The effects of medical tourism: Thailand s experience

Transcription

1 See discussions, stts, nd uthor profiles for this publiction t: The effects of medicl tourism: Thilnd s experience Article in Bulletin of the World Helth Orgnistion My 211 Impct Fctor: 5.9 DOI: /BLT Source: PubMed CITATIONS 35 READS uthors: Anchn Nrnong Ntionl Institute of Development Adminis 5 PUBLICATIONS 67 CITATIONS Viroj Nrnong TDRI: Thilnd Development Reserch Insti 11 PUBLICATIONS 72 CITATIONS SEE PROFILE SEE PROFILE Avilble from: Viroj Nrnong Retrieved on: 11 My 216

2 Reserch The effects of medicl tourism: Thilnd s experience Anchn NRnong & Viroj NRnong b Objective To explore the positive nd negtive effects of medicl tourism on the economy, helth stff nd medicl costs in Thilnd. Methods The finncil repercussions of medicl tourism were estimted from commerce ministry dt, with modifictions nd extrpoltions. Survey dt on 4755 foreign nd Thi outptients in two privte hospitls were used to explore how medicl tourism ffects humn resources. Trends in the reltive prices of cesren section, ppendectomy, herni repir, cholecystectomy nd knee replcement in five privte hospitls were exmined. Focus groups nd in-depth interviews with hospitl mngers nd key informnts from the public nd privte sectors were conducted to better understnd stkeholders motivtions nd prctices in connection with these procedures nd lern more bout medicl tourism. Findings Medicl tourism genertes the equivlent of.4% of Thilnd s gross domestic product but hs excerbted the shortge of medicl stff by luring more workers wy from the privte nd public sectors towrds hospitls ctering to foreigners. This hs rised costs in privte hospitls substntilly nd is likely to rise them in public hospitls nd in the universl helth-cre insurnce covering most This s well. The brin drin my lso undermine medicl trining in future. Conclusion Medicl tourism in Thilnd, despite some benefits, hs negtive effects tht could be mitigted by lifting the restrictions on the importtion of qulified foreign physicins nd by txing tourists who visit the country solely for the purpose of seeking medicl tretment. The revenue thus generted could then be used to trin physicins nd retin medicl school professors. Abstrcts in,عريب 中文, Frnçis, Pусский nd Espñol t the end of ech rticle. Introduction Unlike generl tourists needing medicl ttention, medicl tourists re people who cross interntionl borders for the exclusive purpose of obtining medicl services. Medicl tourism hs incresed in prt becuse of rising helth-cre costs in developed countries, cross-border medicl trining nd widespred ir trvel. The medicl tourism industry hs been growing worldwide. It involves bout 5 countries in ll continents nd severl Asin countries re clerly in the led. In Asi, medicl tourism is highest in Indi, Singpore nd Thilnd. These three countries, which combined comprised bout 9% of the medicl tourism mrket shre in Asi in 28, 1 hve invested hevily in their helth-cre infrstructures to meet the incresed demnd for ccredited medicl cre through first-clss fcilities. 2,3 In 27, Thilnd provided medicl services for s mny s 1.4 million foreign ptients, including medicl tourists, generl tourists nd foreigners working or living in Thilnd or its neighbouring countries. If we ssume tht bout 3% of ll foreign ptients tht yer were medicl tourists conservtive figure by comprison with the Boston Consulting Group s estimte of 5% in 26 4 the totl number would hve been bout 42. This ws more thn in Singpore, formerly reputed to be the leding Asin medicl tourist destintion nd the medicl hub of Asi. 5 Although medicl tourists re still smll frction of the 1.5 million foreigners who receive medicl cre in Thilnd, they re the tourist group most likely to ffect the country in mjor wy. Unlike generl tourists nd exptrites, medicl tourists re incresing t rpid pce from lmost none to 45 yer in less thn decde. Moreover, medicl tourists tend to seek more intensive nd costly tretments thn other foreign ptients, s result of which their effect on the country is more profound. In this pper Thilnd is used s cse study to exmine the min effects of medicl tourism on country s economy nd helth system. The finl section of the pper discusses policy implictions nd provides some policy recommendtions. Methods This pper focuses on medicl tourism. However, singling out dt for medicl tourists is difficult becuse Thilnd breks their dt down into This nd foreigners but not into foreigners who re medicl tourists nd other foreigners seeking medicl cre. Another reson tht these two groups re usully lumped together is tht most foreign ptients behve similrly when seeking helth cre, shre similr views regrding ptient s rights, nd hve similr helth-cre needs. Once they fll ill nd need helth cre, they tend to hve similr demnds nd requirements. It must be borne in mind, however, tht the fct tht the dt for ll foreigners re lumped together mkes the men vlues obtined for the verge medicl tourist (e.g. in terms of physicin time required) usully higher thn the men vlues obtined for the verge foreign ptient. The study is divided into three prts. The first prt estimtes the effects of medicl tourism on the Thi economy in terms of revenues from medicl services nd vlue dded gined from the ctivities of ptients nd the compnions trvelling with them before nd fter medicl tretment. In generl, revenues from either medicl services or tourist ctivities include the costs of services nd mterils, some of which, especilly new drugs nd dvnced equipment, re imported. Hence, the domestic vlue dded (the revenue left fter subtrcting the cost of imported mterils) is better indictor of the net economic benefit of medicl tourism thn totl revenues. Theoreticlly, however, the vlue dded figures presented here re overestimted, especilly School of Public Administrtion, Ntionl Institute of Development Administrtion, 118 Sereethi Rod, Klong Chn, Bngkpi, Bngkok, 124, Thilnd. b Thilnd Development Reserch Institute, Bngkok, Thilnd. Correspondence to Anchn NRnong (e-mil: nchn@gmil.com). (Submitted: 22 September 29 Revised version received: 14 Februry 211 Accepted: 15 Februry 211 Published online: 28 Februry 211 ) 336 Bull World Helth Orgn 211;89: doi:1.2471/blt

3 Anchn NRnong & Viroj NRnong Reserch with helth-cre providers income included in the clcultions. This is becuse without foreign ptients, these providers would probbly spend more time with Thi ptients nd some positive vlue dded would still be generted (even if lower thn the vlue dded generted from serving foreign ptients) long with improvements in helth sttus nd socil welfre for Thi citizens. The estimted effects of medicl tourism were prtly bsed on dt furnished by Thilnd s Ministry of Commerce, with some modifictions nd extrpoltions to fit vrious scenrios nd ssumptions tht we considered more relistic. The estimtions nd projections were mde in two prts: (i) revenue nd vlue dded from medicl services provided to foreign ptients, nd (ii) revenue nd vlue dded from the ctivities of medicl tourists nd their trvelling compnions, including before nd fter the medicl tretment. The methods (with min scenrios nd ssumptions) used to mke estimtes nd projections re s follows: The study estimtes revenues nd vlue dded from medicl tourism in under high- nd lowgrowth scenrios, s follows: High growth: The number of foreign ptients grows t yerly rte of 16%. The ssumption ws bsed on the verge geometric growth rte of foreign ptients in (figures from the Ministry of Commerce), period in which medicl tourism in Thilnd expnded rpidly. Low growth: The number of foreign ptients grows t one hlf the verge nnul rte of 2.5% seen in becuse of potentil competition or chnges in Thi government policies. This scenrio rests on the ssumption tht the rte of growth of foreign ptients will continue to fll to only hlf of the growth rte in 25 27, period during which, ccording to the Ministry of Commerce, the rte ws the lowest in 7 yers. The verge revenue per foreign ptient in 26 nd 27 ws bsed on figures from the Deprtment of Export Promotion of Thilnd s Ministry of Commerce. The revenues for 28 nd lter were ssumed to grow t 1% per yer on verge. This growth rte is slightly lower thn the 16% verge growth rte in medicl service chrges for high-end hospitls (figure obtined from interviews with hospitl dministrtors) tht resulted from the expected increse in competition in both domestic nd interntionl mrkets. The vlue dded (including wges) of medicl services ws ssumed to be 66.7% of the gross revenue, lower thn the implied rte of 91 92% estimted for Singpore (Ministry of Trde nd Industry of Singpore, The Helth Cre Services Working Group, n.d.). This is likely to be n overestimtion since expensive medicl equipment nd medicines re being imported nd Thi hospitls tend to chrge lower medicl service fees thn their counterprts in Singpore. At the sme time, the vlue dded (including wges) should be greter thn 5%, since lbour costs for public hospitls ccount for pproximtely 5% or more of the totl cost of helth-cre services 6,7 nd privte hospitls, especilly those ttending medicl tourists, should hve higher lbour costs thn most public hospitls. The verge revenue from hotels nd tourism per foreign ptient in the bse yer (28) ws estimted t 1% of totl medicl chrges. This rther low figure reflects the fct tht pproximtely 6% of ll foreign ptients reside in Thilnd nd nother 1% re tourists tht become sick while visiting the country. Only the remining 3% of foreign ptients re medicl tourists who trvel to Thilnd explicitly to seek medicl services nd who generte extr revenue from hotel chrges nd tourism. For these ptients, non-medicl expenses, which would pply to the periods spent outside the hospitl before nd fter tretment, were ssumed to be 33.3% of their medicl chrges (including hospitl room nd mels). The verge revenue from hotel nd tourist chrges for the individuls ccompnying the medicl tourist ws ssumed to be 15% of the totl medicl chrges in 28, other ssumptions being tht only three fourths of the ptients would hve one person ccompnying them (informtion obtined from interviews with hospitl dministrtors nd medicl tour compnies) nd tht ech trvelling compnion would spend twice s much on hotels nd tourism s the ptient. Medicl tourists lmost certinly spend less on hotels nd tourism thn the individuls ccompnying them. However, these individuls re not likely to spend much more thn the ptients themselves, since they spend little time on their own when cring for the ptients. Vlue dded from tourism ws ssumed to be 5% of revenues (s suggested by Singpore s estimtes of %, but wges in Singpore re significntly higher thn in Thilnd) nd to increse by 1% in 28 (due to the high infltion rte tht yer) nd by 6.7% per yer in the following yers. The second prt of the pper estimtes the effects of medicl tourism in Thilnd on helth service prices nd on medicl stffing, prticulrly on the demnd for physicins. To relisticlly estimte foreign ptients demnd for physicins, we collected informtion on the time tht foreign nd Thi outptients spent with physicin in two privte hospitls. One ws the flgship of mjor network of high-end fcilities whose foreign customers re primrily non-asin; the other ws hospitl where most foreign customers were from southern Asi nd the Middle Est. We hypothesized tht foreign ptients would spend longer on verge with the physicin, prtly becuse of the demnds of communicting in English or through interpreters nd becuse non-asin foreign ptients tend to sk more questions nd engge in more interctive discussions with physicins thn Thi ptients. In the first hospitl we collected dt on pproximtely 4 outptients who visited 19 different physicins in vrious deprtments (orthopedics, neurology, gstroenterology, obstetrics nd gynecology, surgery, crdiology, otolryngology nd internl medicine). In the second hospitl we collected dt from 755 ptients who visited 6 physicins. We then used multiple regression to control tretment vribility for ech physicin in different deprtments. We distinguished Thi from foreign ptients on the bsis of first nd lst nmes nd the lnguges in which nmes were entered in the medicl record, nd we used dummy vrible for the ptient s ntionlity. We lso employed 18 nd 5 physicin-specific dummy vribles, respectively, to ccount for the fixed effect Bull World Helth Orgn 211;89: doi:1.2471/blt

4 Reserch Fig. 1. Projected revenue generted by foreign ptients: high- nd low-growth scenrios, Thilnd, High-growth scenrio Revenues (millions of bht) Low-growth scenrio b Revenues (millions of bht) of ech physicin, which could reflect both the physicin s self-effect nd the deprtment-specific effect. The lst prt of the pper mesures trends in the reltive prices of helth-cre services for Thi ptients in privte hospitls. We requested empiricl price dt for from both privte hospitls trgeting primrily foreign ptients nd from hospitls tht focus on Thi ptients. A focus group composed of surgeons nd hospitl dministrtors (lso physicins) from leding privte hospitls chose five representtive surgicl procedures: cesren section, ppendectomy, herni repir, cholecystectomy nd knee replcement. These were conventionl tretments with little price vrition mong ptients nd drugs were not significnt prt of their costs becuse we excluded cses with complictions. We then explored the chnges in totl chrges per ptient (or for typicl ptient under typicl service pckge) over the preceding 5 yers (or the most recent yers for which dt were vilble) p 29p 21p 211p 212p 27 28p 29p 21p 211p 212p Projected medicl services revenue Projected ccommodtion nd tourism revenue Projected totl revenue from interntionl ptients nd their compnions Number of interntionl ptients p, projected. Scenrio in which the number of foreign ptients in Thilnd is ssumed to grow t fster rte thn t present (16% per yer). b Scenrio in which the number of foreign ptients in Thilnd is ssumed to grow t hlf the verge nnul rte of 2.5% seen in (possible resons: greter competition, the estblishment of hospitls overses, or new government regultions) Foreign ptients (millions) Foreign ptients (millions) Rel price chnges for public hospitls, whose service prices re set by the government, re roughly reflected by the per cpit government budget for vrious public schemes under the overrching universl helth-cre coverge scheme. Results Effects on the economy In 28, medicl tourism in Thilnd generted 46 to 52 billion bht (1 United Sttes dollr [US$] = 3 bht) of revenue from medicl services plus 12 to 13 billion bht from relted tourism. This mkes for totl revenues of 58 to 65 billion bht (Fig. 1), which trnslte into vlue dded (Fig. 2) of 31 to 35 billion bht from medicl services plus 5.8 to 6.5 billion bht from tourism. This mounts to totl vlue dded of 36.8 to 41.6 billion bht or.4% of the gross domestic product (GDP). Under vrious scenrios, the vlue dded from medicl tourism is projected to rech between 59 nd 11 billion bht in 212. Anchn NRnong & Viroj NRnong Stffing nd helth service prices This section estimtes the effects of medicl tourism in Thilnd on medicl stff, especilly physicins, who re in shortest supply, 8,9 nd on the price of helth-cre services in privte hospitls. Foreign ptient demnd for physicins In the first hospitl, the verge time physicins spent per outptient visit ws 33 minutes 32 for Thi outptient (bsed on the predicted regression result of the time the medin physicin, i.e. the tenth physicin out of the 19, spent with typicl Thi ptient) nd 33.4 for typicl foreign ptient. Despite its high sttisticl significnce (t = 2.398; P =.17 for the ntionlity dummy vrible), the difference is rther smll (1.4 minutes). This could result from self-selection bis, since the mjority of Thi customers visiting this hospitl re welthy nd my resemble non-asins in their helth-creseeking behviour. In the second hospitl, the medin physicin spent n verge of 29.8 minutes per visit with typicl foreign outptient, compred with 25.3 minutes with typicl Thi outptient. This 4.5-minute difference ws lso sttisticlly significnt (t = 3.725; P =.). The results from both hospitls, despite being slightly different, suggest tht the time spent by ech physicin on medicl tourists gretly exceeds previous projections Thus, full-time physicin would be ble to see only 14 to 16 foreign ptients per dy on verge rther thn 4 to 48 (n verge of 1 to 12 minutes per ptient), s estimted by Pchnee & Wibulpolprsert. 1 The results from these the two hospitls suggest tht the ctul demnd for physicins my be three times s high s estimted by Pchnee & Wibulpolprsert. Therefore, if the more relistic figures from our reserch, which re bout three times higher thn Pchnee & Wibulpolprsert s estimte, re pplied in conjunction with these uthors other ssumptions (e.g. tht interntionl ptients will represent 14 16% of ll ptients in nd 1 12% in ), the dditionl demnd for physicins could climb to in nd to in (Tble 1). Furthermore, most of the physicins demnded by foreigners re specilists who hve trined nd prctised for t lest 1 yers on verge. 338 Bull World Helth Orgn 211;89: doi:1.2471/blt

5 Anchn NRnong & Viroj NRnong Reserch Thi ptient demnd for physicins Thilnd s universl helth-cre coverge includes the socil security scheme, the civil servnt medicl benefit scheme nd gold crd scheme (known s the 3-bht scheme before the 3-bht fee ws bolished in 26). 13 The gold crd scheme requires 1 generl prctitioner per 1 people t the primry-cre level. This stndrd is low. If we ssume n verge of 2.5 nnul visits per ptient, by this stndrd the verge generl prctitioner would hve to see 1 outptients dily nd work 25 dys per yer. When these figures re combined with the optimum rtio stipulted by the Ministry of Public Helth of 1.5 specilists for every generl prctitioner, the overll requirement would be for 1 physicin per 4 people. If we pply the miniml humn resource stndrd set by the gold crd scheme to ll schemes under the ssumption tht physicins re uniformly distributed throughout the country in proportion to popultion density, minimum of physicins would be needed for the 65 million This. However, this ssumption is unrelistic. The per cpit distribution of physicins is very uneven in Thilnd. According to Tble 2, there were physicins in 26. However, in the north-estern region, which is the lrgest both in terms of territory nd popultion, the number of physicins in both the public nd the privte sectors Fig. 2. Projected vlue dded generted by foreign ptients: high- nd low-growth scenrios, Thilnd, High-growth scenrio Revenues (millions of bht) Low-growth scenrio b Revenues (millions of bht) p 29p 21p 211p 212p 27 28p 29p 21p 211p 212p Projected vlue dded from medicl services Projected vlue dded from tourist ccomodtions nd ctivities Projected totl vlue dded from interntionl ptients nd their compnies Number of interntionl ptients p, projected. Scenrio in which the number of foreign ptients in Thilnd is ssumed to grow t fster rte thn t present (16% per yer). b Scenrio in which the number of foreign ptients in Thilnd is ssumed to grow t hlf the verge nnul rte of 2.5% seen in (possible resons: greter competition, the estblishment of hospitls overses, or new government regultions) Foreign ptients (millions) Foreign ptients (millions) Tble 1. Projected demnd for physicins by foreign ptients in Thilnd, Foreign ptient visits per yer (millions) Totl no of outptient equivlent Physicin demnd by foreigners Outptients b (1) Inptients (2) visits per yer (millions) (3) c Projection d (4) Revised projection e (5) p p p p p p p p, projected. Includes ll foreigners, not just medicl tourists. b s 21 23, dt from Ministry of Commerce survey djusted upwrd by 3%; yers 25 nd 27, growth rte ssumed to be t 18 2% per yer; yers 29 nd 211, growth rte ssumed to be t 14 16% per yer; yers 213 nd 215, growth rte ssumed to be t 1 12% per yer. c (3) = [(1) + 2] (2). d Ech physicin ssumed to be ble to ccept 1 to 12 foreign outptient visits per yer (4 to 48 ptients per dy). e Projection revised by the uthor with ech physicin ssumed to be ble to see mximum of 16 foreign ptients per dy. This revised projection ws mde by djusting the ssumption on physicins time spent with ech ptient, which would triple the demnd for physicins: (5) = (4) (3). Source: (1) to (4) dt from Pchnee & Wibulpolprsert. 1 Bull World Helth Orgn 211;89: doi:1.2471/blt

6 Reserch Anchn NRnong & Viroj NRnong Tble 2. Number nd distribution of physicins in Thilnd, by yer, No. of physicins Popultion per physicin Southern region Northern region North-estern region BKK Centrl region Totl Entire country Privte hospitls Public hospitls MPH Other government gencies BKK, Bngkok; MPH, Ministry of Public Helth. is still below the megre stndrd of 1 physicin per 4 people. Pchnee & Wibulpolprsert lso projected the dditionl demnd for physicins by Thi ptients until the yer 215 (Tble 3). 1 Their projection, even fter djustment for foreign ptients demnd for physicins, suggests potentil improvement in the sitution fter 21, when new medicl grdutes will expectedly increse from 15 to 23 per yer nd exceed the dditionl number needed (Tble 4). However, there re severl shortcomings to this pproch. First, the uthors ssume tht one physicin cn ttend from 18 to 2 outptient visits (or 9 to 1 inptients) per yer, or s mny s 72 to 8 ptients per dy. Second, this pproch is bsed on the flow of new demnd nd supply, without considering pst physicin shortges. Third, the ctul distribution of medicl stff is very uneven in Thilnd nd redistribution ttempts hve rrely succeeded. Moreover, most foreign ptient demnd is for specilists verging 1 or more yers of trining nd prctice. Therefore, surging demnd for prticulr specilists from medicl tourism could still generte shortges in prticulr specilty res, despite ny net surplus of new physicins. Physicins re not the only medicl workers in short supply. At present, dentists re in extremely short supply, especilly in rurl res, nd their shortge is rgubly greter thn tht of physicins. In 26, Thilnd hd fewer thn 42 dentists; the rtio of people to dentists ws 15 :1 in the country nd 22 :1 in the north-estern region. 9 Since mny medicl tourists fly in for dentl work, medicl tourism cn hve very profound effect on Thi ptients ccess to dentl cre. The shortge of nurses is nother mjor problem, ccording to severl hospitl dministrtors. Effect on helth-cre service prices In generl, the price of non-exportble good or service is determined solely by domestic demnd nd supply. A flux of medicl tourists (in greter numbers thn ny increse in the number of physicins, including s result of returning from brod or migrting bck into the country) would therefore increse the price of helth-cre services in Thilnd. Although higher prices for helthcre services potentilly generte more foreign revenue for the country, foreign- 34 Bull World Helth Orgn 211;89: doi:1.2471/blt

7 Anchn NRnong & Viroj NRnong Reserch Tble 3. Projected demnd for physicins by Thi ptients, Thilnd, Estimted visits per ptient per yer Popultion (million) Outptient equivlent visits (million) Demnd for physicins by Thi ptients Outptients Inptients NA NA NA NA 23p p p p p p p NA, not pplicble; p, projected. Under the ssumptions tht only 7% of outptients need to see physicin nd tht ech physicin cn ttend 18 to 2 Thi outptients (or 9 to 1 inptients) per yer, equivlent to pproximtely 72 to 8 outptient visits dy. Source: Pchnee & Wibulpolprsert. 1 ers demnd for helth-cre services could undermine locl ptients ccess to qulity helth cre. Here we exmine trends in the reltive price of helth-cre services in vrious privte hospitls, some ctering to foreign ptients nd others to locl ptients. We collected nd nlysed dt for (or for the yers for which the most recent dt were vilble) on the totl chrges per ptient (or for typicl ptient pckge) for the five representtive medicl procedures mentioned erlier in the pper. While the verge chrges for these procedures incresed substntilly during (by 1 25% per yer in most hospitls in this study), between most price increses were single-digit nd prices even dropped in representtive hospitl (e.g. verging 1.1% per yer for cesren section, 8.8% for ppendectomy,.9% for herni repir surgery nd 4.9% for knee surgery). These dt re consistent with public complints tht rpidly rising medicl chrges in privte hospitls re mking it more difficult for mny middle-income This to continue to seek tretment in high-end hospitls, on which they used to rely on regulr bsis. Although dt on prices lone re not sufficient to test the hypothesis tht the recent rpid increse in the price of helth-cre services stems from the expnsion of medicl tourism, they re consistent with predictions bsed on economic theory. While the prices of helth-cre services hve incresed, most This with modest incomes hve now become more dependent on the universl helth-cre coverge scheme. 14 Moreover, since hospitls for medicl tourists hve lured mny highly skilled physicins nd specilists out of public nd teching hospitls, the mjority of This will henceforth probbly receive helth-cre services of lesser qulity (or hve reduced ccess nd shorter visiting times). To mintin the qulity of the services these public schemes provide, in lte 28 the Ministry of Public Helth drsticlly chnged its compenstion scheme by prcticlly doubling physicins totl slry in ll community hospitls nd by substntilly incresing dentists, phrmcists nd nurses compenstion. In lte 29, the sme hikes were lso pplied in the Ministry s provincil nd regionl hospitls. Initilly hospitls hd to finnce their py hikes with their own svings, but fter the first yer the government provided dditionl budget to community hospitls nd subsequently gve n emergency funds to remining Ministry hospitls. Eventully, these py hikes will substntilly increse the cpittion budget for the universl helthcre coverge scheme, which ws lredy more thn doubled between fiscl yers 21 nd 211 (122 versus 2546 bht per cpit, respectively), even before the inclusion of the py hike. Thus, the competing demnd for helth-cre stff generted by medicl tourism will more thn likely led the Thi government to increse its budget for public helth-cre services especilly to cover physicins incomes t higher nd fster rte thn in the bsence of medicl tourism. Tble 4. Projected totl demnd for physicins in Thilnd, by yer, Incrementl demnd by Thi ptients (1) Incrementl demnd by foreign ptients (2) Totl incrementl demnd per 2 yers (3) b Totl incrementl demnd per yer (4) c 27p p p p p p, projected. Estimted by the uthors ssuming tht ech physicin cn see no more thn 16 foreign ptients per dy. b (3) = (1) + (2). c (4) = (3) (2). Bull World Helth Orgn 211;89: doi:1.2471/blt

8 Reserch Anchn NRnong & Viroj NRnong Discussion Medicl tourism generlly involves trnsporting ptients from developed countries to developing countries where they cn get treted t lower expense. These ptients do not necessrily belong to the highest socil brcket in their own countries, but they (nd their insurers) generlly hve greter purchsing power thn most ptients in the destintion countries. Most developing country governments see medicl tourism s n opportunity to generte more ntionl income nd therefore support it strongly However, without pproprite mngement medicl tourism cn become hevy burden for the public helth systems of these countries, especilly those with universl helth-cre coverge. In Thilnd, medicl tourism hs both positive nd negtive effects. For the Thi economy, medicl tourism genertes vlue dded pproximtely equl to.4% of the GDP. It helps rise income for the medicl services sector, the tourist sector nd ll relted businesses, nd it provides other intngible benefits. All of these direct nd indirect positive effects for the Thi economy re well recognized in the business ren. The negtive effects for Thi society stem from hving to provide helth-cre services for 42 to 5 medicl tourists nnully with the sme number of helth-cre stff. In this study these negtive effects re evidenced by both shortge of physicins nd by incresed medicl fees for self-pying This, which re likely to undermine their ccess to qulity medicl services. The very sme problems re likely to pply to other host countries. In Indi, similr dverse effects hve been detected. 18,19 More importntly, the influx of medicl tourists does not lwys led to win-win sitution nd to windfll income for host country governments, which my need to lern the hrd wy tht they will hve to increse their helth budgets to meet the rising nd highly competitive foreign demnd for helth services. To llevite the shortge of stff nd reduce helth-cre costs for This, Thilnd needs to increse its helth sector humn resources, especilly physicins, dentists nd nurses. We recommend tht the government: (i) llow certified foreign physicins to provide medicl services t lest to foreign ptients without hving to tke medicl certifiction exm in the Thi lnguge, s currently required; (ii) increse medicl stff trining in public universities to full cpcity; nd (iii) collborte with privte hospitls in trining more specilists. Medicl eduction in Thilnd is neither self-funded nor privtely funded; rther, it is hevily subsidized by Thi txpyers. With their much higher purchsing power, medicl tourists cn prevent Thi txpyers from ccessing qulity helth cre. Thus, the Thi government hs responsibility to blnce the welfre of Thi citizens ginst the extr income generted by medicl tourism. The government hs strong grounds for levying tx on medicl tourists, who, unlike Thi txpyers nd exptrites residing in Thilnd, rep benefits without helping to py the txes tht support physicin trining. The revenue from this tx should be used to expnd the trining of physicins nd other medicl stff nd to retin the best professors in public medicl schools. In the short run, the txes could lso mitigte the dverse effects of the extr demnd for helth-cre services on the prt of foreigners with higher purchsing power. Acknowledgements The uthors thnk Sirchi Jindrk (resercher), Ammr Simwll, Pnld Tripittykul nd Nontlee Vuttimnop, s well s the prticipnts t the Interntionl Acdemy of Business nd Public Administrtion Disciplines (IABPAD) Conference in Dlls, Texs, April 23 26, 29. Funding: This rticle is grounded in reserch project funded by the Office of the Ntionl Economic nd Socil Advisory Council of Thilnd. The reserch won the 29 Good Reserch Awrd in Politicl Sciences nd Public Administrtion from Thilnd s Ntionl Reserch Council. Competing interests: None declred. ملخص تأثريات السياحة العالجية: الخربة التايالندية الغرض التعر ف عىل التأثريات اإليجابية والسلبية للسياحة العالجية عىل االقتصاد والعاملني الصحيني والتكاليف الطبية يف تايالند. الطريقة أ جر ى تقييم للعواقب املالية للسياحة العالجية من معطيات وزارة التجارة مع إجراء تعديالت واستقراءات عىل تلك املعطيات. وأ جر ى مسح للمعطيات ضم 4755 مريضا خارجيا من األجانب والتايالنديني يف مستشفيني خاصني الستكشاف تأثري السياحة العالجية عىل املوارد البرشية. وف ح ص ت اتجاهات األسعار النسبية لجراحة القيرصية واستئصال الزائدة وإصالح الفتق واستئصال املرارة واستبدال الركبة يف خمسة مستشفيات خاصة. واست خدمت مجموعات الرتكيز وأ جر يت مقابالت متعمقة مع مدراء املستشفيات والجهات الرئيسية املعنية باملعلومات من القطاعني العام والخاص لتوسيع اإلدراك بدوافع ومامرسات أصحاب املصلحة يف ما يتصل بتلك اإلجراءات والتعر ف عىل نحو أفضل بالسياحة العالجية. النتائج ت د ر السياحة العالجية ما يعادل.4% من إجاميل الناتج املحيل يف تايالند لكنها تفاقم من نقص العاملة الطبية نتيجة إلغراء املزيد من العام ل عىل ترك القطاعني الخاص والعام والعمل يف املستشفيات التي تقد م خدماتها لألجانب. وهذا أدى إىل ارتفاع هائل يف التكاليف يف املستشفيات الخاصة ومن املرج ح ارتفاع التكاليف يف املستشفيات العامة والتأمني الصحي الشامل الذي يغط ي غالبية التايالنديني. االستنتاج مع أن للسياحة العالجية يف تايالند بعض املزايا لكن لها تأثريات سلبية ميكن التخفيف منها عن طريق رفع القيود عن استرياد األطباء األجانب املؤهلني وفرض الرضائب عىل السي اح الذين يزورون البلد بحثا عن العالج الطبي فقط. ومن ثم ميكن االستفادة من املوارد املالية امل تحص ل عليها يف تدريب األطباء والحفاظ عىل أساتذة الكليات الطبية. 342 Bull World Helth Orgn 211;89: doi:1.2471/blt

9 Anchn NRnong & Viroj NRnong Reserch 摘要 医疗旅游的影响 : 泰国的经验目的旨在探讨泰国医疗旅游对经济 医务人员和医疗成本的正面和负面影响 方法根据商务部的数据加以修改和推断, 估测了医疗旅游对金融的影响 从两家私立医院 4755 名外籍和泰国门诊病人所得的数据来探索医疗旅游如何影响人力资源 同时还审查了五家私立医院剖宫产 阑尾切除术 疝气修补 胆囊切除术和膝关节置换术相对价格的变化趋势 此外, 通过进行分组座谈会并与公共和私营部门的医院负责人和知情人进行深度访谈, 更好地了解与就医流程有关的利益相关者的动机和做法以及更多地了解医疗旅游 结果医疗旅游带来了相当于泰国国内生产总值.4% 的价值, 但是更多医务人员从私有和公共部门流向为外国人服务的医院, 也在一定程度上加剧了医务人员的短缺 这导致私立医院医疗成本大幅度增加, 并且可能引起公立医院医疗成本增加以及覆盖大多数泰国人的全民医疗保险成本增加 人才外流 还可能破坏未来的医疗培训 结论泰国的医疗旅游尽管有一些好处, 但也有负面影响, 负面影响可通过取消对引进合格外国医生的限制以及向那些仅为治疗而前往本国的旅游者征税的方法予以缓解 由此所产生的收入可用来培训医师和留住医学院教授 Résumé Les effets du tourisme médicl: l expérience thïlndise Objectif Exminer les effets positifs et négtifs du tourisme médicl sur Résultts Le tourisme médicl génère l équivlent de,4% du produit l économie, le personnel de snté et les coûts médicux en Thïlnde. intérieur brut thïlndis, mis il excerbe l pénurie de personnel Méthodes Les répercussions finncières du tourisme médicl ont été médicl en détournnt de plus en plus de trvilleurs des secteurs privé estimées à prtir de données émnnt du ministère du Commerce, vec et public u profit des hôpitux tritnt les étrngers. Cel se trduit des modifictions et des extrpoltions. Les données d une enquête pr une ugmenttion substntielle des coûts dns les hôpitux privés rélisée uprès de ptients mbultoires étrngers et thïlndis et il est probble qu il en ille de même u niveu des hôpitux publics dns deux hôpitux privés ont été utilisées fin d étudier l impct du et de l ssurnce snté universelle qui prend en chrge l pluprt des tourisme médicl sur les ressources humines. Les tendnces des Thïlndis. L «fuite des cerveux» est églement susceptible de porter trifs reltifs de l césrienne, de l ppendicectomie, de l réprtion de tteinte à l formtion médicle dns le futur. hernies, de l cholécystectomie et de l rthroplstie du genou dns cinq Conclusion Le tourisme médicl en Thïlnde, en dépit de certins hôpitux privés ont été exminées. Des groupes cibles et des entrevues vntges, des effets négtifs qui pourrient être tténués pr une pprofondies vec des directeurs d hôpitl et des témoins privilégiés des levée des restrictions ppliquées à l importtion de médecins étrngers secteurs public et privé ont été orgnisés fin de mieux comprendre les qulifiés et pr une txe visnt les touristes qui ne visitent le pys qu en motivtions et les prtiques des prties prenntes liées à ces interventions vue de bénéficier d un tritement médicl. Le chiffre d ffires qui serit et de renforcer les connissnces sur le tourisme médicl. insi généré pourrit ensuite servir à former des médecins et à retenir les professeurs des fcultés de médecine. Резюме Эффект от медицинского туризма: опыт Таиланда Цель Исследовать положительное и отрицательное влияние медицинского туризма на экономику, медицинский персонал и стоимость медицинского обслуживания в Таиланде. Методы Финансовый эффект от медицинского туризма оценивался по данным Министерства торговли с применением модификаций и экстраполяции. Для исследования воздействия медицинского туризма на персонал использовались данные опроса таиландских и иностранных пациентов, получавших амбулаторное лечение в двух частных больницах. Исследовалась динамика относительных цен на проведение кесарева сечения, аппендэктомии, оперативного лечения грыжи, холецистэктомии и замены коленного сустава в пяти частных больницах. Чтобы лучше понять мотивацию и практику участников в связи с этими процедурами и больше узнать о медицинском туризме, проводились фокус-группы и подробные интервью с руководящими работниками больниц и ключевыми информаторами. Результаты Медицинский туризм генерирует доход, эквивалентный,4% валового внутреннего продукта Таиланда. В то же время серьезной проблемой является дефицит медицинских кадров, вызванный переманиванием работников из медицинских учреждений частного и общественного секторов в больницы, обслуживающие иностранцев. Это привело к значительному росту затрат в частных больницах и, по-видимому, будет способствовать их повышению в государственных больницах и системе всеобщего медицинского страхования, охватывающей большинство таиландцев. Кроме того, в будущем «утечка мозгов» может привести к снижению уровня подготовки медицинских кадров. Вывод Медицинский туризм в Таиланде, несмотря на некоторые положительные стороны, порождает негативный эффект, который можно было бы снизить путем ужесточения ограничений на въезд квалифицированных иностранных врачей и усиления налогообложения туристов, посещающих страну исключительно в лечебных целях. Доход, накопленный в результате этого, мог бы быть использован для организации повышения квалификации врачей и стабилизации кадров преподавателей медицинских учебных заведений. Bull World Helth Orgn 211;89: doi:1.2471/blt

10 Reserch Anchn NRnong & Viroj NRnong Resumen Efectos del turismo médico: el cso de Tilndi Objetivo Anlizr los efectos positivos y negtivos que tiene el turismo médico en l economí, el personl snitrio y los gstos médicos de Tilndi. Métodos Ls repercusiones económics del turismo médico se clculron prtir de los dtos del Ministerio de comercio, con diverss modificciones y extrpolciones. Pr investigr cómo fect el turismo médico los recursos humnos se empleron los dtos de un encuest relizd pcientes mbultorios tilndeses y extrnjeros en dos hospitles privdos. Se nlizron ls tendencis de los precios relciondos con l cesáre, l pendicectomí, l herniorrfi, l colecistectomí y l rtroplsti de rodill en cinco hospitles privdos. Se creron grupos de investigción culittiv y se relizron entrevists minucioss los directores de hospitl y los informdores clve procedentes del sector privdo y público pr entender mejor los motivos y ls práctics de los interesdos relciondos con estos procedimientos y, de este modo, prender más cerc del turismo médico. Resultdos El turismo médico gener el equivlente l,4% del producto interior bruto de Tilndi, si bien h grvdo l flt de personl médico l tentr muchos trbjdores procedentes de los sectores público y privdo pr que trbjen en hospitles orientdos los extrnjeros. Esto h provocdo un umento sustncil de los costes en los hospitles privdos y probblemente tmbién conllevrá un umento de los mismos en los hospitles públicos y en el seguro snitrio universl del que se beneficin l myorí de los tilndeses. Est «fug de cerebros» tmbién podrí perjudicr l formción médic futur. Conclusión El turismo médico en Tilndi, pesr de ofrecer ciertos beneficios, present tmbién efectos negtivos que podrín mitigrse reduciendo ls restricciones pr l importción de personl médico culificdo procedente del extrnjero y grvndo con impuestos los turists que visiten este pís con el único propósito de someterse un trtmiento médico. Los ingresos que se obtuviern de este modo podrín emplerse en l formción de médicos y pr que los ctedráticos permneciern en l Fcultd de Medicin. References 1. Asin medicl tourism nlysis (28 212). New Delhi: RNCOS Industry Reserch Solutions; 29. Avilble from: Anlysis-Reports/Asin-Medicl-Tourism-Anlysis IM15.htm [ccessed 18 Februry 211]. 2. Ministry of Public Helth. Strtegies to develop Thilnd s centre of excellent helth cre of Asi. Nonthburi: MPH; Helthcre Services Working Group. Developing Singpore s the compelling hub for helthcre service in Asi. Singpore: Ministry of Trde nd Industry; 22. Avilble from: HEA_Annex1.pdf [ccessed 18 Februry 211]. 4. Overview of medicl tourism give bck deck. Boston Consulting Group; NRnong A, NRnong V, Jindrk S. The development guideline for Thilnd s medicl hub. Bngkok: Ntionl Institute of Development Administrtion; Tisyticom K, Ptchrnrumol W, Tngchroensthien V. Unit cost nlysis: stndrd nd quick methods. J Helth Sci 21;1: Chlie C. Costs of helth cre services of public hospitl: the cse study of four hospitls in Bngkok [thesis]. Bngkok: Chullongkorn University; NRnong V, NRnong A. The flow of helth personnel in public hospitls (Reserch Report No. 5). Bngkok: Thilnd Development Reserch Institute; Ministry of Public Helth. Monitoring nd mngement system (MMS) [Internet]. Bureu of Policy nd Strtegy, Ministry of Public Helth; 26. Thi. Avilble from: php [ccessed 18 Februry 211]. 1. Pchnee CA, Wibulpolprsert S. Incoherent policies on universl coverge of helth insurnce nd promotion of interntionl trde in helth services in Thilnd. Helth Policy Pln 26;21:31 8. doi:1.193/hepol/czl17 PMID: Thmmrngsri T. The pproprite geogrphicl distribution of doctors under the universl helth cre coverge schemes. Bngkok: Helth Insurnce System Reserch Office; Pnnirmi M, Sooksirisereekul S. Projection of illness ptterns nd demnd for doctors. Bngkok: Thilnd Development Reserch Institute; NRnong V, NRnong A, Trimworkul S, Wongmont S. Universl helth coverge schemes in Thilnd (revised Mrch 25). Bngkok: Thilnd Development Reserch Institute; NRnong A. The 3 bht helth cre scheme nd helth security in Thilnd. Bngkok: Ntionl Institute of Development Administrtion; Thukrl P. Indin government ll set to boost medicl tourism. Thindin News. 29 Feb 14. Avilble from: newsportl/press-relese/indin-government-ll-set-to-boost-medicltourism_ html [ccessed 23 Februry 211]. 16. Leng CH. Medicl tourism in Mlysi: interntionl movement of helthcre consumers nd the commodifiction of helthcre (Working Pper Series No. 83) Singpore: Asi Reserch Institute; 27. Avilble from: nus.edu.sg/showfile.sp?pubid=642&type=2 [ccessed 18 Februry 211]. 17. Singpore s Tourism Bord. Singpore set to be helthcre services hub of Asi [press relese]. 23 Oct 2. Avilble from: singporemedicine.com/pr/new21c.sp?id=881 [ccessed 23 Februry 211]. 18. Hzrik I. The potentil effect of medicl tourism on helth workforce nd helth systems in Indi. Asi Pcific Action Allince on Humn Resources for Helth; 28. Avilble from: [ccessed 23 Februry 211]. 19. Rmírez de Arellno AB. Ptients without borders: the emergence of medicl tourism. Int J Helth Serv 27;37:93 8. doi:1.219/ g uu PMID: Bull World Helth Orgn 211;89: doi:1.2471/blt