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286 journal of law, medicine & ethics
Medical
Tourism’s Impact
on Health
Care Equity
and Access
in Low- and
Middle-Income
Countries:
Making the Case
for Regulation
Y.Y. Brandon Chen and
Colleen M. Flood
Travelling internationally to acquire medical
treatments otherwise unavailable or inac-
cessible in one’s home country is not a novel
concept. Conventionally, such medical travel largely
entailed patients from developed countries or wealthy
patients from the developing world seeking care in
Western facilities like the Mayo Clinic in the U.S. and
myriad private clinics along Harley Street in London,
England.1 What is dierent about the topical phenom-
enon known as “medical tourism” is the growing trend
of health services export in the opposite direction.
The number of patients travelling from the developed
world to low- and middle-income countries (LMICs)
for treatments has ballooned in recent years, primarily
driven by diculties with accessing aordable care at
home.2 According to a liberal estimate by the Deloitte
Center for Health Solutions, the number of Ameri-
cans travelling abroad for care rose from 750,000 in
2007 to 1.6 million in 2012.3 On the flip side, Thailand
reportedly treated a total of 1.3 million foreign nation-
als in 2007, which represented a 16% leap from 2001.4
The volume of medical tourists visiting India approxi-
mated 150,000 in 2005, and was expected to continue
expanding by 15% per year.5 In Malaysia, between
2004 and 2008, the number of patients from over-
seas grew by 21.4% annually from around 174,000 to
374,000.6
As the medical tourism industry expands, scholars
have begun to contemplate its potential implications
for health care systems in LMICs. On the one hand,
there is much hype about the potential for medi-
Y.Y. Brandon Chen, J.D., M.S.W., is a Doctor of Juridi-
cal Science candidate at the University of Toronto, Faculty of
Law. He is a Vanier Canada Graduate Scholar, a Canadian
Institutes of Health Research Fellow in Health Law, Ethics and
Policy, as well as a Lupina Senior Doctor Fellow in the Com-
parative Program on Health and Society. He holds a Bachelor
of Science degree from Emory University as well as Master of
Social Work and Juris Doctor degrees from the University of
Toronto. Chen was called to the Bar of Ontario in 2011 after
having articled at the Canadian Civil Liberties Association.
Between 2009 and 2011, he served as a publicly-appointed
member of the Ontario Ministerial Advisory Committee on
HIV/AIDS. Colleen M. Flood, LL.B., LL.M., S.J.D., is a
Professor and Canada Research Chair at the Faculty of Law,
University of Toronto and is cross-appointed to the School of
Public Policy and the Institute of Health Policy, Management
& Evaluation. From 2006-2011 she served as the Scientific
Director of the Canadian Institute for Health Services and
Policy Research. She holds a Bachelor of Arts and Bachelor of
Laws (Honours) from the University of Auckland, New Zea-
land as well as a Master of Laws and Doctorate in Juridical
Science from the University of Toronto, Canada. Her primary
areas of scholarship are in administrative law, comparative
health care law & policy, public/private financing of health
care systems, health care reform, and accountability and gov-
ernance issues more broadly.
global health and the law • spring 2013 287
Chen and Flood
cal tourism to instigate health system and economic
improvements in destination countries. Milica Book-
man and Karla Bookman, for instance, posit: “Medi-
cal tourism is first and foremost related to economic
growth. Not only does it bring in foreign currency but
it also has linkages throughout both the health and the
tourism industries. By way of the multiplier, medical
tourism spills into secondary and tertiary sectors, pro-
ducing cyclical waves of expansion.”7 In other words,
by treating foreign patients on a private for-profit
basis as well as by attracting foreign investments in
the burgeoning medical tourism sector, health care
systems in LMICs could stand to benefit directly from
this fresh revenue. Moreover, since medical tourism
is expected to stimulate development in tourism, hos-
pitality, infrastructure and related industries, such
economic growth could trickle down and enrich the
health care sector in due course. In theory, LMICs
could devote these new resources to upgrade health
care facilities, improve the standard of care, create
new training opportunities for medical practitioners,
and foster favourable working conditions to counter
the brain drain of health professionals to the devel-
oped world.8
On the other hand, some observers have raised
concerns about medical tourism potentially wors-
ening the accessibility of health care for citizens of
LMICs. The expansion of medical tourism, they
argue, diverts resources from basic health and social
services depended upon by the majority of the local
populations to secondary and tertiary care demanded
by foreign patients, thus distorting health spending
in LMICs.9 These critics contend that a successful
medical tourism industry is likely to compete with the
domestic health care regime for the limited number of
health professionals available and therefore contrib-
ute to internal brain drain.10 The increased demand
due to influx of medical tourists could also elevate the
costs of health care and price out local patients, espe-
cially the poor.11 Unlike proponents of medical tour-
ism, these commentators are less optimistic about
the prospect of revenues generated from medical
tourism cross-subsidizing the public health care sys-
tem. Instead, they fear that proceeds are reinvested
back into the medical tourism industry to support its
continuing growth and to satisfy its investors’ profit-
making objectives.12 Ultimately, as suggested by Laura
Hopkins and colleagues, “the prime beneficiaries are
limited to medical tourists and the enterprises that
provide services. The global entrenchment of two-
tiered health care following medical tourism poses the
broader and larger ethical health equity concern.”13
Despite these disagreements, there appears to be
consensus among academics that current understand-
ing about medical tourism and its eects on LMICs
largely derives from “theory, assumption or conjec-
ture.”14 Our objective in this paper is therefore to sur-
vey existing evidence regarding the impact of medi-
cal tourism on low- and middle-income destination
countries. It is not until very recently that researchers
have begun a concerted eort to approach the dis-
course on medical tourism from an evidence-based
perspective. For instance, Glenn Cohen poses six ques-
tions that he argues must be empirically answered by
researchers who seek to establish the adverse impact
of medical tourism on health care access in LMICs,
particularly for the poor, namely: (1) whether health
resources consumed by medical tourists would have
otherwise been available to citizens of destination
countries; (2) whether the medical tourism industry
lures away health providers who served local popula-
tions exclusively; (3) the degree to which the supply
of health care resources in destination countries can
be expanded to meet increasing demand from both
local patients and medical tourists; (4) how success-
ful medical tourism is in countering the emigration of
LMICs’ health professionals; (5) how medical tour-
ism’s positive and negative spillover eects on LMICs’
public health care systems balance against each other;
and (6) the likelihood of economic gains from medical
tourism to trickle down in destination societies.15
Without wishing to engage in a comprehensive eval-
uation of his proposed research agenda, we argue that
there is an a priori bias embedded in how Cohen (and
other commentators) has framed the problématique
of medical tourism. As Cohen explains, his analytical
framework is premised on the principle that “where
there are willing providers of services…and willing
consumers…pursuing an ordinarily morally unprob-
lematic activity (providing medical services) involving
voluntary transactions, the proponents of introducing
new regulatory interventions should come forward
with evidence showing a need to act.”16 In other words,
the burden appears to rest on opponents of medical
tourism to prove its negative consequences on LMICs’
health care access before regulatory actions may be
considered. In contrast, we argue in this paper that
the evidentiary burden should be reversed. We con-
tend that even when access to health care in LMICs
is not adversely aected by medical tourism, there are
still equity-related concerns that in and of themselves
render medical tourism normatively problematic. As
we discuss further below, this inequity can (and often
does) arise, for example, when access to primary and
preventive health services for the general LMIC pop-
ulations maintains the inadequate status quo while
medical tourists from well-resourced developed coun-
tries are aorded cutting-edge secondary and tertiary
288 journal of law, medicine & ethics
SYMPOSIUM
care. If equity is considered a relevant goal for health
care systems and one accepts our conclusion that
medical tourism in LMICs will likely have deleteri-
ous equity impacts, then the burden should be borne
by medical tourism’s proponents to demonstrate its
benefits on health care access and to justify why some
degree of government regulation is inappropriate.
That said, Cohen’s six questions are very helpful in
teasing out the key points of contention in the current
debate over medical tourism’s implications for LMICs.
We will therefore refer to them in a general manner in
this paper to structure our review of evidence regard-
ing medical tourism’s impact, while adopting a dif-
ferent approach to the burden of proof as described.
Although our focus is on LMICs, we will examine rel-
evant evidence from both developed and developing
countries in order to augment our analyses in situa-
tions where evidence from LMICs is unavailable or
incomplete. Ultimately, we suggest that there is some
empirical support for concerns about medical tourism
in its current form — supported by hefty public sub-
sidies and yet subjected to little government oversight
— engendering unequal treatments between foreign
and local patients in destination countries and, to
some degree, adversely aecting health care access for
LMIC residents. We conclude that government regu-
lation and/or intervention is necessary to redirect the
ongoing expansion of medical tourism from its detri-
mental trajectory and that, to the extent possible, gov-
ernments of developed countries should put in place
policies to limit the attractiveness of medical tourism
for their own citizens.
II. Increased Competition for
Health Care Resources
One of the main worries that underpin objections
to medical tourism is that foreign patients would
compete with residents of LMICs for finite health
care resources. For example, according to the World
Health Organization (WHO), there were 3 physicians
per 10,000 population in Thailand in 2010, falling
considerably short of the global average of 14 physi-
cians per 10,000.17 Although the country produced
approximately 1,300 new doctors each year based on
2009 data,18 this number was just sucient to meet
the annual increase in health care demand due to pop-
ulation growth and the influx of foreign patients.19 As
such, medical tourists potentially compete with local
patients for newly trained physicians who could have
otherwise been devoted to closing Thailand’s physi-
cian deficit.
Further intensifying this competition, it has been
observed that medical tourists do not merely displace
resources otherwise available to domestic patients
on a one-to-one ratio. In order to compete for inter-
national patrons, hospitals in destination
countries commonly oer perquisites that go
beyond the requirements of the usual stan-
dard of care, such as personalized nursing
services, ready access to medical specialists,
and hotel-style room accommodation.20 By
one estimate, the amount of resources used
to treat one foreign patient in Thailand is
roughly the same as what is generally needed
to care for four to five local residents.21 Thus,
the presence of even a small number of medical tour-
ists could nevertheless make a notable dent in health
care resources for LMIC residents. Admittedly, it
is possible that some of these health resources may
derive from fresh private investments that would not
have been available to LMIC patients in any event.
However, as we will elaborate below, LMIC govern-
ments have at times reduced health care spending
following increases in private expenditure, thus leav-
ing the countries’ overall health resources relatively
unchanged. Under these circumstances, allocation of
greater resources to medical tourists arguably must
mean fewer resources for local residents. Moreover,
as alluded to above, the level of care and quality of
facilities enjoyed by foreign patients but not available
to most of their local counterparts raises additional
equity concerns.
Aside from diminishing the aggregate health
resources available to local patients, medical tour-
ism could also cause the uneven distribution of health
resources within LMICs’ health systems. As Nathan
Cortez remarks, “As mobile as patients have become,
they do not travel to all countries for all procedures.
Patients generally receive preventative and emergency
care where they live….”22 Therefore, health services
sought by medical tourists are usually elective pro-
cedures that are either not covered by insurance or
have a long waiting list at home, and in which des-
tination countries enjoy a relative cost advantage.23
As examples, treatments most commonly obtained by
medical tourists in Thailand include heart operations,
cosmetic surgery, dental work, cataract removal and
bone-related procedures,24 whereas foreign patients
The level of care and quality of facilities
enjoyed by foreign patients but not available
to most of their local counterparts raises
additional equity concerns.
global health and the law • spring 2013 289
Chen and Flood
to India frequently undergo, inter alia, hip and knee
replacement, bone marrow transplant, coronary
bypasses, cataract surgery, in vitro fertilization and
plastic surgery.25 Enticed by a higher profit margin
associated with caring for foreign patients, health pro-
viders and private investors in destination countries
may redirect their attention to these medical (sub)spe-
cialties, thus further depriving other essential fields of
medicine in LMICs of resources.26
Specifically, concerns are raised that technology-
intensive secondary and tertiary care sought by medi-
cal tourists are favoured over primary and preven-
tive services needed by local residents, particularly
the poor.27 In India, for instance, alongside a robust
medical tourism industry that boasts the capacity to
perform some of the most advanced surgeries in the
world, tuberculosis and diarrhoeal diseases together
continue to claim the lives of over one million people
each year.28 If health personnel and clinical resources
are increasingly diverted to serving medical tour-
ists, the ability for India to develop a functional pub-
lic health care system that would ensure all citizens’
access to at least basic health services may become
ever more limited, and the gross disparities in access
between rich and poor even more accentuated.
Similarly, according to 2005-2006 data from Thai-
land’s Ministry of Public Health, approximately one-
third of the country’s computed tomography (CT)
scanners and two-thirds of its magnetic resonance
imaging (MRI) machines were located in Bangkok,
which is a popular destination among medical tour-
ists. Private health facilities reportedly imported a
large majority of these machines specifically to sup-
port the government’s vision of transforming Thailand
into a medical hub in Asia.29 In fact, one commentator
asserts that the number of Gamma Knife machines,
CT scanners and mammography equipment avail-
able in private institutions in Bangkok alone is greater
than that available in all of England.30 This high con-
centration of medical technologies within the private
sector in one city raises serious doubts about health
resources being spent in a manner that is aligned with
priorities of Thailand’s general population. Further-
more, it implies that a significant number of health
technicians required to operate these machines would
become less available, if at all, to work in the public
health care system.
The growing emphasis on high-tech medical equip-
ments could have an added eect of contributing to
rising health care costs. A field study conducted by
Rohit Varman and Ram Manohar Vikas found that
the spread of specialized facilities and technologies in
India has created an incentive for health providers to
aggressively promote the usage of these equipments
in order to recover their capital investments. Such
provider-generated utilization ultimately drives up
the total health care outlays.31 In the same vein, the
Health Minister of Malaysia chastised the country’s
private health sector in 2007 for allegedly “charg-
ing [patients] excessively and conducting unneces-
sary medical tests and consultations.”32 As the price
of treatment escalates, which we will discuss in more
detail later, local patients face increasing risk of being
“crowded out” of the health care market, with the poor
bearing the brunt of the eects.
In sum, as it has been predicted by some scholars,
a “dual medical system” appears to emerge in LMICs
where “specialization in cardiology, ophthalmology,
and plastic surgery serves the foreign and wealthy
domestic patients while the local populations lack
basics such as sanitation, clean water, and regular
deworming.”33 Such inequalities between foreign and
local patients per se raise significant concerns about
the promotion of medical tourism in LMICs. More-
over, due to direct competition for finite resources and
indirect mechanisms — namely, distortion of health
resources allocation as well as elevation of treatment
costs — we argue that a jump in health care consump-
tion resulting from increased foreign patients is likely
to further reduce the level of health services available
to LMIC residents.
III. Exacerbation of Internal Brain Drain
Among the types of health care resources that are
at risk of being “captured” by medical tourists at the
expense of patients in destination countries, the loss
of human resources has caused particular concern, in
part because of the severe health personnel shortages
already facing LMICs. As discussed above, medical
tourism likely diverts medical personnel into niche
specialties demanded by foreign patients. Beyond this,
however, since medical tourism in many destination
countries is accompanied by an expansion of private
health care, particularly in urban regions, the continu-
ing growth of the industry raises the prospect of medi-
cal personnel moving from the public system into the
private sector and from rural regions into urban cen-
ters, a phenomenon commonly referred to as “internal
brain drain.”
Medical tourism in many destination countries
largely operates within a growing private health sec-
tor.34 In Thailand, for example, four private hospital
chains — namely, Bumrungrad, Bangkok, Thonburi,
and Phyathai — have led the eorts in courting inter-
national clients.35 Likewise, in India, the medical tour-
ism market is dominated by the private Apollo and
Wockhardt hospital groups.36 Such overlaps between
the medical tourism industry and the private health
290 journal of law, medicine & ethics
SYMPOSIUM
care sector are apparently not accidental. According
to Leigh Turner, following the Asian financial crisis
in late 1990s that sharply reduced the purchasing
power of local families, private hospitals in Thailand
began setting their sights on foreign patients to o-
set decline in domestic demands.37 Malaysia’s medi-
cal tourism industry has a similar origin.38 As such, a
notable correlation exists between the development
of the private health care sector in LMICs during
recent decades and the growing prominence of medi-
cal tourism.39
In order to support its continual expansion, evi-
dence suggest that the private health industry is
actively luring medical practitioners from the public
health sector by promising them higher remuneration
and lighter workloads.40 In Thailand, salaries of medi-
cal doctors in private hospitals are reportedly between
six and eleven times greater than what are oered
by public institutions.41 Absent any regulations, such
a significant income disparity is likely to divert pub-
lic sector health workers into private establishments
that are increasingly catering to foreign patients,
thus aecting the accessibility of health care for local
populations, especially the poor.42 To the degree that
privatization of health care in countries like Thailand,
Malaysia and India is predominantly occurring in
urban areas, the problem of internal brain drain may
be accentuated by an uneven geographical distribu-
tion of health care human resources, leaving patients
who rely on public facilities in rural regions most
severely disadvantaged.43
Data from Thailand over the last decade arguably
reinforces the fear that a bustling private health sector,
fuelled in part by a growing medical tourism industry,
may lead to internal brain drain. According to Thai-
land’s Ministry of Public Health, since 2000 there has
been an accelerated attrition of public sector physi-
cians relative to almost constant medical school out-
put. Whereas there was a loss of 41 public physicians
versus 893 new medical school graduates in 2000,
the same statistics were 294 and 913 respectively in
2002.44 A news report further claims that in 2005,
despite the government having managed to boost the
number of newly trained doctors to 1,300, the pub-
lic system also saw the outflow of physicians rising to
almost 700 in that year.45 Other sources, however, have
presented figures that are more modest instead, indi-
cating that over 350 doctors resigned from their pub-
lic sector posts in the fiscal year of 2004/2005,46 fol-
lowed by another 300-plus doctors in the next year.47
Notwithstanding the discrepancies in the empirical
evidence, many agree that public health care facilities
in Thailand have been incurring substantial losses in
human resources on a persistent basis. Malaysia has
also incurred a similar downward trend in the number
of public sector health professionals.48
Although numerous reasons may potentially under-
lie medical practitioners’ exit from the public health
system — for example, as we discuss below, some doc-
tors may emigrate for work opportunities abroad —
there are indications that many of them in medical
tourist destinations do so in order to take up positions
in private medical facilities, which commonly service
foreign patients. For example, a report by Bangkok’s
Chulalongkorn Hospital documented that 70 of the
institution’s medical specialists left between 2005
and 2010 to work at private hospitals that serve for-
eign patients.49 In addition, private sector competition
reportedly caused nearly 6,000 vacancies for medical
practitioners across Thailand’s public health care sys-
tem to go unfilled in 2005.50 In her 2008 interview
with sta at a public infertility clinic in Bangkok,
Andrea Whittaker was similarly informed that public
medical institutions faced much diculty attracting
specialist nurses and laboratory technicians because
private clinics and hospitals were oering more lucra-
tive salaries.51 In contrast to these stang challenges
in the public sector, the number of medical doctors
working in Thailand’s private hospitals grew by 29.6%
from 3,325 to 4,309 between 1997 and 2006.52 Chee
Heng Leng observed a comparable public-to-private
flow of health professionals in Malaysia.53
To add another layer of complexity to the issue of
internal brain drain, commentators have pointed out
that medical practitioners who have moved from the
public to the private sector tend to be those with the
most experience.54 For instance, the approximately
700 Thai doctors mentioned above who resigned
from their public sector positions in the fiscal years of
2004/2005 and 2005/2006 are said to mainly consist
of top specialists at medical school-aliated teaching
hospitals.55 This observation largely corresponds to
what John Connell describes as “foreign preferences
for experienced and skilled doctors,”56 and what was
uncovered by the Israeli newspaper Haaretz in 2010,
namely that medical tourists visiting Israel were either
allowed to select their desired surgeons or guaran-
teed to be treated by senior members of the medical
sta.57 This targeted brain drain of highly skilled prac-
titioners from the public system has human resource
implications beyond the immediate loss of manpower.
On the one hand, insofar as it could take years of on-
the-job training for medical specialists to develop the
necessary skills, the loss of experienced doctors threat-
ens to create a qualitative deficit in the public health
care sector that new medical school graduates cannot
immediately replenish.58 On the other hand, for coun-
tries like Thailand where medical education remains
global health and the law • spring 2013 291
Chen and Flood
largely a responsibility of the public system, the depar-
ture of top specialists that often serve as teaching sta
at medical schools may adversely aect their capacity
to produce new doctors.59
Moreover, pursuant to neoclassical economic the-
ory, intense competition between the public and pri-
vate health facilities for a finite supply of skilled medi-
cal practitioners will generally exert upward pressure
on the costs of health care human resources.60 Citing
India’s software engineering industry as a cautionary
tale, where inflows of foreign investment bid up the
salaries of software engineers that were in short supply,
Thomas Maclean predicts that health services export
would likewise inflate the outlays for health person-
nel in India.61 Anecdotes from Thailand somewhat
corroborate this projection of a system-wide wage
escalation. In an attempt to compete with the higher
salaries oered by the private industry and to counter
the internal brain drain, in 2008 and 2009, Thailand’s
Ministry of Public Health significantly increased the
remunerations for health professionals in the public
sector, including nearly doubling the income of physi-
cians. This has caused observers to conclude that “the
competing demand for health-care sta generated by
medical tourism will more than likely lead the Thai
government to increase its budget for public health-
care services — especially to cover physicians’ incomes
— at a higher and faster rate than in the absence of
medical tourism.”62 Unless economic growth sustains
a concomitant increase in public health care spend-
ing, price inflation is likely to curtail the provision of
public health care services (as price and output are
inversely related when the total health care spending
is held constant). This is likely to have negative eects
on overall resource allocation, particularly as it per-
tains to the most vulnerable.
Exacerbated by the cost pressure resulting from
the aforementioned shift towards technology-based
medicine, the overall prices of health care in some des-
tination countries appear to have increased notably.
According to calculations based on government data,
the inflation-adjusted cost of each hospitalization in
urban India, which receives the majority of medical
tourists visiting the country, escalated by 9% in pub-
lic facilities and 36.5% in private institutions between
1995 and 2004.63 A study that tracks the average costs
of five surgical procedures performed in Thailand’s
private hospitals, having minimized price variations
relating to pharmaceuticals, shows continual price
escalation between 2003 and 2008, with the annual
price increase as high as 10–25% in most hospitals
between 2006 and 2008.64 With costs of treatment
trending upward, signs point to a growing prospect
of patients in destination countries being priced out
of the domestic health care market.65 In Singapore
— itself a popular medical tourist destination — ris-
ing health care charges have led the government to
actively encourage citizens to seek more aordable
services in neighbouring Malaysia.66
Overall, available evidence from destination coun-
tries appears to demonstrate that an expanding pri-
vate health care sector is diverting skilled profession-
als away from the public system with concomitant
eects of raising the costs of medical care and dimin-
ishing service access for local patients. Insofar as med-
ical tourism is complicit in the development of the pri-
vate health care industry in recent years, it arguably
is at least partially responsible for exacerbating these
health system challenges.
IV. Elasticity of Health Resources Supply
in Destination Countries?
Theoretically, LMICs could mitigate the competi-
tion between medical tourists and local patients and
the problems associated with internal brain drain
through boosting the supply of health care resources.
In fact, proponents of medical tourism argue that the
success of the industry itself could enlarge the pool of
Proponents of medical tourism argue that the success of the industry itself
could enlarge the pool of health resources available to destination countries
by stimulating fresh investment, both domestic and foreign, in the health
sector. With this influx of private capital, public resources could theoretically
be freed to focus on delivering health services to individuals who are most
in need. To date, however, this purported benefit has seldom been realized,
as most LMICs lack robust policies to ensure government resources are
appropriately reallocated to engender greater health equity.
292 journal of law, medicine & ethics
SYMPOSIUM
health resources available to destination countries by
stimulating fresh investment, both domestic and for-
eign, in the health sector.67 With this influx of private
capital, public resources could theoretically be freed to
focus on delivering health services to individuals who
are most in need.68 To date, however, this purported
benefit has seldom been realized, as most LMICs lack
robust policies to ensure government resources are
appropriately reallocated to engender greater health
equity.69 In India, for example, while the amount of
private investment in the health sector soars,70 health-
related spending as a proportion of overall govern-
ment expenditure has declined since the mid-1980s
from 3.29% to 2.77% in 2005.71 Within this dwindling
health budget, the amount allocated to public health
initiatives (e.g., trachoma and blindness control,
infectious diseases prevention, etc.) has decreased dis-
proportionally.72 As such, instead of expanding health
resources available to local patients, particularly the
poor, increased private investment in India appears to
have simply allowed the government to retreat from
the health sector.
In addition to waiting for medical tourism itself
to induce health resource expansion, destination
countries have actively pursued policies aimed at
expanding their human resource pool in particular.
Nonetheless, many of these strategies are problem-
atic and have hitherto yielded mixed results. Aiming
at more immediate eects, for instance, countries in
Southeast Asia have sought to acquire health work-
ers from international sources. While such attempts
have reportedly been quite successful in Singapore,
they have been abysmal in Thailand, with fewer than
ten foreign-trained doctors having received licenses
to practice in the country since 1986.73 In Malaysia,
although the government has managed to attract a
sizable number of medical professionals from over-
seas, the country apparently sees an even greater
number emigrating abroad.74 Therefore, the prospect
of success associated with this type of tactics appears
uncertain. Even more importantly, policies as such
induce brain drain on an international scale and raise
global equity concerns. For labor-sending nations,
not only is their capacity to deliver health care to their
citizens inevitably weakened, but they are also eec-
tively subsidizing receiving countries’ costs of health
personnel training.75
Another short-term method to enhance the health
care capacity of destination countries is to stretch the
existing human resource supply to the extent possible.
In Thailand, after noting that an extra 10% of physi-
cians than currently available would be required to
satisfy the increased demand from foreign patients
by 2015, a group of researchers suggested that this
extra demand be met by way of financially incentiviz-
ing doctors to work overtime.76 Similarly, a committee
created by the Israeli Health Ministry in 2010 to study
ways of regulating medical tourism in the country rec-
ommended that international patients be treated in
public hospitals only outside of regular service hours.77
Both proposals expected health providers to serve
medical tourists in addition to, rather than in place
of, caring for their existing domestic patients. How-
ever, besides concerns about an increased workload
potentially compromising quality of care, we query the
extent to which it is possible to create excess capacity
through stretching an already over-extended health
system in LMICs. Even in a developed country like
Israel, it has been reported that hospitals are already
providing afterhours services to local patients to alle-
viate the pressure of wait times.78 Therefore, it is dif-
ficult to see how any more overtime resources could be
made available to foreign clients based on the current
number of health personnel. Furthermore, the success
of such a strategy would largely depend on destina-
tion countries having a sophisticated regulatory and
monitoring system that ensures health practitioners
who treat medical tourists also fulfill their duties to
public sector patients.
A longer term approach to address human resource
constraints in LMICs is to increase the rate of admis-
sions to health professional schools, a policy recently
implemented by Thailand.79 Between 2005 and 2014,
a total of 10,678 extra spots will be created in medical
schools across the country.80 Nevertheless, this strat-
egy is expensive and therefore not always feasible for
other LMICs. In Thailand, where medical training
is heavily subsidized, it cost the government roughly
US$45,000 to produce one physician according to
2002 data.81 Based on this figure, Thailand’s latest
attempt to expand its medical school output would cost
over US$480 million. Moreover, based on past expe-
riences, a country’s eort to increase medical school
enrolments tends to have limited eects on actually
improving health care access in areas where human
resource shortages are the most severe.82 Therefore,
in the medical tourism context, enlarging the sup-
ply of health providers in LMICs may simply feed
ever-expanding demand from foreign patients rather
than reducing human resource deficits faced by local
residents. Of course, LMICs could adopt policies and
regulations to recapture public investments in human
resources (e.g., requiring physicians who receive pub-
lic subsidies for training to be bonded to the public
system for a certain period of time, increased tuition
costs for physicians who plan to practice privately,
etc.). However, the implementation of these kinds of
global health and the law • spring 2013 293
Chen and Flood
measures requires robust governance structures often
lacking in LMICs.
Thus, based on available evidence, neither increased
private investment in the health sector nor govern-
ment strategies to raise the supply of health profes-
sionals appear capable of satisfactorily neutralizing
the diminishing eects of medical tourism on LMICs’
health resources. Without a robust and carefully
tailored regulatory framework that channels any
expanded capacity in LMICs’ health care systems to
pre-existing areas of shortages, the distribution of
these newfound health resources may continue to
skew in favour of medical tourists, and leave the ema-
ciated supply of health services vis-à-vis local resi-
dents, particularly the poor, largely unimproved.
V. Medical Tourism as a Solution
to External Brain Drain?
In order to translate increased production of health
professionals into actual expansion in health service
capacity, LMICs must also stem the outflow of their
health workers. Driven by the prospect of professional
development, greater financial rewards, better work-
ing conditions and more appealing socio-political
environments, medical personnel in many medical
tourist destinations have long pursued career oppor-
tunities abroad.83 Between 1960 and 1975, Thailand
lost approximately 25% of its physicians to the U.S.
alone;84 and, an estimate in 2006 suggested that there
were nearly 60,000 Indian physicians practicing in the
U.S., U.K., Canada and Australia, a number equivalent
to 10% of doctors registered in India.85 Such interna-
tional brain drain has significant financial implica-
tions for labour-sending countries. According to a
2011 study, South Africa – another prominent medi-
cal tourist destination known especially for oering
aordable cosmetic surgeries86 – has approximately
11,000 of its doctors working in the U.S., U.K., Canada
and Australia, which represents a loss of US$1.4 bil-
lion in education-related investment.87
Commentators like Devon Herrick claim that a
successful medical tourism industry would counter
the migration of health practitioners from LMICs to
developed countries by creating “[m]ore opportunities
to work, higher pay and entrepreneurial opportunities
in developing countries....”88 Indeed, preliminary data
confirms that medical tourism reduces the outmigra-
tion of LMICs’ health workers. A 2007 report from the
UN Economic and Social Commission for Asia and the
Pacific observes that a majority of the 600 health pro-
fessionals employed at Bangkok’s Bumrungrad Inter-
national Hospital are Thais who have returned from
the U.S.89 In India, the Apollo hospital group claims to
have hired 138 expatriate doctors by 2008,90 whereas
the Wockhardt hospital chain has attracted another
two-dozen from the U.S. and the U.K.91
However, we caution that, in terms of scale, these
reported successes are comparatively small when
juxtaposed with health personnel shortages facing
LMICs. In Thailand, an injection of 600 new doctors
from abroad, while important, would represent an
increase of less than 0.1 physician per 10,000 popula-
tion,92 and hardly closes the gap between the existing
physician density of 3 per 10,000 population and the
world average of 14 per 10,000. Likewise, the number
of expatriate doctors working in Apollo and Wock-
hardt hospitals falls far short of the 600,000 more
physicians that India requires,93 and it equates only to
10% of the amount of Indian-trained physicians that
enter the licensing process in the U.S. annually.94
Even assuming that medical tourism actually
causes a sizable number of expatriate health work-
ers to return, there remains the concern of how these
extra human resources are distributed within LMICs.
To the degree that services at private urban hospitals
like Bumrungrad, Apollo and Wockhardt are priced
Based on available evidence, neither increased private investment in
the health sector nor government strategies to raise the supply of health
professionals appear capable of satisfactorily neutralizing the diminishing
eects of medical tourism on LMICs’ health resources. Without a robust
and carefully tailored regulatory framework that channels any expanded
capacity in LMICs’ health care systems to pre-existing areas of shortages,
the distribution of these newfound health resources may continue to skew in
favour of medical tourists, and leave the emaciated supply of health services
vis-à-vis local residents, particularly the poor, largely unimproved.
294 journal of law, medicine & ethics
SYMPOSIUM
beyond the reach of most domestic patients and
largely cater to medical tourists,95 the fact that expatri-
ate health professionals have returned to work in these
facilities arguably does not o-set concerns regarding
the adverse equity and access eects of medical tour-
ism. In other words, potential benefits to LMIC health
systems resulting from medical tourism’s success in
curbing external brain drain may be cancelled out by
its simultaneous exacerbation of internal brain drain.
Therefore, as noted by Manuel Dayrit, Director of the
WHO’s Human Resources for Health Department, “it
does not augur well for the health care of patients who
depend largely on the public sector for their services
as the end result does not contribute to the retention
of well-qualified professionals in the public sector
services.”96
Admittedly, even if practicing mainly in the private
sector, there remains the possibility that knowledge
and skills acquired by returning expatriate health
workers from abroad, or extra tax revenues associated
with their incomes, could accrue to the public health
care system through spillovers or trickle-down eco-
nomics, thus indirectly benefiting the entire patient
population. Nevertheless, we must carefully weigh
such positive eects, if any, against the burdens of
medical tourism on LMICs’ health resources.
VI. What about Positive Health Care
Spillovers?
Proponents of medical tourism argue that gains
enjoyed by the private sector will spillover into the
public health care system in destination countries in
at least four ways, and ultimately benefit local resi-
dents at large.
First, some commentators posit that the medical
tourism industry — often boasting internationally
accredited facilities, state-of-the-art technologies,
and practitioners with credentials from developed
countries — may “drive public hospitals to invest in
their own medical infrastructure and possibly revital-
ize weak health-care systems.”97 However, during the
course of our research, we did not uncover empirical
data that clearly demonstrates such constructive com-
petition between the public and private health sectors.
Rather, as aforementioned, the overemphasis on med-
ical technologies and the pressure to vie for skilled
health practitioners appear to have distorted health
care supply and demand, and pushed up the prices
of treatments in some medical tourist destinations.
Thus, medical tourism-induced inter-sectoral compe-
tition may well increase health care outlays without
necessarily upgrading health service quality.
Second, arguments have been made that private
health care establishments profiting from medi-
cal tourism could share their facilities and human
resources with the public sector at a discounted rate,
and thereby enable a larger segment of the local pop-
ulation to benefit from a higher standard of care. In
some cases, the medical tourism industry has under-
taken such cross-subsidization of its own accord. Both
Bumrungrad and Apollo hospitals offer charitable
cardiac treatments to low-income children, and the
Wockhardt hospital group operates a mobile eye clinic
and deworming camps for underprivileged Indians.98
Nonetheless, since these initiatives are never formally
evaluated, little is known about their cost-eective-
ness.99 Moreover, as these programs are philanthropic
in nature, their scope and length are solely determined
by private donors, sometimes based on considerations
that are independent of the programs’ ecacy. There
is also room for debate regarding whether these ini-
tiatives represent an ecient allocation of a society’s
resources vis-à-vis health priorities since they may
selectively target patients whose circumstances have a
higher profile or are media-friendly.
Destination country governments sometimes man-
date this sharing of health resources between private
and public sectors through public-private partner-
ship arrangements. Even in this context, however,
any increase in local residents’ access to private sector
resources may remain trivial. In 1988, the municipal
government of Delhi, India entered into an agreement
with the Apollo hospital group to jointly develop a
multispecialty medical centre. While the government
provided land and portions of the start-up capital
amounting to nearly US$8 million, it tasked Apollo
The overemphasis on medical technologies and the pressure to vie for skilled
health practitioners appear to have distorted health care supply and demand,
and pushed up the prices of treatments in some medical tourist destinations.
Thus, medical tourism-induced inter-sectoral competition may well increase
health care outlays without necessarily upgrading health service quality.
global health and the law • spring 2013 295
Chen and Flood
with operating the medical centre and ensuring that
one-third of the inpatient and 40% of the outpatient
capacity would be available at no cost to low-income
patients referred from public hospitals. Nevertheless,
in 2003, a committee assembled by High Court of
Delhi revealed that Apollo’s undertakings were mostly
honored in the breach:
• less than 19% of the hospital’s beds (and only
10% of the beds in the intensive care unit) were
allocated to public patients;
• of all outpatient services provided in
2002/2003, a meager 0.0015% was to public
patients;
• instead of free care, public patients were billed
for costs relating to diagnostic imaging, medical
consumables and pharmaceuticals; and,
• facilities designated for public patients were
qualitatively inferior to those enjoyed by private
patients.100
Although Apollo’s disregard for its contractual obliga-
tions was ultimately condemned by the High Court
of Delhi as having violated indigent patients’ right to
health,101 similar practices are apparently common
within India’s private health sector and often occur
with legal and political impunity. A study in early 1990s
found that among 27 private health facilities that had
agreed to oer free services to low-income patients in
exchange for government subsidies, a majority failed
to fulfil their promises.102 Another study by India’s
Public Accounts Committee in 2005 reached similar
conclusions.103 Commentators observe that public
ocials generally turn a blind eye on these contrac-
tual breaches as they are frequently oered free treat-
ments at these public-private partnership hospitals.104
Thus, as described by the Public Accounts Committee,
“what…started [as] a grand idea of benefiting the poor
turned out to be a hunting ground for the rich in the
garb of public charitable institutions.”105
A third claim is that governments could allocate
portions of the medical tourism industry’s revenues
to subsidize the public system by way of, for example,
an industry-specific levy. In comparison to cross-sub-
sidization initiated by private hospitals, government-
led strategies like this could better ensure that private
resources are utilized in accordance with identified
health priorities. Nevertheless, as Chantal Blouin
notes, there is no indication to date that any desti-
nation countries have adopted this type of resource
transfer mechanisms.106 Some scholars have gone
further to suggest that such cross-subsidization is not
currently feasible in many LMICs that lack the rigor-
ous government regulations needed to enforce inter-
sectoral resource sharing.107 Thus, this kind of solu-
tion requires further thought and encouragement;
although it potentially provides a way forward, it can-
not be assumed to be a panacea given governance,
regulatory and enforcement challenges.
Indeed, instead of imposing an industry-specific
levy to better ensure the benefits from medical tour-
ism are translated to public patients, destination
countries seem to be increasingly oering substan-
tial subsidies to the medical tourism industry in an
attempt to maintain a competitive edge globally. In
India, hospitals serving foreign patients enjoy cor-
porate tax concessions, reduced taris on imported
medical equipment, and financial assistance with
marketing expenses;108 and, the drain of publicly
trained physicians into the private sector represents
another government subsidy estimated to total over
US$100 million each year.109 In Malaysia, the gov-
ernment has proposed tax exemptions on hospital
revenues resulting from services delivered to foreign
patients.110 The United Arab Emirates, seeking to
enter into the medical tourism market, is develop-
ing a health care “free zone” in which trades in health
services will be completely tax-free.111 These policies
indicate that, to the extent that government-directed
cross-subsidization actually occurs in destination
countries, health resources have tended to flow from
the public to the private sphere instead of the other
way around.
A fourth possibility is that, for destination countries
with a small population, medical tourism may sustain
the development of certain medical specialties or sub-
specialties by enlarging the demand, thus facilitating
domestic patients’ access to these health services. This
argument has particularly underscored the promotion
of medical tourism in Singapore where public ocials
claim, for example, that the country would not have
been able to support its three living-donor liver trans-
plant teams without foreign patients.112 As such, medi-
cal tourism not only allows Singapore to retain some of
its skilled medical specialists but also enables citizens
to receive advanced medical procedures at home, thus
keeping health care expenditures within the coun-
try. While these advantages deserve acknowledge-
ment, they arguably do not cancel out medical tour-
ism’s adverse impact on Singaporean citizens’ access
to health care. As mentioned above, medical tourism
has also contributed to the rising health care costs in
Singapore to the point that the government is now
actively encouraging citizens to seek cheaper medical
services abroad. As one weighs the improved physical
accessibility of some specialized treatments against
the diminishing financial accessibility of health care
in general, we argue that medical tourism’s spillover
296 journal of law, medicine & ethics
SYMPOSIUM
benefits in the Singaporean context are not as obvious
as its government purports.
In sum, whether it is constructive competition,
cross-subsidization or sustaining the development of
medical subspecialties, available evidence largely sug-
gests that gains made by the private health care sector
through medical tourism are not yet permeating into
the public sector to any significant degree. In the rare
cases where there are positive spillovers, allocation of
private resources within the public system is appar-
ently influenced by favoritism rather than health care
needs and priorities. This seemingly limited success
of medical tourism in generating spillover benefits is
particularly accentuated when juxtaposed with the
sizable amounts of public resources that have been
poured into cultivating, marketing and promoting the
industry, which could have been devoted to improv-
ing health access for the general LMIC population
instead.
VII. What about Eects of Trickle-Down
Economics?
Besides positive spillovers, it is claimed that medical
tourism could benefit LMICs by way of trickle-down
economics. Supporters expect medical tourism to spur
developments and create jobs in not only the health
care sector but also related industries like tourism,
hospitality, transportation and construction.113 As
LMICs’ overall economies expand, it is hypothesized
that trade profits will diuse throughout all segments
of their societies.114 In terms of access to care, presum-
ably, with improved financial status, LMIC residents
may be in a better position to purchase health services
that were previously out of reach. At the same time,
economic growth could enlarge the tax base and stim-
ulate government investments in the public health
care system to improve its access and quality.
Indeed, medical tourism generates significant
amounts of foreign currency for destination coun-
tries. Data from 2007 shows that Thailand earned up
to US$1.35 billion in profits from medical tourism, of
which approximately 84% were from health service
provision and the remainder from tourism-related
activities.115 In the same year, the estimated revenues
from medical tourism for Singapore and Malaysia
were US$1.2 billion and US$78 million respectively.116
However, it is unclear how much of the medical tour-
ism revenue, if at all, actually trickled down to the
bottom of these countries’ economic pyramids, as we
have not yet come across relevant empirical data on
this matter.
When we examine the experiences of the broader
tourism sectors in LMICs, which have similarly been
expected to generate foreign currency that would then
spread to other industries and ultimately benefit the
poor, the trickle-down eect appears to have been
limited. As a large percentage of businesses in LMICs’
tourism industries is foreign owned, the UN Confer-
ence on Trade and Development estimates that, on
average, almost half of the tourism revenues accrue
to stakeholders overseas.117 With foreign direct invest-
ments in medical tourism on the rise,118 comparable
profit leakages may occur and as a result significantly
curtail the prospect of any trickle-down benefits. For
example, a Malaysian company’s recent takeover of
Parkway Holdings, which was Singapore’s main hospi-
tal chain and had previously merged with the second
largest health care conglomerate in India, prompted
observers to caution that profits from medical tourism
in Singapore and India may largely end up benefiting
Malaysia.119
In fact, research is yet to conclusively prove the
validity of trickle-down economics in general. A study
by Santonu Basu and Sushanta Mallick regarding the
impact of economic expansion on the rate of rural
poverty in India actually finds that “the trickle down
eect has never taken place …; rather, it is the govern-
ment redistribution policy…that not only produced
a higher growth rate but also reduced the incidence
of poverty at a much faster rate.”120 Even when schol-
ars have identified a negative correlation between the
incidence of poverty and economic growth triggered
by laissez-faire policy, seemingly arming the trickle-
down theory, they discover that the trickle of wealth
evaporates and rarely reaches those lowest on the
socioeconomic ladder.121
VIII. Conclusion
Our review of medical tourism’s impact on LMICs
reveals an evidentiary gap in the scholarship. To
the extent that relevant evidence exists, it remains
largely anecdotal rather than statistical in nature.
However, based on the limited information that
we have uncovered, there are signs of correlation
between medical tourism and the expansion of pri-
vate, technology-intensive health care in LMICs and
this raises inherent equity concerns about the dier-
ential treatment between the local population and
medical tourists. As such, contrary to arguments that
have been advanced in literature, we contend in this
paper that governments have a legitimate interest in
managing the medical tourism industry in light of the
likelihood of a two-tier health care regime emerging
in LMICs, and that such interventions need not be
premised on the discovery of incontrovertible proof
of medical tourism’s deleterious eect on health care
access in destination countries. In fact, we argue
that the burden should rest on supporters of medical
global health and the law • spring 2013 297
Chen and Flood
tourism to demonstrate not only its benefits but also
that these benefits outweigh the negative impacts on
equity, and to justify why some degree of well rea-
soned, carefully designed governmental regulation is
inappropriate.
Based on our review of evidence, medical tourism’s
purported benefits — namely, reversal of external
brain drain, positive health care spillovers and trickle-
down economics — appear to have not yet been real-
ized to any significant extent so as to outweigh its
deleterious impact on equity, notwithstanding the
devotion of substantial public resources to cultivate
and promote the medical tourism industry by LMIC
governments. If LMICs continue to lack robust gov-
ernance and regulatory structures that will ensure
medical tourism revenues are channelled to the public
health care system instead of being reinvested to per-
petuate the industry’s growth, the prospect of attain-
ing these claimed benefits will, in our view, remain
bleak. We argue that, generally, one cannot assume
that “markets” would work in the same manner in
health care as they do in other sectors: the supply of
medical personnel is not highly elastic and is heavily
publicly-subsidized; there is information asymmetry
between providers and consumers of health services;
and, health insurance creates an incentive for moral
hazard. Thus, assumptions about the benefits associ-
ated with the global trade of services in other sectors
do not necessarily apply to the health care context.
To date, commentators have put forth a number of
recommendations for governments to regulate medi-
cal tourism. Mohd Jamal Alsharif, Ronald Labonté and
Zuxun Lu, for instance, have considered the possibility
of managing the medical tourism industry through a
global governance regime where countries engaging
in medical tourism would agree to a set of “best prac-
tices” concerning equitable health access in destina-
tion countries.122 While such a multilateral strategy
arguably requires further consensus-building among
stakeholders before it may be realized, we believe
international collaboration is essential for the success-
ful regulation of medical tourism. At a minimum, we
contend that sending countries, particularly those in
the developed world, should implement public poli-
cies so that their citizens receive (or are required to
obtain insurance for) adequate and timely health care
coverage, and that health insurers are barred from
sending patients to LMICs for treatment. Implement-
ing such policies could reduce the incentive for medi-
cal tourism and hence its equity-related concerns. For
example, the 2010 enactment of The Patient Protec-
tion and Aordable Care Act in the U.S. is expected
to radically lower the number of Americans without
health insurance and to prevent private health insur-
ers from dropping the coverage of policyholders who
are ill. The scope of this legislative reform would likely
decrease the impulse for Americans to travel to LMICs
for more aordable care in the future.
Admittedly, even when sending countries adopt our
prescription and assume responsibility for providing
adequate care to their own constituents, thus throt-
tling down some demand for medical tourism, there
may still be patients who travel to LMICs for care,
including individuals seeking health services that are
prohibited in their countries of origin. As such, it will
also be critical for sending countries to re-examine the
legitimacy of laws that render illegal certain health-
related activities domestically but not extraterritori-
ally, with a view to either liberalize these prohibitions
or extend their extraterritorial application. Moreover,
destination countries should pursue policies that
would facilitate the transfer of some of medical tour-
ism’s profits to the public health care sector as cross-
subsidies. For example, it has been suggested that des-
tination countries could levy taxes on medical tourists
or mandate private providers to contribute to a health
care fund, which can then be earmarked for strength-
ening their public health care systems.123 Rory John-
ston and colleagues, on the other hand, have proposed
the adoption of certain “equitable buying guidelines”
that aim at encouraging medical tourists to purchase
services from medical facilities with a track record of
contributing to health equity in LMICs.124 Similarly,
one could envision a hospital accreditation system
that takes into account the extent to which a private
establishment provides free or discounted health
care to public patients. The success of these strategies
would depend heavily on the political context of each
destination country, and unfortunately, many LMICs
are marred by governance and regulatory failures that
have hitherto hampered the successful implementa-
tion of this kind of policies. Nevertheless, the inter-
national community should encourage and support
LMICs to continue fostering these policy instruments,
and hopefully as time passes, LMICs will develop the
governance structures needed to ensure a reasonable
portion of the fruits of medical tourism indeed flows
back to improve and expand their respective public
health care systems.
There is no easy or obvious regulatory solution to
ameliorate the problems posed by medical tourism in
LMICs. Our support for international collaboration
in managing medical tourism is with the acknowl-
edgment that there will be many barriers to achiev-
ing this goal. Although challenges exist, we think it is
beholden on wealthier countries to put their shoulder-
to-the-wheel and work with LMICs to head o and
counter the adverse eects of medical tourism rather
298 journal of law, medicine & ethics
SYMPOSIUM
than allowing the cost of their poor policy choices to
be borne by the poorest of the poor.
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34. By pointing out the nexus between medical tourism and the
private health care sector in most destination countries, we do
not imply that medical tourism cannot occur within a public
health care regime, nor do we wish to suggest that medical
tourism does not pose a threat to health care human resources
when led by the public sector. Arguably, it is possible for inter-
nal brain drain to take place in the public health care context
when, for example, physicians reallocate treatment times origi-
nally designated for domestic patients to foreign patients.
35. A. Saniotis, “Medical Bioethics and Medical Tourism in Thai-
land,” Eubios Journal of Asian and International Bioethics 18,
no. 5 (2008): 150-151, at 150.
36. See Connell, supra note 1, at 70.
37. See Turner, supra note 11, at 312-313.
38. See Leng, supra note 6, at 342.
39. There is evidence that the coalescence of the private health
sector and the medical tourism industry occurs in Southeast
Asia as well as in countries such as India and Tunisia. See N.
Pocock and K. H. Phua, “Medical Tourism and Policy Impli-
cations for Health Systems: A Conceptual Framework from
a Comparative Study of Thailand, Singapore and Malaysia,”
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40. J. Connell, “A New Inequality? Privatisation, Urban Bias,
Migration and Medical Tourism,” Asia Pacific Viewpoint 52,
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global health and the law • spring 2013 299
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physicians who exited the public health care system ended up
entering into the private system; some of them, for example,
simply went into retirement or left for opportunities in other
countries.
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High Court of Justice in 2009, see in this issue A. Gross, “Is
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90. See Cortez, supra note 2, at 110. However, the number of expa-
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300 journal of law, medicine & ethics
SYMPOSIUM
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93. See Hazarika, supra note 5, at 249.
94. See Hopkins et al., supra note 8, at 192.
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96. See Chinai and Goswami, id.
97. See Tata et al., supra note 89, at 24.
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100. All India Lawyers Union (Delhi Unit) v. Government of
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Zealand did consider the possibility of imposing a medical
tourism tax in 2009, as reported in G. Armstrong, “‘Medi-
cal Tourism’ Levy Under Scrutiny in New Zealand,” eTur-
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suer from medical injuries while seeking care in New Zea-
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patients.
107. See Whittaker, supra note 51, at 110.
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110. See Leng, supra note 53, at 13.
111. See Alsharif et al., supra note 106, at 329.
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Kenya are leaked to foreign businesses).
118. See for example, Z. Meghani, “A Robust, Particularist Ethical
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119. See Pocock and Phua, supra note 39, at 6.
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122. See Alsharif et al., supra note 106, at 330-331.
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124. See Johnston et al., supra note 10, at 10.
