Attracting medical tourists to Canada is a risky experiment
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* Matthew Stanbrook
* John Fletcher

See related news article on page [977](http://www.cmaj.ca/lookup/volpage/186/977) and at [www.cmaj.ca/lookup/doi/10.1503/cmaj.109-4874](http://www.cmaj.ca/lookup/doi/10.1503/cmaj.109-4874).

Canadian hospitals are not-for-profit corporations funded mostly by taxpayer dollars and, to a lesser extent, charitable donations. This befits their purpose: to care for Canadians as a key component of a universal public health care system that provides care that is free at the point of delivery. But recently, Canadians have been asked to make room in a few prominent hospitals for international patients who receive expedited treatment on a private, for-profit basis. Although these are mostly small-scale pilot programs, they have sparked debate about whether they represent an innovative solution essential to sustaining our hospitals, or usher in the end of single-payer public health care in Canada. We need evaluation and evidence to help us weigh the potential benefits and concerns.

International patient programs currently exist at four large academic teaching hospitals in Toronto, but other regions have been exploring this model of health care delivery. British Columbia’s health minister rhapsodized in 2010 about making his province “the Mayo Clinic of the North” by attracting medical tourists from the United States,1 although to date the BC government has not acted in this direction. Other provinces have been colder to the idea, notably Quebec, whose health minister unequivocally rejected medical tourism after a 2013 revelation that the McGill University Health Centre, in Montréal, had performed cardiac surgery on a Kuwaiti patient for profits that exceeded $100 000.2

Hospitals that offer health care to international patients claim that they are bringing the excellence of Canadian health care to the world and that this health care is intended for patients for whom adequate care is not available or accessible in their home country.3,4 This is analogous, it is argued, to provinces paying for Canadian patients to go to the US for care not available at home. Even many critics of medical tourism support providing humanitarian health care in Canada to international patients, yet the distinction between the two may be less clear than some assert. The care being provided to victims of Libya’s civil war at Toronto’s University Health Network5 might be considered an example of humanitarianism. Should we feel differently about it because the care is paid for by the Libyan government at net profit to the hospital, rather than donated by a charity or by the hospital and staff?

Hospital administrators say that budget constraints have forced them to seek new revenue sources. Staff at the University Health Network argue that revenue from its program has enabled the network to open an additional operating room and two hospital beds, which are used for Canadian patients 85% of the time. They claim that for every international patient who receives treatment, they are able to provide treatment to two extra Canadian patients awaiting elective surgery.5

Critics have raised several important concerns that deserve thoughtful consideration.6,7 Most salient is that allowing recruitment of medical tourists will permanently reshape our health care system, embedding a second, private tier. Alarm at the notion of any private component to health care is perhaps a uniquely Canadian perspective, in contrast to the US and Europe, which have long solicited international patients for profit. We should not prejudge health care models with the rhetoric of opposing all things private, but instead judge them based on whether they will improve health care for Canadians as a whole.8 However, if medical tourists are allowed to become an important source of hospital revenue, this funding source, with intense market pressures behind it, may dictate the nature and priorities of hospital operations. Similarly, if health professionals are able to make substantially more money providing private care to international patients, some will do so, depriving the public system.

Perhaps more compelling is the argument that medical tourism is a solution to an unnecessary crisis. If our health care system has the capacity to provide private care to patients, perhaps such capacity should be used to treat Canadians who are waiting for the same interventions. Medical tourism must not become a mechanism that allows governments to evade their responsibility to fund the health care system adequately and efficiently enough to meet the needs of Canadians. If we really believe in the value of universal public health care, it seems irrational to conclude that we can sustain it only by abandoning its underlying principles.

Responding to public concerns, the Ontario government recently ordered an informal review of medical tourism programs. But an assessment behind closed doors, without clear parameters, will not do for an issue that is so important to Canadians. If our hospitals are going to experiment with medical tourism, first let the government commission a study to evaluate the impact of such a model — not just on the hospital services directly involved, but also on hospital operations and health care delivery to Canadian patients overall. Appropriate comparisons should be made with control hospitals that do not offer such programs. The study should be conducted transparently by independent, qualified researchers, and the results should be made public. It would be wise for other Canadian jurisdictions to await the results of such a study before embarking on their own medical tourism programs.

## Footnotes

*   See references, [www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.141047/-/DC1](http://www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.141047/-/DC1)

*   **Competing interests:** See [www.cmaj.ca/site/misc/cmaj\_staff.xhtml](http://www.cmaj.ca/site/misc/cmaj_staff.xhtml). Matthew Stanbrook is a staff physician at the University Health Network but has not delivered care through the hospital’s International Patient Program.