Overall, both focus groups touched on many of the same issues and shared a similar tone and perspective on the opportunities and challenges posed by medical tourism. The nurses spoke in both their capacity as Barbadian citizens and users of the health system, bringing their experiences as health care professionals to some, but not all, issues. As such, there was a great deal of thematic convergence across the focus groups, both being broadly supportive of the idea of a larger medical tourism sector in Barbados. Both groups approached medical tourism as an economic benefit, a means to increase local access to medical specialties not available on the island. However, the conversations also raised numerous concerns about how the sector could negatively impact the country and its health system. The nursing focus group additionally identified potential positive and negative outcomes stemming from medical tourism in relation to employment of nurses, Barbados’ medical culture, and nursing training. Thematic analysis identified four cross-cutting focus group themes that clarify the sources, bounds, and intersections of the expectations and concerns that were raised. Here we organize these themes into the two broad domains of ‘Local Setting’ and ‘Competing Expectations’. Themes pertaining to ‘Local Setting’ were largely descriptive and worked to situate medical tourism in a localized understanding of the Barbadian context. In contrast to this are the themes associated with ‘Competing Expectations’ that highlighted tensions in ideas around how the developing medical tourism industry and its impacts might unfold in Barbados. These domains and their themes are explored in detail below. Unless specifically noted, the themes and issues raised were common to both focus groups and where quotes are provided, the focus group source is noted in brackets.
Local setting
The first of the two major thematic domains that arose across the focus groups were ideas and issues pertaining to Barbados as a dynamic tourism-dependent setting that a larger medical tourism sector would be developing from and interacting with. As a setting, Barbados’ long experience with and reliance upon tourism was critical in participants’ understandings of the potential economic and social impacts medical tourism creates for the country. Likewise, the longstanding international networks that connect Barbados’ patients and health workers to hospitals abroad in terms of training, employment, and care seeking, served to normalize medical tourism for the participants and offer a lens with which to interpret their understanding of and expectations for the sector.
Health services export as niche form of tourism
The significant role of recreational tourism in Barbados’ economy and society served as the most common point of reference for participants across both focus groups and situated their understanding and expectations of medical tourism. Participants noted that medical tourism was one among a host of diversification strategies for the country’s tourism sector being discussed in public forums alongside sports, heritage, and eco-tourism. Both focus groups noted that public conversation about medical tourism has been ongoing but sporadic, with government press releases and investor plans for facilities triggering ‘buzz’ in the media for developments that had yet to be realized. Altogether, medical tourism was not a pressing concern for participants and was situated unremarkably as just one form of tourism within the ongoing public conversation about tourism diversification and development. Because the existing tourism industry served to prime participants’ initial understandings of medical tourism and their expectations for its development, medical tourism was initially framed as an economic development issue and only secondarily understood as one concerning healthcare.
Participants of both focus groups perceived that Barbados has an international reputation for safety and privacy and that this reputation is a critical support for its tourism sector. However, medical tourism was seen as a disruption to maintaining the country’s reputation for safety due to the regulatory and monitoring challenges the sector poses. One participant summarized this concern:
…if you had a serious issue like you know some virus broke out because of whatever malpractice issue … then all of a sudden no one is going to come here anymore for any medical tourism and then they may also impact on the general tourism, the sun, sea and sand because like say in Barbados you allow person to come there for treatment and they die. (Citizens)
Mirroring participants’ emphasis on interpreting medical tourism through their understanding of the recreational tourism sector, the potential negative impacts of health services export included wider economic impacts, not just those of healthcare and health equity.
Existing international healthcare connections
The stories shared by participants demonstrated that there is a popular awareness that Barbados is deeply integrated within existing international networks of care, in terms of Barbadians traveling for treatment, Barbadian hospitals providing care for patients in the surrounding region, and the well-established international routes of health workers moving to and from the country. Existing outbound medical travel by Barbadians was raised in both focus groups and was more relevant to participants than inbound medical tourism, summarized here by one participant stating
I really don’t think that medical tourism is much on people’s radar here as something that is very prevalent or touches people’s lives from day to day you know, I don’t think most people even know to what extent that it happens …I think the average person is more, has more on their radar leaving for a medical procedure if it’s necessary than other people coming. (Citizens)
Discussions of mobility among Caribbean patients highlighted existing regional outbound healthcare networks. One participant noted that “I can envision people, wealthy Barbadians who would go to Miami, who would go to New York and those kind of places… I can see some of them remaining here, if there is such a facility and that saves us foreign exchange (Nurses).” The idea of patients traveling abroad for medical care was, thus, a familiar one.
Further discussion among participants indicated that a factor influencing utilization of non-local health services was a desire to see specialists with higher volumes of patients, and thereby expertise, than is possible locally. For example:
I think a lot of the issue with having the best care is not necessarily somebody here being unable to give you an opinion or unable to do the procedure, but when you look for example at Miami Children’s and you think about the fact that if you have to have something done for you [sic] child here who has a relatively rare something that the doctor here may have seen twice, whereby you’ve got 500 children going through Miami every year […] the level of expertise is always going to be different. (Citizens)
Although there was recognition that the development of a medical tourism sector could enable Barbadians to access care locally that is not currently available, there was concern among some participants that they would not want the presence of such services to lessen their access to procedures abroad that are funded by government or private insurance. “I would be very upset to be forced [by my insurance company] to go to [a renovated] St. Joseph Hospital [in Barbados built for medical tourists] because it’s now available here but it’s not necessarily the best care” (Citizens). Participants were keen to ensure that the development of a domestic medical tourism sector would not erode their own access to health services both at home and abroad.
While discussions on existing patient mobility mainly focused on Barbadians traveling to international destinations, inbound regional care networks were also mentioned as playing an important role in providing healthcare to Caribbean patients. Discussions on regional patient mobility particularly emphasized Barbados as an existing destination for patients from smaller nearby islands such as Antigua. Some participants indicated that the development of medical tourism in Barbados should consist of a concerted effort to increase the regional patient flow to Barbados. This was seen as a measure to enhance access to the “best care on home ground” (Citizens) for Caribbean patients by using the income generated from the increased provision of healthcare regionally to support health worker specialization and technological innovation locally; “If technologically it is more advanced and more effective and that is what you need for your health, if it is accessible, then I think we should make a way to make it available [to other Caribbean citizens]” (Citizens). Participants thereby expanded their understandings of scope of medical tourism beyond the existing local narrative of inbound Americans, Europeans, and Canadians to include a regional focus.
Clarifying expectations
The focus groups explored different dimensions of an expanded Barbadian medical tourism sector, which were informed by participants’ knowledge of and exposure to medical tourism in Barbados thus far, specifically the Barbados Fertility Clinic and the planning for the St. Joseph Hospital renovation by American World Clinics. Discussion of these two very different projects, in terms of scale, ownership, range of specialization, and system integration clarified participants’ expectations for what shape medical tourism in Barbados might take, the potential for local economic benefits, and the facilities’ degree of integration with the existing healthcare system. Discussions also highlighted some tensions between their expectations around the potential benefits to and negative impacts on the Barbadian healthcare system. For example, participants debated the system changes emerging as a result of interactions between medical tourism and the existing health system in relation to local regulations, professional associations, healthcare professionals, and local patients. In this section, we examine two distinct groupings of expectations, those pertaining to the scope and structure of the sector and those pertaining to its impacts on the health system.
Scope and structure of a medical tourism sector
The ongoing planning to develop foreign-owned hospitals in Barbados that will primarily staff non-local specialists and export their services to international patients (i.e. offshore medical services) was generally accepted by participants, but they did raise concerns about the degree of meaningful integration with the local economy. Some participants drew unfavourable parallels with all-inclusive recreational resorts in the Caribbean. Participants critiqued this tourism model for generating (mostly low-skill) employment for locals but few additional economic benefits for the host communities. There was shared agreement that medical tourism facilities had no obligation to reinvest profits locally but should in turn not be granted public subsidies such as tax concessions. It was also generally agreed among participants that any new medical facilities in Barbados should be affordable to local users such that they might directly benefit from their presence. Overall, a skeptical current ran through both focus groups as to the scale of benefits for Barbados in hosting foreign-owned hospitals:
I don’t think that Barbados will benefit to the extent that we may think, that you may have a lot of spin offs, you can have thousands of jobs being generated and that sort of thing. I don’t want to sound too pessimistic, but I like to err on the side of caution… the bulk of money will be staying over there [with international investors], it won’t be here. Yes we will get something, but it will be the crumbs. (Nurses)
Participants wondered if and how any new medical tourism facilities might rely on, or operate in complete distinction from Barbados’ public healthcare facilities. Participants across both focus groups almost unanimously agreed that any new facilities should be self-sufficient in delivering the full spectrum of care they require, including critical care for emergent complications, and that they should not require any support or services from public hospitals and clinics. Because Barbados currently has only one (public) hospital capable of delivering tertiary care, participants did not want any private facilities introducing additional burden to the public system, one stating:
[W]e don’t want a situation where the new facilities impact on the QEH. They should be able to contain themselves. I think they should have an ICU [intensive care unit] and if there are any complications they should be able to maintain or at least…so that it doesn’t impact on general healthcare. (Citizens)
In the citizen focus group, some participants considered the potential for private facilities arranging to pay for any public care services they might need in the event of an emergency, but this was rebutted by other participants who thought any private imposition on the already burdened public system was unacceptable as it would directly translate into reduced access for local patients.
Finally, participants in both focus groups articulated a vision for what they thought would be the most successful and well received form of medical tourism among Barbadians. At first consideration, participants closely associated medical tourism with cosmetic surgeries, for which there was widespread acceptance for a well-developed export sector. More generally, participants encouraged a form of medical tourism to Barbados that focused on elective, low risk specialties and developing an internationally renowned niche.
[S]o what I’m say is instead of doing all these things if you were to build a facility and you were to advertise to the world, right that we have this facility we do knee replacements, we do hip replacement or we do something or the other and pick out half a dozen thing that you would specialize in so if you want a brain tumour work on, go somewhere else we don’t want you come here because we’re not involved in that. (Citizen)
Relatedly, some participants expressed a preference for local physicians forming the core of a Barbadian medical tourism industry through cultivating specialist niches among local providers instead of hosting large, foreign owned and staffed medical facilities. “What are we willing to invest in our people and getting our country up? Why not look at it that way… Why bring in somebody to run it for us?” (Nurses)
System disruption versus system improvement
Participants raised concerns that medical tourism could work to loosen regulatory standards for healthcare providers and weaken the nurses’ labour union. Discussion about professional oversight indicated that some participants were concerned that the potential for reliance on foreign healthcare professionals to provide the labour in new medical tourism facilities could overwhelm or elude professional regulation, one saying “are [foreign healthcare providers] just going to walk all over or circumvent the Barbados Medical Council or Nursing Council?” (Nurses). Participants in the nursing focus group emphasized their expectations that local training and licensing requirements should apply to foreign trained care workers and questioned the potential for pressures by international investors in private medical tourism facilities to change the standards set by these professional bodies. One participant raised the strong unionised labour tradition in Barbados, including nursing staff, and a concern that nurses could be impacted “if the owners of these facilities do not want persons who are unionised” (Nurses). This concern was framed by discussions of past instances of resistance to organized labour among international corporations set up in Barbados. Taken together, the focus groups demonstrated that there is concern about how offshore medical facilities would integrate with existing local professional institutions and labour norms.
Participants expressed an expectation that the development of a medical tourism industry would improve the existing healthcare system. It was hoped that medical tourism would provide local patients access to a wider range of specialties and services while also offering opportunities for knowledge-exchange between international and local care providers. This hope was partly informed by existing experiences where there have been cases of “a patient who has a special need and they bring down their specialised doctor, when the procedure is being done, both parties are present; the [doctor] from Barbados and the specialised doctor. So there is a little training goin’ on” (Nurses). However, participants were also concerned that foreign health workers at new medical tourism facilities may serve to alter local patients’ health and healthcare expectations. This concern is summarized by the following quote:
It’s going to be a little bit of an issue for our medical professionals here. Because if you are going to get a real specialised person that is going to say ‘the doctor in the West Indies says that after 5 minutes you are dead, that is a lie, I can resuscitate you in 2 minutes or in half a second.’ So then the average person is going to say ‘oh well these doctors and medical people here [in Barbados] don’t really know what they are doing, I want outside treatment. (Nurses)
The expectation for collaborative, in-person engagement among health professionals that is suggested by the particular form of medical tourism participants advocated for in Barbados was thus seen to be in tension with the potential for conflict between clinical cultures and competition for patients.
Participant discussions highlighted concerns about the potential loss of healthcare workers in the public sector due to the emergence of medical tourism facilities as they expected the medical tourism sector would be a more attractive employer for health workers than the public sector. One participant expressed this concern in saying:
if the whole industry tends to grow, [and] if the facilities are set up in such a way that locals can’t really use the services and the doctors are attracted to go and work with these facilities and then locals don’t have access… to qualified doctors. Because obviously the most experienced ones are going to be attracted to go and work privately and they may not spend a lot of time working for the QEH. (Citizens)
Alternatively, participants also framed the medical tourism industry as a potential catalyst for improved working conditions in the public sector, expecting that increased competition from the private sector could “force our government, force our nursing governing body to review, to respect us, to encourage to continue education and give the opportunity for us to further our education without any further harassment or obstacle” (Nurses). The potential for new private facilities to increase local demand for nurses and introduce direct exposure to different clinical management styles raised hope among the nurse participants for improved working conditions, pay, and overall respect for the nursing profession in Barbados. However, this was tempered by concerns that foreign owned facilities might plan on importing nurses to provide specialties rather than employing locals and providing employment and training opportunities.