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Providers’ perspectives on inbound medical tourism in Central America and the Caribbean: factors driving and inhibiting sector development and their health equity implications

Background Many governments and health care providers worldwide are enthusiastic to develop medical tourism as a service export. Despite the popularity of this policy uptake, there is relatively little known about the specific local factors prospectively motivating and informing development of this sector. Objective To identify common social, economic, and health system factors shaping the development of medical tourism in three Central American and Caribbean countries and their health equity implications. Design In-depth, semi-structured interviews were conducted in Mexico, Guatemala, and Barbados with 150 health system stakeholders. Participants were recruited from private and public sectors working in various fields: trade and economic development, health services delivery, training and administration, and civil society. Transcribed interviews were coded using qualitative data management software, and thematic analysis was used to identify cross-cutting issues regarding the drivers and inhibitors of medical tourism development. Results Four common drivers of medical tourism development were identified: 1) unused capacity in existing private hospitals, 2) international portability of health insurance, vis-a-vis international hospital accreditation, 3) internationally trained physicians as both marketable assets and industry entrepreneurs, and 4) promotion of medical tourism by public export development corporations. Three common inhibitors for the development of the sector were also identified: 1) the high expense of market entry, 2) poor sector-wide planning, and 3) structural socio-economic issues such as insecurity or relatively high business costs and financial risks. Conclusion There are shared factors shaping the development of medical tourism in Central America and the Caribbean that help explain why it is being pursued by many hospitals and governments in the region. Development of the sector is primarily being driven by public investment promotion agencies and the private health sector seeking economic benefits with limited consideration and planning for the health equity concerns medical tourism raises.


Introduction
The number of patients traveling internationally for medical care is believed to have increased over the past decade (1Á9). This growth is attributed to the improved quality of medical care available worldwide and the relative ease of marketing and researching care online. While the actual number of patients traveling for care is unknown due to poor surveillance and inconsistencies in distinguishing the different modalities of international patient flows, this swell in health service exports has significant implications for the resources and operations of health systems globally (4Á9). In this article, we focus on 'medical tourism', defined as the intentional, private purchase of elective biomedical services outside of a patient's country of residence. This definition excludes related, but fundamentally dissimilar, health service-seeking practices such as emergency care sought by vacationers, routine care accessed by expatriates living abroad, and cross-border care arranged for patients by their home health care systems that are regularly included in global estimates of 'medical tourism' specifically (9).
Many governments and health care providers worldwide are enthusiastic to develop medical tourism as a service export (1Á3). Despite the popularity of this policy uptake, there is relatively little known about the specific local factors and discourses informing development of this sector. While there are studies of established medical tourism sectors, particularly from Southeast Asia (2Á5), the existing literature has focused on theorizing the potential economic and health system impacts of the practice (6Á9). These analyses are predominately retrospective examinations of successful health services exporters; as such they have inherent limitations on the insights they offer into why medical tourism has taken root where it has and the implications for its development elsewhere.
This article draws from the first comparative case study of medical tourism in the Central American and Caribbean (CAC) region using primary qualitative data. This analysis examines common factors driving and inhibiting the contemporary development of medical tourism in Mexico, Guatemala, and Barbados. These countries are all health service exporters, albeit on very different scales and in distinct socio-economic contexts, and have governments and hospitals working to increase the number of visits by medical tourists (10Á12). The varying magnitude of existing medical tourism among the three countries, as a function of health system capacity and quality, was purposely sought to explore the factors driving medical tourism across a range of developmental contexts. In Mexico, stakeholders were limited to Tijuana, Monterrey, and Mexico City as the former are known to be centres of health service exports and the latter is the administrative and economic centre of the country. We report here on the findings from interviews with public-and private-sector stakeholders in these countries' health, tourism, trade, and civil society sectors that identify common factors informing the industry's development. These factors illustrate why and how medical tourism is being actively promoted in CAC countries and articulates impacts it may have on regional health equity.

Methods
This analysis contributes to the second stage of a multicountry case study examining the health equity implications of medical tourism in Mexico, Guatemala, and Barbados. The first stage of the study documented retrospective accounts of existing medical tourism activity and sector development in each study site using secondary data. This stage was conducted over a period of 12 months from June 2012 to June 2013 to provide a baseline understanding of medical tourism activity and discussions in each country. The third stage, conducted in the autumn of 2014, consulted Canadian health system stakeholders about the second stage findings to explore their perspectives on the resulting kinds of responsibilities and planning responses by high-income countries implicated in medical tourism via foreign investment and international consumption of health services by their citizens. The second stage comprises 150 semi-structured interviews with stakeholders involved in or affected by medical tourism, drawn equally from each country. Participants were sought from four broad domains: 1) health human resources, 2) government ministries and public companies, 3) the private health and tourism sectors, and 4) civil society. The study protocol prospectively set recruitment targets of 15 participants for the first three professional domains and five participants for the last domain, which were met in all three of the study sites. Participants from the domain of health human resources include individuals involved in certification, training, and regulation of nurses and physicians as well as front-line service delivery. Participants from the public sector comprised those involved in analysing and developing public policy for the trade and health sectors, health system administrators and researchers, and representatives from public investment and trade promotion organizations. Participants from the third domain, the private health and tourism sector, include private hospital administrators, tourism operators, and private tourism, health care, and trade consultants. Lastly, civil society participants were drawn from non-governmental organizations with public health mandates and local journalists and academics.
Potential participants were identified from secondary data collected on medical tourism projects (13Á15), professional roles in relevant ministries, organizations, or companies, and rolling recruitment from participants. Each potential participant's domain was classified by the interviewing researcher and confirmed by the site's lead researcher. All participants remained enrolled in the study until conclusion.
Ethics approval for the study design was granted by the research ethics boards of the lead researchers in each study site. Study invitations were sent to interview participants in advance clearly explaining the study rationale and goals as well as the potential risks and benefits of participation. The invitations also introduced both the international and local researchers, their affiliations, and their respective research ethics boards, with contact information provided for all parties. Participants were informed of their rights to not answer any questions they want and to withdraw their contribution at any point during the study. These rights were provided both in advance with the study invitation and at the time of the interview for those who agreed to participate. Participants' consent was sought and documented prior to beginning of each interview, with documented verbal consent provided for in cases where participants requested not to provide signed consent due to cultural norms. The anonymity of participants was guaranteed and protected by researchers throughout the research process. All digital interview files related to the project were centrally stored and circulated securely using a private computer server physically located in the lead researcher's lab.
The interview guide was created in English and translated into Spanish by a professional translator. The guide comprised a general set of opening questions regarding the participant's background, health system knowledge, and general knowledge of medical tourism, followed by five sets of questions in key domains of medical tourism development and impact: health human resources, trade and investment, government involvement, the public health sector, and the private health sector. Following the opening questions, each participant was asked only questions from their domain of knowledge so as to increase the specificity of their answers, while reducing frustration by avoiding areas of questioning not relevant to their expertise.
An initial round of fieldwork by RJ, VAC, and JS was conducted in Barbados in the summer of 2013 to establish the usefulness of the interview guide. Interviews were then conducted on-site by AC and a research assistant in Guatemala and EON and three research assistants in Mexico between August 2013 and November 2014. All Spanish language interviews were conducted by local researchers in both Guatemala and Mexico. Interviews across all sites lasted from 30 to 60 min. Interviews were digitally recorded and transcribed, with the Spanish interviews translated to English by the same two Guatemalan translators for consistency and sensitivity to cultural ambiguities.
All transcriptions were uploaded to the qualitative data management software NVivo10 (16) for coding. Following a review of five unique transcripts apiece, the lead investigators independently created an initial coding scheme. A meeting was held to consolidate the codes into a single scheme, which was applied to six transcripts (two from each site) to identify redundant and missing codes and produce a final coding scheme following further discussion among the lead investigators. To maintain coding consistency and coherence across the data set, RJ coded all 150 transcripts. The data coded for 'drivers' and 'inhibitors' of medical tourism development were reviewed by RJ and VAC to identify and compare cross-cutting themes and issues that emerged across the data set and were discussed with the larger team to seek consensus on interpretation. This thematic analysis, as part of our comparative case study, was made possible through identical sampling and interview schedules used across the three countries.

Results
The interviews highlighted unique factors in Mexico, Guatemala, and Barbados that are informing the development of the medical tourism sectors in each country.
The comparative thematic analysis identified four drivers and three inhibitors common to sector development in all three countries. Tables providing illustrative quotes of these factors accompany each section.
Factors driving sector development Stakeholders across Barbados, Guatemala, and Mexico understand medical tourism as, first and foremost, an economic issue. The sector is being developed in order to diversify tourism sectors and create economic returns. Very few stakeholders, even within public health sector authorities, framed medical tourism as an issue of health systems operations and planning. Four interrelated and crosscutting factors driving the development of medical tourism were raised by stakeholders in all three countries: 1) excess capacity in the private health sector, 2) foreign-trained health workers, 3) international hospital accreditation, and 4) medical tourism promotion and development initiatives by publicly owned investment and export promotion companies.

Excess private sector capacity
Interview participants in all countries explained how insufficient local demand for private healthcare has stoked interest among private care providers in bringing international patients to fill underutilized hospital beds. While this lack of local demand was attributed to limited private insurance uptake and financial barriers to private care among local patients, the small population of Barbados was identified as an additional contributing factor because of the limits it places on local demand. Select private facilities with advanced infrastructure and staff with foreign training in all three countries were reported to be planning for or marketing to foreign patients (Table 1).

Foreign-trained health workers
Health workers with foreign training, particularly physicians educated in the United States and Europe, were frequently discussed in relation to medical tourism. Firstly, foreign-trained health workers were framed as indicators of the quality of care available locally and understood to be an asset of marketing medical care to patients from high-income settings. Physicians with international training, particularly those who also own their facilities, were raised as key players in advancing private sector interest in marketing care to foreign patients. In addition to the prestige and interpretability of their qualifications for foreign patients, internationally trained physicians' English language proficiency and motivation to maintain their skill set while practicing in high-end clinical environments were discussed as factors motivating medical tourism development ( Table 2).

International hospital accreditation
Medical tourism is widely understood to be a 'pay-to-play' arena, where international hospital accreditation is the entry fee. Many large private hospitals in Mexico have been internationally accredited, two in Guatemala were seeking accreditation at the time of data collection, a clinic in Barbados has obtained such accreditation and development plans for a new private facility there note that international accreditation will be sought. It was reported that while international accreditation serves as a quality indicator for marketing to international patients, it was also widely understood to permit access to the American health insurance market, without which it would be difficult to be considered a legitimate care provider. Perhaps most significantly, Mexican stakeholders reported that  domestic hospital accreditation is currently being harmonized with international hospital accreditation standards to improve care quality and facilitate insurance portability (Table 3).
Public promotion of private medical tourism projects Public trade development corporations that promote exports and foreign investment have all been active in developing public policy and analyses for the sector in all three countries, disseminating information locally and advancing hospital and marketing projects internationally. ProMexico has identified 'clusters' of medical facilities in each state that they plan to advertise abroad as the best quality of care available in the country. INGUAT is coordinating private and public sector efforts to export health services from Guatemala while promoting its hospitals internationally. Invest Barbados has organized and attended medical tourism trade shows to promote the sector and facilitated the planning for a new private hospital that will be oriented to foreign patients. These export and investment development corporations are the common lead actors in sustaining the conversation around medical tourism in their home countries and promoting its development ( Table 4).
Inhibitors of health services export A common, cross-contextual narrative about the challenge of sustaining interest in medical tourism emerged from the Mexican, Guatemalan, and Barbadian stakeholders.
Interviewees described an initial period of enthusiasm among private-and public-sector stakeholders for sector development, spurring workshops and inter-sectoral planning. However, in spite of the working groups, policy initiatives, and hospital projects that the enthusiasm for becoming medical destinations spurred, stakeholders consistently described significant setbacks in expanding their medical tourism sectors. Three cross-cutting inhibitors were found to be shared across the sites: 1) the high expense of entering the medical tourism market, 2) incoherent planning within and between the private and public sectors, and 3) structural socio-economic issues such as insecurity and relatively high business costs and financial risks.
High expense of market entry Participants identified the high cost of entry to the international health service market as a large and immediate barrier to sector development. Medical facilities looking to attract international patients were generally understood as having to be aesthetically modern with upto-date technology, infrastructure, and safety protocols.
Costs resulting from international hospital accreditation, both the process itself and upgrading to its requirements, were regularly raised by participants from the private health sector as the most significant barrier. As a result of the perceived high costs of competing for medical tourists, promotion of the sector is largely limited to the bestfinanced and equipped private facilities (Table 5).

Incoherent sector-wide planning
In each country, participants identified two sources of incoherence in advancing the medical tourism sector. Firstly, intra-governmental responsibilities and goals for the sector are not well defined, with initiatives poorly coordinated between different levels of government, ministries, and public trade promotion corporations. Concerted efforts to bolster medical tourism ultimately failed to outlive the tenure of cabinet ministers who initiated them. Secondly, hospitals and physicians in the private health sector are described as wary of one another's efforts. In Guatemala and Mexico, existing private hospitals have established rivalries and do not want to benefit competitors through sector-wide coordination. In Barbados, many physicians are wary of large-scale medical tourism projects that plan to import foreign physicians, introducing additional private-sector competition for local patients (Table 6).

Local insecurity and high cost of care
Two perceived socio-economic inhibitors identified by participants were country specific. Insecurity was the most frequent social issue raised by Mexican and Guatemalan participants as inhibiting the development of medical tourism in their countries. It is thought that ongoing local violence would deter international patients. Barbados was distinct from the other sites as low rates of violent crime have been identified as a strength in developing medical tourism. However, the high operating and labour costs relative to Barbados' regional CAC competitors played a similar (albeit much less prominent) role in participants' discussions of endemic barriers to sector development (Table 7).

Discussion
Our findings are consistent with key elements of existing accounts of medical tourism development elsewhere (2Á4, 17,18), supporting their relevance and attendant implications in new contexts. In particular, three of the driving factors identified by our analysis, private-sector oversupply, local availability of internationally trained physicians, and international hospital accreditation, echo what has been documented in the literature (2Á9, 19,20). However, participants' accounts emphasize different facets of each driver that have not been identified in previous analyses, such as the coordination of local hospital standards with international accreditation, the role of Table 6. Illustrative quotes of incoherent sector-wide planning Barbados '[Medical tourism promotion] happens but it has not really been as structured as perhaps it could be. And then the other thing too . . . is that you have silos, so one entity is doing something, the next entity is doing something and they're not really coming together'. international hospital accreditation in supporting internationally portable health insurance, and interest in the sector being driven in part by internationally trained specialists seeking to maintain their skills and practice in resource-intensive clinical settings.
In the CAC region, medical tourism is understood to be a solution to address unused capacity in the private health sector (21,22). For Guatemala and Mexico, this capacity already exists and is seeking utilization; for Barbados, the demonstrated viability of tapping into the international market to reach a sufficient catchment of private patients is facilitating planning for new private facilities. On the surface, this supports the idea that medical tourism can be a relatively benign source of additional revenue for health systems that bolsters health infrastructure and economic development (8). However, as it is the existence of severely inequitable distribution of medical resources domestically that has given rise to the rationale for private medical providers to turn to international patients, the benefits associated with medical tourism are unlikely to reach beyond the silo of the private health sector without accompanying redistributive policies. Developing and enforcing redistributive policies thus remain a priority for governments pursuing medical tourism if they intend to ensure that their health systems for the local population are strengthened by sector development (3,23).
The driving role of attracting and retaining highly trained health workers has been highlighted as a key factor in accounts of the development of medical tourism elsewhere (8,19,20,24). Previously, these accounts have focused on internationally trained health workers as internationally marketable assets, framing their role in driving development of the industry as relatively passive resources to be drawn on (1,18,24). Our interviewees emphasized the active, entrepreneurial role of internationally trained physicians in stoking interest in the sector. This entrepreneurship was articulated in terms of profit seeking, but perhaps of more interest, also in terms of a desire to operate in excellent clinical environments while retaining and further developing their skills. These findings support the notion that medical tourism is one means to attract and retain health workers who might otherwise emigrate, but tease out the multi-faceted rationale by which it may do so beyond its potential to support higher wages. The findings also raise further questions of how health system planners are to engage the skills of foreign-trained health workers within the local epidemiologic and health system context if medical tourism supports highly skilled practitioners to opt out of treating the most pressing domestic needs (2, 5Á7).
The third driving factor identified by the findings, international hospital accreditation, is unsurprising as it is found throughout the existing literature as a standard 'ingredient' in the developmental formula for medical tourism (1Á8, 25). However, participants clarified the role international hospital accreditation is playing in planning for the sector in the CAC region. While existing discussion of international hospital accreditation focuses on its role as a marketable credential and means to improve and Table 7. Illustrative quotes of local insecurity and high cost of care Guatemala 'We shouldn't waste our time in going to the US to promote and sell our packages Á even if American Airlines gives us free tickets Á because we are more expensive than the rest of the region and no one will want to come. There's also another matter . . . it's very unsafe in the country'.
(Private Sector Á 16) 'Our first problem is insecurity . . . Who is going to come to Guatemala if here you get mugged or killed over a cell phone? So, for example, with a group of brokers we had, we drove them around in a shuttle bus, and we had a police   standardize quality of care, many participants emphasized international hospital accreditation as a precursor to accessing private insurance funds outside of their countries. International hospital accreditation should thus be understood not only as an emerging standard of care, but also as a precursor to scaling up flows of international patients into the future (21,26).
The fourth driving factor that emerged from this analysis, promotion and planning for medical tourism by public export development and investment corporations, is not well reflected in existing accounts of sector development. While instances of medical tourism being coordinated and promoted by government agencies are found in the literature (2Á5, 21), the parallel roles of the public export and investments promotions corporations in all three countries are striking in their formulaic recurrence and its consequent implications for health policy in each country and across the region. As the most visible government organizations driving medical tourism in CAC are both removed from health systems planning and approaching medical tourism solely as an economic development project, the risk of the sector developing with only cursory consideration of the many health equity concerns medical tourism raises (2Á8, 27) is significantly heightened. If well managed by a wide range of organizations and stakeholders, it is argued elsewhere that medical tourism has the capacity to benefit the overall health system in the form of cross-subsidization of care, advanced infrastructure, and support for a wide range of specialities (8,27). However, the narrow frame of reference and expertise that is informing the development of the sector in CAC reduces the likelihood of achieving these wider systemic gains.
Lastly, the inhibitors raised by participants, those of high costs to market entry, incoherent planning, and endemic socio-economic burdens, raise larger questions of the suitability of a wholesale health services export sector for the CAC region. High costs of market entry will likely restrict the revenues of medical tourism to the already best resourced facilities and further narrow the potential benefits of the sector. Incoherent planning that has proceeded in spurts in all three countries is preventing a comprehensive vision for what the sector aims to achieve, in terms of both economic and health development, its potential pitfalls, and which parties should oversee its development. Neglecting to address these barriers while the underlying driving factors push development of medical tourism ahead will further entrench the inequitable tiers of care that have given rise to the phenomenon.

Conclusions
There are a number of shared factors shaping the development of medical tourism in CAC that help explain why it is being pursued by many hospitals and governments in the region. Our analysis of 150 stakeholder interviews from Barbados, Guatemala, and Mexico identifies four common driving factors: 1) excess capacity in the private health sector, 2) foreign-trained health workers, 3) international hospital accreditation, and 4) medical tourism promotion and development initiatives by publicly owned investment and export promotion companies. The analysis also identified three common inhibiting factors: 1) the high expense of entering the medical tourism market, 2) incoherent planning within and between the private and public sectors, and 3) structural socio-economic issues.
This study indicates that medical tourism development is primarily being driven by public investment promotion agencies and the private health sector as they seek economic benefits with limited consideration and planning for the health equity concerns medical tourism raises. The factors identified here as currently shaping the industry in CAC should be incorporated into planning for the sector to ensure that the wider potential gains of medical tourism are channeled into the health system as a whole.

Authors' contributions
VAC, JS, and RL were primarily responsible for the study design, while VAC oversaw the full study. VAC, RJ, and JS conducted the interviews in Barbados with the support of an additional research assistant. AC and WGF oversaw data collection in Guatemala by identifying participants and managing interview data, with AC conducting many of the interviews. AC and WGF also coordinated the work of research assistants who completed interviews not conducted by AC and translated all Spanish transcripts from the project. EON oversaw data collection in Mexico by identifying participants, conducting interviews, managing data, and overseeing the work of research assistants who also conducted interviews with participants in Mexico. RJ coded the data. All authors reviewed selected transcripts and data extracts to identify and confirm the themes reported herein, and VAC, RJ, and AC met in person to review data and outline the analysis. RJ drafted the manuscript with all authors iteratively reviewing drafts and providing editing and critical intellectual feedback throughout the writing process. RJ, VAC, AC, RL, JS, EON, and WGF have all reviewed and approved the final manuscript.
industry or from any organizations other than the public research funding body noted in the Acknowledgements.

Paper context
The ongoing development of medical tourism has significant global health implications, particularly in regard to health system capacity and the equitable distribution of health resources. This analysis of 150 stakeholder interviews from three Central American and Caribbean countries identifies a confluence of common factors that are prospectively influencing regional interest in medical tourism. Identifying these factors assists in understanding how and why medical tourism is being so widely pursued and can support the creation of policies that enhance equitable outcomes while minimizing the potential harms of the sector.