Stakeholder perspectives on ‘Swiss quality’ healthcare in the context of inbound medical tourism to Switzerland: An exploratory qualitative study

Abstract

Background

Global literature on medical travel focuses on patients from high-income countries traveling to middle-income countries reputed for providing high quality care at significantly lower costs. However, little is known about the movement of wealthy foreign patients to high-income countries such as the USA, the UK or Switzerland.

Objective

In this paper, we focus on Swiss medical tourism stakeholders and their strategies to attract a niche of self-paying foreign patients to undergo medical treatment in Switzerland. We describes how they harness the label of ‘Swiss quality’ healthcare to promote Switzerland in global medical travel industry.

Methods

We conducted semi-structured, in-depth interviews with 30 medical tourism stakeholders including 15 healthcare professionals (HCPs) treating self-paying foreign patients in publicly funded and privately owned hospitals in French- and German-speaking regions of Switzerland. The data were inductively coded using thematic analysis.

Results

We present their views on ‘Swiss quality’ healthcare under three themes: health-related human resources, Swiss medical infrastructure, and foreign patients’ perceived trust in the ‘Swiss quality’ label. Participants equated Switzerland's global image and ‘Swiss quality’ as a ‘brand’ and believed that foreign patients’ trust in ‘Swiss quality’ is a unique selling point of Swiss healthcare system.

Conclusion

By problematizing the use of ‘Swiss quality’ label to attract wealthy patients to Switzerland, we highlight a few ethical questions that deserve further scrutiny.

Keywords

International medical travel medical tourism quality of care Switzerland in-depth interviews thematic analysis

Introduction

Individuals traveling abroad in search of improved health is not new. In the 19^th century, the European elite were traveling to foreign countries to benefit from the hot springs and clean mountain air.¹ With highly professionalized international medical travel (IMT) industry characterized by targeted marketing, internet-based brokers linking patients to health-care facilities and easier access to information on treatment options including cost comparison, more patients can now travel abroad for medical care if they have necessary financial resources or international health insurances.² There are interactive websites, which allow individuals to contact medical specialists, organize their treatments, reserve flights and accommodation, and even plan tourist excursions.³

There is no consensus on the definition of medical tourism or ‘medical tourist’. Even though some patients might undertake a few tourism activities in the destination country after their medical intervention (e.g. visiting Taj Mahal after a hip replacement surgery in India), scholars argue that tourism is never their main motivation to travel abroad.^4,5 However even in exclusive medical travel, patients and their accompanying family members contribute to domains traditionally associated with tourism such as hotel stays, food and beverage consumption and shopping in destination country.⁶ The national statistics on tourism in many countries therefore include limited information on incoming foreigners for medical treatment.^3,7

The reasons patients leave their home country to seek healthcare are manifold - dependent on the health system in the home country and the available financial resources.^4,8 Apart from receiving necessary medical treatment at lower cost than in their country of residence (e.g. the US citizens traveling to Mexico or Canada and Western European patients traveling to Eastern Europe), some might undertake IMT to receive treatments, which are illegal in their home country (e.g. organ transplantation, certain forms of assisted reproductive technologies).⁵ Some travel abroad to bypass long waiting lists especially for surgeries in their home country, opting to receive the state-of-the-art surgical care abroad at a considerably lower cost.^1,5 Some high-income countries reduce the burden on the home healthcare system by encouraging patients to travel abroad for healthcare. In such cases, the insurance companies and health authorities approve a list of accredited hospitals in foreign countries for specific treatments and reimburse the costs incurred by the patients for these interventions abroad.⁸

A majority of patients undertaking IMT represents individuals with financial means from the high-income countries (e.g. The US, the UK, Canada) traveling to medical travel destinations in middle-income countries (e.g. India, Thailand, Mexico). However, a few individuals with financial resources from low and middle-income countries also travel to world-renowned treatment centers in high-income countries to receive the state-of-the-art medical treatment.^8,9 Many hospitals in the US and the UK attract wealthy self-paying foreign patients. Destination countries for medical travel irrespective of their economic status perceive incoming foreign patients as a source of economic benefit.⁶ Therefore, many national governments support medical tourism and sometimes even invest in it.^10,11

Scholars have developed theoretical and conceptual frameworks to better understand the supply (health service providers) and the demand (international medical travelers/patients) side factors shaping IMT. Glinos and colleagues have identified four motivations from the patients’ perspective that facilitate IMT. These are availability, affordability, familiarity and perceived quality of care. Combining these four motivations with availability or unavailability of financial means to undertake international travel for health care, they have defined and described eight types of patients that travel abroad for health care.⁸ Österle and colleagues, in their conceptual framework to understand why patients travel abroad to seek healthcare, similarly focus on patient related factors. They integrate patients’ healthcare needs with the facilitatory factors such as the cost, quality and access to healthcare services abroad and predisposing elements such as socio-cultural factors in the destination country.¹² Heung and colleagues integrate both the supply and demand related factors in their framework. On demand side, they focus on how patients chose the country to travel to, a hospital within that country and then a specific doctor within that hospital based on information available to them (via formal channels such as hospital websites, medical travel coordinators and informal sources such as the recommendations from friends, family or their physicians within home country), their perception on quality of care available in the destination country and finally the cost incurred to receive that care. On the supply side of IMT, they take into account the available healthcare infrastructure, how the country and hospitals promote themselves as a destination, the measures of quality assurance in place such as accreditations and means of communication available.⁶ Understanding in-bound medical travel to Switzerland in context of these existing frameworks of IMT is interesting for researchers and policy makers because it attracts patients despite disproportionately high cost of treatment compared to cost incurred in neighboring European countries that have similar health infrastructure and expertize.

In this paper, we will focus on (usually wealthy) foreign patients traveling to Switzerland for medical diagnoses and/or treatments. We exclude those traveling to Switzerland for receiving assistance in dying, visiting spas or wellness centers, patients seeking cosmetic treatments or aesthetic surgeries, poor patients from low and middle-income countries traveling to Switzerland for treatment with the help of NGOs and humanitarian organizations and those treated in Swiss hospitals in emergency settings due to accidents during their holidays in Switzerland. We also exclude European patients treated in Swiss hospitals with prior approval from their home country. These treatments are managed through formal agreements between the countries of the European Union and European Economic area and Switzerland.

Overview of Swiss healthcare system and in-bound medical tourism

Switzerland has a highly developed health system. According to the OECD report, in 2013 Switzerland spent 11.5% of its GDP on health, which is one of the highest shares in Europe and well above the EU average of 9.5%.¹³ Switzerland has comparatively high number of hospitals for its population, although they vary greatly in size and specialized treatments available.¹⁴ The report published by the Federal Office of Public Health in the year 2020 states that Switzerland had 276 hospitals for its population of 8.2 million. Of these 276, 168 were private stock-holding companies (AG or GmbH), 55 were run by the associations or foundations (Verein or Stiftung), 51 were identified as ‘public companies’ (Öffentliches Unternehmen) managed by the public sector through the funding from the federal, cantonal and community level taxes and two were owned by the individuals (Einzelfirma/Gasellschaft). Although the hospitals managed through public companies were only about 19% of all hospitals, they treated 43% of all in-patient admissions in 2020 indicating their important role in care delivery.¹⁵ The highest level of care is provided by the university hospitals situated in Zurich, Geneva, Basel, Bern and Lausanne.¹³ These university hospitals and several privately owned multi-specialty hospitals are most attractive for self-paying foreign patients seeking healthcare in Switzerland. As far as we know, all hospitals in Switzerland are allowed to treat self-paying foreign patients as long as it doesn't adversely affect the healthcare delivery to local patients covered through mandatory health insurance.

Switzerland was rather late in actively promoting itself as a medical travel destination for a niche of wealthy foreign patients. In 2008, the Office Suisse d’Expansion Commerciale (OSEC) together with the Switzerland Tourism Association founded ‘Swisshealth’ - an umbrella organization to promote Switzerland as a medical travel destination. Swisshealth created a countrywide network of hospitals in public and private set-up and focused on Russia, CIS countries, the countries in the Middle East and China as its target. It pooled resources from its member hospitals for marketing and promoting Swiss healthcare and attracting foreign patients to Switzerland. However, factors that led to its eventual dismantling are poorly explored. In 2019, Swiss Tourism (ST) launched a network of 26 hospitals and clinics with the aim “to position Switzerland in the area of health tourism among the top five destinations in the premium sector”. This network also focuses on China, Russia and Gulf countries and stresses on “medical expertise and the quality of the infrastructure available in Switzerland– in combination with its location in a pristine natural setting and a relaxing environment” in their communication with potential foreign patients. They estimated that patients’ family and accompanying members can potentially contribute to tourism turnover of CHF 245 million by 2022 if Swiss medical tourism is actively promoted.¹⁶

The scholarly literature on medical tourism to Switzerland is extremely limited. The paper by Hofer and colleagues is the only academic paper in English with a specific focus on defining and clarifying health tourism in Swiss context.¹⁷ In line with the call by Heung and colleagues for additional research in the field of medical tourism from the supply side,⁶ our exploratory qualitative research project aimed at understanding the scope and organization of medical travel to Switzerland was one of the first attempts to contribute to Switzerland specific empirical literature on IMT. In this manuscript, we describe the views of stakeholders of medical tourism to Switzerland regarding ‘Swiss quality’ healthcare. Swiss hospitals keen to attract foreign patients harness this label of ‘Swiss quality’ healthcare to distinguish their services apart from the treatment options available in other destinations for IMT such as Germany, France or Spain and believe that the foreign patients who can get treated anywhere in the world are attracted to Swiss healthcare system due to their trust in Swiss quality label.

Materials and methods

Study design

In this exploratory qualitative study, we conducted semi-structured, in-depth interviews with 30 stakeholders of Swiss medical tourism. Being aware of strict privacy policies pertaining to foreign patients and their desire to remain discrete while being treated in Switzerland, we did not envision interviews with self-paying foreign patients in this study.

Study participants

We interviewed 15 healthcare professionals (HCPs) treating foreign patients in Switzerland and 15 individuals involved in promoting, organizing or supporting healthcare delivery to self-paying foreign patients (e.g. medical travel coordinators, heads of international services within hospitals).

Identifying and recruiting study participants

The stakeholders were identified through media coverage, review of websites of university hospitals and private clinics actively engaged in treating foreign patients and professional networks of the second and the third author within Switzerland. While identifying healthcare professionals treating foreign patients, we focused on disciplines that often attract self-paying foreign patients such as oncology including pediatric oncology, cardiac surgery, orthopedic surgery and sports medicine, and neuro-rehabilitation. We consciously included stakeholders affiliated with publicly funded and privately owned hospitals from French and German speaking regions of Switzerland to incorporate their varied experiences with and perspectives on treatment of self-paying foreign patients.

Data collection

The third author approached all identified stakeholders with an email describing the study goals and requested their participation. In case of non-reply, whenever possible, she called concerned departments or individuals on phone or sent two follow-up emails. A list of open-ended questions built on international medical travel literature facilitated these interviews and explored (a) scope and scale of medical tourism to Switzerland, (b) ‘uniqueness' and competitive dis/advantages of Swiss healthcare system compared to popular medical travel destinations, (c) ethical issues if any arising from promoting Switzerland as destination for medical tourism and (d) potential benefits and harms from inbound medical tourism to local patients and healthcare system.

Interviews were arranged in person or via phone call according to participants’ preference. She obtained their permission to record the interview on an audio device and verbal informed consent. The duration of interviews ranged from 17 to 100 min, depending on time constraints of the interviewees and their interest in the topic; the average interview lasted 40 min. A few interviewees facilitated snowball sampling by suggesting individuals we could approach for this study. We stopped recruitment when additional interviews did not reveal new insights on our topic. The study participants did not receive financial compensation for their participation. Their characteristics are described in Table 1.

Table 1.

Characters of interviewees.

Participant number	Profile	Role	Organization	Gender	Language region
R1	Stakeholder	Independent Consultant	Private	Male	German
R2	Stakeholder	Head International Services	University Hospital	Female	German
R3	Stakeholder	Head of Guest Services	Private Clinic	Male	German
R4	Stakeholder	CEO	Private Clinic	Male	German
R5	Stakeholder	Head International Services	University Hospital	Male	German
R6	Stakeholder	COO	Private chain of Hospitals	Female	French
R7	Stakeholder	General Secretary	Children's Hospital	Male	German
R8	Stakeholder	International Patient Coordinator	Private Rehabilitation Clinic	Female	German
R9	Healthcare professional	Cardiac Surgeon	University Hospital	Male	German
R10	Stakeholder	Head of International Services	University Hospital	Male	German
R11	Healthcare professional	Dermatologist	Children's Hospital	Female	German
R12	Stakeholder	Representative of International affairs division	Federal Dept. of Public Health	Male	German
R13	Healthcare professional	Cardiologist	Private Clinic	Male	German
R14	Stakeholder	Travel coordinator	Private Company	Male	German
R15	Healthcare professional	Orthopedic surgeon	University Hospital	Male	German
R16	Healthcare professional	Oncologist	Children's Hospital	Male	German
R17	Healthcare professional	Nurse	Children's Hospital	Female	German
R18	Healthcare professional	Cardiologist	University Hospital	Male	German
R19	Healthcare professional	Oncologist	University Hospital	Male	French
R20	Healthcare professional	Neurorehabilitation Specialist	Private Clinic	Male	German
R21	Healthcare professional	Burns specialist	Children's Hospital	Male	German
R22	Stakeholder	Independent Consultant	Private	Male	French
R23	Healthcare professional	Intervention Radiologist	Private Clinic	Male	German
R24	Healthcare professional	Cardiologist	University Hospital	Male	German
R25	Healthcare professional	Oncologist	University Hospital	Male	German
R26	Stakeholder	Marketing and Sales	Private Hospital	Female	German
R27	Healthcare professional	Orthopedic surgeon	University Hospital	Male	German
R28	Stakeholder	Director	Cantonal Health Authority	Male	French
R29	Stakeholder	Medical Directorate	University Hospital	Female	French
R30	Healthcare professional	Consultant Physician	University Hospital	Female	French

Data analysis

In parallel with the data collection, the third author transcribed interviews verbatim and removed identifiable personal information. Each participant received their interview transcript to review and to provide additional input if any. However only one participant provided minor semantic feedback on transcript. The first and the last authors read each transcript several times to familiarize themselves with the data. Working as a team, we coded the data inductively according to the thematic analysis methodology by Braun and Clarke and developed a thematic structure described in this paper.¹⁸ The codes were organized with qualitative data analysis software MAXQDA licensed by University of Basel. Several discussions among the authors helped resolve differences in coding, refined thematic structure, reduced subjective bias, aided triangulation and improved the rigor of analysis. Our completed consolidated criteria for reporting qualitative research (COREQ) checklist is available as supplementary material.

Ethics approval

The ethics committee of Northwest Switzerland exempted the study from the ethics review according to the Swiss Human Research Act since we did not interview any patients or vulnerable population.

Results

This manuscript, describes the views of Swiss stakeholders of medical tourism and HCPs on ‘Swiss quality’ healthcare, which they believed was the unique selling point of Swiss health system and was the most attractive factor for the self-paying foreign patients seeking treatment in Switzerland despite it being significantly more expensive than in other countries. The study participants often stated that Switzerland is famous globally for its ‘high quality’ and expensive, niche products such as watches or technology. They equated this image of Switzerland and ‘Swiss quality’ as a ‘brand’ and elaborated ways in which this ‘Swiss quality’ is also reflected in health services provided by the Swiss hospitals. We provide a brief overview of the scope and scale of in-bound medical tourism to Switzerland as narrated by the stakeholders and then describe their views on ‘Swiss quality’ healthcare under three main themes and several subthemes.

Scope and scale of in-bound medical tourism to Switzerland

At the beginning of each interview, we enquired about the scale of in-bound medical tourism. The stakeholders informed us that each hospital maintains the records of foreign patients differently, some track only hospital admissions while others include all visits including health checkups, second opinion and planned diagnostic and therapeutic interventions. Some participants stated that in their hospital less than 1% of all admissions are attributed to self-paying foreign patients whereas others estimated this number to be 2–5% of all patients (hospital's annual footfall in-patient and out-patient). They insisted that these numbers are not comparable across hospitals due to variable ways in which this data is collected.

All participants indicated that in no clinic or hospital in Switzerland, the proportion of self-paying foreign patients would exceed 5%. These hospitals are reluctant “to open the flood gates” to receive more foreign patients. According to them, Swiss medical tourism model is targeted at a niche of very wealthy foreign patients who are keen to receive highest level medical care while enjoying exclusivity, privacy, luxurious stay and comfort. Despite their small numbers, incoming foreign patients make substantially higher financial contribution to the hospital through their treatment and stay compared to the contribution made by the local patients with mandatory health insurance.

The participants did not provide us concrete information on the mode of payment used by these foreign patients but suggested that most would pay the cost up front and out of pocket and few might then seek reimbursement from their private international health insurance if it covers treatment in Switzerland. The interviewees explained that most self-paying foreign patients traditionally come from Russia and former USSR states, a few from the Eastern European countries and some from the Middle Eastern Countries. That is why most hospitals and clinics who are keen to attract international patients have at least part of their website in Russian, Arabic and increasingly also in Chinese. A few participants from French speaking Switzerland reported that sometimes they treat patients from Francophone African nations but even for these patients France is often the first priority to seek healthcare.

Health-related human resources in Swiss hospitals

All participants described the contributions made by the health-related human resources available in Swiss hospitals in provision of high quality healthcare. We categorize these contributions into three subthemes, high healthcare personnel to patient ratio, technical skills and expertize, and interpersonal skills and intercultural competencies.

The interviewees argued that Swiss hospitals have a ‘considerably higher doctor to patient or nurse to patient ratio compared to Germany, Austria or the UK’, which means that each patient receives more time and personal attention from their healthcare team. This high ‘HCP to patient ratio’ is particularly pronounced in treatment of self-paying foreign patients, though this is also the case for local patients with private health insurance. Interviewees argued that patients feel ‘well looked after’ for they receive more personal care and attention from their healthcare team. While in the hospital, they receive medication, physiotherapy, diagnostic interventions without any delays. Their healthcare teams can allot more time to explain their progress, to answer questions or address any concerns. Thus according to the study participants, more time dedicated by the staff to each ‘self-paying’ patient is a result of higher ratio of health staff to patients and contributes to patients’ subjective feeling of being ‘treated well’, however, it also makes medical treatment in Swiss hospitals significantly more expensive than in other countries similarly known for high quality, cutting-edge healthcare.

The participants described the ‘unique selling point’ of the Swiss health system in terms of its highly skilled workforce. They reported that these skills consist of professional and technical skills as well as interpersonal and intercultural skills, both deemed equally crucial for high quality medical care. Many interviewees argued that ‘self-paying’ patients from abroad are attracted to the ‘top notch’ doctors or ‘the prominent professors’ in a particular field of medicine, who happen to work in Swiss hospitals. Some interviewees referred to the Swiss history of pioneering medical procedures and argued that ‘many of the world's first procedures (e.g. heart transplant) were performed in Switzerland’ which led to Switzerland's reputation as a ‘high-tech and research oriented’ country and that its doctors strive for ‘precision’ and improved patient outcomes in medical care. Another factor they highlighted was the interdisciplinary approach to medical care, where depending on patient's needs, different medical specialties ‘work closely together’ generating a profitable ‘exchange of knowledge’. The participants deemed such interdisciplinary teams or specialized ‘treatment boards’ crucial in rehabilitation programs, oncology treatments, and in management of patients with comorbidities. Most interviewees stated that Switzerland invests heavily in training its health-related human resources and in maintaining excellence in treatments provided in its hospitals. However, one interviewee disagreed with this claim and argued that ‘there should be no difference’ between doctors in Switzerland, France or Germany in terms of skills or trainings.

In addition to highly trained staff, the study participants reported that HCPs in Swiss hospitals represent diverse nationalities and routinely work in an intercultural environment, which helps in understanding needs of foreign patients better. In addition to various language skills, they bring along intercultural competencies. The strong sense of teamwork and the ‘less hierarchical work culture for example compared to Germany’ enables HCPs to work together and promotes cooperation aimed at achieving improved patient outcomes. The Swiss culture also values ‘being polite, calm, gentle and respectful’. Interviewees argued that Swiss hospitals heavily promote good communication skills, often visible in the ways in which professionals communicate with their patients. Such doctor-patient interactions help patients feel calm, relaxed and reassured and gives them a sense of well-being rather than ‘being rushed or pushed around’ (Table 2).

Swiss medical infrastructure

The study participants explained how the medical infrastructure available in Switzerland helps in providing better quality care. This theme consists of three related subthemes, physical infrastructure, technological modalities and hospitality departments facilitating high-level comfort for patients.

The physical infrastructure refers to the available hospitals and hospital beds across Switzerland. Many interviewees argued that Switzerland has a high density of hospitals compared to its population and therefore a surplus capacity to treat more patients. This medical infrastructure consists of various multispecialty hospitals and clinics, organized in private settings or publicly funded university hospitals and regional hospitals. The consensus among interviewees was that Switzerland is able to absorb some ‘self-paying’ patients from abroad without compromising the quality of healthcare provided to local population. The hospitals that attract most foreign patients are either university hospitals in major Swiss cities or private hospitals and clinics located in the mountains or in the lake regions. Though both private and university hospitals can offer high quality multidisciplinary medical treatments, some participants argued that the physical infrastructure of university hospitals was built in the 1950s and 60s and now ‘is at the end of its life’. Many university hospitals are in the process of building new infrastructure, which will provide high levels of comfort and privacy expected by the niche of self-paying foreign patients. Several private clinics on the other hand were described as ‘really beautiful hotels with nice views’ that can easily arrange their private suits and hospital floors to accommodate the self-paying foreign patients with their ‘entourage’. These clinics can provide the foreign patients with the highest level of physical comfort and discretion they desire without negatively affecting the routine service delivery to local patients. The rooms hosting ‘self-paying’ patients are large, spacious with great views of the surrounding areas. Some participants argued that the location of private clinics ‘closer to nature’ and all possible convenience and comfort they can provide for the patients helps in creating a subjective sense of wellbeing in patients. Both private and university hospitals make considerable efforts to renovate and refurbish hospital rooms where foreign patients stay. These include amenities such as large TV screens with international channels or extra sofas and attached rooms for families to stay.

Interviewees also reported that Swiss hospitals invest heavily in establishing the state of the art technical infrastructure. This includes latest medical and surgical technology, instruments and equipment. This infrastructure facilitates provision of best possible medical treatment with minimum delay or waiting period. This is also crucial in neuro-rehabilitation departments, where adequate numbers of available tools and equipment together with personnel mean that patients can have individualized and rigorous rehabilitation programs and their progress can be closely monitored. Swiss hospitals not only pride on their ‘high-tech’ infrastructure but also on the technical ‘know-how’ of their specialized medical teams to provide the best possible medical care supported by the latest scientific evidence.

In addition to physical and technological infrastructure, the participants argued that Swiss hospitals also provide high levels of hospitality and comfort for self-paying foreign patients. These non-medical aspects that contribute to patients’ perceived feeling of being treated well is facilitated through specialized hospitality teams, which look after minute details of comfort during patients’ hospital stays. The participants referred to Switzerland's long tradition in the hospitality industry and explained that the hospitality teams within hospitals can provide ‘champagne and caviar’ if a patient or his family demands it. Hospitals also have special departments or teams (e.g. international services) exclusively looking after self-paying patients from abroad. They maintain websites describing services provided by a particular hospital in several languages (e.g. Russian, Chinese, Arabic). They are the first contact for many foreign patients seeking medical care in Switzerland and they accompany patients during the entire process from planning treatment until discharge and their return home. The staff working in these departments are multi-lingual and have years of work experience in ‘intercultural’ contexts. They form an important liaison between the patient and the medical team, explain to patients all financial aspects of their stay and treatment and assist families and patients in any day-to-day concerns. Though these dedicated teams for international patients are not unique to Swiss hospitals, some interviewees argued that the ‘personal touch’ added by these departments’ staff helps foreign patients feel at ease while navigating the Swiss ‘hospital environment and culture’ (Table 3).

Table 2.

Health-related human resources in Swiss hospitals.

Subtheme	Select quotations
High healthcare personnel to patient ratio	This belongs to the amount of staff. In Germany, in a university hospital, you do not have the amount of staff like you have here. We have another key (ratio), like number of nurses is different. It is less in Germany. Also the nurses in Germany are not allowed to do things like the Swiss nurses are allowed to do. I know or I heard that the Swiss nurse is allowed to give an injection for example. In Germany: no. …. If patient needs an injection or if it is written there that every day at 10 he needs an injection and if there is no doctor here, maybe because of operation or emergency cases, outpatient clinic, then the patient has to wait, wait and wait. May be they will forget. This is then something from the patient safety. Is everything done? Here if he is on ward, the nurse can do it. The nurse is always there. There is nobody spends so much time with the patient like the nurse. (R2 International services, university hospital) I think there is no country worldwide with so many doctors. … Also the number of hospitals. All these factors together. YES. On one side, there are capacities searching for new patients and on the other side statistics showing everything is healthy, everything is clean. That is selling point. (R14 International medical travel coordinator)
Technical skills and expertize	Where we are strong is that the service is very good and the medical treatment. We are really, we have all kinds of divisions, medical specialties and these doctors are closely working together in kind of ‘medical boards’ where they really exchange the knowledge. Therefore, this attracts really the people, these heavy, heavy (severe) medical diseases. It can be neurological, oncological, cardiological. These are difficult (cases) and these are patients that are really attracted to our institutions. (R5 International services, university hospital) So you have to make sure that the doctors are seen as being the important doctors because they go to the internet and check whether this doctor and that doctor is internationally recognized. They are very much looking forward to excellence. If the hospital cannot provide this, they will have hard time to run such a program. (R18 Healthcare professional, university hospital) YES, it gives a name, it gives a credit and the patients will come because of this professors or doctors. This is one of the most important things, the doctors. The patients will always come because of the doctors. They will not come because of the view of the room or because I am very friendly to him as international service staff. They will have this even more in a private clinic, but here in our university hospital, he will come because of reputation of the doctor, the skills and technology. And this is also our sales strategy. I am not selling hospital rooms with golden things for VIPs, this is not the university hospital $$$. (R2 International services, university hospital) So the first and the foremost is the medical care, very good medical care, it is a must, an absolute must and I think we have that. …. I think we have very good doctors. I think that is absolutely crucial, let's say. I think that is really one thing that they (self-paying foreign patients) look at. (R6 Hospital administrator, private clinic) We are also a reference centre (for excellence) for some diseases like retinoblastoma and sarcoma. So a lot of people come to our hospital for that reason because we are a reference centre for these cases. (R29 Hospital administrator, university hospital)
Interpersonal skills and intercultural competencies	Then we come to the intercultural aspect, which is very important. I think this is for any culture an important, the question of respect. If you do not respect the patient, he will not come again. People are sensitive enough really to feel that. We have to also little bit approach towards the culture, what do they request? What are their feelings? Then you can really be successful. (R5 International services, university hospital) Intercultural skills are indeed very important. For doctors, they are used to because most of them studied abroad but the whole rest of the hospital has to adapt not just in terms of language skills that you mentioned such as intercultural behavior, values, how to greet, how to small talk are very important. (R1 Independent healthcare management consultant) (while hiring a new staff member) I do not care what they did in the past. I just focus on this person who is sitting in front of me, and assess them on service level, on mentality of being there for the patient, being patient (attitude of patience) as well. If you do that, you have quite a good standard of service quality and the people have a same way of thinking, meaning that there are no ‘difficult patients’, it does not exist. It is only lack of service mentality if this is the case. (R4 Hospital administrator, private clinic) The mother language is absolutely the basic (emphasis in original, basic implying non-negotiable, absolute must). So the patient has (emphasis in original) to communicate in his mother tongue. We have dolmetscher (translators) here, Chinese, of course, slowly, slowly, slowly, everybody speaks English, even Chinese, even Russians, the young Russians they all speak English. The older Russians of course not (emphasis in original)! So that means we have always interpreters, dolmetschers here in the house, sleeping here in the house, really 24 h service because they are patients, they have pain, they need medicament. They have to really explain themselves in their mother tongue otherwise, it does not work. (R4 Hospital administrator, private clinic) Then, also the mentality of Swiss people in the hospital. The mentality is a little bit more gentle. In Germany, a lot of it is like ‘how are you?’ (with harsh, matter of fact tone) Ta da ta da ta da (indicating harshness, rush, impersonal, dry interaction and fast paced). Fast, fast, schnell (German word for fast), not everybody of course. The patient feels that they are stressed. Here they are also stressed but I think sometimes you do not feel it. (R2 International services, university hospital)

Stakeholders’ views on patients’ perceived trust in the ‘Swiss’ quality label

Study participants explained how Switzerland's global image as a clean, beautiful, high tech country contributes to foreign patients’ perceptions that Swiss hospitals provide better quality care. Most foreign patients perceive Switzerland to be a highly organized society where one can depend on the system including medical services. Switzerland's political neutrality, stability and security also appeals to niche patients coming from conflict prone regions of the world. They feel safe while receiving healthcare in Switzerland. Interviewees explained that the Swiss nature, proximity to big lakes or the Alps brings patients closer to nature and triggers a sense of wellbeing while patients are away from the hectic and polluted daily life in their home countries.

According to the participants, many foreign patients associate Switzerland with ‘transparency’ and ‘trustworthiness’ and therefore Swiss hospitals benefit from high level of trust, which foreign patients often lack in the healthcare systems of their home country. Several participants described this trust foreign patients seem to have in Swiss health system. They explained that these self-paying foreign patients can consult the best doctors and receive the best possible treatment in Switzerland immediately and need not fear being exploited because they have money to spend. This often attracts rich foreign patients, who can travel anywhere in the world to receive medical treatment, to Switzerland.

Many participants argued that Switzerland's stricter privacy policies are particularly attractive for high-profile patients (celebrities, political figures, sportspersons) seeking best quality medical treatment without compromising their privacy. Swiss hospitals can admit ‘such’ patients with a pseudonym if needed, especially if the patient has concerns that his or her medical condition would become a public knowledge through journalists or media reports. Protection of privacy and discretion offered by Swiss hospitals also helps patients seek treatment for mental health issues, which cause stigma if known publicly (Table 4).

Table 3.

Swiss medical infrastructure.

Subtheme	Select quotations
Physical infrastructure	I think if you do this, you have to do this with specialized wards with dedicated service for these patients (self-paying foreign patients). Most important thing is that we do not diminish the quality to our own patients. I think we have really very high quality for everybody, every Swiss citizen. (R13, Healthcare professional, private clinic) In our hospital, the rooms are not that attractive. Private clinics can provide nice rooms; they use that as their marketing strategy. (R18 Healthcare professional, university hospital) There may be, you will probably also have a look at ### or these private clinics; you will see that these are really beautiful hotels with nice views or whatever. This is something really what people, high-end level rich people who really appreciate that. (R5 International services, university hospital)
Technical modalities	It is a clinic that is over 40 years old. …, we get the newest technology. I think that is also something that people from abroad are asking for or are looking for because maybe in their home country, they do not have that infrastructure, they do not have that newest technology. Here we can provide it for them. (R8 Healthcare professional, private clinic) Very good technical infrastructure and that is not the same everywhere. That is also a big thing for them, very positive. Big part of them (foreign patients) need all the technology that we have here and all the medical knowledge that we have here. (R6 Hospital administrator, private clinic) I think the asset Switzerland has is still the capacity and the rather well-equipped hospitals, well-trained staff.(R12 Public health authority)
Hospitality focus	Swiss professionalism. For example, in our (international services) department, we all have background in five star hospitality, so we have that service minded approach which is sometimes lacking when you are dealing with other clinics and you have an administration for example in an university clinic with 1500 beds. You cannot treat a VIP patient like a VIP patient but these people are expecting it because they are paying a lot of money for that. We have had patients here that ordered oysters and champagne and Caviar. It is done from our hospitality department. So that is where we come in play and I believe that is one of the USPs (unique selling points) that we can rely on. (R3 International services, private clinic) We are still, we want an emphasis on that ‘we are (emphasis in original) a medical facility, we have additional services which brings people to us but the reason people are coming to us is not the hotel facility, they come to us for medical care. That is critical, I think for our group and that is also the policy of our group. (R6 Hospital administrator, private clinic)

Discussion

The results of this study indicate that for self-paying foreign patients, Switzerland offers an attractive opportunity with its state-of-the-art, high-tech healthcare infrastructure, highly skilled and world-renowned healthcare professionals, and values associated with Swiss society such as transparency, trust, honesty, cleanliness, respect for privacy and safety. The participants described these elements as a ‘brand’ of ‘Swiss quality’ that is appealing to a niche of foreign patients who prefer medical treatment in Switzerland despite significantly higher costs.

Table 4.

Stakeholders’ views on patients’ perceived trust in the ‘Swiss’ quality label.

Image of Switzerland	I think Switzerland has the reputation of being precise, clean, and reliable and so on and that is also the key success factor. The family can enjoy the location. It is not Birmingham Alabama but Zurich or Geneva. (R18 Healthcare professional, university hospital) Switzerland has a great reputation for being neat, organized with high quality of standard of living here and I believe that is what they come here for. (R3 International services, private clinic) But one of the good motives is the Swiss label. I really think that this is something that we should definitely contribute to ensure people from all over the world that this is a good label. So my actions, I am always thinking, and I am not alone, the other people in other domain do the same. We do not have to talk about it but well, this is what we are proud of. We are proud of the quality, we want to be good. We have many conflicts, but if it comes to this (quality), there is no compromise on quality. I think, this is maybe one of the reasons. (R23 Healthcare professional, private clinic) And in Switzerland, of course we do not have those historic links but Swiss quality is the part of the deal. (R22 Independent medical travel management consultant)
Trust in Swiss health system	Sometimes they even come to Switzerland to buy their medication because they want to make sure it is the best quality and it is really the medication written on the package. Sometimes they really do not trust their doctors in their countries. It is terrible. (R16 Healthcare professional, university hospital) The fact that they trust this good research and the clinical work, and they believe that it is fantastic and it is better than in other countries in Europe, which is probably wrong but that is what they believe. (R19 Healthcare professional, university hospital) I am not sure we have something more except that there is security as well and ethically as well, caring for the patients, following the protocols and ethical committees and so we are not abusing anything or anyone. So again that is trust. (R19 Healthcare professional, university hospital) People coming here in Switzerland, they really can afford it, they want (emphasis in original) to come because they trust our system, our quality, they are ready to spend money. (R4 Hospital administrator, private clinic)
Privacy and discretion	Yes, it is highly discrete. You know, you have famous people, musicians, sports figures, celebrities in general, so they really prefer to come here and nobody knows, even sometimes with the pseudonym. I know that in Germany for instance, this is much more difficult to really cover their personalities because then you have journalists, you have staff speaking around and that is another point why for instance German patients who come to Switzerland because it is discrete. (R4 Hospital administrator, private clinic) Our patients (from abroad) come here also to have this privacy. If you have 15 Russian patients in one room, I am sure one will know the other. (R2 International services, university hospital) We want to show patients also the exclusiveness and therefore showing that we are very unique in a way also that … the people can really be assured that nobody is talking about them. May be in their country, they are famous, they come to our country and they know that nothing can happen. (R5 International services, university hospital) It is all discretion, so nobody knows. If you are president of India and nobody should know that you are very ill, you go for holidays to Switzerland, maybe. But in fact, you are in the hospital. I know that the royals from Europe who had depression, who were treated in Switzerland. So I think there are both things: medical, nobody should know- so confidentiality and especially for problematic conditions like dependency on alcohol etc. (R1 Independent healthcare management consultant) I want to add that, privacy, we have medical secrecy very much in place and we cannot even share any kind of information even to their own insurances without their acceptance that we are going to share these reports or any kind of information with the insurance company. (R29 Hospital administrator, university hospital)

To the best of our knowledge, this is the first empirical study exploring the perspective of healthcare professionals and stakeholders involved in ‘inbound’ medical tourism to Switzerland. Published scholarly literature (legal, theoretical, and empirical) focuses mainly on patient flow from high-income countries to middle-income countries^{4,5,9,19–22} or views of agents and medical travel coordinators.^2,23,24 However, the literature on strategies used by the high-income countries (e.g. the US, the UK) to attract self-paying foreign patients is limited. By focusing on inbound medical tourism to Switzerland, this manuscript attempts to provide initial insights on this particular aspect of IMT.

Swiss medical tourism model fulfills fully two out of four motivations from patient side described by Glinos and colleagues.⁸ A variety of advanced diagnostic and therapeutic modalities are available in Switzerland and foreign patients perceive the quality of care provided in Swiss hospitals to be very high similar to other Swiss products they are familiar with. Affordability is not the characteristic one would associate with medical treatment in Switzerland if one thinks of an average individual traveling abroad for health care. However, Switzerland has positioned itself as a medical travel destination for a premier section of the society comprising of wealthy individuals who are familiar with Swiss culture either through holidays or business and finance related activities and are expecting high level of luxury, privacy and discretion. Österle and colleagues also focus on the cost, access, quality and the socio-cultural factors in their conceptual framework.¹² Socio-cultural familiarity definitely plays a key role in Swiss medical tourism model. Those who travel to Switzerland for medical treatment often have some prior connection with Switzerland, might even have family or business colleagues living there. Wealthy patients from the geographic regions affected by the socio-political conflicts or war are attracted to Switzerland's position as a neutral country. For these patients, a sense of safety matters more than cultural, linguistic or religious connection with Switzerland. Swiss hospitals heavily focus on having healthcare workers with international experience and multiple language skills and also employ the teams of translators for facilitating communication between the doctors and the patients. This further reduces any cultural differences between the HCPs and patients and enhances patients’ belief that they are being well looked after.

Quality in healthcare is a complex and multidimensional concept,^25,26 not easy to measure.^27,28 If quality is measured only in terms of the treatment outcome or success rates, then one must take into account patients’ disease stage, general health and co-morbidities in addition to health infrastructure, highly skilled healthcare professionals and systems in place to strengthen patient safety. Several hospital ranking and accreditation systems account for many of these factors, however none are comprehensive.^29,30 Although Switzerland has quality based ranking and standardization processes for its hospitals, only one participant referred to them while elaborating his views on the ‘Swiss quality’ in healthcare. The others described the ‘Swiss quality’ in terms of infrastructure, human resource, and general image of Switzerland as a country. Although these components provide patients a subjective sense of wellbeing, a belief that they are in the best hands and are being treated in a culturally sensitive manner in a trustworthy health system, they capture only some aspects of ‘quality’ of healthcare. Furthermore, the participants were restrained while elaborating management or reporting of medical errors (if they occur) in foreign patients or how these patients are followed up after return to their home country raising questions about continuity of care.

The treatment costs in Switzerland for self-paying patients are significantly higher than in Germany, France, or Spain.¹³ Therefore, only a niche of self-paying foreign patients opt to be treated in Switzerland. Several participants referred to the Swiss medical tourism model as the one, which attracts a ‘select’ high-end class of medical tourists and not the mass exodus. Despite their small number, these patients contribute significant amounts of money into the healthcare system based on their chosen doctors, treatment options, hospital rooms and amenities and relatively longer duration of stay. This again distinguishes the Swiss medical tourism model than the one in India or Thailand, which depends on treating a large number of patients at relatively lower cost.³¹ One can assume that Swiss hospitals would then do everything in their capacity to achieve the best treatment outcomes, to prevent or adequately manage any errors or medical complications that might occur, provide personal attention, and spend enough time to address any concerns these patients or their families might have regarding treatment. This ‘patient centered’ approach reinforces the trust these patients have in ‘Swiss quality’ label and facilitates the word of mouth publicity for Swiss hospitals.³² Thus ensuring ‘quality’ healthcare is crucial for Swiss hospitals trying to attract wealthy foreign patients and to protect the ‘trust’ these patients bestow on the Swiss health system. The delicate relationship between the quality of care and trust in healthcare services has several implications for foreign and local patients.

Limitations of the study

Owing to our qualitative research design and purposive sampling strategy, these results are indicative rather than representative and must be interpreted with caution. Some Swiss clinics and hospitals known for treating large numbers of self-paying foreign patients did not respond to our repeated requests for interview. We cannot ascertain if their views are significantly different. Although a majority of interviewees participated in this study in their personal capacity and not as a representative of their hospital/clinic, some might have presented a rather positive image of what Swiss hospitals can offer to the foreign patients. The absence of perspectives from foreign patients regarding their treatment experiences in Switzerland is another limitation of this study. We could get some insight into patient perspectives indirectly as narrated by the study participants who had closely worked with several foreign patients over many years but that is rather limited. While designing this exploratory study, we were acutely aware that accessing these patients for a survey or interview study will be impossible due to strong privacy policies and therefore as a first step, we focused on other stakeholders of Swiss medical tourism industry including HCPs who were relatively easier to approach. Despite our own professional contacts within the Swiss healthcare system, recruiting study participants was challenging. Those who agreed to participate in this study were rather reluctant to share their views on this ‘sticky’ topic and categorically refused to discuss the financial aspects of the in-bound medical tourism. However, while discussing their views on ‘Swiss quality’ healthcare, they were relatively more forthcoming and shared similar beliefs except one participant who rejected these claims about ‘Swiss quality’ healthcare. We are aware that Swiss psychiatric clinics and rehabilitation centers also receive self-paying foreign patients seeking treatment for stigmatized mental health conditions such as addictions or depression. We were keen to understand the experience of mental health professionals in this regard but could not interview them. We believe privacy concerns was the main reason of their reluctance to participate in this study.

Practical implications for Swiss healthcare system

Though this research focuses on the medical tourism to Switzerland, its insights are valuable for the Swiss healthcare system in general, as well as the policy, practice, and future research on medical tourism to Switzerland and beyond. We begin with the implications in the Swiss context. Currently, the number of self-paying foreign patients traveling to Switzerland for healthcare is small. The Swiss hospitals can treat them without compromising healthcare delivery to local patients. However, for sustaining ‘Swiss quality’ healthcare delivery for local and foreign patients in the long run and protecting the trustworthiness of healthcare system, a systematic oversight on treatment of foreign patients is needed. For example, a system to capture the number of self-paying foreign patients annually treated in Switzerland, the conditions for which they seek treatment and the financial contributions they make to the healthcare system is currently lacking. The tariffs for treating ‘foreign’ patients vary across regions and hospitals. Similar to the concerns raised in the US context,³ some interviewees were unsure whether the high cost to quality ratio in Swiss hospitals is favorable for self-paying foreign patients.

To generate evidence on Swiss medical tourism that could feed into policy decisions and practice, additional research is needed. The topics for future research include foreign patients’ experiences in Swiss hospitals and their expectations about ‘quality’ healthcare; experiences of local patients in hospitals that treat several foreign patients, economic analysis of financial contributions of ‘self-paying’ foreign patients and potential ethical implications of increased in-bound medical tourism. If self-paying foreign patients are seen as a source of increased revenue to the healthcare system, there is a risk of these patients being exposed to unnecessary but lucrative medical investigations or treatments. These concerns have been discussed in the treatment and care of privately insured patients.³³ Unnecessary investigations and treatments can weaken the trust these foreign patients currently have in Swiss healthcare system.

Finally, we must briefly reflect on the impact of Covid pandemic on Swiss healthcare system and incoming self-paying foreign patients. In the absence of data or reports, we cannot make confident claims whether any self-paying foreign patients with severe corona infection were treated in intensive care facilities of Swiss hospitals. Once travel restrictions were lifted, wealthy foreign patients with symptoms of long Covid might have preferred to recuperate in Swiss rehabilitation facilities. But one can only speculate. The pandemic has revealed several weaknesses in the publicly funded health system in Switzerland, the healthcare professionals have experienced significant brunt on their own health. There has been ongoing discussion on how to strengthen healthcare system and improve training and numbers of trained healthcare professionals including some legal and policy changes. We do not think that putting more effort to attract self-paying foreign patients to Switzerland is going to be the current priority for the stakeholders especially those responsible for publicly funded health system.

Practical implications for research on IMT

Several world-renowned hospitals in the US (e.g. Mayo clinic) and the UK (The London Clinic, Guy's Hospital) have been treating much larger numbers of self-paying foreign patients from around the world for a significantly longer time compared to the numbers treated in Switzerland. However, little is known about their experiences of treating foreign patients. The Swiss medical tourism model resembles closely to these facilities in the US and the UK than the ones researched extensively (e.g. India, Mexico, Thailand). The insights from the world-renowned hospitals in the high-income countries that offer infrastructure and health human resources similar to that in Swiss hospitals will be instructive for analyzing the claims about the unique selling point of the ‘Swiss quality’ healthcare and will also make valuable conceptual and theoretical contributions to better understand these less studied models of IMT.

Conclusion

This exploratory qualitative study provides initial insights on the ways in which Swiss stakeholders of medical tourism describe ‘Swiss quality’ healthcare, a concept which they believe attracts a niche of self-paying foreign patients to Switzerland. More research is needed to unpack this quality label in order to prevent its misuse and to protect the trust the local and foreign patients have in the Swiss healthcare system. This study also identifies lacuna in global literature on ethical and economic implications of IMT by wealthy self-paying patients from around the world to high-income countries.

Supplemental Material

sj-docx-2-cri-10.1177_25160435221102124 - Supplemental material for Stakeholder perspectives on ‘Swiss quality’ healthcare in the context of inbound medical tourism to Switzerland: An exploratory qualitative study

Supplemental material, sj-docx-2-cri-10.1177_25160435221102124 for Stakeholder perspectives on ‘Swiss quality’ healthcare in the context of inbound medical tourism to Switzerland: An exploratory qualitative study by João Couceiro, Bernice S. Elger and Priya Satalkar in Journal of Patient Safety and Risk Management

Footnotes

Contributorship

PS conceptualized the research project and received funding for it together with BE. She also conducted all interviews and transcribed them. JC and PS carried out inductive coding for sections of interview describing quality of health care. With inputs from BS, the analysis was finalized. PS and JC wrote the first draft of the manuscript. Both PS and BE provided inputs in finalizing the manuscript. All authors have reviewed and approved the final manuscript.

Acknowledgments

We acknowledge all the interview participants of this study who provided us with valuable insights into medical tourism to Switzerland. We also thank two anonymous reviewers and the editor for their valuable comments that helped revise this manuscript.

Data sharing

The qualitative interview data collected during this research project and sections of analyzed data used in this manuscript are not available for public sharing. We do not have the permission from the study participants to make their interview data publicly accessible.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Schweizerische Akademie der Medizinischen Wissenschaften, (grant number Käthe-Zingg-Schwichtenberg-Fonds (KZS-Fonds)).

Ethics approval

The Ethikkommission Nordwest- und Zentralschweiz (EKNZ), (the Ethics Committee of Northwest and Central Switzerland) reviewed and exempted this study from ethics approval as regulated by the Swiss Human Research Act article 2. Therefore, the study did not require an approval from the ethics committee.

Guarantor

The corresponding author takes responsibility for the integrity of the work and confirms that he controlled the decision to publish.

ORCID iD

Priya Satalkar

Supplemental material

Supplemental material for this article is available online.

References

Carrera

Lunt

. A European perspective on medical tourism: the need for a knowledge base. Int J Health Serv 2010; 40: 469–484.

Snyder

Crooks

Adams

, et al. The ‘patient’s physician one-step removed’: the evolving roles of medical tourism facilitators. J Med Ethics 2011; 37: 530–534.

Johnson

Garman

. Impact of medical travel on imports and exports of medical services. Health Policy 2010; 98: 171–177.

Kangas

. Traveling for medical care in a global world. Med Anthropol 2010; 29: 344–362.

Foley

Haglin

Tanzer

, et al. Patient care without borders: a systematic review of medical and surgical tourism. J Travel Med 2019; 26. DOI: 10.1093/jtm/taz049

Heung

Kucukusta

Song

. A conceptual model of medical tourism: implications for future research. Journal of Travel & Tourism Marketing 2010; 27: 236–251.

Swiss Tourism Federation. Swiss tourism in figures: structure and industry data. Bern, Switzerland, 2019.

Glinos

Baeten

Helble

, et al. A typology of cross-border patient mobility. Health Place 2010; 16: 1145–1155.

Hanefeld

Lunt

Smith

, et al. Why do medical tourists travel to where they do? The role of networks in determining medical travel. Soc Sci Med 2015; 124: 356–363.

10.

Labonte

Crooks

Valdes

, et al. Government roles in regulating medical tourism: evidence from Guatemala. Int J Equity Health 2018; 17: 50.

11.

Crooks

Labonté

Ceron

, et al. “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. Hum Resour Health 2019; 17: 53.

12.

Oesterle

Johnson

Delgado

. A unifying framework of the demand for transnational medical travel. Int J Health Serv 2013; 43:http415–436.

13.

De Pietro

Camenzind

Sturny

, et al. Switzerland: health system review. Health Syst Transit 2015; 17: 1–288.

14.

OECD/WHO. OECD Reviews of health systems: Switzerland 2011. OECD Publishing, 2011.

15.

Bundesamt für Gesundheit BAG. Kennzahlen der Schweizer Spitäler, 2022.

16.

Swiss Tourism. Product Development Health Tourism, 2019.

17.

Hofer

Honegger

Hubeli

. Health tourism: definition focused on the Swiss market and conceptualisation of health (i) ness. J Health Organ Manag 2012; 26: 60–80.

18.

Braun

Clarke

. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77–101.

19.

Connell

. From medical tourism to transnational health care? An epilogue for the future. Soc Sci Med 2015; 124: 398–401.

20.

Crooks

Cohen

Adams

, et al. Inbound medical tourism to Barbados: a qualitative examination of local lawyers’ prospective legal and regulatory concerns. BMC Health Serv Res 2015; 15: 91.

21.

Hanefeld

Smith

Horsfall

, et al. What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. J Travel Med 2014; 21: 410–417.

22.

Lunt

Carrera

. Medical tourism: assessing the evidence on treatment abroad. Maturitas 2010; 66: 27–32.

23.

Dalstrom

. Medical travel facilitators: connecting patients and providers in a globalized world. Anthropol Med 2013; 20: 24–35.

24.

Chee

Whittaker

Por

. Medical travel facilitators, private hospitals and international medical travel in assemblage. Asia Pac Viewp 2017; 58: 242–254.

25.

Anufriyeva

Pavlova

Stepurko

, et al. The validity and reliability of self-reported satisfaction with healthcare as a measure of quality: a systematic literature review. Int J Qual Health Care 2020; 33. DOI: 10.1093/intqhc/mzaa152

26.

Turner

. Quality in health care and globalization of health services: accreditation and regulatory oversight of medical tourism companies. Int J Qual Health Care 2010; 23: 1–7.

27.

Hanefeld

Powell-Jackson

Balabanova

. Understanding and measuring quality of care: dealing with complexity. Bull WHO 2017; 95: 368.

28.

Kruk

Kelley

Syed

, et al.

Measuring quality of health-care services: what is known and where are the gaps?

Bull WHO 2017; 95: 389.

29.

Brubakk

Vist

Bukholm

, et al. A systematic review of hospital accreditation: the challenges of measuring complex intervention effects. BMC Health Serv Res 2015; 15: 1–10.

30.

Araujo

Siqueira

Malik

. Hospital accreditation impact on healthcare quality dimensions: a systematic review. Int J Qual Health Care 2020; 32: 531–544.

31.

Turner

. ‘First world health care at third world prices’: globalization, bioethics and medical tourism. BioSocieties 2007; 2: 303–325.

32.

Hyder

Rydback

Borg

, et al. Medical tourism in emerging markets: the role of trust, networks, and word-of-mouth. Health Mark Q 2019; 36: 203–219.

33.

Andersen

Pedersen

Dupont

, et al. General practitioners’ attitudes towards and experiences with referrals due to supplemental health insurance. Fam Pract 2017; 34: 581–586.

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