Post on 30-Jun-2015
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Kristen D Smith Research Fellow School of Population & Global Health University of Melbourne, Australia
Medical tourism
and bioethics: Imprints left by
the global neoliberalisation
of health
What is medical tourism?
Medical Tourism (MT) is generally used as an
umbrella term (Connell, 2012) – defined as
travel with an aim to improve health.
Focus on biomedical procedures as
opposed to Complementary and
Alternative Medicines.
• Changing trends and greater complexity in
patient origins & destinations alongside
motivations.
• Shifts in types of health services sought
abroad.
Global Health inequalities and the
‘market’
In past 40 years, health status disparities between
Developed and Developing countries have been linked
to:
(1) The relationship between the reduction of the
role of the public sector in health systems and the
correlating commercialisation of health.
(2) The conduct and influence of international
organisations on health.
(3) Market led health care models and health
protection for vulnerable groups.
The World Bank: late 80s
World bank 1987 report ‘Financing Health
Services in Developing Countries’ heralded
health reform movement
Moved away from public funding model for
health service provision
Consolidated links between population health
status and economic development of nations
Argued that curative services should be provided
& regulated by market.
Medical Tourism and the WTO
General Agreement on Trade in Services (GATS)
Under the GATS, health is one of 12 listed services provided for.
Within the GATS medical tourism falls under the second mode as “consumption abroad”
The GATS have drawn critique the secrecy of the negotiations
Human Rights and Health
• The view of health as a human right has evolved alongside other human rights discourses
• The Alma Ata Declaration (1978) expressly states that health is a human right
• Farmer (2002) contends equal access to medical care is a social and economic right
An ethnography of
medical tourism in
Mumbai
5 private hospitals in Mumbai.
Observations in hospitals waiting rooms, board
meetings, administrative meetings, hospital wards,
waiting rooms and consultancy rooms.
Semi-structured, in-depth interviews with healthcare
professionals (consultant surgeons, medical directors,
hospital management personnel).
Health care System Shifts in India 1980 – 1990
•1980s saw a major shift in policy direction as seen in seen in the
National Health Policy 1982.
•Over the decade 1980s external foreign debt doubled.
•1991, a Structural Adjustment Program (SAP) was introduced
•Soon followed by the New Economic Policy.
•The NEP directly impacted on health sector through reduction of grants
to state public health and disease control programs.
• Growing demand for medical services saw the proliferation of health
services within the private sector throughout the 1990s.
Wards in two Public
Hospitals in Mumbai
The Rise of the Corporate Hospital in India
First corporate hospitals emerged in early 1980s
>150 private tertiary healthcare conglomerates.
Growth of corporate hospitals puts pressure on Trust (not for
profit) Hospitals.
Financial Director of Hospital B in study claimed only options
for Trust hospitals:
1. Transform core ideals towards a market based ethos;
2. Outsource management to the larger health care
conglomerates to attain sufficient funding;
3. Submit to the inevitability of closure.
“Turning around sick hospitals has become the latest rage in
the healthcare industry”(Sharma, 2007 )
Scenes from two Private Hospitals
in Mumbai
Medical tourism: healthy for
the health system?
Public discussion framed by three central claims:
Claim 1: MT will increase export earnings through
attracting foreign exchange into the country, lowering
fiscal deficit and assisting the economic development.
“…well it’s like this, we had the boom in the IT industry. Now
there’s a boom in healthcare industry. Healthcare in the same
way, government are spending lots of money on the
infrastructure. You know the government, the next goal for the foreign exchange is the healthcare industry.”
(Dr. Nair: Mumbai Interviews 2009)
Medical tourism: healthy for the health system
cont.…
Claim 2: Promotion of medical tourism will raise the
national standards of health care through competitive
market practices (also translating to an increase of
the standards in the public sector).
Movements towards national and international
accreditations, but increasing the standards is likely
to increase costs for local patients.
Is medical tourism healthy for the health system
cont.….
“Yes, if I focus a lot on medical tourism obviously I’ll
increase my charges. That means my local people, if I don’t have a dual billing, will have to pay more. Okay. And
the infrastructure costs, to match up to international
standards, which I feel is required, will increase the costs
again and the local population will not be able to afford it.
The health insurance has not reached to its optimal level
yet. Where, you know, people cannot afford the
healthcare in a, in a facility like, our hospital. So the
facility that can be afforded by this hospital is more of a middle, middle upper class population”
(Dr Rao: Interviews, Mumbai 2010)
Region Public Private
Rural 35.8 42
Urban 43.4 53.7
Total 39.9 49.1
Increase in Medical Cost of Hospitalisation
between 1994-95 and 2004 (%)
Source: data adapted from NSSO 2006
Is medical tourism healthy for the health system
cont.….
Claim 3: The economic growth medical tourism
generates would result in an overall increase of
national income, thus creating equity in access
through allowing more of the population access to
private care.
Employs the widely critiqued notion of the trickle-
down concept, but is thinly veiled.
“Improving the lives of billions of people at the bottom of
the economic pyramid is a noble endeavour. It can also be a lucrative one.” (Prahalad & Hammond, 2002)
“It will put us on the world map, I think. The
world has considered us as a Third World
Country, we still are. Let’s face facts. This can
change things. Definitely. But the message is,
we will now go to work, in all departments, in
all faculties of medicine. Very good, well
trained doctors. Very well educated, not
generally the backward class I’m talking. By
on large the bulk of us are a very good lot.”
(Dr Patel, Mumbai interviews, 2010)
Conclusions
Still very little empirical knowledge on
volume, nature and broader practices of MT
MT provides a window through which to
identify & analyse broader issues relating to
the health care internationally.
Global rise of market-led healthcare: MT one
of many bi-products.
Highlights need for more critical analysis of
dominant discourses.
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