Lessons from COVID-19's impact on medical tourism in Cambodia.

Making medical tourism a more valuable healthcare system is a significant public health issue. However, little discussion has been conducted on what lessons can be learned from the impact of COVID-19 on medical tourism. This study aimed to discuss the issues and barriers faced by patients unable to seek medical tourism, and the medical care experience at private general hospital in capital, Cambodia. First, when patients seeking medical tourism were unable to go abroad due to the pandemic or other reasons, some of them could not easily visit domestic health care facilities. Second, even if patients received medical care in the home country's hospitals due to the interruption of medical tourism, sharing the patient's medical information between domestic and overseas medical institutions was difficult. The third problem in medical tourism is that dependence on overseas medical resources might hinder the development of medical professionals, facilities, and other environments in the country of origin. This experience revealed the need to encourage patients who were unable to undertake medical tourism to visit domestic medical facilities, make efforts to share patient information across countries, and to invest in developing each department in domestic hospitals. Support for patients who are unable to undertake medical tourism is urgently needed.

Medical tourism in Cambodia

Medical tourism is the medical care that patients seek across national borders. Patients seek medical tourism for various purposes; however, medical tourism is mainly in two directions: patients from low-and middle-income countries (LMICs) seeking higher quality medical care and patients from high-income countries (HICs) seeking low-cost medical care [1]. The host countries consider medical tourism as a source of economic profits [1]. Previous research in Korea, a patient-accepting country, concluded that the benefits of medical tourism outweigh the negative impacts of universal health coverage and the constriction of medical supply [2]. Moreover, medical tourism might be a powerful tool for reducing inequalities in healthcare worldwide [3]. Therefore, making medical tourism a more valuable healthcare system is a significant public health issue.

However, medical tourism is greatly influenced by COVID-19. Many countries have closed national borders, imposed isolation rules for residents from abroad or foreigners, and have made negative polymerase chain reaction (PCR) results mandatory for entry into the country. For instance, Bumrungrad Hospital in central Thailand, catering to half of the overseas patients, reached a 32.9% of decrease in patients in 2020 compared to the previous year [4].

Further, the effects of COVID-19 on medical tourism have continued into 2021 [5], adversely affecting medical tourism. However, little discussion has been conducted on what lessons can be learned from the impact of COVID-19 on medical tourism and what improvements are required to make medical tourism a part of a more beneficial healthcare system.

Cambodia, located in Southeast Asia, is a country where many patients undertake medical tourism to seek high-quality medical care [6]. Cambodian people go to other countries for medical checkups, surgical treatment, and chronic disease treatment. Many people have sought medical tourism to date; for instance, 3,837 patients made more than 10,000 trips to Thailand for medical care in 2010 [7]. Medical tourism is not only meant for wealthy people, but also for people of middle economic status in Cambodia, due to the concern for their health and the ease of traveling across the border to neighboring countries. Thus, medical tourism is an essential part of Cambodia's healthcare. Moreover, patients have less trust in domestic medical care owing to the extremely sparse number of medical professionals who emerged under the Khmer Rouge regime of 1975–79; the number of doctors was estimated to be 6,550 in 2016, approximately 0.4 doctors per 1,000 people [8].

In Cambodia, the total number of people infected with COVID-19 surged in April 2021 and reached 13400 on April 30, 2021, in spite of measures such as quarantining of people entering the country, lockdowns, and community residents’ education to protect them from infection. Due to restrictions on travel as a countermeasure of infection prevention, some patients who sought medical tourism are now visiting public and private hospitals in Cambodia. One such private hospital is Sunrise Japan Hospital Phnom Penh (SJH), which was established by Sunrise Healthcare Service, a joint venture between Japanese private companies (JGC Japan Corporation, Innovation Network Corporation of Japan, Kitahara Medical Strategies International) in 2016. It currently has 50 beds and provides medical care in 14 departments, including neurosurgery, pediatrics, and emergency medicine. In SJH, the number of patients varies each month, and the patient characteristics have changed since the COVID-19 pandemic.

This study aimed to discuss the issues and barriers faced by patients unable to seek medical tourism, and the medical care experience at SJH. We discussed the improvements required to make medical tourism a part of a more beneficial healthcare system.

The issues and barriers to seek medical tourism under COVID-19 influence

First, when patients seeking medical tourism were unable to go abroad due to the pandemic or other reasons, some of them could not easily visit domestic health care facilities. In the case of Cambodia, during the pandemic of COVID-19, some patients whose medical tourism was interrupted due to COVID-19, did not visit a domestic medical institution for more than a year, some purchased over-the-counter medicines in Cambodia without visiting hospitals or clinics, worsening their pre-existing conditions. Besides, medical tourism will be discontinued, not only due to the risk of pandemics like COVID-19, but also because of the high price of medical tourism itself. A previous study showed that 43% of medical tourists in the Maldives, an LMIC patient sending country, were forced to bear destructive household burdens [9]. Considering that medical tourism from Cambodia has an aspect of flight from domestic healthcare, similar phenomena may occur in Cambodia. This indicates that even if the pandemic is over and things return to normal, there will be patients who will have to give up medical tourism midway. For such patients to be able to visit domestic hospitals and clinics smoothly, establishing a system that allows them to easily access information on suitable domestic medical institutions is required. Besides, it is necessary to educate people on the importance of treatment continuity and cooperation between foreign and domestic hospitals.

Second, even if patients received medical care in the home country's hospitals due to the interruption of medical tourism, sharing the patient's medical information between domestic and overseas medical institutions was difficult. Some patients who discontinued medical tourism and visited SJH did not have complete documentation of their medical information and did not provide exact details of their disease. Thus, they had to perform all the tests again. They were unable to seek the best treatment because the doctors could not access the patient's medical history. This problem might be partly caused due to patients' low literacy level, and language barriers, causing miscommunication between the doctor and patient. In a previous study, the necessity of sharing information between overseas treatment institutions and family physicians was discussed to ensure the continuity of treatment in medical tourism [10]. In the field of medical tourism, it is necessary to pay more attention to the sharing of medical information and provide explanation to patients to ensure continuity of medical care. Changes to policies and regulations might be required to accelerate the sharing of patient's medical information crossing border.

The third problem in medical tourism is that dependence on overseas medical resources might hinder the development of medical professionals, facilities, and other environments in the country of origin. Although there is a neurosurgery department at SJH, several brain tumor patients had gone abroad before the COVID-19 pandemic; however, the majority of the brain tumor patients came to the capital hospital after the pandemic. A previous study reported barriers in medical oncology, surgery, radiotherapy, imaging, pathology, and palliative care departments for cancer patients who discontinued medical tourism due to the COVID-19 pandemic and went back to their countries; cooperation between these departments is needed [11]. Thus, to provide high-quality medical care tailored to each individual, the development of various sectors and cooperation between departments is required. Investment in medical facilities and human resources to break the vicious cycle of distrust in the home country's medical care that promotes medical tourism is required.

Conclusion

In this COVID-19 era, many patients are affected due to the loss of medical tourism. In Cambodia, where the obvious problem of providing medical care to people in own country as part of lifeline has not yet been solved, medical tourism has become a tentative solution that has prevented fundamental solutions to the problem. The COVID-19 pandemic has forced Cambodia to confront this problem by making medical tourism unfeasible. This experience revealed the need to encourage patients who were unable to undertake medical tourism to visit domestic medical facilities, make efforts to share patient information across countries, and to invest in developing each department in domestic hospitals. Support for patients who are unable to undertake medical tourism is urgently needed. Furthermore, medical tourism for profitmaking purposes might have a negative impact on sustainable healthcare, which needs to be reconsidered.

Funding

This study did not receive any specific funding.

Ethical approval

Not required.

Authorship contributions

MK, YK, KK, MO and MT contributed to writing the papers. All authors reviewed the present paper and contributed to the discussion of this work.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.