"Medical tourism will obligate physicians to elevate their level so that they can compete": a qualitative exploration of the anticipated impacts of inbound medical tourism on health human resources in Guatemala.

BACKGROUND: Medical tourism, which involves cross-border travel to access private, non-emergency medical interventions, is growing in many Latin American Caribbean countries. The commodification and export of private health services is often promoted due to perceived economic benefits. Research indicates growing concern for health inequities caused by medical tourism, which includes its impact on health human resources, yet little research addresses the impacts of medical tourism on health human resources in destination countries and the subsequent impacts for health equity. To address this gap, we use a case study approach to identify anticipated impacts of medical tourism sector development on health human resources and the implications for health equity in Guatemala. METHODS: After undertaking an extensive review of media and policy discussions in Guatemala's medical tourism sector and site visits observing first-hand the complex dynamics of this sector, in-depth key informant interviews were conducted with 50 purposefully selected medical tourism stakeholders in representing five key sectors: public health care, private health care, health human resources, civil society, and government. Participants were identified using multiple recruitment methods. Interviews were transcribed in English. Transcripts were reviewed to identify emerging themes and were coded accordingly. The coding scheme was tested for integrity and thematic analysis ensued. Data were analysed thematically. RESULTS: Findings revealed five areas of concern that relate to Guatemala's nascent medical tourism sector development and its anticipated impacts on health human resources: the impetus to meet international training and practice standards; opportunities and demand for English language training and competency among health workers; health worker migration from public to private sector; job creation and labour market augmentation as a result of medical tourism; and the demand for specialist care. These thematic areas present opportunities and challenges for health workers and the health care system. CONCLUSION: From a health equity perspective, the results question the responsibility of Guatemala's medical education system for supporting an enhanced medical tourism sector, particularly with an increasing focus on the demand for private clinics, specific specialities, English-language training, and international standards. Further, significant health inequalities and barriers to care for Indigenous populations are unlikely to benefit from the impacts identified from participants, as is true for rural-urban and public-private health human resource migration.

Cross-border spatial accessibility of health care in the North-East Department of Haiti.

BACKGROUND: The geographical accessibility of health services is an important issue especially in developing countries and even more for those sharing a border as for Haiti and the Dominican Republic. During the last 2 decades, numerous studies have explored the potential spatial access to health services within a whole country or metropolitan area. However, the impacts of the border on the access to health resources between two countries have been less explored. The aim of this paper is to measure the impact of the border on the accessibility to health services for Haitian people living close to the Haitian-Dominican border. METHODS: To do this, the widely employed enhanced two-step floating catchment area (E2SFCA) method is applied. Four scenarios simulate different levels of openness of the border. Statistical analysis are conducted to assess the differences and variation in the E2SFCA results. A linear regression model is also used to predict the accessibility to health care services according to the mentioned scenarios. RESULTS: The results show that the health professional-to-population accessibility ratio is higher for the Haitian side when the border is open than when it is closed, suggesting an important border impact on Haitians' access to health care resources. On the other hand, when the border is closed, the potential accessibility for health services is higher for the Dominicans. CONCLUSION: The openness of the border has a great impact on the spatial accessibility to health care for the population living next to the border and those living nearby a road network in good conditions. Those findings therefore point to the need for effective and efficient trans-border cooperation between health authorities and health facilities. Future research is necessary to explore the determinants of cross-border health care and offers an insight on the spatial revealed access which could lead to a better understanding of the patients' behavior.

Financial Implications of Atypical Mycobacterial Infections After Cosmetic Tourism: Is It Worth the Risk?

BACKGROUND: Cosmetic tourism has become increasingly popular despite many associated risks. The economic impact of atypical mycobacterial infections in cosmetic tourism is poorly defined in the literature. We sought to investigate the costs and clinical course of patients with these infections. METHODS: A retrospective review of all patients managed by the Plastic Surgery Division at Columbia University Medical Center from 2013 to 2014 with atypical mycobacterial surgical site infections after cosmetic surgery outside the United States was performed. Data including patient demographics, procedure costs, clinical course, impact on daily life, and costs associated with complications were collected using hospital billing information, patient questionnaires, telephone interviews, and clinical charts. Cost analysis was done to identify the personal and societal costs of these complications. RESULTS: Data from 10 patients were collected and analyzed. Management of mycobacterial infections cost an average of $98,835.09 in medical charges. The indirect cost of these infections was $24,401 with a mean return to work time of 6.7 months. Total patient savings from cosmetic tourism was $3419. The total cost of a mycobacterial infection was greater than $123,236.47. Although the incidence of mycobacterial infection abroad is unknown, the potential cost of an infection alone outweighs the financial benefits of cosmetic tourism if the risk exceeds 2.77%. CONCLUSIONS: Atypical mycobacterial infections as a result of cosmetic tourism come at considerable cost to patients and the health care system. When our results are taken into consideration with other risks of cosmetic tourism, the financial risks likely far outweigh the benefits.

Cosmetic tourism for breast augmentation: a systematic review.

BACKGROUND: The medical tourism industry, and in particular cosmetic tourism for breast augmentation, is becoming an increasingly popular global phenomenon. The objective of this study is to determine the extent of medical literature and the patient risk profiles associated with cosmetic tourism for breast augmentation both locally and abroad. DATA SOURCES: OVID MEDLINE, OVID Embase, Cochrane Central and Proquest electronic databases. METHODS: The search was conducted through to April 2017. Studies pertaining entirely or partly to cosmetic tourism for breast augmentation were considered for inclusion. Exclusion criteria included non-English articles, studies relating to non-cosmetic or non-implant breast augmentation, and studies that did not separately report on findings associated with breast augmentation abroad. RESULTS: We identified 17 observational studies. Common destinations included Europe, South America and South East Asia. Infectious complications were common. Wound dehiscence and aesthetic dissatisfaction also featured. Catastrophic outcomes such as sepsis, intubation and ventilation, radical bilateral mastectomy, irreversible hypoxic brain injury and death were also reported. There were expectations that home country health systems would treat complications and provide non-medically indicated revision procedures. The burden on home country health systems was evident from a public health perspective. CONCLUSION: Determining the extent of cosmetic tourism for breast augmentation, including outcomes and complications, will help to inform Australian patients who this seek procedure abroad. Furthermore, it will aid in better understanding the health system implications and may help to guide future research and public health interventions both locally and internationally.

"That's enough patients for everyone!": Local stakeholders' views on attracting patients into Barbados and Guatemala's emerging medical tourism sectors.

BACKGROUND: Medical tourism has attracted considerable interest within the Latin American and Caribbean (LAC) region. Governments in the region tout the economic potential of treating foreign patients while several new private hospitals primarily target international patients. This analysis explores the perspectives of a range of medical tourism sector stakeholders in two LAC countries, Guatemala and Barbados, which are beginning to develop their medical tourism sectors. These perspectives provide insights into how beliefs about international patients are shaping the expanding regional interest in medical tourism. METHODS: Structured around the comparative case study methodology, semi-structured interviews were conducted with 50 medical tourism stakeholders in each of Guatemala and Barbados (n = 100). To capture a comprehensive range of perspectives, stakeholders were recruited to represent civil society (n = 5/country), health human resources (n = 15/country), public health care and tourism sectors (n = 15/country), and private health care and tourism sectors (n = 15/country). Interviews were transcribed verbatim, coded using a collaborative process of scheme development, and analyzed thematically following an iterative process of data review. RESULTS: Many Guatemalan stakeholders identified the Guatemalan-American diaspora as a significant source of existing international patients. Similarly, Barbadian participants identified their large recreational tourism sector as creating a ready source of foreign patients with existing ties to the country. While both Barbadian and Guatemalan medical tourism proponents share a common understanding that intra-regional patients are an existing supply of international patients that should be further developed, the dominant perception driving interest in medical tourism is the proximity of the American health care market. In the short term, this supplies a vision of a large number of Americans lacking adequate health insurance willing to travel for care, while in the long term, the Affordable Care Act is seen to be an enormous potential driver of future medical tourism as it is believed that private insurers will seek to control costs by outsourcing care to providers abroad. CONCLUSIONS: Each country has some comparative advantage in medical tourism. Assumptions about a large North American patient base, however, are not supported by reliable evidence. Pursuing this market could incur costs borne by patients in their public health systems.

Binational utilization and barriers to care among Mexican American border residents with diabetes.

OBJECTIVE: To assess whether U.S.-Mexico border residents with diabetes 1) experience greater barriers to medical care in the United States of America versus Mexico and 2) are more likely to seek care and medication in Mexico compared to border residents without diabetes. METHODS: A stratified two-stage randomized cross-sectional health survey was conducted in 2009 - 2010 among 1 002 Mexican American households. RESULTS: Diabetes rates were high (15.4%). Of those that had diabetes, most (86%) reported comorbidities. Compared to participants without diabetes, participants with diabetes had slightly greater difficulty paying US$ 25 (P = 0.002) or US$ 100 (P = 0.016) for medical care, and experienced greater transportation and language barriers (P = 0.011 and 0.014 respectively) to care in the United States, but were more likely to have a person/place to go for medical care and receive screenings. About one quarter of participants sought care or medications in Mexico. Younger age and having lived in Mexico were associated with seeking care in Mexico, but having diabetes was not. Multiple financial barriers were independently associated with approximately threefold-increased odds of going to Mexico for medical care or medication. Language barriers were associated with seeking care in Mexico. Being confused about arrangements for medical care and the perception of not always being treated with respect by medical care providers in the United States were both associated with seeking care and medication in Mexico (odds ratios ranging from 1.70 - 2.76). CONCLUSIONS: Reporting modifiable barriers to medical care was common among all participants and slightly more common among 1) those with diabetes and 2) those who sought care in Mexico. However, these are statistically independent phenomena; persons with diabetes were not more likely to use services in Mexico. Each set of issues (barriers facing those with diabetes, barriers related to use of services in Mexico) may occur side by side, and both present opportunities for improving access to care and disease management.

Binational utilization and barriers to care among Mexican American border residents with diabetes / Utilización binacional y barreras a la atención en las personas con diabetes que residen en la frontera mexicano-estadounidense

OBJECTIVE: To assess whether U.S.-Mexico border residents with diabetes 1) experience greater barriers to medical care in the United States of America versus Mexico and 2) are more likely to seek care and medication in Mexico compared to border residents without diabetes. METHODS: A stratified two-stage randomized cross-sectional health survey was conducted in 2009 - 2010 among 1 002 Mexican American households. RESULTS: Diabetes rates were high (15.4%). Of those that had diabetes, most (86%) reported comorbidities. Compared to participants without diabetes, participants with diabetes had slightly greater difficulty paying US$ 25 (P = 0.002) or US$ 100 (P = 0.016) for medical care, and experienced greater transportation and language barriers (P = 0.011 and 0.014 respectively) to care in the United States, but were more likely to have a person/place to go for medical care and receive screenings. About one quarter of participants sought care or medications in Mexico. Younger age and having lived in Mexico were associated with seeking care in Mexico, but having diabetes was not. Multiple financial barriers were independently associated with approximately threefold-increased odds of going to Mexico for medical care or medication. Language barriers were associated with seeking care in Mexico. Being confused about arrangements for medical care and the perception of not always being treated with respect by medical care providers in the United States were both associated with seeking care and medication in Mexico (odds ratios ranging from 1.70 - 2.76). CONCLUSIONS: Reporting modifiable barriers to medical care was common among all participants and slightly more common among 1) those with diabetes and 2) those who sought care in Mexico. However, these are statistically independent phenomena; persons with diabetes were not more likely to use services in Mexico. Each set of issues (barriers facing those with diabetes, barriers related to use of services in Mexico) may occur side by side, and both present opportunities for improving access to care and disease management.

OBJETIVO: Evaluar si las personas con diabetes que residen en la frontera mexicano-estadounidense 1) encuentran mayores barreras para obtener atención médica en los Estados Unidos de América que en México; y 2) acuden a México en busca de atención y medicación con mayor probabilidad que las personas no diabéticas que residen en la frontera. MÉTODOS: Durante el 2009 y el 2010, en una muestra de 1 002 hogares mexicano-estadounidenses, se llevó a cabo una encuesta transversal de salud en dos etapas, estratificada y aleatorizada. RESULTADOS: Las tasas de diabetes eran elevadas (15,4%). La mayor parte de las personas con diabetes (86%) notificaron comorbilidades. En comparación con los participantes no diabéticos, los afectados de diabetes experimentaban dificultades algo mayores para pagar US$ 25 (P = 0,002) o US$ 100 (P = 0,016) por recibir atención médica, y encontraban mayores barreras en materia de transporte e idioma (P = 0,011 y 0,014, respectivamente) para ser atendidos en los Estados Unidos, aunque era más probable que contaran con una persona o lugar adonde acudir en busca de atención médica y para ser sometidos a tamizaje. Una cuarta parte de los participantes acudían a México en busca de atención o medicamentos. Una edad menor y el haber vivido en México se asociaban con la búsqueda de atención en México, pero no el padecer diabetes. La presencia de múltiples barreras financieras se asociaba independientemente con una probabilidad aproximadamente tres veces mayor de acudir a México en busca de atención médica o medicación. Las barreras idiomáticas se asociaban con la búsqueda de atención en México. La confusión acerca de los trámites para recibir atención médica y la percepción de no recibir siempre un trato respetuoso por parte de los proveedores de atención médica en los Estados Unidos se asociaban con la búsqueda de atención y medicación en México (odds ratio, 1,70 - 2,76). CONCLUSIONES: La notificación de barreras modificables a la atención médica fue frecuente entre los participantes y algo más frecuente entre 1) las personas con diabetes; y 2) los que buscaban se atendidos en México. Sin embargo, estos fenómenos son estadísticamente independientes; no era más probable que las personas con diabetes utilizaran servicios en México. Ambos conjuntos de problemas (las barreras que deben afrontar las personas con diabetes, las barreras relacionadas con el uso de servicios en México) pueden coexistir, y proporcionan oportunidades para mejorar el acceso a la atención y el tratamiento de las enfermedades.

Medical tourism in the Caribbean region: a call to consider environmental health equity.

Medical tourism, which is the intentional travel by private-paying patients across international borders for medical treatment, is a sector that has been targeted for growth in many Caribbean countries. The international development of this industry has raised a core set of proposed health equity benefits and drawbacks for host countries. These benefits centre on the potential investment in health infrastructure and opportunities for health labour force development while drawbacks focus on the potential for reduced access to healthcare for locals and inefficient use of limited public resources to support the growth of the medical tourism industry. The development of the medical tourism sector in Caribbean countries raises additional health equity questions that have received little attention in existing international debates, specifically in regard to environmental health equity. In this viewpoint, we introduce questions of environmental health equity that clearly emerge in relation to the developing Caribbean medical tourism sector These questions acknowledge that the growth of this sector will have impacts on the social and physical environments, resources, and waste management infrastructure in countries. We contend that in addition to addressing the wider health equity concerns that have been consistently raised in existing debates surrounding the growth of medical tourism, planning for growth in this sector in the Caribbean must take environmental health equity into account in order to ensure that local populations, environments, and ecosystems are not harmed by facilities catering to international patients.

Acculturation and cross-border utilization of health services.

Health services from Mexico constitute an important source of care for U.S. residents living along the U.S.-Mexico border. Data from The Cross-Border Utilization of Health Care Survey (n = 966) were used to estimate logit models that related acculturation, as measured by generational status, to the use of medication, physician, dental, and inpatient services from Mexico by U.S. residents in the Texas border region. Relative to first-generation Mexican immigrants, later-generation Mexican-Americans were progressively less likely to go to Mexico for health services. This finding holds with or without adjusting for the effects of selected demographic and socioeconomic variables. Addressing unmet needs in medical care in the southwestern U.S. border area should go beyond a simple expansion of health insurance coverage--it is also important to deliver health services that are sensitive to generational differences within the population in terms of linguistic and cultural barriers to health care access.

Medical tourism in the Caribbean.

Although travel for medical reasons has a long history, it has more recently evolved from a cottage industry to a worldwide enterprise. A number of countries are positioning themselves to attract visitors who are willing to travel to obtain health services that are more accessible, less expensive, or more available than in their countries of origin. This has in turn given rise to medical packages that combine tourism with health. Several Caribbean nations - including Cuba, Barbados, Jamaica, and Puerto Rico - hope to expand their revenues in this new market. Each country has selected specific service niches and promotes its services accordingly. While Cuba has been promoting its services to other countries for several decades, medical tourism is just beginning in the other islands. Ultimately, these nations' economic success will hinge on their comparative advantage vis-à-vis other options, while their success in terms of improving their own health care depends on the extent to which the services for tourists are also available to the islands' populations.

"Almost invisible scars": medical tourism to Brazil.

Along with a handful of other nations in the developing world, Brazil has emerged as a top destination for medical tourism. Drawing on the author's ethnographic fieldwork in plastic surgery wards, this article examines diverse factors - some explicitly promoted in medical marketing and news sources, others less visible - contributing to Brazil's international reputation for excellence in cosmetic plastic surgery. Brazil's plastic surgery residency programs, some of which are housed within its public health system, attract overseas surgeons, provide ample opportunities for valuable training in cosmetic techniques, and create a clinical environment that favors experimentation with innovative techniques. Many graduates of these programs open private clinics that, in turn, attract overseas patients. High demand for Brazilian plastic surgery also reflects an expansive notion of female health that includes sexual realization, mental health, and cosmetic techniques that manage reproduction. Medical tourism is sometimes represented as being market-driven: patients in wealthier nations travel to obtain quality services at lower prices. This article ends by reflecting on how more complex local and transnational dynamics also contribute to demand for elective medical procedures such as cosmetic surgery.

Bioethics and transnational medical travel: India, "medical tourism," and the globalisation of healthcare

Health-related travel, also referred to as "medical tourism" is historically well-known. Its emerging contemporary form suggests the development of a form of globalised for-profit healthcare. Medical tourism to India, the focus of a recent conference in Canada, provides an example of the globalisation of healthcare. By positioning itself as a low-cost, high-tech, fast-access and high-quality healthcare destination country, India offers healthcare to medical travellers who are frustrated with waiting lists and the limited availability of some procedures in Canada. Although patients have the right to travel and seek care at international medical facilities, there are a number of dimensions of medical tourism that are disturbing. The diversion of public investments in healthcare to the private sector, in order to serve medical travellers, perversely transfers public resources to international patients at a time when the Indian public healthcare system fails to provide primary healthcare to its own citizens. Further, little is known about patient safety and quality care in transnational medical travel. Countries that are departure points as well as destination countries need to carefully explore the ethical, social, cultural, and economic consequences of the growing phenomenon of for-profit international medical travel.

Plastic paradise: transforming bodies and selves in Costa Rica's cosmetic surgery tourism industry.

Long popular as a nature tourism destination, Costa Rica has recently emerged as a haven for middle class North Americans seeking inexpensive, state-of-the-art cosmetic surgery. This paper examines "cosmetic surgery tourism" in Costa Rica as a form of medicalized leisure, situated in elite private spaces and yet inextricably linked to a beleaguered national medical program. Through historical context and ethnographic analysis of activities at medical hotels and clinics, I describe how the recovery industry operates on the embodied subjectivities of visiting patients and their local caretakers. Recovery sociality and healing landscapes facilitate patients' transition through a period of post-surgical liminality and provide nostalgic transport to an imagined medical arcadia, while clinicians are attracted by a neoliberal promise of prosperity and autonomy. Ultimately, Costa Rica's transformation into a paradise of medical consumption and self-optimization is contingent on a mythology that obscures growing uncertainties and inequities in the nation's broader medical landscape.

A patient mobility framework that travels: European and United States-Mexican comparisons.

OBJECTIVES: To develop a framework that parsimoniously explains divergent patient mobility in the United States and Europe. METHOD: Review of studies of patient mobility; data from the 2007 Flash Eurobarometer and the 2001 California Health Interview Survey was analyzed; and we reviewed government policies and documents in the United States and Europe. RESULTS: Four types of patient mobility are defined: primary, complementary, duplicative, and institutionalized. Primary exit occurs when people without comprehensive insurance travel because they cannot afford to pay for health insurance or directly finance care, as in the United States and Mexico. Second, people will exit to buy complementary services not covered, or partially covered by domestic health insurance, in both the United States and Europe. Third, in Europe, patient mobility for duplicative services provides faster or better quality treatment. Finally, governments and insurers can encourage institutionalized exit through expanded delivery options and financing. Institutionalized exit is developing in Europe, but uncoordinated and geographically limited in the United States. CONCLUSIONS: This parsimonious framework explains patient mobility by considering domestic health system characteristics relating to cost and quality.