Ethical and sustainable healthcare tourism development: A primer

Abstract

In recent years, healthcare tourism has emerged as a viable economic sector for several regions. Although the sector offers economic benefits, it has been suggested that pursuit of such benefits is often associated with unethical and unsustainable practices. To assuage these concerns, this article argues that destinations should adopt a collaborative stakeholder-driven approach. It also offers suggestions which can aid regions in developing this sector in a sustainable and ethical manner. The proposed framework and suggestions are not intended as panaceas for healthcare tourism development. Instead, they are offered as discussion starting points to provoke thought, discussion, and debate about how regions can leverage healthcare tourism resources in a profitable, ethical, and sustainable manner. Additionally, the framework and suggestions can be adopted by tourism policy planners and practitioners to assist in the ethical and sustainable development and management of the healthcare tourism sector.

Keywords

Healthcare tourism ethical and sustainable tourism development and management

Introduction

Healthcare tourism has become one of the fastest growing tourism niche market. Increasingly, destinations are actively engaging in this relatively “new” tourism product development, primarily because of its revenue generating potential and ability to diversify a region’s tourism product-service offerings (Chambers and McIntosh, 2008; Ramya, 2010; York, 2008). Although exact global healthcare tourism figures such as destination visitations and expenditures per tourist are largely unknown and are typically less than reported estimates (Connell, 2013), current statistics suggests bourgeoning demand and strong potential for this sector. For example, the global healthcare tourism market is projected to grow at approximately US$4.4 trillion per annum globally (Chanda, 2004). For the United States, medical tourists traveling overseas for medical procedures are projected to reach 17 million by 2017 and generate revenues of $228 billion (Deloitte Center for Health Solutions, 2008). This trend suggests that healthcare tourism is not a fad or novelty. Instead, it represents a viable tourism niche that has become a global economic and political phenomenon. Furthermore, several destinations have reported this niche as their fastest growing tourism segment (World Bank News, 1998).

Definition and scope

Healthcare tourism or the travel of patients who are residents of one country or region (home country or home region) to another country or region (destination country or destination region) is not a new phenomenon. Historical records suggest that it can be traced back to the Roman era and early travel to European spas in the 19^th century (Cohen, 2012). In fact, components of the earliest forms of travel and tourism were associated with healthcare (Connell, 2006; Smyth, 2005). However, as a modern-day economic activity, commercial healthcare tourism was first categorized as a separate commercial tourism product within the travel and tourism industry in 1973 (Yim, 2005). Healthcare tourism is generally defined based on travel motivations, procedures performed, and tourism activities or products and services offered (Connell, 2013). As a product, healthcare tourism can be divided into three broad categories based on services offered. These are: spas and alternative therapies, which include services such as acupuncture, aromatherapy, beauty care, herbal healing, homeopathy, massage, meditation, yoga, and other general well-being spa treatments; cosmetic surgery, including facelifts, augmentation; liposuction, and other nonessential medical procedures and; medical tourism, which includes medical services such as health screening, surgeries, cancer treatment, joint replacement, and other surgical operations requiring hospitalization and professional medical care. Hence, medical tourism differs from other forms of healthcare tourism in that it involves clearly defined medical interventions (Garcia-Altes, 2005). Thus, medical tourism is a subset of healthcare tourism or a component of the health tourism market (Boultbee, 2012; Henderson, 2004). From a destination perspective, healthcare tourism is defined for consistency and measuring purposes as concerted efforts by a tourism facility or destination to attract tourists through the promotion of healthcare services in addition to other tourism services and facilities (Goodrich and Goodrich, 1991).

The recent growth in healthcare tourism can be attributed to globalization or global trade of healthcare services which manifests itself in several ways including the development of relatively new forms of healthcare organizations and cross border health service delivery. In general, trading in healthcare services occurs in one of four delivery modes: cross border delivery, consumption abroad, commercial presence, and movement of healthcare personnel (Chanda, 2004). All modes entail the utilization of services that require the movement of personnel, resources, and customers from the point of supply to ultimately, the place of consumption. In this regard, healthcare tourism is best described by the “consumption abroad” mode where patients travel for the consumption of healthcare services including diagnosis, treatment, and health enhancement (Yim, 2005).

Healthcare tourism differs from traditional tourism in that healthcare and general medical treatments are the primary reasons for travel and traditional tourism-related activities are secondary or nonexistent in travel-related decisions (Chambers and McIntosh, 2008). Hence, from an economic perspective, healthcare tourism represents an economic activity that takes place in at least two sectors, healthcare and travel and hence, can be further defined as a product derived from trading healthcare services on the international market.

Current challenges

Current trends suggest that the healthcare tourism sector has a bright future, and further that it offers positive development attributes for destinations that can leverage existing healthcare tourism resources. However, in recent years, the sector has experienced controversies surrounding ethical and sustainability issues. Ethical issues are wide ranged and have centered on medical procedural ethics, inequality, and social equity. For example, it has been argued that the promotion and development of healthcare tourism perpetrates social inequalities within destinations. Typically, inequalities relate to utilization of scarce resources which are often diverted from addressing host country residents’ social issues to promoting and supporting the development of healthcare tourism infrastructure and services. It is suggested that at some destinations, spending on facilities for private healthcare, the sector that generally caters to healthcare tourists supersedes spending on public healthcare facilities. Further, healthcare provided by facilities developed primarily for healthcare tourism are often cost prohibitive for residents. In some instances, residents are often barred from utilizing these facilities, thereby creating a situation where public access to quality healthcare might be lacking while private, sophisticated healthcare tourism support facilities are available to healthcare tourists (Yim, 2005). It is also suggested that under conditions of scarce resources, healthcare tourism might exacerbate other social issues at destinations. For example, it could: promote brain drain of qualified healthcare professionals from the public sector to the more financially lucrative healthcare tourism private sector, increase disparities between public and private healthcare facilities, and exacerbate inequalities in healthcare resource allocation (Chanda, 2004; NaRanong and NaRanong, 2011). Conversely, it is also been argued that revenues generated from healthcare tourism, especially foreign exchange can be invested in public healthcare to improve facilities and general health standards. However, such actions are only possible through direct government policies that require resources to be expended in such manner. Under such circumstances, governments would have to ensure that tax revenues generated from healthcare tourism are reinvested in healthcare development initiatives (Yim, 2005). Such policies would help to ensure sustainability of healthcare tourism development for destinations since residents are likely to discern tangible benefits from this sector. Another challenge facing this sector is that it has been suggested that healthcare tourism has the potential of transferring healthcare problems associated with the developed world to the developing world (Vijaya, 2010). Finally, perhaps the most difficult challenge faced by this sector is that it has been linked to medical procedural practices that are often deemed unethical such as: transplant tourism, where patients travel to foreign countries to receive illegal organ transplants; stem cell tourism; and reproductive medical tourism (Deonandan et al., 2012; Kokubo, 2009; Levine and Wolf, 2012).

The preceding arguments suggest that healthcare tourism offers opportunities for destinations to diversity their tourism product-service offerings. However, there is also increasing discussion about challenges germane to its development. The preceding arguments also suggest that if destinations and regions want to develop their healthcare tourism sector and achieve its true potential as a viable economic product, an ethical approach to its development and management should be undertaken. In addition, like other tourism products, healthcare tourism’s development, growth, and management should be addressed with sustainability in mind. Hence, the suggested approach can be utilized by tourism policy planners and practitioners to assist in the development and management of healthcare tourism in an ethical and sustainable manner. Further, if destinations want to leverage healthcare tourism resources and optimize the potential of this economic sector, an ethical approach to its development and management should be undertaken.

The purpose of this paper is to propose a framework and offer suggestions which can be adopted and utilized by tourism policy planners and practitioners to assist in the ethical and sustainable development and management of healthcare tourism. The framework is not intended to be a panacea for healthcare tourism development. Instead, it is intended to act as a discussion starting point and as such, should provoke thought, discussion, and debate about how destinations can leverage healthcare tourism resources in a profitable, ethical, and sustainable manner.

Literature review

Several general factors are suggested for the recent growth in healthcare tourism. These include: increased globalization which makes it easier for healthcare tourists to travel, patients’ need to bypass clinical trial processes in developed countries and seek new and innovative treatment in less developed countries where the medical laws are often less stringent, and the rising cost of healthcare treatment in developed countries (York, 2008). In general, 40% of healthcare tourists seek treatment facilitated by advanced technology, 32% seek access to better healthcare, 15% seek faster medical services, while 9% engage in healthcare tourism in search of lower healthcare costs (Ehrbeck et al., 2008). Other specific factors driving the growth of the sector include: patients seeking access to better quality of medical service and expertise; access to modern medical facilities; new “innovative” medical treatments; availability of pre and post care; attractiveness of other tourism products (for patients and companions); price transparency and package pricing; lack of health insurance and under insured in home country; government policies that prohibit execution of certain medical procedures in patients’ home country; improvements in technology and standards of care in developing countries; reduced cost of international travel; long waiting times for medical procedures in home countries (approval and procedures); limited malpractice liability in destination countries; and availability of streamlined, “focused factory” type healthcare services (Cohen, 2012).

Institutional policies in developed countries are also suggested as driving forces behind healthcare tourism’s growth. For example, insurance companies in the developed world are encouraging participation in “tourism-incentivized” plans that offer patients rebates, waived deductibles, and other cost-saving incentives if they receive cheaper treatments abroad (Cohen, 2010). Global societal factors are also suggested as influential factors in the growth of healthcare tourism. These include: demographic—global population trends indicate that lifespans are getting longer, which increases the demand for healthcare services; medical—the number of noncommunicable illnesses continues to increase; economic—in general, disposable income has increased and medical insurance in several jurisdictions has become portable; and sociocultural factors—people are more knowledgeable about the world and are more willing to travel, especially since travel costs have decreased over the past two decades (Bookman and Bookman, 2007).

In recent years, a growing segment in healthcare tourism has been patients from developed countries who often engage in “circumvent tourism,” or the process of bypassing medical service challenges in their home countries, such as long queues or waiting for approval of procedures (Yim, 2005). Destinations on the other hand attempt to attract healthcare tourists primarily for the actual or purported economic benefits destinations receive (Connell, 2006). However, success for such destinations is often contingent on their ability to convince potential healthcare tourists that the level of service provided is comparable to or exceeds the services they would receive in their home country (Connell, 2006). It should also be noted that although healthcare tourism is currently dominated by international tourists, domestic healthcare tourism represents a viable option for several destinations, and as such, this aspect of healthcare tourism should not be ignored (Hudson and Li, 2012).

Despite the positive economic attributes associated with healthcare tourism, the industry as a whole has been linked to purported or actual ethical issue or concerns. The first set of ethical issue relates to the legality of healthcare services sought by healthcare tourists. Specifically, these ethical issues surround the provision of healthcare services that are illegal in the healthcare tourist’s home country and the destination country. Another set of ethical issue surrounds what has been described as “circumvention tourism” which relates to healthcare tourists travelling to seek healthcare services that are either illegal or unapproved in their home country but legal in the host country. For example, services such as fertility treatment, usage of experimental drugs, and stem cell usage fall into this category. Still, others have questioned the ethics of healthcare tourists who travel for services that are legal both in their home country and the destination country. In most instances, healthcare tourists seeking such services typically seek them to obtain cost advantages, gain access to better expertise, or they are simply trying to circumvent queuing times in their home country. The ethical issue surrounding these types of services relates to the possibility that they create social problems for the destination since resources, human and otherwise are diverted from serving the needs of the locals to serving the needs of healthcare tourists (Cohen, 2010). These ethical issues therefore relate to inequity in healthcare at destinations, exacerbated by healthcare tourism (Borman, 2004), which raises the issue of whether or not international bodies have a fiduciary responsibility to ensure that such circumstances do not occur (Cohen, 2011a, 2011b).

Ethical and sustainable approach

It is advisable that regions or destinations interested in developing healthcare tourism as a viable sustainable commercial sector should adopt a collaborative stakeholder approach. This approach will help to ensure that all relevant stakeholders share in the benefits generated from healthcare tourism. In addition, a corroborative approach will help to ensure buy in and support by relevant stakeholders (Jackson, 2006). Furthermore, participation by all relevant stakeholders will further help to ensure that the healthcare tourism product is developed in an ethical manner since collective stakeholder benefits will be lost or compromised if ethical concerns are not addressed. In this regard, it is suggested that destinations adopt and implement the United Nations World Tourism Organization's (UNWTO) Global Code of Ethics for Tourism and use this convention as a guideline for developing ethical stakeholder driven guidelines for their healthcare tourism sector. Specifically, Articles 5, 6, and 9 should be adopted since they address: how local populations can participate and benefit from tourism product development (Article 5), obligations and responsibilities of stakeholders (Article 6), and the rights and responsibilities of entrepreneurs and workers in the industry Article 9 (World Tourism Organization, 2001).

Ethical theories that support this perspective or approach include consequentialism and deontology ethical perspectives. The specific branches of these theories that are applicable focus on moral principles and include: Kantianism (a branch of deontology) which suggests that actions of all parties concerned about an issue should satisfy all imperatives associated with the issue under consideration, and Utilitarianism (a branch of consequentialism) which suggests that development should be accomplished for the benefit of all parties (stakeholders) concerned and further, that the actions taken should generate the most intrinsic good for everyone concerned (DesJardins and McCall, 2004).

Stakeholder-driven approach

The first step in the stakeholder-driven collaborative approach is to identify all the key stakeholders and destination interest groups that actively participate in the healthcare tourism sector. For most destinations, this will include: residents, governmental agencies, suppliers, providers of healthcare services, business owners, healthcare tourists, and developers of health care facilities. It is imperative that all interest groups, even those on the periphery of the industry are included in all relevant decisions related to the commercial development of the sector. For example, assistance should be offered to stakeholder groups that are willing to participate, but lack the resources to fully do so. For instance, if interest groups in remote locations want to participate in discussions germane to the sector, but lack necessary resources to actively participate, assistance should be offered by relevant authorities such as local, state, and federal government organizations to encourage and support such participation. It is also crucial that all stakeholder groups are included and relevant issues germane to each group addressed since each group has vested interest in the success of the sector. The following section outlines the roles and responsibilities of each key stakeholder group.

Owners of healthcare tourism facilities, large or small have a financial stake or interest invested in the entity. Thus, it is important that they adhere to the principles of sustainable development as well as ethical development since their long-term financial interest and investments are at stake. Employees within the sector have their jobs and livelihood at stake. In most cases, most of these employees will be skilled workers, providing specialized services to the sector. In some instances, since they have specialized skills, there is often no perfect elastic market for such skills. In return for their labor, healthcare tourism can provide job security, wages, and meaningful employment. Suppliers, another stakeholder group, are critical to the industry as well. They are a vital source of success for the sector since they provide necessary materials and products, which will ultimately determine price and ultimately customers’ perception of quality. According to stakeholder theory, customers, perhaps the most important stakeholder group will exchange resources, financial or otherwise for the healthcare tourism products and services they receive. They are the lifeblood of the sector especially as it pertains to ensuring economic vitality. It is therefore advisable that destinations pay close attention to the various types of healthcare tourists and ensure that each customer segment is treated in an ethical manner. From the perspective of the customer, this entails addressing issues such as truth in advertising, charging fair and equitable prices, providing excellent standards of care, and provision for follow-up after treatment services. An ethical perspective as it relates to advertising will also require ensuring that healthcare service providers at host destinations disclose both the benefits and risks inherent in consumption and use of healthcare tourism products and services. This ethical approach will depart from current approaches undertaken by some destinations that often promote the benefits of healthcare tourism with little or no mention of risks inherent in certain procedures or practices (Mason and Wright, 2011). Furthermore, this full disclosure, ethical approach will help to indemnify service providers against potential malpractice lawsuits, while simultaneously enhance their perceptions as honest and forthcoming service providers. Governmental agencies for their part have a fiduciary responsibility to all stakeholders to ensure that the necessary legal and regulatory frameworks are established to facilitate growth, development, and management of a viable and sustainable commercial healthcare tourism product. As such, these agencies should act in a manner that ensures the long-term viability of each stakeholder group. Governmental agencies should also ensure that information exchange about the healthcare tourism products is accurate and safety regulations and generally accepted global health standards are in place and enforced. These safeguards will positively influence word-of-mouth information exchange about the destinations’ healthcare tourism products (Lee et al., 2012).

It is also incumbent of governments to establish the types of healthcare tourism that are allowed within host countries or destinations. Although these types of government interventions can be contentious, they are necessary to curb or prevent engagement in healthcare tourism practices that are universally classified or deemed as unethical or illegal. While these types of interventions are important for the long-term economic viability of all destinations, they are especially important for destinations that are in the early stages of commercial healthcare tourism development. This can be seen from the perspective that over the past two decades, several destinations have become known for, or associated with specific types of healthcare tourism. In fact, some destinations are virtually synonymous with healthcare tourism services that are currently classified as unethical or illegal. Hence, prevention of illegal or unethical healthcare tourism practices through policy interventions can enable destinations to establish and manage their brands as premier healthcare tourism destinations, thereby increasing overall destination brand equity.

Once a destination has identified its relevant stakeholder groups, the next and perhaps most crucial step is to establish effective communication links between the stakeholders. Tourism authorities or appropriate governmental planning groups should take the initiative to initiate the communication process. Although there are several ways through which this communication can take place, initially, it is recommended that a participatory approach is taken. This can be done through community workshops or community outreach programs, where destination stakeholders are invited to discuss their concerns in open dialogue. This format will allow for key issues and concerns to be identified and discussed by each stakeholder group. However, as the stakeholders become more acquainted and establish working relationships, other forms of communications such as newsletters, e-mails, and interviews can be used in conjunction with the participatory method. As much as possible, there should be the perception among all stakeholders that they have shared power and an equal voice in the development and management of the healthcare tourism product.

Collaborative efforts should be also encouraged with government entities at the community level. These entities often times grant the rights and permits to build the necessary supporting facilities. In turn, if the sector is successful, the community as a whole benefits from tax revenues as well as from direct and indirect social and economic contributions generated from healthcare tourism development. From an ethical and sustainable perspective, care should be taken to ensure that healthcare facilities are developed with environmental sustainability in mind and hence, designed and developed in a manner that: does not create hazards, minimize effluent, and preserve natural artifacts where necessary. It is also imperative that from a socially responsible standpoint, healthcare tourism facilities and services should be accessible to local residents. Local residents, as opposed to migrant or expatriate workers should be trained and encouraged to work in the healthcare tourism sector. If healthcare tourism service providers are able to forge these bonds within the locals in which they operate they will undoubtedly develop formal and informal social contracts with the community which could possibly result in mutually beneficial sustainable relationships.

To ensure economic sustainability, it is advisable that destinations identify their unique healthcare tourism resources or those that can be developed into viable commercial products and position themselves based on their unique product service offerings. This can be seen from the perspective that from a commercial standpoint, healthcare tourism is a specialized segment of the tourism market and caters to customers who have specific and often complex needs and wants, which require specialized and often complex treatments including customized products and services. As such, it is therefore advisable that each destination segments its healthcare tourism markets based on available resources, both natural and manmade. Once this is accomplished, destinations can target specific customer segments with their healthcare tourism product service offerings. For some regions, particularly those with diverse geographic regions and abundance of healthcare tourism resources, the practice of segmentation based on resource availability will assist in the enhancement of the overall healthcare tourism sector while generating the net effect of enhancing overall destination appeal (Gan and Frederick, 2011).

Successful development of healthcare tourism as a viable commercial activity is also contingent on the establishment of partnership and collaboration between public and private entities. For a fact, in most instances, healthcare tourism as a viable economic activity requires large volumes of business to ensure economic sustainability. As such, the sector cannot operate in an economic vacuum. Instead, successful execution requires integration and collaboration with other economic sectors and social institutions, in a mutually beneficial symbiotic relationship. These public–private relationships are important since they will establish the framework and enable the development and implementation of necessary infrastructure and regulatory environment essential for the sector’s sustained growth. For example, in some jurisdictions, the healthcare tourism can be developed in a planned context under the auspices of the government. The private sector as well as cottage industries involving small entrepreneurs can then be encouraged to develop and provide supporting services, necessary supplies, services, and infrastructure all in a collaborative effort to attract healthcare tourists.

The role of governmental agencies should be limited to establishment of the regulatory framework and provision of the necessary policies that will enable each relevant healthcare service provider and healthcare tourism supply chain entities to excel at their respective endeavors. To enhance the healthcare tourism product, it is also advisable that relevant training germane to the healthcare products offered is provided through government supported programs. For example, providers of traditional and nontraditional healthcare services could be trained and certified, thereby enhancing the destination’s healthcare tourism image since it will help to assuage potential patients’ anxieties and trepidations regarding standards of care. In fact, this type of training is important since healthcare standards and quality of service are paramount for patrons seeking healthcare services. Hence, service providers should receive relevant certifications and credentials, thereby enhancing the quality of the destination’s healthcare tourism product. This attention to quality will improve patients’ perception of each destination’s healthcare tourism product, which is essential since value was found to be a key determinant in enhancing destinations’ healthcare tourism product (Wang, 2012). In addition, it is also advisable that governments establish benchmark standards for service, facility development and upkeep, and equipment maintenance and care. Policies should also be established for patient access to follow-up service and care following treatments, especially for medical procedures.

Conclusion

Healthcare tourism has emerged as a new and potentially lucrative economic sector within the tourism industry. As such, several regions, countries, and destinations have embraced this tourism product because of its ability to diversify product service offerings and generate economics benefits. Several factors are responsible for the growth of this relatively new tourism sector. These include: patients seeking access to better quality of medical service, access to modern medical facilities, new “innovative” medical treatments, proximity and ease of accessibility, availability of pre and post care, medical technological capability, attractiveness of other tourism products, lack of health insurance and under insured in home country, government policies that prohibit execution of certain medical procedures in the patients’ home country, improvements in technology and standards of care in developing countries, reduced cost of international travel, limited malpractice liability, and streamlined “focused factory” type services.

While healthcare tourism offers economic opportunities for destinations and their residents, it has been linked to several unethical issues and practices. To overcome these ethical issues, it is suggested that a stakeholder-driven collaborative approach is adopted by destinations to leverage healthcare tourism resources, while ensuring that all relevant stakeholders benefit in a sustainable manner. The stakeholder-driven collaborate approach will also help to ensure that sustainability of the tourism product is maintained since the survival of the industry is in the best interest of all stakeholders, and thus they are incentivized to protect all healthcare tourism resources. It is advisable that the UNWTO’s Global Code of Ethics in Tourism is adopted and utilized as the framework for developing destination specific codes of ethical and responsible conduct. However, for the code to be effective, it is important that governments establish the regulatory environment that is conducive to ethical and sustainable healthcare tourism development. In addition, it is advisable that destinations track and monitor positive and negative outcomes of medical tourism to ascertain net gains. In this regard, future studies are encouraged to address the positive and negative impacts of medical tourism on destinations.

Footnotes

Author Biographies

Leonard A Jackson, PhD, teaches graduate and undergraduate classes in the hospitality management department, Robinson College of Business, Georgia State University. His research interests include sustainable tourism development, sustainability and financial performance, hotel REIT performance, business combinations and executive transition impact.

Diana S Barber, J.D., CHE, CWP, is a specialist in hospitality law having been vice president and in-house counsel for The Ritz-Carlton for over 14 years. She is a senior lecturer and the director of the School's study abroad program at Georgia State University. Ms. Barber is a member of the State Bar of Georgia and the Georgia Hospitality & Lodging Association. Diana Barber is the recipient of the 2010 Hospitality Faculty of the Year award GSU and won the Teaching Excellence Award from the J. Mack Robinson College of Business for 2011. Ms. Barber is also the faculty advisor for the student chapter of the American Hotel & Lodging Association at Georgia State and was recently honored nationally as a co-recipient of the Anthony G. Marshall Hospitality Law Award presented by Hospitalitylawyer.com.

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