of these countries
shop for health services overseas using new information face challenges in ensuring basic health service coverage
sources, new agents to connect them to providers, and for their own citizens [3]. Two tier healthcare provision

Table 2 Export of health services [2,4,5]

Estimated No. foreign Origin of patients Specialty
earnings patients (in order of volume)
Thailand Baht 36 billion 1.4 million Japan, USA, South Asia, UK, Middle East, Cosmetic and sex change surgery
(2006) (US$ 1.1 billion) ASEAN countries
Singapore S$ 1.7 billion 571 000 Indonesia, Malaysia, Middle East Cardiac and neuro surgery, joint replacements,
(2007) (US$ 1.2 billion) liver transplants
Malaysia 253.84 million 341 288 Indonesia, Singapore, Japan, India, Europe Cardiac and cosmetic surgery
(2007) MYR
(US$78 million)
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has emerged in Malaysia, with private services limited to facilitating the growth of the medical tourist industry.
those who can afford it and public services for the rest Bridging the social science disciplines, the public policy
of the population [14]. Thailand’s public to private approach to research is a pragmatic one, with the end
health worker brain drain has strained public health goal of translating research into useful policy recom-
provision, especially in rural areas [15,16]. Trade in mendations, in this instance those that optimise the
medical supplies, organs, pharmaceuticals and health benefits of medical tourism for both foreign and local
worker migration have dominated policy debates about consumers and mitigate the risks. Research methodol-
the impact on health systems in developing countries, ogy is outlined below, followed by the policy implica-
including concerns about intellectual property rights tions of medical tourism for health systems at their
and access to affordable drugs, the latest medical tech- governance, delivery, financing, human resources and
nology, and retaining doctors and nurses within the regulation functions [32,33]. The conclusion empha-
public sector and/or within the country’s health system sizes the need for concerted data collection efforts and
at all. There are growing concerns about the impact of identifies variables for further analysis of medical tour-
medical tourism on health systems, particularly equity of ism’s potential impact on health systems.
access for both foreign and local consumers [17].
Inequities at home, either by low quality services and/or Research methodology
inability to pay, prompt people to seek cheaper and high Media reports on the medical tourism industry and parti-
quality care treatment overseas. As Blouin (2010) con- cipation in regional conferences enabled the researchers to
tends, a policy question that remains unanswered is pinpoint Singapore, Thailand and Malaysia as the three
whether medical tourism can improve the capacity of main hubs for medical tourism in Southeast Asia for com-
poor people in developing countries to access health parative analysis. Broadly, there are four types of compara-
services. She calls for the exploration of policy mechan- tive health policy analyses. The first constitute descriptive
isms that mitigate the risks associated with medical studies, with no hypothesis or testing of explanations on
tourism, whilst harnessing the potential benefits, for why patterns exist, leaving policy explanations implicit for
local consumers [18]. the reader to gauge. The second include collections of
In the academic literature, conceptual analyses of medi- international case studies with some assessment of perfor-
cal tourism have emerged from a tourism management mance, whilst the third type includes studies employing a
perspective, analysing supply and demand factors [19-22], common framework for analysis (e.g. privatization). The
and as a node in the trade in health perspective [10,23-26]. fourth type of cross national studies are those that show a
Legal literature is beginning to cover patient liability issues fundamental theoretical orientation, with a specific theme
when surgery is carried out overseas [27]. Recent work has or question as a focus of analysis (Marmor et al 2005:
begun to analyse medical tourism and its potential impact 341 - 2) [34]. We decided to undertake this fourth type of
on health systems in specific countries [1,28,29]. Yet not comparative analysis, in order to generate a conceptual
all health systems functions are analysed in these accounts. framework that could be usefully employed by policy-
A core concern is whether medical tourism diverts makers to understand the policy implications of medical
resources from public components of health systems in tourism on health systems with similar structures. Meth-
destination countries [30]. Furthermore, conceptual frame- ods employed focussed on conceptualising rather than
works in the health systems literature focus on the impact describing, where one or more new concepts are devel-
of targeted, vertical interventions in health systems [31]. oped to explain what is being studied [35]. An inductive,
But medical tourism is a phenomenon rather than an theory building approach [36] is appropriate to examine
intervention; its policy implications have yet to be consid- medical tourism where knowledge is far lacking, especially
ered within the context of a health system. in relation to health systems.
This paper presents a conceptual framework of medi- An initial informal literature scan using the search cri-
cal tourism and policy implications for health systems teria “medical tourism AND Asia” in google scholar
in Southeast Asia, drawing on the cases of Thailand, revealed a lack of data and authoritative sources on medi-
Singapore and Malaysia, via an extensive review of the cal tourism, particularly figures for number of patients
academic and grey literature, as well as insights from and estimated earnings. Academic literature was searched
health consultancies in the public and private sectors exhaustively in the PubMed and Social Science Research
across the region. This framework provides a basis for Network databases using the search criteria “medical
more detailed country specific studies on the benefits tourism AND Asia” (92) and “medical travel AND Asia”
and disadvantages of medical tourism, of special rele- (806), generating a range of mostly conceptual research.
vance for policymakers and industry practitioners in Abstracts were scanned for reference to Thailand, Singa-
other Southeast Asian countries with similar health pore and Malaysia and/or reference to health systems in
systems where governments have expressed interest in general. Additional articles were located using the
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reference list of selected articles. Study selection was not and regulation) remain nationally bounded. Additionally,
systematic; no article was omitted but considered in the trade objectives of increased liberalisation, less govern-
context of health systems/medical tourism in Asia (43). ment intervention and economic growth generally do not
Articles gathered were then categorised according to emphasize equity, whereas health sector objectives like
content focus (e.g. privatisation of health systems, medi- universal coverage do. Consequently, actors in the trade
cal tourism empirical evidence, health and trade nexus). and health policy spheres tend to have conflicting objec-
Following categorisation, all articles were analysed to tives, and trade and health governance processes remain
identify medical tourism interaction points across the relatively separate at three levels; the international
health system functions, with new material continually (World Trade Organisation (WTO) and World Health
brought into the analysis. Concurrent to the theory build- Organisation (WHO)), regional (Association of South
ing process, quantitative data on the nature of health sys- East Asian Nations (ASEAN)) and national (government
tems in the three study countries were retrieved from ministries). Reconciling the aims of economic growth
official country sources and the World Health Organiza- with equitable health service provision and access makes
tion. These data were triangulated with the academic lit- governance of medical tourism within a country’s health
erature to validate claims made about the nature of system challenging at best and contradictory at worst.
health systems. This data also enabled the researchers to At the international level, there are clear tensions
make systematic comparisons between the three country between the goals of protecting and promoting health
health systems. Following this step, grey literature were and generating wealth through trade [23]. Trade and
searched using the above search criteria in Factiva, a health policy negotiations occur in isolation, despite the
news item database, to provide examples of recent devel- growing importance of the trade and health nexus at the
opments in the medical tourist industry in the three global level, e.g. extensive health worker migration and
study countries. Other grey literature sources included cross border consumption of health services (medical
management consultancy research reports, working tourism) [10,23]. WTO membership requires adherence
papers on medical tourism, and medical tourism industry to a multitude of legally binding obligations, including
player’s statistics and promotional materials. Subsequent removal of tariff and non tariffs barriers on goods and
to analysis and identification of the conceptual frame- services. The WTO’s formal governance architecture is
work, potential policy options were outlined based on the embodied in its legally binding trade agreements and
literature and/or innovative examples of comparative compulsory legal dispute mechanism. These legal appara-
health policy responses in the region. We anticipated that tus afford it more compliance clout than the WHO,
the different nature of health systems (e.g. mostly public which by contrast is an advocacy organization. The
versus private delivery) would also generate differential WHO imposes no legal obligations on members, relies
policy implications according to local context. In the on non binding agreements, and has no compulsory dis-
course of our comparative analysis, we found this to be pute mechanism. Thus enforcement capacity in cases of
the case to a large extent; however, medical tourism non compliance to WHO agreements is limited [23].
poses potential risks and benefits regardless of the cur- Economic growth and trade considerations are likely to
rent nature of a health system. As a phenomenon, it can surpass health objectives at the global level when coun-
fundamentally change the nature of health systems them- tries face sanctions or legally punitive measures for non
selves without policy intervention (e.g. shift towards a compliance with trade agreements. Examples of trade
dominantly private hospital sector). Thus, the policy and health policy incoherence include patents on essen-
implications described are broadly applicable to health tial medicines and tobacco promotion in developing
systems in general, but of particular relevance to policy- countries, permitted by trade agreements [37].
makers and industry practitioners in other Southeast Whilst most trade in health services takes place outside
Asian countries where governments have expressed an the framework of existing trade agreements, whether
interest in developing the medical tourist industry. bilateral or multilateral [25], trade in health services
including medical tourism is officially provisioned for
Results under the General Agreement on Trade in Services
Governance in separate domains of trade and health (GATS). The four modes of supply include; 1. The cross
Medical tourism straddles the policy domains of trade border supply of services (remote service provision, e.g.
and health. Its rise is situated within the rapid growth of telemedicine, diagnostics, medical transcriptions), 2.
trade in health services, driven by increased international Consumption of services abroad (medical tourism, medi-
mobility of service providers and patients, advances in cal and nursing education for overseas students) 3. For-
information technologies and communications, and an eign direct investment (e.g. foreign ownership of health
expanding private health sector [10]. Trade by definition facilities) and 4. Movement of health professionals [7].
is international, but health systems (financing, delivery Countries can choose to make GATs commitments
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(which legally bind them to open markets under the aus- profits can be made in the health sector of other coun-
pices and protection of the WTO) sectorally or via a spe- tries, with profits accruing to shareholders overseas and
cific mode. In ASEAN, only Cambodia, Malaysia and few benefits for local consumers, unless profits are taxed
Vietnam have made GATs commitments relevant to the and reinvested in the destination health system. The sub-
health sector [38]. Medical tourism is becoming bureau- stantive economic capacity of these regional players
cratized, formalized and normalized [17] evidenced by means that health policy aims, like universal access to
GATs provisions for the health sector. In the context of healthcare, are likely to come secondary to trade policy
increasing cross border trade in health services, govern- aims, like increasing foreign investment that can be
ments have the option to either schedule GATs commit- gained from medical tourism.
ments in health or continue to trade outside of formal Trade and health policy incoherence in promoting both
agreements. With rapidly changing domestic and interna- medical tourism and universal coverage for local consu-
tional health markets, the latter looks likely, but it is mers at the national level is evident. Whilst several stu-
worth noting that GATS commitments can also limit the dies on medical tourism allude to government’s role in
degree to which foreign providers can operate in the promoting medical tourism [8,16,21], these do not differ-
market [39]. In policy terms, this clause can protect entiate between the role of different government minis-
health systems from monopolization by foreign investors tries and their respective policy aims. Trade and tourism
in the health sector. ministries are primarily concerned with increasing eco-
Regionally, trade also tends to trump health in terms of nomic growth and facilitating international trade in the
policy action. ASEAN is primarily a trade forum, and the services sector. In contrast, a health ministry’s aim is to
1995 ASEAN Framework on Agreement on Trade in Ser- improve overall population health and ensure equity in
vices (AFAS) makes provisions for services liberalisation health service access and delivery. Health systems are
between members beyond the WTO GATs. Unlike the also nationally bounded; maximising scarce public
WTO, ASEAN has no legal authority to enforce compli- resources for health within given territorial constraints
ance, but a dispute settlement mechanism was recently gives rise to healthcare protectionism by governments,
signed. Whilst the health sector is not covered under the typified by strict eligibility requirements for access to
AFAS, it is envisioned that the free flow of all goods, ser- state subsidised services by migrants. Whilst expansionist
vices, investments, capital and skilled labour will be medical tourism policies had been initiated in trade and
achieved to create an ASEAN Economic Community tourism ministries of all three countries, there appears to
(AEC) by 2020 [40,41]. The ASEAN Economic Commu- be a spill over effect on ministries of health (MOH).
nity (AEC) council meets bi annually to work towards Increasingly, MOH’s are establishing medical tourism
deepening and broadening regional economic integration. committees and departments, dedicated to the promotion
In contrast, the ASEAN Health Minister’s Meeting of their respective countries’ health facilities to other gov-
(AHMM) is held every two years. Currently, ASEAN ernments/foreign patients. For example, Thailand’s medi-
health cooperation is limited to disaster preparedness for cal hub policy was initiated in 2003 by the government
natural disasters and infectious disease outbreaks. Agree- agency the Thailand Board of Investment, whilst the
ments in health are limited to sanitary and phytosanitary Ministries of Commerce, Department of Export Promo-
measures, bar a non legally binding Mutual Recognition tion and the MOH in collaboration with private hospitals
Agreement (MRA) on the movement of health profes- are now the main implementers of the policy [15]. Whilst
sionals. The ASEAN Work Plan on Health Development Malaysia’s national health plan does not mention medical
(2010 - 2015) was finalised in July 2010 to cover broader tourism as a strategic aim [45], the MOH formed an
regional health issues, including non communicable dis- inter-ministerial committee for the promotion of medical
eases, maternal and child health and primary health care and health tourism (MNCPHT) in 2003 [28]. Of the
[42,43]. Despite ASEAN’s regional economic and health three countries, Singapore’s government agencies have
integration, there have been no agreements signed con- the most integrated policy stances that strongly support
cerning the medical tourism industry. Foreign direct medical tourism [2], reflective of the country’s prioritisa-
investment by regional players in neighbouring countries tion of economic growth. Singapore’s Tourism Board, the
is accelerating, with private companies like Singapore’s Ministry of Trade and Industry’s Economic Development
Parkway Holdings (one of the largest hospital operators Board and the MOH have set a target to attract 1 million
in Asia) and the Raffles medical group acquiring hospitals foreign patients by 2012 [46], whilst one of the MOH’s
in Singapore, Malaysia, Brunei, India and China [26]. explicit priorities is to “exploit the (country’s) economic
Malaysia’s state investment company Khazanah’s $2.6 bil- value as a regional medical hub” [47]. In 2004, a multia-
lion bid in Parkway Holdings in 2010 gave it a 95% stake gency government initiative (including the MOH) Singa-
in the company [44]. Foreign investment by both private poreMedicine was launched with the aim of developing
and state investment companies implies that significant Singapore as a medical hub. Whilst trade and tourism
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and health ministry objectives are not easily reconciled, poor as this group cannot afford private care, leading to
medical tourism growth provides an opportunity for inter the development of a two tier healthcare system seen in
ministry policy coordination, e.g. via a cross subsidization Thailand and Malaysia [14,51]. Public services are gener-
mechanism whereby medical tourist revenues are taxed, ally perceived to be of low quality or unresponsive in this
providing extra income for public hospitals. In the three region by local consumers [5052]. The steady growth of
countries, an apparent convergence in trade, tourism and private sector hospitals has mirrored the increase in
health ministry priorities is taking place, reflective of medical tourism (tables 2 and 3).
growing acceptance of health as a private good globally. The link between a growing private, for profit sector
Improved data collection on medical tourist flows and that caters to medical tourists and access to such services
health systems use and access by local consumers are by local consumers without the ability to pay is elusive.
necessary to assess whether policies that promote medi- Private ownership of health facilities means that benefits
cal tourism and universal coverage are reconcilable. Pre- accrued (profits from service fees for foreign patients) are
emptively, government ministries should work towards remitted offshore to companies based in different coun-
more integrated governance of medical tourism, espe- tries who are investing in private hospital chains across
cially given the highly privatised health system landscape Southeast Asia. For example, the recent Fortis-Parkway
and existing inequities in health systems use and access merger of the second largest Indian healthcare group
by local consumers, which could be aggravated by foreign with the largest private Singapore-Malaysia group created
patient inflows. the largest hospital chain in Asia. Parkway’s subsequent
take-over bid by Malaysia’s state investment company
Delivery in private versus public sector Khazanah, means that profits accrued are remitted to
Medical tourism is driven by the for profit private sector Malaysia for health services rendered in Singapore and
in health systems. The private sector dominates primary India. Purchase of costly technology that doesn’t have a
care provision in Singapore and Malaysia, but is slowly wider social benefit for the procedures that medical tour-
expanding its role in tertiary hospital care. Private pri- ists demand has raised concerns about “crowding out”
mary care providers are concentrated in urban areas, local consumption of high technology procedures [12].
with public primary care providers catering to those in Furthermore, government subsidies for private sector
rural areas, as seen in Thailand and Malaysia [14,48]. growth, via tax breaks and preferential access to land, is
Hospital services are dominated by the public sector, unlikely to benefit the health system at large nor facilitate
with a 70 - 80% share of beds (table 3) but private hospi- broader public health goals (universal coverage) if private
tal providers are steadily growing. In Thailand, private hospitals cater to larger shares of fee paying, foreign
hospital numbers have hovered consistently at 30% of patients. This can be seen in Malaysia, where tax incen-
total hospitals between 1994 and 2006 [48]. In Singapore, tives are available for building hospitals (industry build-
private sector hospital growth has risen in proportion ing allowance), using medical equipment, staff training
with public sector hospital growth between 1998 and and service promotion (deductions on expenses incurred)
2008 [49]. Private hospitals are smaller in size and tend [8]. Private sector growth in health is implicitly encour-
to be located in urban areas, serving middle to high aged via these benefits, at the same time as government
income patients as well as foreign patients [50]. In gen- construction of new hospitals has stalled due to alleged
eral, the public private mix of healthcare provision in this insufficient public funds [56].
region reflects the country’s level of economic develop- Medical tourism is emerging in public sector hospitals
ment. During economic growth periods, wealthier popu- at the same time as it is being driven by the private sec-
lations have emerged with demand for private providers tor, notably in corporatized (public) hospitals. Corpora-
in response to perceived lower quality public provision. tization of hospitals in Singapore since 1985 granted
Consequently the public sector has become more pro hospitals greater autonomy and exposure to market

Table 3 Public versus private health provision [49,53-55]

Hospitals Beds Beds per 1000 population Primary care clinics
Public (%) Private (%) Public (%) Private (%) Public Private
Thailand 67.9% 32.1% 69.3% 30.7% 2.2 80.5% 19.5%
(2007) (2006) (2006) (2006) (2002) (2007) (2006)
Singapore 63.6% 36.4% (2009) 80.6% 19.4% 3.2 1.5% 98.5%
(2009) (2009) (2009) (2007) (2005) (2005)
Malaysia 40.6% 59.4% 77.9% 22.1% 1.8 32.1% 67.9%
(2008) (2008) (2008) (2008) (2007) (2008) (2008)
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competition under government ownership, with the aim has slowly been declining whilst private health expenditure
of lowering costs and improving service quality [57]. All has increased [28]. The Thai government spent almost
public hospitals in Singapore are Joint Commission double the amount on health as a percentage of total gov-
International (JCI) accredited [58]. Given that these hos- ernment expenditure (14.1%) compared to Singapore
pitals are publicly owned, revenues accruing to medical (8.2%) and Malaysia (6.9%) in 2008 [53]. As table 4 shows,
tourism are taxable and thus profits can be reinvested the Thai government contributes the majority of total
back into the public health system by the government. health spending (75.1%), in contrast to Malaysia and Sin-
In Malaysia and Thailand, some public hospitals are gapore, where private health spending surpasses govern-
allowing their surgeons to operate a private wing for ment health spending. Although both Singapore and
private patients, including medical tourists. This policy Malaysia in theory offer 100% population coverage, high
move could incentivise surgeons to treat the additional out of pocket payments (OPPs) suggest effective coverage
fee paying foreign patients over local consumers, when is less than this [52]. Both countries are encouraging
public health resources are already strained in those greater use of individual financing instruments to pay pro-
countries. viders, in addition to compulsory state insurance schemes
The majority of medical tourists in Southeast Asia hail (Medishield in Singapore) or taxation (Malaysia). These
from neighbouring countries, reflecting inequities in ser- include medical savings accounts (Medisave in Singapore,
vice provision at home, either via unavailability of quality Employee Provident Fund Account 2 in Malaysia) [60]
services or underinsurance. In Singapore and Malaysia, and widespread private insurance. Thailand is the excep-
most medical tourists are from ASEAN countries, whilst tion, where the government’s commitment to enrolling
Thailand’s consumers are often from outside the region, the population in its universal social insurance scheme
with the Japanese accounting for the largest share of for- means that government investment in health has risen
eign patients (table 2) [50]. Indonesians travel to Singapore since 2002 [56,61,62].
and Malaysia for medical treatment, whilst Cambodians The most regressive financing mechanism, out of pocket
cross the border to Vietnam for higher quality health ser- payments (OPPs), dominates private health spending in all
vices. Low quality public and private health provision at three countries. More OPPs for services leads to more
home forces them to leave for overseas treatment. Cost is competition in private healthcare markets, as providers are
a factor, but Malaysian, Singaporean and Thai hospitals more likely to compete for patients based on price, espe-
offer specialised services unavailable in other, especially cially given the price transparency made possible by the
poorer, ASEAN countries [2,50]. The policy implications internet. Medical tourist payments are dominated by
go beyond the potential to crowd out consumption by OPPs, but these payments are becoming more organized
locals. As Chee (2010) points out, when middle class fee as part of insurance coverage. For example, since March
paying patients decide to undertake treatment abroad, 2010 Singapore’s Medisave can be used for elective hospi-
their domestic health systems lose out, not only financially talizations and day surgeries in hospitals of two partner
but in terms of the political pressure that these potential providers in Malaysia, Health Management International
consumers could exert to improve the health system that and Parkway Holdings [63]. Deloitte’s 2009 medical tour-
poorer consumers rely upon [28]. The possibility to “exit” ism industry report highlighted four US health insurers
low quality health systems gives the middle class little who are piloting health plans that permit reimbursement
incentive to exert pressure for quality improvement [59]. of elective procedure overseas in Thailand, India and Mex-
Policy options that raise quality standards and minimize ico [64]. The trend of insurance companies and employers
quality differentials, both within and between countries in turning to foreign medical providers to reduce costs looks
Southeast Asia, would benefit both foreign and local con- set to continue as the medical tourism industry grows [29].
sumers. These include public private linkages via profes- One policy implication of the increase in medical tour-
sional exchanges, joint training initiatives, shared use of ists on health financing is that differential pricing for for-
facilities between public and private providers to maximise eign patients could drive up costs of services for local
resource use, telemedicine, and use of complementary/ consumers over time. Redistributive financing mechanisms
specialised treatments [1,12]. may offset these increases. Policy options include taxing
medical tourist revenues to be reinvested in the public
Healthcare financing and consumerism health system [12], expanding financing instruments that
Consumer driven healthcare is becoming the normalised do not tie access to ability to pay (taxation, social insur-
globally and in this region, partly encouraged by govern- ance) and mandating private providers to participate in
ments and the private sector seeking to shift responsibility schemes that provide coverage to local consumers. Private
for one’s health to the individual in response to rising hospitals could provide services to a specified percentage
healthcare costs and demand for services. Singapore and of foreign patients and local consumers enrolled in state
Malaysia exemplify this trend, as public health expenditure schemes, or provide certain specialist treatment for locals
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Table 4 Health expenditure [53]

Total health Government Government health Private Out of pocket Private prepaid
expenditure as % expenditure on health expenditure as % of expenditure as expenditure as a plans as a % of
of Gross Domestic as % of total total health a % of total % of private private health
Product (2008) government expenditure (2008) health health expenditure expenditure
expenditure (2008) expenditure (2008) (2008)
(2008)
Thailand 4.0% 14.1% 75.1% 24.9% 71.1% 20.9%
Singapore 3.4% 8.2% 35.0% 65.0% 93.9% 2.8%
Malaysia 4.3% 6.9% 44.1% 55.9% 73.2% 14.4%

(depending on a centre’s area of clinical expertise). The reputable universities overseas. Thailand’s Mahidol uni-
need for such policies is pressing when, for example, pri- versity nursing department has established links with
vate hospitals treating foreign patients in Thailand cur- nursing schools in Sweden, Canada, Australia, Korea,
rently do not participate in social health insurance the UK and the USA to facilitate student and teaching
schemes, which covered 98% of the population in 2009 exchanges. Singapore’s National University recently
[25,52,65]. opened a graduate medical school with Duke university
in the USA, and Malaysia’s Sunway university medical
Human resources and specialists school trains students in partnership with Monash uni-
Health worker shortages persist to varying degrees in versity in Australia. Such partnerships facilitate capacity
Southeast Asia, at the same time as demand for health building in human resources for health, as well as access
services from foreign patients is rising. Whilst all three to new markets for universities overseas. Importantly,
countries have health worker densities above the WHO these partnerships signal quality of human resources,
critical threshold of 2.28 health workers per 1000 popula- crucial to the promotion of medical tourism [17].
tion, all countries face pressures to supply trained health Developing the medical tourism industry can be seen as
workers to meet population health needs [66,67]. There a tactic to reduce international emigration of health work-
are low doctor-to-patient ratios in Thailand and Malaysia ers, particularly of specialists. Anecdotal evidence from
(table 5), as well as continual outmigration of doctors Thailand indicates that medical graduates, having acquired
from Singapore and Malaysia. Within ASEAN, these two specialised medical degrees abroad, are finding it lucrative
countries record the highest levels of doctor outmigra- and more satisfying to stay in their home country [2]. Poli-
tion to OECD countries [68]. International outmigration ticians in Singapore have reasoned that in order to recruit
from Thailand is low, but intra-country migration from and retain specialists in a country with a small local popu-
rural to urban areas and maldistribution of health work- lation, that the country must attract a high volume of
ers is common [15,16]. In response to shortages, Singa- medical tourists. However, within countries, the growth of
pore has been able to attract health workers from the medical tourism may exacerbate public to private sector
Philippines and Malaysia. In Thailand, health workers brain drain, notably of specialists who provide elective sur-
must pass medical exams in Thai, limiting potential for geries demanded by foreign patients. Whilst the propor-
physician immigration to the country. Whilst the foreign tion of doctors working in the public sector is higher than
medical workforce inflow to Malaysia has been substan- in the private sector in medical tourist countries (table 5),
tial, this has been insufficient to offset the outflow of dual practice, whereby doctors combine salaried, public
Malaysian doctors to other countries [25]. sector clinical work with fee for service private clientele
Rising demand for health services in the region has [70], is common amongst specialists in Thailand and
precipitated the growth in private medical and nursing Malaysia. Retaining public sector specialists has become a
schools across Southeast Asia and correspondent rise in challenge with the prospect of higher salaries and lower
trained health workers. Public and private medical workloads in the private sector. Singapore has managed to
schools in the region are establishing partnerships with maintain competitive public sector salaries, but in

Table 5 Human resources for health [49,53,69]

Doctors per 1000 population Doctors Nurses per 1000 population Nurses
Public (%) Private (%) Public (%) Private (%)
Thailand 0.4 (2000) 78.4% (2005) 21.6% (2005) 2.8 (2000) 87.8% (2005) 12.2% (2005)
Singapore 1.5 (2003) 54.8% (2009) 45.2% (2009) 4.5 (2003) 68.5% (2009) 31.5% (2009)
Malaysia 0.7 (2002) 60.1% (2008) 39.9% (2008) 1.8 (2002) 71.2% (2008) 28.8% (2008)
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Thailand and Malaysia, with larger public - private pay dis- worldwide. Of the three profiled countries, Singapore
crepancies, medical tourism has the potential to further has the highest number of JCI accredited providers
incentivise specialists to shift to the private sector. (18), followed by Thailand (13) and Malaysia (7) [58].
Evidence from Thailand suggests that medical tourism is JCI accreditation is an important quality signal to
not negatively impacting the health system by pulling doc- attract medical tourists, but this process is voluntary.
tors from rural areas. Rather, specialists from teaching The differing quality accreditation channels at the
hospitals in urban areas are shifting to private hospitals national (private hospital associations vs. MOH) and
catering to foreign patients [67,71]. All three countries international levels may lead to inequitable quality
have a high number of doctors with specialty training e.g. standards between the public and private sectors,
77.5% in Thailand in 2006, [48]. But these specialists are whereby private hospital standards surpass those in
concentrated in the private sector; in Malaysia, only 25 - public hospitals, reflective of the current situation in
30% of specialists work in the public sector [72]. Singapore low to middle income countries in Southeast Asia. This
is the exception, where 65% of specialists are in the public has implications for the quality of care received by
sector [73]. The type of surgery matters; for local consu- local consumers without the ability to pay for private
mers seeking specialist, essential surgery (e.g. cardiac, services, and the potential divergence of health out-
transplantation procedures), paying to see a specialist in a comes between private fee paying patients (foreign and
private hospital may be the only option. High quality, spe- local) and those that can’t afford such services. Malay-
cialised care is typically provided in private hospitals and sia’s Society for Quality in Health (MSQH), a joint reg-
can only be afforded by middle to high income patients ulatory body launched by the Ministry of Health,
[50]. Association of Private Hospitals of Malaysia and the
Medical tourism could exacerbate already endemic pub- Malaysian Medical Association, was recently awarded
lic to private brain drain in the region. A related concern international accreditation by the ISQua on par with
in Thailand is that medical education is largely publicly JCI. As the MSQH covers both public and private hos-
funded; private hospitals do not share the costs of such pitals, this kind of international standard setting for
education, yet hire from the same pool of graduates as the both sectors could provide a regulatory template for
public sector [50]. Policy options to mitigate internal brain other countries pursuing medical tourism, in order to
drain include instituting capitation payments for health ensure that both local and foreign consumers enjoy
costs and standard fees for doctors, regardless of whether similar quality standards. Policy options include com-
a patient is local or foreign. Offering higher salaries in the mon standards for public and private providers [1]
public sector and bonding publicly funded graduates are regulated by government, as well as compulsory JCI
options for governments (all three countries bond their accreditation for hospitals catering to medical tourists.
graduates for between 3 to 5 years). Dual practice of spe- New brokers that arise between hospitals and patients
cialists could be allowed but regulated, so that specialists are proliferating rapidly. These agencies are located in
dedicate a specified amount of time to treat local consu- developed and developing countries, connecting prospec-
mers. When public funds are used to train specialists who tive patients to providers via the internet. As yet, the medi-
then shift to the private sector (potentially to treat medical cal brokerage industry has no codes of conduct, and the
tourists), redistributive government regulations like paying lack of medical training of brokers raises questions about
a fee to leave the public sector (Thailand) may plug a how these new actors evaluate quality of care when choos-
short term financial resource gap, but recruitment and ing which facilities to promote to prospective patients.
retention is a persistent problem in this region. There are also no explicit formal standards when estab-
lishing referral networks, which could be open to abuse, e.
Regulation of quality control and new actors g. financial incentives for brokers from providers to pro-
Private hospitals in the three countries are accredited via mote facilities) [17]. Regulating medical tourist brokers
different channels, leading to differing quality standards should be a policy priority in both source and destination
between public and private hospitals. Private hospital asso- countries.
ciations encourage industry self regulation, whereas public
hospitals are regulated by the MOH or quasi governmen- Discussion and directions for future research
tal bodies. For example, publicly owned corporatized hos- Based on the health systems functions of governance,
pitals in Singapore operate with autonomy in a delivery, financing, human resources and regulation
competitive environment, but government ownership [32,33], the conceptual framework (Figure 1) aims to
allows them to shape hospital behaviour without cumber- provide a basis for further empirical studies weighing
some regulation [74]. the benefits and disadvantages of medical tourism for
Joint Commission International (JCI) is the most health systems, of particular relevance to countries in
established medical tourist industry accreditor Southeast Asia.
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The framework facilitated the identification of the private sectors, number of specialists treating foreign
following variables for empirical analysis: patients.
Governance: the number and content of GATs health Regulation: number of JCI accredited hospitals, num-
sector commitments, the number and size of medical ber of medical tourist visits facilitated by brokers.
tourist government committees or agencies, availability At present there is an acute lack of reliable empirical data
of medical tourist visa. concerning medical tourist flows. Most urgently, a universal
Delivery: number of hospitals in public and private definition of who counts as a medical tourist (e.g. per pro-
sector treating foreign patients, consumption of health cedure or per inpatient) should be agreed on, ideally at the
services by domestic and foreign population (hospital international (WHO) or regional level (amongst Ministries
admissions). of Health, Trade, Tourism and private hospital associa-
Financing: medical tourist revenues, type of medical tions). Variation in definitions and estimates amongst the
tourist payment (service fee or insurance, level of copay- three study countries alone are significant. Singapore’s
ment), foreign direct investment in the health sector. Tourism Board estimates medical tourist inflows based on
Human resources: doctor and nurse ratios per 1000 tourist exit interviews with a small sample population,
population, proportion of specialists in the public and whilst the Association of Private Hospitals in Malaysia

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Figure 1 Conceptual framework for medical tourism and policy implications for health systems.
Pocock and Phua Globalization and Health 2011, 7:12 Page 11 of 12
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collects data only from member hospitals and includes all References
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