Pleasure and pain: Medical travel in Asia

Abstract

The trade in health services for foreign patients, often termed ‘medical tourism’ or medical travel, is a growing industry being aggressively marketed across Asia. This paper explores the industry development in four countries: Thailand, India, Malaysia, and Singapore, providing a preliminary review of the political economy of the industry, marketing strategies, and linkages. As yet, there has been neither academic work considering the implications of this trade for public health, nor studies on the medical travellers themselves and their experiences. The final part of this paper contemplates some of the implications for public health in the region, and the ethical issues this globalized trade presents.     

Ethics of care in medical tourism: Informal caregivers' narratives of responsibility,vulnerability and mutuality

This study examines the experiences of informal caregivers in medical tourism through an ethics of care lens. We conducted semi-structured interviews with 20 Canadians who had accompanied their friends or family members abroad for surgery, asking questions that dealt with their experiences prior to, during and after travel. Thematic analysis revealed three themes central to an ethics of care: responsibility, vulnerability and mutuality. Ethics of care theorists have highlighted how care has been historically devalued. We posit that medical tourism reproduces dominant narratives about care in a novel care landscape. Informal care goes unaccounted for by the industry, as it occurs in largely private spaces at a geographic distance from the home countries of medical tourists.     

发展国际医疗旅游的意义、经验及建议

本文归纳整理了近年来有关国际医疗旅游的中文文献,总结了发展国际医疗旅游对于拉动经济增长、扩大就业、提升国际竞争力等的重要意义,梳理了全球国际医疗旅游发展的主要驱动力和泰国、印度、马来西亚、日本、韩国等国家(地区)发展国际医疗旅游的主要经验,根据我国医疗旅游发展现状及优劣势,借鉴国际经验,提出了促进我国国际医疗旅游业发展的主要建议,包括完善医疗旅游管理体制和管理制度、尽快研究制定国际医疗旅游发展战略规划、打造以中医药为特色的医疗旅游品牌、建设国际医疗旅游先行区和示范区、推进医疗机构和服务的国际化认证等建议。     

Ownership, control, and contention: challenges for the future of healthcare in Malaysia

The recent history of healthcare privatisation and corporatisation in Malaysia, an upper middle-income developing country, highlights the complicit role of the state in the rise of corporate healthcare. Following upon the country's privatisation policy in the 1980s, private capital made significant inroads into the healthcare provider sector. This paper explores the various ownership interests in healthcare provision: statist capital, rentier capital, and transnational capital, as well as the contending social and political forces that lie behind state interests in the privatisation of healthcare, the growing prominence of transnational activities in healthcare, and the regional integration of capital in the healthcare provider industry. Civil society organizations provide a small but important countervailing force in the contention over the future of healthcare in the country. It is envisaged that the healthcare financing system will move towards a social insurance model, in which the state has an important regulating role. The important question, therefore, is whether the Malaysian government, with its vested interests, will have the capacity and the will to play this role in a social insurance system. The issues of ownership and control have important implications for governance more generally in a future healthcare system.     

SARS in healthcare facilities, Toronto and Taiwan

The healthcare setting was important in the early spread of severe acute respiratory syndrome (SARS) in both Toronto and Taiwan. Healthcare workers, patients, and visitors were at increased risk for infection. Nonetheless, the ability of individual SARS patients to transmit disease was quite variable. Unrecognized SARS case-patients were a primary source of transmission, and early detection and intervention were important to limit spread. Strict adherence to infection control precautions was essential in containing outbreaks. In addition, grouping patients into cohorts and limiting access to SARS patients minimized exposure opportunities. Given the difficulty in implementing several of these measures, control measures were frequently adapted to the acuity of SARS care and level of transmission within facilities. Although these conclusions are based only on a retrospective analysis of events, applying the experiences of Toronto and Taiwan to SARS preparedness planning efforts will likely minimize future transmission within healthcare facilities.     

Weaknesses and challenges of primary healthcare system in Iran: a review

While the primary healthcare (PHC) services in Iran were appropriate to the needs of the population in the late 1970s and 1980s, the changing burden of disease and shifting demand patterns have rendered the existing PHC system no longer suitable for meeting current and emergent needs. This has serious implications for the PHC system in Iran, which has clearly succeeded in addressing high levels of communicable diseases, maternal deaths and infant mortality, but appears less well prepared to address the emerging challenges of noncommunicable diseases (NCD). We conducted a systematic review of the available literature in the past 10 years related to the PHC system in Iran to assess its weaknesses and challenges. This paper categorizes PHC system weaknesses from the studied articles into two groups: (i) those related to the key functions of PHC, and (ii) others, which refer to health system weaknesses existing with the current PHC model. Iran can draw on international experience and evidence regarding interventions, which can be used to develop an effective and responsive PHC system designed to address current and emerging needs, in particular the NCD burden.     

Lean healthcare in developing countries: evidence from Brazilian hospitals

The present study evaluates how five sectors of two Brazilian hospitals have implemented lean healthcare concepts in their operations. The main characteristics of the implementation process are analyzed in the present study: the motivational factor for implementation, implementation time, form (consultancy or internal), team (hospital and consultants), lean implementation continuity/sustainability, lean healthcare tools and methods implemented, problems/improvement opportunities, lean healthcare barriers faced during the implementation process, and critical factors that affected the implementation and the results obtained in each case. The case studies indicate that reducing patient lead times and costs and making financial improvements were the primary factors that motivated lean healthcare implementation in the hospitals studied. Several tools and methods were used in the cases studied, especially value stream mapping and DMAIC. The barriers found in both hospitals are primarily associated with the human factor. Additionally, the results obtained after implementation were analyzed and improvements in financial aspects, productivity and capacity, and lead time reduction of the analyzed sectors were observed. Further, this study also exhibited four propositions elaborated from the results obtained from the cases that highlighted barriers and challenges to lean healthcare implementation in developing countries. Two of these barriers are hospital organizational structure (and, consequently, how the senior management works with medical staff), and outsourcing hospital activities. This study also concluded that the initialization and maintenance of lean healthcare implementation rely heavily on external support because lean healthcare subject knowledge is not yet available in the healthcare organization, which represents a challenge. Copyright © 2015 John Wiley & Sons, Ltd.     

医疗卫生产业化进程中的六大障碍

医疗卫生产业化是市场经济进程中卫生改革的新命题,该文总结了医疗卫生产业化改革的六大障碍,包括补偿体系扭曲,投入引导不力;凭经验盲目推行改革;相关部门及人员的既得利益;待完善的财税、物价、人事政策;条块分割;产业结构不合理等方面,以明确医疗卫生体制改革难点问题的主要解决思路.     

政府购买卫生服务的国内外改革经验评析

国内外实践表明，政府购买卫生服务需要一定的资源、管理和技术条件，而且需要配套改革措施。在我国各地经济社会发展不平衡的情况下，可在条件允许的地方进行“购买服务的试点”，但对于市场发育较差的领域和地区，更适合直接提供而不是购买。     

Preventing mother-to-child transmission of HIV in Vietnam and Indonesia: Diverging care dynamics

How do women and frontline health workers engage in preventing mother-to-child HIV transmission (PMTCT) in urban areas of Vietnam and Indonesia, where HIV is highly stigmatized and is associated with injecting drug use and sex work? This qualitative study explores local dynamics of care, using a mix of observations, focus group discussions, and interviews. In Indonesia the study was conducted in a community-based PMTCT program run by an NGO, while in Vietnam the study explored the care dynamics in routine PMTCT services, implemented by district and provincial public health facilities. In both of these PMTCT arrangements (the routine provider initiated approach in Vietnam and a more client-oriented system in Indonesia), pregnant women value the provision of HIV tests in antenatal care (ANC). Concerns are raised, however, by the unhappy few who test positive. These women are unsatisfied with the quality of counselling, and the failure to provide antiretroviral treatments. Acceptability of HIV testing in ANC is high, but the key policy issue from the perspective of pregnant women is whether the PMTCT services can provide good quality counselling and the necessary follow-up care.We find local level providers of PMTCT are pleased with the PMTCT program. In Vietnam, the PMTCT program offers health workers protection against HIV, since they can refer women away from the district health service for delivery. In Indonesia, community cadres are pleased with the financial incentives gained by mobilizing clients for the program.We conclude that achieving the global aims of reducing HIV infections in children by 50% requires a tailoring of globally designed public health programs to context-specific gendered transmission pathways of HIV, as well as local opportunities for follow-up care and social support.     

Implementation of a model for service delivery and organisation in mental healthcare: a qualitative exploration of service provider views

The purpose of the present study was to investigate factors influencing the implementation of a model for service delivery and organisation in mental healthcare. A qualitative case-study approach was employed involving in-depth interviews with 25 service providers from across mental health and social care in one local authority area in northern England. Purposive sampling achieved a broad coverage across geographical areas, voluntary and statutory services, and primary, secondary and specialist mental healthcare. The findings indicate that implementation was influenced by three interrelated factors: the means by which the model was introduced to the workforce; use of the model itself by service providers; and the broader service context. Thus, negative reactions to the way the model was initially presented strongly influenced service providers' subsequent views of it. Moreover, observations regarding the broader context of mental healthcare revealed a service that was ill-equipped to manage change because of over-stretched resources and that was disinclined to accept imposed change because of poor staff morale. Finally, differential interpretation of the model's tiers by service providers led to defensive practice that manifested itself as over-referral of service users within the system. Changing practice behaviour is a complex process, particularly at a service level that consists of numerous professional groups with differing cultural norms. Successful reorganisation of services is unlikely if those responsible for delivering care are not part of the process of change. Moreover, unsuccessful attempts to change professional practice may exacerbate existing tensions within a workforce, which may be to the detriment of those requiring care. A full diagnostic analysis of the system, including service providers' concerns, should be carried out before introducing change or reconfiguring services.     

Geographical inequalities in healthcare utilisation and the contribution of compositional factors: A multilevel analysis of 497 districts in Indonesia

Substantial inequalities in healthcare utilisation are reported in Indonesia. To develop appropriate health policies and interventions, we need to better understand geographical patterns in inequalities and any contributing factors. This study investigates geographical inequalities in healthcare utilisation across 497 districts in Indonesia and whether compositional factors – wealth, education, health insurance – contribute to such inequalities. Using data from a nationally representative Basic Health Research survey, from 2013 (N = 694,625), we applied multilevel logistic regressions, adjusted for need, to estimate associations of compositional factors with outpatient and inpatient care utilisation and to assess variability at province and district levels. We observed large variation of healthcare utilisation at district level and smaller variations at province level. Cities had higher utilisation rates than rural districts. Compositional factors contributed only modestly to geographical inequalities in healthcare utilisation. The effect of compositional factors on individual healthcare utilisation was stronger in rural areas as compared to cities and other areas with higher population densities. Unexplained district variation was substantial, comparable to that associated with health insurance. In policies to tackle inequalities in healthcare utilisation, addressing geographical factors such as service availability and infrastructures may be as important as improving compositional factors like health insurance.     

医疗旅游研究现状及启示

健康和观光结合在一起的医疗旅游是一种新兴的旅游形式,已成为旅游业新的经济增长点。本文梳理了国内外学者针对医疗旅游的相关研究,综合分析了医疗旅游的影响因素、效应分析、医疗旅游者的行为以及医疗旅游利益相关者的行为四个方面的研究结果。在此基础上,提出未来研究可以综合运用定性和定量研究方法,着重探讨医疗旅游者的行为特征,并建议通过提高医疗服务质量、促进医疗旅游的国际化、推出特色医疗旅游产品、完善医疗旅游政策法规、加强医疗旅游营销、发挥医疗旅游利益相关者的作用等措施促进我国医疗旅游业良性发展。     

整合医疗的联盟类型和组织机理——基于组织理论的联盟识别和治理重审

整合医疗体现了在正式制度安排下,医疗成员单位之间的相互合作和交换的组织关系,再现了医疗联盟的组织行使权力和配置资源的各种安排。从组织理论的逻辑出发,根据联盟组织面临的任务环境、组织结构和运行机制,把整合医疗分为医共体、紧密医联体、松散医联体和远程医疗协作网等不同类型。依据组织理论的分类策略,识别不同类型联盟组织的机制和运行成效,认为组织学分类逻辑是判定联盟特征,从而识别治理基础的关键。结合不同类别的联盟案例梳理治理要点。     

Delivering healthcare services to children with cerebral palsy and their families: a narrative review

Children with cerebral palsy have complex healthcare needs and often require complex multidisciplinary care. It is important for clinicians to understand which approaches to healthcare service delivery for this population are supported in the literature and how these should be applied in clinical practice. This narrative review aims to identify and review the evidence for current approaches to healthcare service delivery for children with cerebral palsy. Databases were searched using key terms to identify relevant research articles and grey literature from December 2011 to September 2013. Search results were screened and sorted according to inclusion and exclusion criteria. Thirty‐two documents were included for evaluation and their content was analysed thematically. Three current approaches to healthcare service delivery for children with cerebral palsy identified in this narrative review were family‐centred care, the World Health Organisation's International Classification of Functioning, Disability and Health, and collaborative community‐based primary care. However, healthcare services for children with cerebral palsy and their families are inconsistently delivered according to these approaches and the identified guidelines or standards of care for children with cerebral palsy have limited incorporation of these approaches. Future research is required to investigate how these approaches to healthcare service delivery can be integrated into clinical practices to enable clinicians to improve services for this population.     

Poverty,vulnerability, and provision of healthcare in Afghanistan

This paper presents findings on conditions of healthcare delivery in Afghanistan. There is an ongoing debate about barriers to healthcare in low-income as well as fragile states. In 2002, the Government of Afghanistan established a Basic Package of Health Services (BPHS), contracting primary healthcare delivery to non-state providers. The priority was to give access to the most vulnerable groups: women, children, disabled persons, and the poorest households. In 2005, we conducted a nationwide survey, and using a logistic regression model, investigated provider choice. We also measured associations between perceived availability and usefulness of healthcare providers. Our results indicate that the implementation of the package has partially reached its goal: to target the most vulnerable. The pattern of use of healthcare provider suggests that disabled people, female-headed households, and poorest households visited health centres more often (during the year preceding the survey interview). But these vulnerable groups faced more difficulties while using health centres, hospitals as well as private providers and their out-of-pocket expenditure was higher than other groups. In the model of provider choice, time to travel reduces the likelihood for all Afghans of choosing health centres and hospitals. We situate these findings in the larger context of current debates regarding healthcare delivery for vulnerable populations in fragile state environments. The ‘scaling-up process’ is faced with several issues that jeopardize the objective of equitable access: cost of care, coverage of remote areas, and competition from profit-orientated providers. To overcome these structural barriers, we suggest reinforcing processes of transparency, accountability and participation.