The upside of trade in health servicesBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l2208 (Published 28 May 2019) Cite this as: BMJ 2019;365:l2208
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Hanefeld and Smith are right to note that “the effect on health systems of patient and health worker movement differs depending on the type of movement.” As researchers who have also conducted studies on these mobilities, we would add that the effect is also greatly determined by the context of the destination country and its health system. Our research on medical tourism in the Caribbean region speaks to this. In this region most countries are small, and their health systems are limited in size and scope both for practical reasons (e.g., population size) and operational challenges (e.g., health worker shortages). Medical tourism is mostly occurring in small, privately-owned medical facilities throughout the Caribbean. With regard to an “upside” of medical tourism in this context, many of the stakeholders we have talked to in the Caribbean region have commented on the potential for medical tourism to increase the patient base to the point that it will be possible to provide services not currently sustained by local populations alone - and particularly specialist care. Should this happen, it may hold spillover benefits for public health systems in the Caribbean as well as the deeply established regional cross-border care networks that exist. This type of “upside” is very much driven not only by the movement of International patients to Caribbean countries but also by the nature of health systems in small island nations. Whether or not there is a net health equitable outcome will depend on the extent to which revenues from private international patients in primarily private facilities are taxed at sufficient levels to provide meaningful cross-subsidization of public facilities or affordable access for its citizens. Thus, we agree with Hanefeld and Smith's point that to realize medical tourism’s “upside”, regulation and oversight is needed nationally, but add that such oversight must also extend regionally in cases where nearby countries are competing with each other to seek entry into the medical tourism sector.
Competing interests: No competing interests