Gul 2014 stephanie agu paper

The Role of Medical Tourism in Urban Centers: A Case Study of London and Istanbul Stephanie Agu 25/04/2014

Created for Global Urban Lab Rice University: School of Social Sciences & Kinder Institute for Urban Research

Table of Contents Table of Contents .......................................................................................................................................... 1 Executive Summary....................................................................................................................................... 2 Introduction .................................................................................................................................................. 3 The Issue ....................................................................................................................................................... 3 The Research ................................................................................................................................................. 6 The Findings .................................................................................................................................................. 6 Conclusion ................................................................................................................................................... 10 Bibliography ................................................................................................................................................ 13 Acknowledgements …………………………………………………………………………………………………………………………… 15

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Executive Summary Medical tourism is the movement of people from one country to another for medical care. While the movement of people for health reasons is not a new phenomenon, medical tourism is its current state is remarkable. No longer the independent whim of the wealthy, it is now a feasible option for many people in the developed world who find their home’s provision of health care to be inadequate. For many developing countries, it is also touted as a road to economic independence.

Most medical tourism research takes place from a perspective in which the state is the level of analysis. However, medical tourism does not simply involve healthcare. It is a joint venture between the medical industry and the tourist industry in which both sides utilize their best resources to attract visitors.

For both, their most significant resources are located in urban centers so it follows that the cities with the most to offer in both realms are the most impacted by this phenomenon. Global cities are magnets for human, economic, cultural, and intellectual capital. They define the region in which they exist. For this reason, London and Istanbul make for excellent case studies in this urban analysis as they are true outliers within their respective areas and are resource-rich by every definition.

This paper explores medical tourism in London and Istanbul, considering the impact this phenomenon has on the respective cities. This research can lead to a great understanding of medical tourism as experienced by tourists and inhabitants, and aims to initiate dialogue on the future of the practice.

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Introduction Globalization has done much to facilitate the movement of humans and goods around the world. In 2013, the World Travel and Tourism Council (WTTC) reported that an estimated one billion people visited another country. Overall, tourism is one of the fastest growing industries in the world, and within that realm exists the subset of medical tourism.

Medical tourism is the occurrence of people travelling abroad to access medical treatment, and it contributed 9 percent of global GDP in 2011 (Grout). Although humans have migrated to different parts of the world for health reasons for centuries, in recent years interest in medical tourism has skyrocketed. It is fueled predominantly by the availability and affordability of air travel, access to medical information via the internet, internet marketing by providers, and increasing out-of-pocket expenditures in home countries (Vijaya). Most researchers have paid particular attention to the fourth reason. The fact that health care costs are rising in many places around the world incentivizes people to take advantage of the arbitrage opportunity the differentials create, either by seeking care elsewhere or helping others seek care elsewhere.

Cheaper travel, in conjunction with rising health costs, have given patients flexibility with regards to their health care. As access to health care has become more limited (either for financial reasons or restrictions) in developed nations, people have become more frequently motivated to travel elsewhere to get it.

Medical tourism encompasses a distinctly separate arena from that of normal tourism. For the most part, tourists and natives occupy separate spaces within the city. There are distinct places which tourists are known to visit (colloquially referred to as the ‘touristy’ areas) and natives, for a variety of reasons, tend to avoid. Medical tourists engage in spaces that are ‘touristy’, but also utilize resources delegated specifically for inhabitants. Medical tourism is a collision of these two spheres, and can create a situation with far reaching urban impacts. This report aims to contribute to the literature by viewing this trend through an urban lens, and London and Istanbul make for perfect case studies due to their sizes and significance to their respective regions.

The Issue There are three distinct types of medical tourism: (1) traveling to another country to obtain services that are illegal in both the home and destination, (2) traveling to obtain services that are illegal at home but legal in the destination, and (3) traveling to obtain services legal both at home and the destination (Cohen). One service can qualify for all three categories, so the distinction between these types is primarily defined by the home-destination country relationship.

The first type focuses on the legality of services. The reason the tourist is traveling is because the service can be pursued more easily in the destination country despite its legality status. Abortions and female genital mutilations are both services that fall under this category.

The problematic and contentious nature of these is due to the ethical and morality ambiguities surrounding the practices (Cohen). This particular type of travel is the least common of the three, but its controversial nature has made it become one of the most notorious features of the medical tourism debate.

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The second type focuses on travel with the intent of accessing services illegal in the patient’s home country, but legal elsewhere. Many plastic surgery procedures are motivated by this reason because in addition to it being a costly endeavor, it is a highly regulated one as well.

The U.S. National Institute of Health recommends that bariatric surgery (weight loss surgery) not take place unless the patient is between the ages of 18-65, thus the majority of US plastic surgeons within will adhere to this guideline. Hospitals in another country may be internationally accredited, but obey a different set of guidelines. This enables someone who desires a specific procedure to take advantage of this differential. Also, people may leave in order to take advantage of experimental medical procedures not practiced in their home country. Stem cell implantation is an oft cited example. While in some nations the topic invokes moral and ethical criticisms, a hospital in Turkey is proud to state that it is the “Umbilical Cord Blood Bank of the Highest Capacity in Turkey” (Group) . Another example of this again has to do with organ transplantation. In the United States, the difficulties of obtaining an organ in a timely manner are well documented (Howard) due to the strict legalities surround donations. By contrast, organs were more available in China due to a system that relied on the involuntary organ donations of death row prisoners’ until very recently (Feck). Equally ethically contentious is the sale of organs. In Pakistan, the organ sales business is legal and thriving. For laborers living on an income of 85 cents per day, the $1224 they can earn by selling an organ is a true profitmaking opportunity (Walsh).

The third and final reason for medical travel concerns predominantly the rising cost of healthcare and waiting times associated with different procedures. The people traveling to take advantage of these arbitrage opportunities are overwhelmingly from the global ‘North’. The procedures in the destination countries are cheaper and it takes a certain amount of capital as well as information access to be able to participate in this phenomenon (Hanefield). For example, in the UK a shoulder operation would cost $17,000, yet in India its $2,900 (Vijaya). Even with the additional expenditures of airfare, food, and accommodation upon arrival, the cumulative cost of a visit to India would still be less than the cost of the procedure in the UK. For many, it is more cost-effective to leave.

Table 1. Prices of Surgeries in Selected Countries United States Turkey Thailand Germany Singapore England $11,37515,000

$11,000 $10,500 $1,200 $50,00060,000

$5,200

Heart Bypass Knee Replacement Liposuction Bone Marrow Transplantation

$129,750

$300,000

$11,200 $3,333 $40,00070,000

Hysterectomy (DEIK)

$20,000

$7,000

$40,000 $9,000

$17,335

$30,00033,000

$27,770

$11,781 $4,376

$9,350 $3,000

$20,432 $4,950

$250,000

$40,000

$200,000

$5,5007,000

$9,00010,500

$10,100

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Waiting times also are an issue as shown in the figure below. From this figure, one can understand why patients can be motivated to look elsewhere for care.

Figure 1. Waiting time of four weeks or more for a specialist appointment.

(OECD) Overwhelmingly, oncology, reproductive care, general surgery top the list of medical purposes for travelling (Hanefield). That being said, specific countries are known for specific specialties. UK dental patients prefer Hungary and Poland (Smith), and Brazil and Thailand are considered the best places to go for plastic surgery (Ormond). Often, the logistics of the trip are not arranged by the patient themselves but rather by a hospital or a third party provider. They provide transfer from the airport to the hotel, which is typically within walking distance of the hospital. If the patient is unsure of the hospital to which they want to go, the third party provider can also help them select a specialist, as well as arranging the logistics once the patient arrives.

Medical tourists are unique in that although medical care may be the impetus for their travel, it is not the only reason for their stay. Promotion of these destination countries employ photos of national landmarks as much, if not more, than photos of hospitals and the technologies (Ormond) Tourists choose to go to places that have something to offer by way of entertainment, shopping, and culture (ErdoÄ&#x;an). Urban centers in particular are visited for the same reasons that make the cities themselves notable—cultural sites and vast resources.

Tourist Destinations: London and Istanbul In terms of tourist volume, London and Istanbul are featured in the top ten of global tourist destinations in 2012 (Wong). London welcomed 16 million international overnight visitors in 2013, a number which is double that of the city’s population. Istanbul welcomed over ten million international overnight visitors. For both cities, tourism is an essential part of their economies. The top sites in both London and Istanbul for visitors are those reflecting the cultural

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heritage of the city, such as Westminster Abbey in London, and the Hagia Sophia in Istanbul (Wong). These are cities that people desire to come to, regardless of health issues.

The Research In London, several midwives at King’s College Hospital (KCH) were informally interviewed. Interviews with midwives were not scheduled, but their opinions on this particular topic were gathered informally through the course of conversations and projects related to foreign visitors. A formal interview was conducted with the Head of the Overseas Visitor Department at the same hospital. The questions asked concerned the official stance of the National Health Service (NHS) on medical tourism, medical tourism within London, medical tourism at KCH specifically, and the characteristics of the visitors. A professor from the department of Global Health and Policy from the London School of Hygiene and Tropical Medicine was also formally interviewed regarding medical tourism in the UK and London specifically. The formal interviews lasted for thirty minutes to an hour.

In Istanbul, a medical professional from Amerikan Hospital and Koc University was formally interviewed about the state of medical tourism in Turkey and Istanbul, specifically.

Two medical doctors at Acıbadem Hospital were informally interviewed regarding their hospital’s relationship to medical tourism and the effect it has on medical professional hiring. All interviews took place during March 2014 and April 2014. In addition to interviews, published academic journal articles were relied upon throughout the course of the research.

No analysis of medical tourism is complete without mentioning the difficultly of obtaining reliable national data, much less urban data. For that reason this report will mainly focus on the general attitude and infrastructure within each city for medical tourism. Data, where available, are referenced.

The Findings A.

London

Because so many people visit London, it follows that it is also a popular destination for medical tourism (Stephens). But this is not a new occurrence. London has always been a popular destination for medical tourists due to the high quality of facilities and research universities located there. The city has some of the finest research institutions in the world, and has been known having a large number of private specialists since the 19th century. In coming to London, as tourist receives the best of both worlds. However, many Londoners are leaving to seek care elsewhere. The UK is a net exporter of medical tourists, and London follows that trend (Hanefield).

Private and Public Hospitals Public and private hospitals experience different patterns of visitors due to London’s geography and the nature of the NHS. The NHS is the publicly funded system that ensures access to healthcare for all British citizens. With the exception of some charges, such as optical and dental services, the NHS remains free at the point of use for all UK citizens. It is because of this guarantee that UK hospitals have become infamous for their waiting times and 6|Page

issues regarding bed availability and occupancy (Martin). Usage of NHS hospitals can be problematic for anyone, regardless of nationality.

Every NHS hospital has a department that specifically handles non-British citizens receiving care. However, the majority of medical tourists utilize the services of private specialists in central London, where London’s attractions and specialists are (Stephen). Within this area, the hospitals tend to serve predominantly European and American patients (Stephens).

Exact numbers on the visitors using specialty services are unavailable as private clinics have no requirement to disclose, but it is reasonable to assume that traditional medical tourists coming to London will utilize these more than NHS hospitals (Hanefield).In the areas located further away from tourist attractions, the medical visitors tend to match the demographic make-up of the area.

Public hospitals in the residential areas of London receive many foreign visitors as well.

For one hospital in London, the vast majority of the foreign visitors consist of migrants hoping to settle within the city or people who have overstayed their visas (Stephens). Because London is an immigrant hub, the characteristics of medical tourists vary depending on the area. For example, King’s College Hospital serves the boroughs of Southwark and Lambeth which are known to have a large African diaspora community. As a result, many of the foreign visitors are African.

Many of the visitors are in London to visit family members, and have the expectation of eventually settling in London. These health visitors “take advantage of the NHS system, particularly in regards to maternity” (Stephens) in order to stay in the country. Although these patients cannot be considered medical tourists in the traditional sense, their presence contributes greatly to the negative public perception of the practice.

Public Opinion and Government Support The 2011 EU Directive on Cross-Border Health Care grants a fundamental right to access healthcare services across the European Economic Area for all EEA citizens (NHS). This encourages many British citizens to receive health care abroad in state-run hospitals and by private service providers. British citizens must pay the costs up front and seek reimbursement afterwards, but to receive this benefit they must prove that they are entitled to treatment. If a British citizen cannot have the same treatment in the UK within a medically acceptable period, than they are granted reimbursement. If a citizen has a cold and wants to go to Germany for examination, that will not be covered because that is not a time-sensitive illness, and the examination can occur in the UK. This Directive has helped to alleviate pressure on the NHS system. The Directive is reciprocal so Europeans can receive care in the UK under this system, but Britons are more likely to leave than continental Europeans are to enter (Hanefield).

The NHS and this EU Directive facilitate overseas travel. UK residents tend to travel to Poland and Hungary specifically for dental treatment (corresponding with the varied availability of dental treatment by the NHS), but to Cyprus and Spain for fertility treatment. Rather than being an importer of medical tourists, gathered research suggests that Londoners are leaving at a higher rate than people are entering. It is even possible that Londoners leave more than other British citizens simply because overcrowding within London hospitals is extraordinary. In a 2011/2012 report, 23 of London’s 35 hospitals trusts (hospital groups) reported being at 85% capacity (Watts). Most Londoners react positively to the idea of being able to seek care elsewhere and get reimbursed by the NHS. Across the UK, evidence shows that people going overseas for care generates millions for the NHS (Smith).

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By that same token, medical tourism is viewed warily and negatively when it comes to people entering. The British are proud of their healthcare system, but also recognize its challenges with waiting times and overcrowding. A representative of the NHS made the commented that while few foreign visitors in his particular hospital were entitled to receive NHS benefits, yet only 15% of the hospital’s visitors pay out of pocket for their services. The other 85% display the intention to pay, yet “when we send them their bill, it turns out that they lied about their contact information and we never see them again” (Stephens). These foreign visitors may not be medical tourists by this paper’s definition, and often the term ‘medical tourist’ is commonly misunderstood and equated with foreigners using health services. For the particular hospital referenced above, the numbers of foreign visitors were small relative to the overall population. Still, these payment patterns fuel the negativity. In response, local government officials advocate for laws to severely restrict access foreigners have to the NHS system (Mason). The nature of the NHS creates a conceptualization of health as a commodity that people must compete over, since one person’s usage does have an impact on that of someone else’s. As a result of that and misinformation, the discussion surrounding foreigners visiting public hospitals is fraught with anger and suspicion.

Discussions with NHS representatives are distinguished by statements stressing the mission of the NHS, but also the difficulty of striking a balance between being providing care and being cost-effective. The NHS attempts to keep clinical concerns separate from those of cost, yet inherent in medical tourism is the trading of health services converts health into just another commodity to be traded for profit. This creates a contradiction that can prove challenging to reconcile.

II. Istanbul Unlike London, for which medical tourism is a contentious issue, Istanbul has overwhelmingly embraced the influx of visitors to its shores. Istanbul overwhelmingly imports medical visitors. Istanbul hosts a multitude of annual medical tourism conventions each year, and it is a government supported endeavor. Istanbul’s success in medical tourism stems from its ability to identify its unique resources as they relate to medical tourism while exploiting the demand of today’s tourist for authentic experiences (Chambers). This means that medically, the tourist wants the most cutting-edge treatment. On a tourist level, however, they want to experience aspects of the city that fits their image of Istanbul. This desire is sated by the hospitals and third-party providers. A component of a typical health package to Istanbul includes a visit to Sultanahmet, the oldest part of Istanbul. The area itself is a UNESCO World Heritage Site, and patients are encouraged to visit the area with a guide provided by the hospital.

Istanbul’s geographic location as the link between Europe and Asia has always made it an attractive destination for Europeans and Americans. It makes it a perfect destination for meeting exchanges, such as conferences and conventions, allowing Istanbul to disseminate information about its offerings with ease. Additionally, the strength of Istanbul institutions as well as educated work force has also served to attract people from all over. Many private hospitals in Istanbul have partnered with prominent American universities such as Harvard, Johns Hopkins, and Stanford for research. Although the partnerships are primarily in a research capacity, they still have helped to boost the profile of the Istanbul health care sector.

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Quality of Care The pace at which global health is changing necessitated the creation of an international body that could ensure the quality of care was appropriate. The American-based Joint Commission International company aims to serve this purpose. JCI accreditation recognizes a hospital for achieving international standards within health care (Canadan), and signifies to visitors that the hospital’s services are of comparable quality to those of any Western facility.

Hospitals emphasize their JCI accreditation, along with the training of the medical specialists, in order to attract Westerners. Hospitals must pay a fee to be accredited, and this casts doubt on the JCI’s ability to be a true barometer of quality (Hanefield). Despite this, JCI accreditation remains the ‘gold’ benchmark in medical tourism, and appears to have pressured medical professionals and administrators to raise the standards of their hospitals in order to obtain JCI accreditation.

JCI has accredited more than 123 medical facilities and organizations across the world, and at 43 Turkey has some of the most accredited facilities in the world (Ortac). One of Istanbul’s most renowned hospitals, the Acıbadem Health Group, was declared one of the world’s best hospitals

by Forbes magazine (Van Dusen), and boasts a variety of its honors in a 140 page booklet on its offerings. Every pamphlet published by the group boasts the JCI accreditation symbol on the cover. Acibadem is a good example of a private institution with many tourists. Most, if not all, of the staff is fluent in English, and they have contact numbers for different languages.

Acıbadem Kadıköy Hastanesi. The five clocks show the time in various cities, such as London, Istanbul, and New York. (Lazer)

Medical Professionals Well educated physicians compose the basic building block of medical tourism (MirrerSinger). Consequently, Istanbul is a prime candidate for visitors due to the high quality of medical professionals practicing in the city (Erdoğan). The quality of the health professionals in the private sector in Istanbul and the medical institutions is what draws in visitors, as well as the aforementioned, high profile partnerships. The nature of medical tourism allows Istanbul professionals to reap never ending rewards from the endeavor. Medical tourists overwhelmingly travel in search of specialist care to treat rare illnesses. Thus, medical professionals become exposed to rare illnesses that serve to further their expertise in the field, as well as gain notoriety for both the physician and the hospital (Erdoğan). This notoriety attracts more medical tourists, and so the cycle continues.

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For the medical professionals, there are greater rewards to be reaped by working in the private sector. The high wages are attractive, and the ratio of patient to physician is smaller in private hospitals than it is in public hospitals. Furthermore, the exposure to unique medical cases is attractive for research clinicians. Some do argue that the union of medical tourism and private hospitals furthers the disparity of quality of care between private and public hospitals (Republic of Turkey Minister of Health, 2011) and different cities, and can also lead to a shortage in doctors practicing general medicine (Vijaya). There are others who simply accept both arguments as a feature of a modern health care system, and argue that Istanbul has always been the greatest initial recipient of Turkish resources the eventually trickle down (Erdoğan).

Moreover, it is worth noting that the debate regarding overspecialization is not unique to Turkey or even the developing world, nor is the argument of public versus private quality of care. All should be inclined to agree that the fact the medical professionals remain in Turkey is a positive feature of the current system. It is difficult for foreign born doctors to practice in Turkey so the majority of physicians in Istanbul hospitals are Turkish, yet many have received some kind of training abroad in some form (Ortac). If there is a ‘brain drain’ occurring in Istanbul and other Turkish cities, then medical tourism provides the talent with a reason to stay near the Bosphorus.

Public Opinion and Government Support In Istanbul, media coverage on medical tourism is overwhelmingly positive and government involvement further promotes Istanbul as medical tourism center. It appears as if most people agree that medical tourism is the way for Turkey to become an even more dominant power in the region, and can also increase Turkey’s chances in entering the EU (Yilmaz). If the nation is granted membership, the EU Directive for Cross Border Health would undoubtedly change medical tourism in favor of the Turks. Three federal departments have special agencies solely devoted to medical tourism, and the Ministry of Health alone has two The Foreign Economic Relations Board (DEIK) is the main government department that handles medical tourism issues and inquiries. The Ministry of Finance has instituted favorable tax allowances to hospitals in which 50-100% of their revenues that are associated with medical tourism are tax deductible (Erdoğan). Private hospitals that are known to receive many visitors also attract government grants which pave the way for the hospitals to further increase in size and spread to other cities, as well as conduct research (Erdoğan). Istanbul is the 2014 location of the World Medical Tourism Conference. To attract more foreign visitors, the Istanbul airport is building another terminal (making the airport due to be the largest in the world in 2020) and the city’s largest hospitals—Medical Park and Acıbadem—are undergoing plans to open more hospitals in the city (Erdogan) to accommodate the incoming visitors.

Conclusion This report, through gleaning what data are available and first-hand interviews, has compared medical tourism in London and Istanbul. The results of this comparison are instructive, suggesting important implications. The first relates to data availability. Medical tourism is booming but due to the difficulty of data access and amalgamation, there are many harmful gaps of knowledge that remain. The confounding definitions of medical tourism alone distort the conversation and the opacity of the data further contributes to the distortion. Most research focuses on specific countries where the impact of medical tourism is the greatest, such as India. But even within that, getting exact numbers about who is coming, how many are 10 | P a g e

coming, and what happens after they return is complicated by the fact that tourists have no reason to explicitly state their reasons for travel and private clinics have no reason to reveal how many people are using their services. The phenomenon is one that everyone knows is occurring, but the exact details and numbers are unclear. Moreover, the health risks and chances for patient exploitation by shady clinics and third-party providers are significantly increased. To remedy this problem, upon arrival to a city, medical tourists should be required to fill out a form stating that they are in the city to receive healthcare, name the procedure, the cost, and how they are expecting to pay for it. Once officials have a clear view as to what the actual number of visitors are, then changes can be made to the system accordingly.

Most of the report focused on the medical tourism from a macro perspective, but certain consequences to the individual can be impactful. For both cities, malpractice issues loom over the sector. One study found that many online infertility treatment resources were outright misleading (Okamura), and another found 44 of 130 sites contained false information on breast augmentation (Jejurikar). The wide availability of information is both a blessing and a curse by giving prospective patients who have ‘done their homework’ a false sense of security. Another legal issue is in tort law with respect to negligence. Most third-party medical providers absolve themselves of guilt through agreements with the patient (Lunt), and courts would find it difficult to determine who is at fault should an adverse event occur.

Additionally, determining jurisdiction is a near impossible task. If a case involves a third party provider, many courts are not sure if the case should be tried in the location of the patient’s residence, the location of the provider’s headquarters, or the location in which the patient received care (Mirrer-Singer). The current situation could deter medical tourists from receiving care in other countries, and the lack of a cognizant, international body regulating medical tourism will likely become an even greater issue as the phenomenon gains in popularity. Jurisdiction in the field of international is an extremely sensitive matter, so it is unclear if this issue will ever be fully resolved. For now, the JCI is the best mechanism utilized to preemptively correct asymmetric information.

In both Istanbul and London, private hospitals overwhelmingly appear to benefit from medical tourism than their public counterparts. While the NHS is a fairly equitable system, in Istanbul, this imbalance between public and private hospitals can be severe. Private hospitals receive numerous government bank credits as well as grants to pursue research that increases the profile of the hospital, and simultaneously increasing the amount of tourists visiting the hospital.

Private hospitals attract talented professionals at a greater rate than that of their public equivalents, although the medical expertise would be of greater service in the public sector.

There should be a redistribution of medical tourism revenue to ensure that the public hospitals are also operating at the same level as the private hospitals (Lunt) to prevent a two-tiered system.

Hospitals and providers try to convert what can be a nerve racking experience into one that is safe, cost-effective, and fun. In both London and Istanbul, the impact on the city and the city’s response has been telling. London is a city that views foreigners warily since the sheer scope of the population places great pressure on the health care infrastructure. Any additional pressure is unwelcomed. Istanbul, on the other hand, has had an enthusiastic response to medical tourism. As the cities are on the same strata with regards to tourism, many lessons can be gathered from how each city has respond to medical tourists. Urban data is nearly nonexistent, so

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first-hand accounts of the effect of medical tourism on each city was extremely helpful. Future research into this area will be extremely valuable to the overall topic.

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Acknowledgments I would like to thank the Women’s Care Group at King’s College Hospital for being so accommodating, and connecting me with others to talk to. I would like to thank Carlton Stephens for illuminating many unclear aspects of health visitors, and the NHS system. I would finally like to thank Dr. Michael Emerson and Dr. Nia Georges was their continuous guidance, and Ipek Martinez and Abbey Godley for their structural support in Istanbul.

I would also like to thank Acibadem Kadikoy Hospital for being so gracious to share their client materials with me, and am thankful for having had the opportunity to meet with Dr. Onder Ergonul.

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