Media reports on the medical tourism industry and participation in regional conferences enabled the researchers to pinpoint Singapore, Thailand and Malaysia as the three main hubs for medical tourism in Southeast Asia for comparative analysis. Broadly, there are four types of comparative health policy analyses. The first constitute descriptive studies, with no hypothesis or testing of explanations on why patterns exist, leaving policy explanations implicit for the reader to gauge. The second include collections of international case studies with some assessment of performance, whilst the third type includes studies employing a common framework for analysis (e. g. privatization). The fourth type of cross national studies are those that show a fundamental theoretical orientation, with a specific theme or question as a focus of analysis (Marmor et al 2005: 341 – 2) [ 34 ]. We decided to undertake this fourth type of comparative analysis, in order to generate a conceptual framework that could be usefully employed by policymakers to understand the policy implications of medical tourism on health systems with similar structures. Methods employed focussed on conceptualising rather than describing, where one or more new concepts are developed to explain what is being studied [ 35 ]. An inductive, theory building approach [ 36 ] is appropriate to examine medical tourism where knowledge is far lacking, especially in relation to health systems.
An initial informal literature scan using the search criteria “medical tourism AND Asia” in google scholar revealed a lack of data and authoritative sources on medical tourism, particularly figures for number of patients and estimated earnings. Academic literature was searched exhaustively in the PubMed and Social Science Research Network databases using the search criteria “medical tourism AND Asia” (92) and “medical travel AND Asia” (806), generating a range of mostly conceptual research. Abstracts were scanned for reference to Thailand, Singapore and Malaysia and/or reference to health systems in general. Additional articles were located using the reference list of selected articles. Study selection was not systematic; no article was omitted but considered in the context of health systems/medical tourism in Asia (43). Articles gathered were then categorised according to content focus (e. g. privatisation of health systems, medical tourism empirical evidence, health and trade nexus). Following categorisation, all articles were analysed to identify medical tourism interaction points across the health system functions, with new material continually brought into the analysis. Concurrent to the theory building process, quantitative data on the nature of health systems in the three study countries were retrieved from official country sources and the World Health Organization. These data were triangulated with the academic literature to validate claims made about the nature of health systems. This data also enabled the researchers to make systematic comparisons between the three country health systems. Following this step, grey literature were searched using the above search criteria in Factiva, a news item database, to provide examples of recent developments in the medical tourist industry in the three study countries. Other grey literature sources included management consultancy research reports, working papers on medical tourism, and medical tourism industry player’s statistics and promotional materials. Subsequent to analysis and identification of the conceptual framework, potential policy options were outlined based on the literature and/or innovative examples of comparative health policy responses in the region. We anticipated that the different nature of health systems (e. g. mostly public versus private delivery) would also generate differential policy implications according to local context. In the course of our comparative analysis, we found this to be the case to a large extent; however, medical tourism poses potential risks and benefits regardless of the current nature of a health system. As a phenomenon, it can fundamentally change the nature of health systems themselves without policy intervention (e. g. shift towards a dominantly private hospital sector). Thus, the policy implications described are broadly applicable to health systems in general, but of particular relevance to policymakers and industry practitioners in other Southeast Asian countries where governments have expressed an interest in developing the medical tourist industry.