Understanding 21st-century patient mobility. Towards a rationale of transnational health region development
by Tomas Mainil
University of Antwerp / NHTV Breda University of Applied Sciences
Publisher: NRIT Media, Nieuwegein ISBN: 978-90-5472-219-9 (non-commercial edition)
Dr. Tomas Mainil is Lecturer at Breda University of Applied Sciences (the Netherlands). He is responsible for the research line ´Transnational health care in sending and receiving contexts´ which was originated at the Centre for cross-cultural Understanding (CCU). He is research fellow at the Research Centre for Longitudinal and Life Course Studies (CELLO), University of Antwerp (Belgium). He holds an MA in Sociology (Medical Sociology) and a MSc in Quantitative Analysis, and previously worked at the University of Antwerp (department Sociology) and Ghent University (department of General practice and primary health care) on health-related subjects. His main interests are globalization and health, the policy and governance dynamics of transnational health care (PhD) and the internal and external characteristics of the transnational health user.
A full version of the PhD can be made available by the author: firstname.lastname@example.org email@example.com
Also forthcoming: Botterill, D., Pennings, G. and Mainil, T. (2013). Medical Tourism and Transnational Health Care. Basingstoke: Palgrave Macmillan.
International patients increasingly choose to be treated abroad. However, there are differences between the European perspective and other regional discourses about the globalizing health economy. The EU seeks to regulate internal patient mobility and values equality and social protection. Other regional discourses are confronted with more privatizing/commodification in relation to patient mobility. The thesis examines the different terminologies that exist – such as cross-border healthcare and medical tourism -, arguing towards the global terminology of transnational health care (Mainil et al., 2012): 2 archetypes of international patients (TBASs or Trans-border Access Searchers and CBASs or Cross-border Access Searchers) and 2 archetypes of professional stakeholders (RCAs or Receiving Context Actors and SCAs or Sending Context Actors) are distinguished. Characteristics distinguishing TBASs and CBASs are geographical proximity/ distance, cultural proximity/distance and search strategies. Transnational health care is defined by more professional structures and communication networks that are also visible to and can be used by the patient.
The thesis then examines the life world of the transnational health user: 1. The role of the concept of ‘world-making’ on the websites of providers (Mainil et al., 2011); 2. The role of culturalism in the relations between medical professionals and patients (Mainil et al., 2013); 3. The role of the media in the discourse about medical tourism (Mainil et al., 2011); 4. The role of quality management in transnational health care (Mainil et al., 2012); 5. The relationship between public health and transnational healthcare (Mainil et al., 2013) and finally 6. The role of (regional) governments to steer patient mobility through context-controlled, sustainable health destination management (SHDM)/development (Mainil et al., 2012; Mainil et al., 2013).
1. The role of the concept of ‘world-making’ on the websites of providers
Globalization of health care also means that the internet is used by international medical providers to attract international patients. Providers use appealing lyrics and alluring images to use (smiling beautiful female patients and physicians) on their websites. However, the reality of offering health care is less related to the context of leisure, joy and pleasure. Within the study of tourism we know the concept of world-making: displaying images of vacation destinations that are not consistent with reality. The use of world-making in a healthcare context can, then, be ethically unjust.
2. The role of culturalism in the relations between medical professionals and patients
Jargen Habermas describes how two modes of action can be found in today’s society: communicative and strategic action. Communicative action takes place in mutual consultation and dialogue based on historical use while strategic action is based on decisions, power and speed. These two forms of action are also found in the medical tourism industry. We analyze how a department (International Office) within a hospital seeks to find a balance between these two types of action: they move between the international patients and medical professionals. It concerns the dialogue-based world of the patient with his concerns and hopes and on the other side the professionalized world of doctors in a hospital who act strategically and work. This department attempts to act on the basis of a cultural sensitivity to the other, from an understanding of how the life world of the international patient is constructed. Therefore a need exists to act from an equilibrium in which cultural management can play a role.
3. The role of the media in written discourse on medical tourism
International newspapers (The Guardian, The Financial Times) as well as local newspapers (The Straits Times, Singapore, Bangkok Post, Thailand) display a discourse on medical tourism. This information is available to everyone. Often this information is normative. Before 2002, an ethical discourse is shown: be aware of the dangers for patients and medical professionals, medical tourism as a threat to national health systems. After 2002 both international and local newspapers chose the market discourse in discussing medical tourism: it offers chances for new markets to consolidate and offers opportunities to multiple stakeholders. The ethical discourse is still present but has been serving the market perspective. It is this discourse that is reflected in public opinion.
4. The role of quality management in transnational health care
Key stakeholders in transnational health care are hospitals. Hospitals’ focus on international patients can be formalized in an International Office (IO) to cater to non-medical services. In Belgium, this is less common, but in Germany or Singapore, such facilitation is present. We conducted a pilot study with regards to quality within such IOs through a benchmarking instrument, incorporating the variables: medical treatment / facilities (accommodation / travel) / financial issues / quality (cultural / communicative / satisfaction). The various phases of the pilot study show that quality challenges largely depend on the national context and the strategy of the hospital.
5. The relationship between public health and transnational health care
The European Union has a history of regulations on patient mobility. The synthesis of these regulations led to the “Directive on the Application of Patients ‘Rights in Cross-Border Healthcare”, soon to be implemented by the Member States. This legal discussion can be linked to the debate over whether international patients can be seen as consumers or citizens with patient rights. The following considerations emerge: Do Europeans want to travel for their health? How should governments act when taking into account socio-economic differences between citizens and between states? How do these differences relate to the current economic crisis? These considerations lead to several scenarios based on limited or extensive implementation of the Directive, whereby European international patients at times will be citizens with rights, but on other occasions care consumers.
6. The role of (regional) governments can use to steer patient mobility through a context-controlled, sustainable health destination management (SHDM) framework
Finally, all the factors in the context of transnational health care are bundled in a strong plea for a larger role for (regional) governments to strengthen their capacity to position their regions as transnational health regions. In consultation with various stakeholders in the region, governments determine priorities for the regional system of medical expertise and specialization. In managing this regional health system, governments can make their health region profile visible to transnational health users and other regions. Governments are urged to work as health regions to depict both domestic and foreign patients in structuring the identity of the region. Health regions comprise a sustainable policy route, as (regional) governments seek to attain public health goals. We propose combining the notion of sustainable health destination management (SHDM) with the framework of (Smith et al., 2011) on bi-lateral agreements in transnational health care settings. If developed countries arrange bi-lateral agreements with developing and/or BRIC countries to assure health care exchanges, these agreements could align with a SHDM logic. If for example the UK has bi-lateral agreements with India on health care exchanges, the UK could decide in a first stage to focus on a bi-lateral agreement structure with a particular region in India, sending off patients to that region, building capacity, and ensuring that public health goals of both the UK and this Indian region are guaranteed. In a second stage, other Indian regions could be targeted, with a focus on other medical specializations or even focusing on specific age groups such as senior citizens. In using bi-lateral regional steering mechanisms, this could alleviate the current divide between the goals of NGO’s and WHO, as opposed to the projection of private healthcare diaspora in transnational health care. In combining SHDM and bi-lateral trade mechanisms the proposed framework would serve as a vehicle or change agent to reverse the global south debate and to build up health care capacity based on collaborative governance (Brand and Michelsen, 2012).
Mainil T., Platenkamp V., Dinnie K., Botterill D., Van Loon F., and Meulemans, H. (2012). Transnational health care: the quest for a global terminology. Health Policy, 108(1), 37-44.
Mainil T., Platenkamp V. and Meulemans, H. (2011). Diving into the contexts of in-between worlds: world-making in medical tourism. Tourism Analysis, 15(6), 743-754.
Mainil, T., Platenkamp V. and Meulemans, H. (2013) Habermas, Transnational health care and cross-culturalism. In D. Botterill, G. Pennings & T. Mainil (Eds.), Medical Tourism and Transnational Health Care. Basingstoke: Palgrave Macmillan.
Mainil T., Platenkamp V. and Meulemans H. (2011). The discourse of medical tourism in the media. Tourism Review, 66(1/2), 31-44.
Mainil T., Platenkamp V., Dinnie K., Botterill D., Van Loon F., and Meulemans, H. (2012). Framing and measuring international patient management. In L.H. Friedman, G.T. Savage & J. Goes (Eds.), Annual Review of Health Care Management: Strategy and Policy perspectives on Reforming Health Systems, Volume 13, Bingley, UK: Emerald
Mainil, T. Commers, M. and Michelsen, K. (2013) Cross-border mobility within the European Union: from international to transnational health systems?. In D. Botterill, G. Pennings & T. Mainil (Eds.), Medical Tourism and Transnational Health Care. Basingstoke: Palgrave Macmillan.
Mainil, T., Dinnie, K., Botterill, D., Van Loon, F., Platenkamp, V. and Meulemans, H. (2013). Towards a model of sustainable health destination management based on health regions. In D. Botterill, G. Pennings & T. Mainil (Eds.), Medical Tourism and Transnational Health Care. Basingstoke: Palgrave Macmillan.
Botterill, D., Pennings, G. & Mainil, T. (2013). Medical Tourism and Transnational Health Care. Basingstoke: Palgrave Macmillan.
Smith, R., Martinez Alvarez, M., Chanda, R. (2011). Medical tourism: a review of the literature and analysis of a role for bi-lateral trade. Health Policy 103(2-3):276-82.
Brand, H., & Michelsen, K. (2012). Collaborative governance: The example of health conferences. In D. V. McQueen, M. Wismar, V. Lin, C. M. Jones, & M. (. Davies, Intersectoral Governance for Health in All Policies. Structures, actions and experiences (pp. 165-184). Copenhagen: WHO Office for Europe on behalf of the European Observatory on Health Systems and Policies.