the problematization of medical tourism: a critique of neoliberalism

ARTICLES

THE PROBLEMATIZATION OF MEDICAL TOURISM:A CRITIQUE OF NEOLIBERALISMdewb_318 1..8

KRISTEN SMITH

Keywordsmedical tourism,developing world bioethics,medical travel,commercialization of health

care,India, health systems,human rights

ABSTRACTThe past two decades have seen the extensive privatisation and marketisationof health care in an ever reaching number of developing countries. Within thismilieu, medical tourism is being promoted as a rational economic developmentstrategy for some developing nations, and a makeshift solution to the escalat-ing waiting lists and exorbitant costs of health care in developed nations. Thispaper explores the need to problematize medical tourism in order to movebeyond one dimensional neoliberal discourses that have, to date, dominatedthe arena. In this problematization, the paper discusses a range of understand-ings and uses of the term ‘medical tourism’ and situates it within the context ofthe neoliberal economic development of health care internationally. Drawing ontheory from critical medical anthropology and health and human rights per-spectives, the paper critically analyzes the assumed independence betweenthe medical tourism industry and local populations facing critical health issues,where social, cultural and economic inequities are widening in terms of access,cost and quality of health care. Finally, medical tourism is examined in the localcontext of India, critiquing the increasingly indistinct roles played by govern-ment and private sectors, whilst linking these shifts to global market forces.

INTRODUCTION

If the promotional material originating from industry andthe governments of an increasing number of countries areto be believed, the dynamic growth of a fledgling industrycatering to the travel of people abroad for the purpose ofthe consumption of high-tech, specialised biomedical ser-vices is set to explode internationally. The internationalmarket in medical tourism is ostensibly driven by thecomplementary pressures of high demand and cost oftreatment in the West and the low cost and high quality ofcare in a number of developing countries. Reports on thecurrent global economic status of this service industry arewide ranging and predominantly industry based. Somereports have estimated it could be currently worth as muchas US$60 billion and growing at a rate of 20% per annum.1

Although much remains unquantified, the increasinglyaggressive development of medical tourism in countriessuch as India, Thailand and Malaysia indicate the impor-tance that is being placed on the sector as a vehicle forfuture economic development. From international tradeagreements through to national and state policies, theeconomic impetus for developing countries with thecapacity to cater for health-seeking travellers is growing.

India is positioning itself as one of the front-runners inthe global medical market, forging a reputation in anumber of health care services such as cardiac, cosmeticand joint surgery.2 One of the key drivers is theiradvanced medical technology, offered at vastly lower costthan the international equivalent. Hospitals, medicalbrokers, private practices and other ‘touts’ offer packagesthat include medical services, accommodation, air travel,

1 N. MacReady. Developing Countries Court Medical Tourists. Lancet2007; 369: 1849.

2 P. Shetty. Medical Tourism Booms in India, but at What Cost? Lancet2010; 376: 671–672.

Address for correspondence: Kristen Smith, University of Melbourne – Centre for Health and Society, Room 421A, Level 4 207 Bouverie Street,Parkville, Melbourne, Victoria 3010, Australia. Email: [email protected] of interest statement: No conflicts declared

Developing World Bioethics ISSN 1471-8731 (print); 1471-8847 (online) doi:10.1111/j.1471-8847.2012.00318.xVolume 12 Number 1 2012 pp 1–8

bioethicsdeveloping world

© 2012 Blackwell Publishing Ltd., 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.

bookings and the arrangement of tourist retreats andtours for the recuperation period.

Medical tourism is being promoted as a rational eco-nomic development strategy or export niche for develop-ing nations with a comparative advantage and a way ofoutsourcing healthcare for Western countries with esca-lating waiting lists and costs. However, left behind in thewake of these hospitals of excellence are local popula-tions facing critical health issues, where social, culturaland economic inequities are widening in terms of access,cost and quality of health care. This situation is exacer-bated in many of the countries actively promotingmedical tourism, as they are incrementally decreasingpublic health funding whilst continuing in patterns ofhealth care system commercialisation.

A concentration on inequity raises the question of whythe focus of medical tourism resides on economic profits.Dominant discourses centre almost solely on the partiesbenefitting from an industry that has both public andprivate entities pouring resources into high-cost, high-tech care for the comparatively rich. The comparativelyrich inclusively refers to the supposedly disenfranchisedAmerican medical ‘refugees’ without health insurance,who in terms of purchasing power parity are certainly so.3

An economic focus serves to ignore, or at least assume, alevel of independence between the industry and theabysmal lack of access to health care for the vast majorityof populations within countries such as India. This papercalls for a problematization of medical tourism, througha critique of the predominantly neoliberal discourses cur-rently framing the area.

An initial discussion examines a range of understand-ings and uses of the term ‘medical tourism’. Medicaltourism is then situated within the historical context ofneoliberal economic development in developing nationsand the concurrent push towards privatization of healthcare, primarily driven by international financial organi-zations. Drawing on theory from critical medical anthro-pology, the paper analyzes the dominant discoursesarising in the area.4 Then, from a health and human rightsbased perspective, questions are raised regarding the

absence of equity considerations in current debates.5

Finally, medical tourism is examined in the local contextof India, critiquing the increasingly blurred roles playedby government and private sectors, whilst linking theseshifts to global forces.

WHAT IS MEDICAL TOURISM?

In contemporary times medical tourism occurs acrossand between both richer and poorer countries and ismotivated by a variety of elements such as: cost of treat-ment; quality of services; length of waiting time; proce-dure (il)legality; and availability of complementary andalternative medicine.6 One of the first countries to activelypromote this new form of medical tourism was Cuba. Inthe early 1990s the Cuban government advertised ‘sunand surgery’ packages including dental, cardiac, organtransplant and cosmetic procedures in conjunction withspa or ‘wellness adventures’.7 In subsequent years, thelabels health tourism, cross-border care, medical traveland medical tourism have been used broadly and some-what interchangeably.8

The definition of medical tourism used within thisarticle is the movement of individuals abroad primarily toseek biomedical services. However, further examinationof this terminology is required in order to examine theusefulness, or more so, the applicability of the word‘tourism’.

The partner of an American that to travelled to Indiafor heart surgery due to a lack of health insurance cov-erage at home commented in a hearing before the UnitedStates Congress, ‘we were not tourists seeking an inex-pensive, exotic vacation while having medical treatment.

3 A.B.R. de Arellano. Patients Without Borders: The Emergence ofMedical Tourism. Int J Health Serv 2007; 37: 193–198.4 N. Scheper-Hughes & L.J.D. Wacquant. 2002. Commodifying bodies.London: Sage; H. Baer, M. Singer & I. Susser. 2003. Medical Anthro-pology and the World System. Westport, Connecticut, London: Praeger;L. Cohen. Migrant Supplementarity: Remaking Biological Relatednessin Chinese Military and Indian Five-Star Hospitals. Bod Soc 2011; 17:31; E.F.S. Roberts & N. Scheper-Hughes. Introduction: MedicalMigrations. Bod Soc 2011; 17: 1; N. Scheper-Hughes. Mr Tati’s Holidayand João’s Safari-Seeing the World through Transplant Tourism. BodSoc 2011; 17: 55; E.J. Sobo, E. Herlihy & M. Bicker. Selling medicaltravel to US patient-consumers: the cultural appeal of website market-ing messages. Anthropol Med 2011; 18: 119–136; M.C. Inhorn & Z.Gürtin. Cross-Border Reproductive Care: A Future Research Agenda.Reprod BioMed Online 2011; 22: 673–685.

5 P. Farmer. Rethinking Health and Human Rights: Time for a Para-digm Shift. J Law Med Ethics 2002; 30: 655; P. Farmer. 2005. Patholo-gies of Power: Health, Human Rights, and the New War on the Poor.Berkeley and Los Angeles: University of California Press; J.Y. Kim,J.V. Millen, A. Irwin & J. Gershman eds. 2000. Dying for Growth:Global Inequality and the Health of the Poor. Monroe, Maine: CommonCourage Press; B. Rylko-Bauer & P. Farmer. Managed Care orManaged Inequality? A Call for Critiques of Market-Based Medicine.Med Anthropol Q 2002; 16: 476.6 M.Z. Bookman & K.R. Bookman. 2007. Medical Tourism in Devel-oping Countries. New York: Palgrave Macmillan; V. Crooks, P. Kings-bury, J. Snyder & R. Johnston. What is known about the Patient’sExperience of Medical Tourism? A Scoping Review. BMC Health ServRes 2010; 10: 266.7 S. Eckstein. 2003. Back from the future: Cuba under Castro. NewYork: Routledge.8 I.G. Cohen. Medical Tourism: The View from Ten Thousand Feet.Hastings Cent Rep 2010; E.J. Sobo. Medical Travel: What It Means,Why It Matters. Med Anthropol 2009; 28: 326–335; L. Hopkins, R.Labonté, V. Runnels & C. Packer. Medical tourism today: What is thestate of existing knowledge? J Public Health Policy 2010; 31: 185–198;I. Glinos, R. Baeten, M. Helble & H. Maarse. A typology of cross-border patient mobility. Health Place 2010: 1145–1155.

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We were fighting for Howard’s life’.9 The contentionbeing that the label ‘tourism’ suggests a light-heartednessthat disregards the trauma involved for many engaging inthis kind of activity.

Similarly, an increasing number of academics have dis-puted the use of the word ‘tourism’ due to what isregarded as its ill-fitting, ‘suggestion of leisure and frivol-ity’ and lack of neutrality.10 However, it is precisely thisreason that makes it entirely appropriate, as the couplingof the two terms directly highlights the bioethical con-cerns inherent in the industry.

To break this down further, it is useful to separate the‘industry’ from the individual practice of medicaltourism. Although individuals certainly travel for pur-poses outside the traditional realms of commonly under-stood notions of tourism, the industry itself, in both itspromotion and presentation, positions itself firmly withinthis sphere. The uncanny parallels of the modern, five-star corporate hospital offering health services formedical travellers, with the corporate five-star hotelindustry do not arise by accident. Hospital websitesadvertise their international patient administrators as‘concierges’ and promote hotel style accommodationprovided for international patients, some even repletewith kitchenettes, adjoining bedrooms, gymnasiums,swimming pools and wall mounted, wide-screen televi-sions. These commercial, touristic elements are aggres-sively promoted by many hospitals participating in thetrade.

Within this current neoliberal capitalist paradigm, thecontinued use and coupling of the terms ‘medical’ and‘tourism’ can be seen as constructive as it serves to high-light the uncomfortable position and awkward self-conscious placement the industry occupies. It is here thatthe bioethical dimensions of the practice and industry arebrought into a much sharper focus than could beachieved with a more benign, descriptor such as the term‘medical travel’, which seems to be increasingly favouredby promoters within the industry and academia alike.11

It is important to recognize that this is an industrylauding itself in developing countries as a saviour tofloundering local public health systems and a driver forthe economic development of their nations. However, the

minute you step inside the opulent surrounds of an inter-national patient suite in a corporate or other tertiaryprivate hospital in India, and compare it to the crum-bling, overcrowded, open wards of public hospitals thatin some cases stand merely blocks away, it is evident thatthere is something seriously amiss within the limiteddominant discourses emerging from the sector.

NEOLIBERALISM ANDMEDICAL TOURISM

The global rise of market-led healthcare

The emergence of literature on the increasing role playedby the market in health has featured prominently in aca-demic journals, policy research papers for internationalinstitutions and international commissions. Contempo-rarily, mainstream development literature, informed byneoliberal economic theory, contends governmentsshould fund only an ‘essential’ or ‘basic’ level of curativecare where individuals are argued to be empowered asconsumers, due to the nature of competition. The ‘effi-ciency’ approach to health care came to dominanceacross the globe due to Structural Adjustment Programs(SAP) implemented across many countries in the 1980sand early 1990s, imposed by the World Bank and theInternational Monetary Fund (IMF). Generally, theSAPs ensured there were considerable reductions inpublic expenditure on health, amongst other sectors,through a range of measures argued to make the sectorsmore ‘efficient’.12

Arguments critiquing the impact of SAPs upon healthcare have generally focused upon their negative effectupon: (a) health outcomes of those in poverty; (b) reduc-tion in public health care budgets; and (c) the subsequentdecrease in quality, cost and provision of health careservices.13 This literature mainly argues that the rapid

9 United States Senate Special Committee on Aging. 2006. The Glo-balization of Health Care: Can Medical Tourism Reduce Health CareCosts? Washington, DC, USS. Available at: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_senate_hearings&docid=f:30618.pdf [Accessed 24 Jan 2012].10 B. Kangas. Hope from Abroad in the International Medical Travelof Yemeni Patients. Anthropol Med 2007; 14: 293–305, A. Whittaker, L.Manderson & E. Cartwright. Patients without Borders: UnderstandingMedical Travel. Med Anthropol 2010; 29: 336–343.11 B. Kangas. Traveling for Medical Care in a Global World. MedAnthropol 2010; 29: 344–362; Sobo. Medical Travel: What It Means,Why It Matters, Med Anthropol 2009; 28:326–335; Whittaker, Mander-son & Cartwright. op cit. note 10: 336–343.

12 S. Agarwal. India’s Emerging Economy: Performance and prospectsin 1990’s and Beyond. Finance India 2006; 20: 649–652; F. Ebrahimi.1996. Structural Adjustment in India. Geneva: Operations EvaluationDepartment (OED), World Bank. Available at: http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2004/05/07/000011823_20040507112856/Rendered/PDF/28681.pdf [Accessed24 Jan 2012].13 R. Baru. 2001. Health Sector Reforms and Structural Adjustment: AState-Level Analysis. In Public Health and the Poverty of Reforms: TheSouth Asian Predicament. I. Qadeer, K. Sen and K.R. Nayar, eds. NewDelhi, Thousand Oaks & London: Sage Publications: 211–234;I. Qadeer. 2001. Impact of Structural Adjustment Programs of Con-cepts in Public Health. In Public Health and the Poverty of Reforms: TheSouth Asian Predicament. I. Qadeer, K. Sen and K.R. Nayar, eds. NewDelhi, Thousand Oaks, London: Sage Publications: 117–136; J.E.Paluzzi & P.E. Farmer. op cit. note 5; 12–18; M. Fort, M.A. Mercer &O. Gish eds. 2004. Sickness and Wealth: The Corporate Assault onGlobal Health. Cambridge, Massachusetts: South End Press; J. Bennett.2001. Structural Adjustment and the Poor in Pakistan. In Public Health

The Problematization of Medical Tourism 3


integration of neoliberal, pro-privatisation policiesimplemented through SAPs have been to the detriment ofsocial welfare infrastructure in developing countries.14

Gloyd argues that the overall goal of economic growthencouraged in these development policies often overridesand conceals the negative outcomes, particularly in theway it intrinsically destabilises health and other socialservices.15 Several case studies of different countries inSouth Asia have also shown how SAPs undermine thecomprehensive nature of primary health care and encour-age vertical health programs, which have historicallybeen deemed as ineffective in either reducing the diseaseburden or in promoting health status.16

Despite widespread criticism, neoliberal efficiencyprinciples have guided systematic health reform acrossthe globe, with the primacy of the World Bank in influ-encing health policy dramatically increasing over thistime. There has also been an increasing concern regardingthe growing inequalities in the quality, access and cost ofhealth care services across different socio-economicgroups, which has been examined in multiple case studiesacross a wide range of international contexts.17 Commer-cialisation of health care services within systems has beenlinked to cycles of inequality within populations, includ-ing increased health care costs that place unsustainablefinancial burdens on households. These burdens causefurther exclusion from care and reduction in income dueto poor health and foster the divisive delivery of healthcare services in terms of quality, reinforcing social segre-gation whilst increasing health disparities within popula-

tions.18 A number of papers originating from the WorldBank have conceded that these effects are due to thefailure of markets to accommodate for the negativeimpacts of liberalisation on the poor in developing coun-tries, who are argued to be the most vulnerable to diseaseand least able to pay for market driven medical services.19

Medical tourism and neoliberal claims

Medical tourism is a prime example of a market-driven,commercialised medical service that is increasingly pro-moted as a vehicle for economic development in ‘lagging’economies. The emergent literature on medical tourismuses three central claims to argue its potential benefits.Firstly, it is contended that medical tourism will increaseexport earnings through attracting foreign exchange intothe country, hence lowering the fiscal deficit and assistingthe growth of the national economy.20 Secondly, it isargued that the combination of increased medical tech-nologies and the growth in the number of health special-ists and greater levels of expertise will generally raise thestandards of health care across the country through com-petitive market practices, which will eventually translateto an increase of the standards in the public sector.21

Thirdly, in line with standard neoliberal theory of eco-nomic development, it is argued that the economicgrowth medical tourism could generate would result in anoverall increase of national income, thus creating equityin access through allowing more of the population accessto private care.22

Despite these outlined arguments encouraging medicaltourism as a driver of economic development, it is widelyacknowledged that many economic development pro-grams implemented in the past have been extremely det-rimental to different sectors of the population due to the

and the Poverty of Reforms: The South Asian Predicament. I. Qadeer, K.Sen and K.R. Nayar, eds. New Delhi, Thousand Oaks, London: SagePublications: 51–62.14 R. Ahasan, T. Partanen & L. Keyoung. Global Corporate Policy forFinancing Health Services in the Third World: The Structural Adjust-ment Crisis. Int Q Community Health Educ 2001; 20: 3–15; Paluzzi &Farmer, A.-E. Birn & K. Dmitrienko. The World Bank: Global Healthor Global Harm? Am J Public Health 2005; 95: 1091.15 S. Gloyd. 2004. Sapping the Poor: The Impact of Structural Adjust-ment Programs. In Sickness and Wealth: The Corporate Assault onGlobal Health M. Fort, M.A. Mercer & O. Gish eds. Cambridge: SouthEnd Press. 43–54.16 Bennett, I. Qadeer, K. Sen & K.R. Nayar eds. 2001. Public Healthand the Poverty of Reform: The South Asian Predicament. New Delhi,Thousand Oaks, London: Sage Publications.17 E.A. Kerr, E.A. McGlynn, J. Adams, J. Keesey & S.M. Asch. Pro-filing the Quality of Care in Twelve Communities: Results from the CQIStudy. Health Aff 2004; 23: 247–256; A. Wagstaff. 2002. Inequalities inhealth in developing countries: swimming against the tide? Washington,DC: World Bank Publications; D. McIntyre, L. Gilson, H. Wadee, M.Thiede & O. Okarafor. Commercialisation and Extreme Inequality inHealth: The Policy Challenges in South Africa. J Int Dev 2006; 18:435–446; M. Mackintosh & S. Kovalev. Commercialisation, Inequalityand Transition in Health Care: The Policy Challenges in Developingand Transitional Countries. J Int Dev 2006; 18: 387–391; M. Mackin-tosh. Commercialisation, Inequality and the Limits to Transition inHealth Care: A Polanyian Framework for Policy Analysis. J Int Dev2006; 18: 393–406.

18 M. Mackintosh, op. cit. note 17.19 M. Das Gupta & M. Rani. 2004. India’s Public Health System: HowWell Does It Function at the National Level. In World Bank PolicyResearch Working Paper No. 3447. Washington, DC.: World Bank.Available at: http://www-wds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2004/11/30/000012009_20041130093207/Rendered/PDF/WPS3447.pdf [Accessed 24 Jan 2012]; S.V. Lall & M.Lundberg. 2006. What are Public Services Worth, and to Whom? Non-parametric Estimation of Capitalization in Pune. In World Bank PolicyResearch Working Paper 3924. Washington, D.C.: World Bank. Avail-able at: http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2006/05/19/000016406_20060519143259/Rendered/PDF/wps3924.pdf [Accessed 24 Jan 2012]; E. Diaz-Bonilla, J. Babinard,P. Pinstrup-Anderson & M. Thomas. 2002. Globalizing Health Benefitsfor Developing Countries. Washington, D.C.: International Food PolicyResearch Institute.20 Crooks, Kingsbury, Snyder & Johnston, op. cit. note 6.21 Bookman & Bookman, op. cit. note 6.22 J.C. Henderson. Healthcare Tourism in Southeast Asia. Pac TourismRev 2004; 7: 111–121; L. Turner. First World Health Care at ThirdWorld Prices: Globalization, Bioethics and Medical Tourism. BioSoci-eties 2007; 2: 303–325.

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disregard of their cumulative social effects. Alas, there area number of indicators that the medical tourism boomwill not prove any different.

In practice, all three of these arguments are, at best,optimistic ideals of what could possibly occur if regula-tory mechanisms within different countries are rigorouslyemployed to ensure the ‘trickle down’ outlined. Addition-ally there are a number of significant concerns regardingthe industry, particularly when operating in developingcountries. Firstly, the high-tech nature of most medicaltourism brings with it an association with modernism,which places it prominently and positively in the publiceye, serving as an example of a nation’s ‘progress’ and‘development’. This draws attention away from falteringpublic health systems and public health via a distortion ofpriorities.

Secondly, government promotion, concessions andincentives directed towards the medical tourism industryare challenged in contexts where public health expendi-ture is consistently reduced.23 Lastly, one of the mostwidely employed criticisms of medical tourism refers tothe further entrenchment of a two-tiered health system,where it could cause, or at least serve to exacerbate adual market structure consisting of: (1) a high qualityand high priced sector catering to foreigners and affluentnationals; and, (2) a resource constrained and lowerquality sector catering to the majority of the localpopulation.24

Human rights and equity concerns

The view of health as a human right has evolved along-side other human rights discourses. Although notexpressly stated as a right within the United Nations(UN) Universal Declaration of Human Rights, the UNEconomic and Social Council has directly stated that‘(h)ealth is a fundamental human right indispensable forthe exercise of other human rights’.25 The World HealthOrganisation has had substantial involvement in the pro-motion of health as a human right, as illustrated in theinfluential 1978 Alma Ata Declaration, which defineshealth as ‘a state of complete physical, mental and socialwellbeing, and not merely the absence of disease or infir-

mity’.26 This declaration expressly states that health is ahuman right, requiring the engagement of a range ofother social and economic areas in order to realise themaximum level of health.

When placing medical tourism in a rights-based healthframework, initial questions of inequity emerge as aprimary consideration. The definition of inequity, interms of health, is usually explained in conjunction withhealth inequality. Most simply defined, ‘inequity is anunfair and remediable inequality’, where health inequal-ity is a relative disparity in health status between differinggroups as defined by characteristics such as social, cul-tural, regional, economic and gender.27 Hence, theconcept of inequity entails a moral or ethical dimensionand is focused upon ‘creating equal opportunities forhealth and with bringing health differentials down to thelowest level possible’.28 Although equity approaches inhealth are broad in scope, most question the ostensiblyconflicting understandings of the way health and healthcare should be distributed.

This is highly pertinent to medical tourism, particularlyin countries with teetering public health systems, highlevels of income poverty, low levels of health insuranceand high levels of out-of-pocket spending. Medical tour-ism’s increasing prominence in the international systemcan be viewed as a result of its compatibility with thegrowth of the international market economy and throughits capacity to support the dominant capitalist class, in amanner that transcends national borders. Therefore,when viewed through the lens of claims on the humanright to health, healthcare services sold to medical tour-ists can be viewed as a form of appropriation. This isillustrated by countries such as India and Thailand,where the medical tourism industry is being developed astechnologically advanced, highly specialised health ser-vices specifically targeting those with considerably highereconomic capacity than the general populace. This will befurther explored in the context of India in the next sectionof the paper.

MEDICAL TOURISM IN INDIA

Commercialization of healthcare in India

Evidence of liberalisation within the health care systemhave emerged in India over the past thirty years, wherethe 1980s saw a major shift in policy direction, which upuntil that time had been dominated by the not-for-profit

23 P. Chacko. Medical Tourism in India: Issues and Challenges, MBAReview 2006; 4: 123–129; M. Lautier. Export of health services fromdeveloping countries: The case of Tunisia. Soc Sci Med 2008; 67: 101–110.24 R. Chanda. 2002. Trade in health services. Bull World Health Organ.Available at: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862002000200012&lng=en&nrm=iso. [Accessed 24 Jan2012]; A. Whittaker. 2007. Medical tourism in Asia. Up Close. Austra-lia: The University of Melbourne, de Arellano op cit. note 3.25 United Nations Economic and Social Council (ECOSOC). 2000. Theright to the highest attainable standard of health. Committee on Eco-nomic, Social and Cultural Rights. Geneva: ECOSOC.

26 World Health Organization (WHO). 1978. Declaration of Alma-Ata.International Conference on Primary Health Care. Alma-Ata, USSR.27 R.G.A. Feachem. Poverty and inequity: a proper focus for the newcentury. Bull World Health Organ 2000; 78: 1–2.28 M. Whitehead. The concepts and principles of equity and health.Health Promot Int 1991; 6: 217–228.



and public sector. By 1986–87, it was recognised in theNational Statistical Survey Organisation 42nd Round thatover 70% of the nation’s populace were utilising someform of private health care.29 When Rajiv Gandhi cameto power in 1984, he implemented a set of macroeco-nomic adjustment policies, and consequent growth levelsof over 8% were recorded in 1985.30 However, over thecourse of the decade, external foreign debt had doubled.India’s foreign exchange reserves were at an all time lowin early 1991, coupled with an inflation rate that reached16.7 per cent at its worst.31

With the promise of substantial debt relief from theWorld Bank and the IMF in the form of additional loans,in May of 1991, a SAP was introduced. Additionally in1991, the central government introduced the New Eco-nomic Policy which extended earlier macroeconomicadjustments.32 The New Economic Policy directlyimpacted upon the health sector through the cutting ofcentral health expenditure. In spite of the economicdownturns, an ever growing demand for medical servicessaw the implementation and proliferation of health ser-vices within the private sector throughout the 1990s,although it was still mainly limited to cities in the south ofthe country.33 Additionally, due to further lowering ofregulations regarding foreign direct investment, anumber of foreign investors began to collaborate withIndian health care providers, particularly in corporatehospital groups, being an early indication of the commer-cialization appearing within the system. Between 1991and 1997, the Foreign Investment Promotion Boardapproved US$100 million of foreign direct investment thehealth care sector.34

Currently India has what is considered one of the mosthighly privatised health care systems in the world. India’sthree-tiered public health system, consisting of primaryhealth centres, district hospitals and tertiary care hospi-tals, are increasingly overloaded and unable to attend tothe health needs of the population. The stark differencesbetween private and public health-care centres are seen asan obvious statement of the widening gap between therich and poor.35

The idea of governments and corporations pursuingcommercial health for comparatively wealthy foreignersin a country where almost a quarter of the local popula-tion go untreated for illness due to indebtedness (seeFigure 1) may seem somewhat absurd on external exami-nation, but forceful arguments of economic rationalismdrive both local and international support of thisindustry.

This market-driven healthcare model operates in thecontext of a population with high levels of incomepoverty, sparse health insurance and extensive out-of-pocket expenditure. The second highest cause of indebt-edness in rural India is due to medical expenses. Althoughover 80% of India’s population live in rural areas, over75% of biomedical doctors and over 70% of hospital bedsare located in urban centres (see Figure 2). Additionally,approximately 75% of specialists are located in theprivate sector.

The near unfettered expansion of the private system,both in the formal and informal sectors over the past twodecades has occurred at a pace too rapid and unregulatedto monitor. At a similar time we find some of the gianteconomies such as the United States and the UnitedKingdom in differing, but similar predicaments withregard to their own health systems in terms of the declin-ing access their citizens have to health care services. Thus,when individuals from these comparatively income richcountries discover access to inexpensive, technologicallyadvanced healthcare services, free of waiting times andonly a flight away, it is highly unsurprising that medicaltourism has become a new growth industry.

Private reports have stated that as little as seven yearsago there were only approximately 10,000 foreigners’

29 B. Lefebvre. 2009. ‘Bringing World-class Health Care to India’: Therise of corporate hospitals. In Indian Health Landscapes under Global-ization. A. Vaguet, ed. New Delhi, India: Manohar Publishers &Distributors.30 D.B.H. Denoon. Cycles in Indian economic liberalization 1966–1996. Comp Polit 1998; 31: 43–60.31 Agarwal, op cit. note 12.32 S. Alok. Political economy of India 1800–2001. Int J Comm Manag2001; 11: 1.33 Baru, op. cit. note 13.34 B.C. Purohit. Private initiatives and policy options: recent healthsystem experience in India. Health Policy Plan 2001; 16: 87.35 R.G. Chinai, Rahul. 2005. Are we ready for medical tourism? TheHindu 17 April.

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Figure 1. Illnesses in India Going Untreated due toIndebtedness (%).Source: data retrieved from National Sample SurveyOrganisation (NSSO). (2006). Morbidity, Health Careand the Condition of the Aged: NSS 60th round. NewDelhi: Ministry of Statistics and Programme Implemen-tation, Government of India.

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nation-wide obtaining medical services in India. Cur-rently, that number is estimated at up to 450,000 a year,with the sector generating in the region of US$350 millionannually.36 In an interview for the newspaper The IndianExpress, the president of the Apollo Group Hospitalsstated their hospital in Delhi admitted 12,000 foreignpatients in 2005, and that 15% to 18% of the hospital’spatients are foreigners.37 In a 2001 World Health Orga-nization Bulletin, it was estimated that from Bangladeshalone, 50,000 people per year travel to India in order totreat specialised diseases.38 The estimated revenue haseven been speculated to increase to US$2 billion by2012.39

Within the milieu of Indian health care, corporate hos-pitals, run by a number of conglomerates, have beenmultiplying in the urban centres of the nation, typicallydelivering high-tech, super-specialised biomedical servicesprovided at a cost the vast majority of the populationcannot access for mainly economic, but also socio-cultural and geographic, reasons. These corporate hospi-tals are aggressively marketing the new boom serviceindustry of medical tourism, endeavouring to attract for-eigners through offering health services of comparablestandard and considerably lower prices. The slogan of‘First World Treatment at Third World Prices’ used by anumber of companies advertising medical tourism in

India quite succinctly illustrates the social and economicinequities inherent in current medical tourism dis-courses.40 Individuals globally are now able to go onlineand select from a range of variables for their requiredsurgery directed by any range of preferences includingprice-point, country, hospital, suite and surgeon. Thesepreferences can then be coupled with the selection of apost-surgery recuperative retreat at a nearby five starbeach-side/mountain/village resort. The options for indi-vidual ‘healthcare consumers’ are blossoming and beingcapitalised upon by corporations looking to cash in onthe healthcare dollar.

The role of the Indian government inmedical tourism

One of the key ethical issues raised in medical tourismdiscourses in India is the increasingly indistinct rolesplayed by both the public and private sectors. In Septem-ber 2003, the central government introduced the Public-Private-Partnership (PPP) policy to guide futuredevelopments in the health sector. This policy outlines anumber of measures such as: (a) the outsourcing of man-agement of public facilities from government to non-governmental organisations; (b) the outsourcing ofprivate specialist services; and, (c) the contracting out ofhospitals’ subsidiary services.41 Despite initial attempts topromote affiliations between the public and privatesectors, it remains a relatively ad hoc arrangement,whereby planned strategies and monitoring of the out-comes of the relationships are either weak or absent.

Whilst the government owns and runs many largemajor/general hospitals, the mix between public andprivate is becoming increasingly blurred. State HealthCorporations sponsored by the World Bank have seencollaborations between the public and private sector,where the government may officially own a hospital, butthe management of and equipment provision are con-tracted out to private companies. In 2001 the World Bankgave the Government of Maharashtra a US$134 millionloan, with an attached conditionality that 5% of thisamount was to be used to build a corporate tertiary hos-pital in Mumbai. This hospital, the Wockhardt Hospital

36 Ernst & Young. 2006. Healthcare Industry. New Delhi: India BrandEquity Foundation (IBEF).Available at: http://ibef.org/download/Healthcare_sectoral.pdf[Accessed 24 Jan 2012].37 Z. Nazir. 2006. Just what the hospital ordered: Global accreditations.The Indian Express 18 September.38 R. Chanda. 2002. Trade in health services. Bull World Health Organ.Available at: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862002000200012&lng=en&nrm=iso. [Accessed 24 Jan2012].39 P. Shetty. op. cit. note 2.

40 Go Med Travel. 2010. Be Colombus Explore Health. Cuttack, India:[email protected]. Available at: http://www.gomedtravel.com/[Accessed 24 Jan 2012]; Healism.com. 2010. Cheap Healthcare in India:First World Quality at Third World Rates. Available at: http://www.healism.com/blogs/the_stanley_rubenti_medical_tourism_blog/cheap_healthcare_in_india:_first_world_quality_at_third_world_rates/[Accessed 24 Jan 2012].41 Government of India Planning Commission (GIPC). 2004. Report ofthe PPP Sub-Group on Social Sector. R.R. Shah, ed. New Delhi: GIPC;Ministry of Health & Family Welfare (MHFW). 2005. Report of theNational Commission on Macroeconomics and Health. New Delhi: Gov-ernment of India.

0% 20% 40% 60% 80% 100%

Hospitals

Beds

RuralUrban

Figure 2. National Distribution of Hospitals and Beds inIndia.Source: data from Central Bureau of Health Intelligence(CBHI). (2006). Health Information India. Retrieved 12September 2006, from http://cbhidghs.nic.in/Intro.asp



Mumbai, was built by PPP under the management of theWockhardt Group.42 This was the precursor of futurefunding in the private tertiary sector, where the Interna-tional Financial Corporation, the private lending branchof the World Bank Group, now regularly sets up financefor many corporate hospitals in India. As many as 150private corporations such as the larger conglomeratesApollo, Max and Fortis now have interest in hospitalsacross the country. Many of these are technologicallydriven, multi super-specialty, 100 plus bed facilities, withthe vast majority located in urban centres. The dominantfinancial backing of these hospitals comes from financialand industrial groups.43

Another example of PPP in the context of medicaltourism can be seen in the recently established MedicalTourism Council of Maharashtra. In November 2003, thecouncil was launched as the joint initiative of the Govern-ment of Maharashtra and The Federation of IndianChambers of Commerce and Industry (FICCI). FICCI isan association with a membership of 1500 corporate busi-nesses and approximately 500 chambers of commerce andis the leading national advisory body for businesses,working with the government in shaping major economicpolicies in the country. One of the stated core aims of theMedical Tourism Council of Maharashtra is to ‘regulateand monitor the medical tourism sector’.44 The Councilacts similarly to an ombudsman using a dispute resolutionmechanism. This Council is campaigning for a nationalstandardisation of health regulations, where India’s lackof such is seen as a major obstacle for the industry.Another example of government support of medicaltourism in India is demonstrated in the influentialNational Health Policy (2002), which states:

To capitalise on the comparative cost advantageenjoyed by domestic health facilities in the secondaryand tertiary sector, the policy will encourage the supplyof services to patients of foreign origin on payment.The rendering of such services on payment in foreignexchange will be treated as ‘deemed exports’ and willbe made eligible for all fiscal incentives extended toexport earnings.45

Duggal argues these fiscal incentives directed towards thelarge corporate hospitals participating in medical tourism

should be conditional, whereby the idle capacity of thesehospitals should be formally required to provide fee-freecare for Indian nationals.46

CONCLUSION

Despite the growing significance of medical tourism inthe international arena, it remains a distinctly under-studied area by all fields of academia. This paper high-lights the urgent need for a move towards a richerunderstanding of medical tourism that reaches beyondthe dominant, one dimensional neoliberal discourseshighlighted within. These discourses have not allowedeffective representation of the multiple complex bioethi-cal dimensions, particularly with regard to equity for themore vulnerable groups within destination countries.

A number of important questions need to be addressedin order to ascertain and negotiate the value of such anindustry in the contexts within which it currently oper-ates. Will market mechanisms actually intrinsicallyensure that the growth of medical tourism will improvethe wider health systems in poorer countries? Or will itserve to further undermine the health requirements ofcurrently under-served, poorly-resourced populations?Who are the main groups and actors to actually benefitfrom the policies and new institutions created for thepromotion of medical tourism? What are the major socialrisks created through the growth of the industry andwhich groups are most likely to be subjected to them?

This paper calls for further research problematizingmedical tourism through addressing such questions,where both macro and micro studies across multiple con-texts are needed in order to augment our understandingsof the vertical processes, practices and impacts of medicaltourism internationally. The challenge remains for arange of multidisciplinary scholars to come together inorder to engage in these issues of power, place, equity,human rights and ownership in order to allow the voicesof not one, but many, to be heard.

Biography

Kristen Smith is in the final year of a PhD in Social Health (MedicalAnthropology). She is situated in the Centre for Health & Society at theUniversity of Melbourne. Her current research interests focus on thepolitical economy of medical tourism in India, alongside equity issues inthe context of global health.

42 G. Yamey. World Bank funds private hospital in India. BMJ 2001;322: 257.43 Lefebvre, op. cit. note 29.44 Federation of Indian Chambers of Commerce and Industry –Medical Tourism Council of Maharashta (FICCI-MTCM). 2003.About FICCI-MTCM. Mumbai: Available at: http://www.ficci.com[Accessed 24 Jan 2012].45 Directorate-General of Health Services (DGHS). 2002. NationalHealth Policy 2002. India: Ministry of Health & Family Welfare.

46 R. Duggal & A. Verma. 2003. Should public hospitals participatein medical tourism?: Debate. Healthcare Management Express 15December.

8 Kristen Smith


the problematization of medical tourism: a critique of neoliberalism

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