Medical Tourism Overseas: A Challenge to Kuwait’s Healthcare System

The world is a global village. People, cultures, and nations are becoming more connected, especially in the modern world where technological advancement has occurred. Healthcare systems have also exhibited such changes and are no longer restricted by national borders. Citizens of various countries have the leverage to seek medical care in any country of their choice, even in non-emergency conditions.1 The practice of seeking medical care abroad in non-emergency situations is known as medical tourism.2 No general term has yet been coined for patients seeking healthcare elsewhere. They are generally referred to as “medical tourists” or “health tourists.” However, the use of the term “tourists” suggests that these medical visits are for leisure or pleasure purposes.1-5 Many countries have performed thorough evaluations of their healthcare positions because of globalization.1-5 Some nations have inadequate medical facilities, and therefore, patients opt to seek medical treatment in other countries that have better services. The case of medical tourism in Kuwait has been challenging to determine. Government officials and members of parliament (MPs) have been accused of using medical treatment as a conduit to siphon public funds for travel abroad. The same malpractice has been prevalent in different nations across the world. Despite many claims that there is a decline in outbound medical tourism, given submissions to Parliament revealed that the trend of traveling overseas for medical treatment (with government funds) increased astronomically in 2017.6,7 To slash the cost of sponsoring Kuwaitis abroad for medical treatment, new regulations for overseas treatment was endorsed by the Minister of Health in 2017. In a step toward eradicating corruption and political influence, the use of public funds for overseas treatment was made subject to approval by an independent medical board before the release of funds.6-8 The approach led to a political row with board members http://ijtmgh.com Int J Travel Med Glob Health. 2020 Mar;8(1):22-30 doi 10.34172/ijtmgh.2020.04 TMGH IInternational Journal of Travel Medicine and Global Health J


Introduction
The world is a global village. People, cultures, and nations are becoming more connected, especially in the modern world where technological advancement has occurred. Healthcare systems have also exhibited such changes and are no longer restricted by national borders. Citizens of various countries have the leverage to seek medical care in any country of their choice, even in non-emergency conditions. 1 The practice of seeking medical care abroad in non-emergency situations is known as medical tourism. 2 No general term has yet been coined for patients seeking healthcare elsewhere. They are generally referred to as "medical tourists" or "health tourists. " However, the use of the term "tourists" suggests that these medical visits are for leisure or pleasure purposes. [1][2][3][4][5] Many countries have performed thorough evaluations of their healthcare positions because of globalization. [1][2][3][4][5] Some nations have inadequate medical facilities, and therefore, patients opt to seek medical treatment in other countries that have better services.
The case of medical tourism in Kuwait has been challenging to determine. Government officials and members of parliament (MPs) have been accused of using medical treatment as a conduit to siphon public funds for travel abroad. The same malpractice has been prevalent in different nations across the world. Despite many claims that there is a decline in outbound medical tourism, given submissions to Parliament revealed that the trend of traveling overseas for medical treatment (with government funds) increased astronomically in 2017. 6,7 To slash the cost of sponsoring Kuwaitis abroad for medical treatment, new regulations for overseas treatment was endorsed by the Minister of Health in 2017. In a step toward eradicating corruption and political influence, the use of public funds for overseas treatment was made subject to approval by an independent medical board before the release of funds. [6][7][8] The approach led to a political row with board members accusing government officials and MPs of influencing decisions and using medical treatment as a conduit to siphon public funds for holidays abroad. 9 Despite claims that there was a decline in medical tourism, figures reported by the Parliament show that the number of people traveling abroad has actually increased; Approximately 12 000 people traveled in 2017, and in 2018, people spent 188 million Kuwaiti dinars. The nation accused MPs and other government officials of using government funds to sponsor themselves, their friends, and their families to seek medical treatment abroad. 5-9 Moreover, a lot of money is spent on catering to medical services inside the nation; yet, the government can develop medical institutions to provide for the needs of the people, regardless of their social, political, or financial status. Several factors encourage patients and non-patients to seek treatment abroad due to the predicaments faced by various countries. These include easy access to information about foreign medical services, the low cost of transportation across countries, and a reduction in language barriers, all thanks to globalization as well as the unavailability of treatments in the home country (for cultural, legal, or religious reasons), long waiting lists for some medical procedures 2 (as in Canada), and inadequate insurance health coverage (as in the United States). [10][11][12] However, a few barriers were found to hinder medical tourism. For instance, financial costs, lack of confidence in the healthcare system, ill health, unfamiliarity, and discouragement by home-based and family physicians affected the execution of medical services. 13 People who patronize medical tourism companies purchase a variety of services ranging from cosmetic procedures to organ transplants, orthopedic procedures, and cancer therapies. The costs of medical tourism packages vary, depending on destination, the type of medical procedures, duration of stay, and accommodations. 14 Some ethical issues have also been raised concerning medical travel. This is more evident when health policies vary in a particular country, especially with packages that differ for citizens and foreigners. Informed consent constitutes a critical legal and ethical issue as it requires medical tourism companies to explain the risks and benefits of medical treatment overseas to the patients. 13 Other ethical concerns include disruption of care for patients and exacerbation of medical inequities in source and destination countries.
The current study was designed to investigate why the public in Kuwait prefers to seek treatment in other countries, whether tourism and abuse of power are still relevant after the new regulations, and if the public would prefer alternatives.

Methods
This cross-sectional study was carried out in 2018. An Arabic questionnaire comprised of 42 questions was constructed based on existing and troublesome public complaints against the Ministry of Health in Kuwait. The authors made an initial draft of the questionnaire which was reviewed and edited by the Treatment Abroad Committee of Kuwait's Department of Health. Then the questionnaire was given to two independent public health physicians to obtain their expert opinions on current state matters. The final draft was produced after a consensus was reached by all physicians involved. A pilot study of 10 people was done, and their feedback was used to improve the survey.
The Medical Council provided the registry of patients who went abroad for treatment (both surgical and non-surgical) in the year 2018. Since all patients who go through the process fall under the same regulations, no exclusions were made. The phone numbers of 1067 patients were obtained, and a Google form was sent to them to complete electronically. Attached to the Google form was a brief description of the contents of the questionnaire and a detailed consent form which participants were asked to sign before proceeding with the questionnaire. A reminder to complete the questionnaire was sent to the patients two weeks later. One month after the initial distribution, 590 responses had been received; only one survey was not correctly completed.
Statistical analyses were performed using R v3.6 software (R Foundation for Statistical Computing Vienna, Austria, 2018), IBM ® SPSS ® Statistics version 26, and GraphPad Prism v.8. Descriptive statistics were performed using counts and percentages for categorical variables and mean ± standard deviation for continuous variables. For checkbox questions, the rate for each response was calculated from the total sample size. The chi-square test of independence was implemented to evaluate the relationship between two categorical variables. To investigate the reliability and validity of the questionnaire, first, the unidimensionality of each factor was measured using principal component analysis. 15 The criterion of Fornell-Larcker was also used to assess the degree of shared variance between the latent variables of the model. AVE (Average Variance Extracted) was used to measure the level of variation captured by a construct versus the standard due to measurement error. Values above 0.7 were considered very good, and the level of 0.5 was acceptable. CR (composite reliability) is a less biased estimate of reliability than Cronbach alpha; the fair value of CR was considered to be 0.7 or higher. 16 The association between two categorical variables was assessed using the chi-square test of independence. Hypothesis evaluation was done at a 5% level of importance.

Results
The study sample included 589 respondents who completed the survey. Therefore, the percentage was calculated based on the number of valid responses for each question.

Survey Validity and Reliability
In this study, domestic issues in Kuwait, costs of treatment abroad, language barrier, level of complications, and perceived experience abroad were considered to be factors that could determine the attitude of Kuwaitis toward health tourism. To address the unidimensionality of these factors, PCA was performed. Factors with eigenvalues above one were considered, which comprised the core of the survey used in this study (Table 1). 15 To examine the reliability of each construct, CR was used instead of Cronbach's alpha, as shown in Table 2. All constructs had a CR value higher than 0.7, which showed acceptable reliability. Moreover, all constructs had more significant AVE values of 0.5, which is not a perfect, but an acceptable level of measured variance. Since the square root of AVE was higher than the correlations among constructs, it can also be concluded that the constructs had an acceptable level of discriminant validity.
Descriptive Analysis of the Survey Based on Table 3, males and females were similarly represented in the research sample (52.3% and 47.7%, correspondingly). The mean age for the study sample was 41±13.4 years.
Approximately half of the respondents (approximately 45.3%) were married and had children. Most of the remaining respondents were either married but had no children (21.9%) or single (23.8%). All respondents received medical treatment abroad with 52.3% and 47.7% stating that they received it once and more than once, respectively. Participants who were treated at the expense of the state were also more likely to respond with "more than once" compared with those who were not (50.6% vs. 39%, P < 0.05).
The results showed that 75.2% of participants received medical treatment abroad at the expense of the state only, and half of them (49.1%) received medical treatment abroad at their own cost at least once.
A statistically significant association was observed between source of funding for medical treatment abroad and number of treatment times. Participants treated at their own expense were more likely to respond with "more than once" compared with those who were not (57.1% vs. 38.7%, P < 0.001). Participants who were treated at the expense of the state were also more likely to respond with "more than once" compared with those who were not (50.6% vs. 39%, P < 0.05).
The results showed that 57% of the participants were diagnosed in Kuwait compared with only 7% who were not, and 37% of the participants received incorrect diagnoses. When questioned about receiving medical treatment in Kuwaiti hospitals, (25.6%) of participants stated that the required treatment was not available, (13.2%) refused treatment, (17.5%) did not continue with treatment, and (43.1%) reported that the procedure was not correct. The results shown in Figure 1A show that the main reasons for traveling abroad were to obtain better medical care (49.75%), and the higher efficiency of medical cadres outside Kuwait (49.41%). Other reasons included low confidence in medical services in Kuwait (46.86%), inadequate health facilities (37.35%), long waiting lists (27.33%), and non-availability of treatment (26.99%). Over 63.3% of the participants had only one medical problem, while 21.6% and 8.8% had two and three medical issues, respectively.
The results showed that there was no statistically significant difference in the distribution of medical problems between males and females (P > 0.05 for all comparisons).
Participants were asked about their preference for receiving treatment in a particular country; 62% responded with "yes" (they preferred a specific country), while 38% responded with "No" (they had no preference for any country).
As seen in Figure 2A, the United States of America and Germany were the most preferred countries for medical treatment (47.81% and 44%, respectively). Britain (30%), France (15.57%), and Thailand (12.3%) came in third, fourth, and fifth place, respectively. Language was not a significant barrier to making a selection, as perceived by 91% of the participants. Responses were missing for one respondent. Figure 2B shows that the main reasons for the selection of a country were healthcare reputation (64.52%), recommendations made by doctors (35.31%), and previous experiences (24.45%). Tourism and nature were selected by (3.4%) of participants.
The answers to the question about preferred escorts varied among participants, with 22.4% choosing two people from among relatives, 19.4% choosing one offspring, and 17.9% choosing one relative. Other responses included husband/ wife (15.3%), a friend (11.2%), and father/mother (5.3%). One and two escorts were reported by (41.7%) and (39.5%) participants, respectively. Only 24 (4.1%) respondents reported having no escorts. Over 50% reported that the gender of the escort made no difference; 16% preferred females, and 28% preferred a male ( Figure 3).
There was a statistically significant difference in the distribution of responses based on gender (P < 0.001). The  percentage of females that preferred female escorts was significantly higher than the rate of males, and the opposite was observed for male participants. Over 50% of the participants mentioned that the treating hospital provided an interpreter (53%) compared to 13% that replied with "No. " One quarter said that they did not need an interpreter (8%). The reported trip length varied from two weeks or less (10.2%) to one year or more (5.3%). The most commonly reported trip length was three to six months (33.3%). Trip time was reported to be sufficient in 67.5% of participants and insufficient in the remaining 32.5% of participants. There was no statistically significant difference in the patients' perception of time sufficiency based on the reported trip length (P = 0.206) ( Figure 4). Concerning the number of health problems recorded, only 1.3% of the participants mentioned that they received treatment that corresponded to their health problem as well as the health problem of their escort. The rest of the participants received treatment for either one (58.2%) or at least one health problem (40.5%) ( Figure 5).
The results indicated that 30.3% of the respondents had confidence in Kuwait's general medical capabilities, while 69.7% did not; however, the greater majority did not regret the decision to be treated abroad (96%). Of the respondents, 64.3% wanted to return to Kuwait earlier, and 56% said they would not have gone for treatments abroad had the attending doctor been available in Kuwait. The responses further showed a positive attitude towards treatment abroad, as shown by the high percentage of participants (86.7%) that would consider seeking treatment abroad again. The greater majority of respondents (95.8%) thought that they needed treatment abroad, and only 66.3% of the respondents looked for the attending doctor's reports before traveling.
If the means for receiving medical treatment abroad had not been provided by the state, 38.4% of respondents would    (Table 5).
The results, shown in Figure 6, showed that the majority of participants (84.18%) did not stay long after completing their medical treatment, but some stayed longer as tourists (5.44%) or for the treatment of their escort (10.37%). In addition, the responses showed that 32.48% of the participants perceived the application process as a lengthy one and 22.79% of them did not. The remaining participants (44.73%) responded with "Yes, through intermediaries. " Moreover, at least 50% of the participants reported no complications during or after treatment (n = 365, 62.07%), while simple, predictable, and severe complications (affected life or required intensive care) occurred in 30.44% and 7.48% of participants, respectively. As reported by 25.9% of the respondents, the travel experience was convenient, but the rest of the participants (74.2%) mentioned that their experience was frustrating, because they were away from relatives and their homeland. The majority of respondents (62.99%) mentioned that they returned to their accommodations after completing the treatment/follow up. Other activities reported included sightseeing or taking a walk (39.73%) and shopping (20.37%), while some respondents (16.3%) never left the hospital throughout the treatment.
As shown in Table 6, about 45.1% of the participants followed up in a governmental hospital after their treatment was complete, 16.5% went back to the country where they received treatment, 19% followed up in a private hospital, and the remaining participants (19.4%) never followed up. More than half (68.5%) of the participants reported having no insurance, while others (10.7%) had medical insurance (AFIA), retiree insurance (17.9%) for people over than 65 paid fully by the government, or had insurance but did not use it (2.89%). Moreover, 61.22% of the participants did not prefer having a nurse during the trip, 31.29% preferred having a special nurse at the expense of the state, and 7.48% preferred having a nurse at their own personal expense.

Discussion
Because of the rise in medical tourism, it is believed that global public health systems will be negatively impacted; the growing importance of medical tourism notwithstanding, there is not much evidence of its impact on health systems. 14 The medical communities in host countries have begun to recognize medical tourism as a phenomenon that has great impacts on the medical profession, medical practitioners, and patients, 17 which implies that the limited statistical data on medical tourism cannot be compared across countries, even though the observations available suggest that a substantial number of patients seek healthcare abroad. For instance, in  2007, 360 000 foreigners from the Association of Southeast Asian Nations (ASEAN) visited Malaysia for healthcarerelated purposes. 12 The literature attributes this to the fall in the number of privatized hospitals in countries such as Canada and the UK, and the subsequent increase in the medical market influx between countries. [18][19][20] This could be the reason why places like India, Malaysia, and Thailand are increasingly becoming well-known medical hubs, and thus attracting patients, especially from the west, who feel that their national healthcare systems have failed. [21][22][23] The current study shows that the United States was the most visited and preferred medical tourism destination for the survey participants, and thus accounted for 47.81% of medical tourism visits. It was closely followed by Germany at 44%. The driving motivators for this include the availability of advanced medical technology, as reported by 64.52% of the respondents, as well as highly qualified and sophisticated physicians. 23 This is quite unlike a study in Saudi Arabia which   reported that 49% of patients preferred Pakistan as their destination for renal transplants, followed by the Philippines at 28%, Egypt at 11%, and the United States at 3.2%. 24 Patients in Oman, however, were reported to have visited Thailand and India as their top destinations for medical treatment. 25 Fifty-three percent of the participants selected pure tourism as their intention to go abroad, while atmosphere and nature were selected by 1.87% of the participants. Oman's healthcare system, which is similar to that of Kuwait, reported that 10% of their patients go abroad for tourism. 25 This low tourism figure might be attributable to the fact that participants in the current study went abroad for the primary purpose of healthcare and then decided to tour the host country at the same time. The reason American citizens travel abroad for treatment, however, is mainly tourism. A study by Deloitte Consulting estimated that up to 750 000 Americans sought healthcare services abroad in 2007; this figure rose to 1.6 million in 2012. 13 However, unlike the current study population, these medical travelers were self-sponsored, not governmentally funded. 13 The leading reason for Kuwaitis traveling abroad for medical treatment (69.7%) was that the patients had no confidence in Kuwait's general medical capabilities. As a result, about 34% of the traveling populace never sought their doctor's assessment before traveling. This reflects a positive attitude towards treatment abroad, since about 89% of the survey takers in the current study would repeat their experience.
A study covering reproductive health tourism in Saudi Arabia hinted that another purpose for travel is privacy, and it is of great importance in an environment where in vivo fertilization and infertility are frowned upon. 25,26 In this study, about 4% of the participants stated that they would choose medical treatment abroad, because they sought privacy. Although it is a general belief that medical care abroad is cheap, the general costs are high, and the financial implications could be detrimental for the country's economy; however, the economic growth in hosting counties has been estimated to reach 26.8% by the current literature.
About 30% of the participants experienced simple, predictable complications, while 7.48% had severe complications. The authors believe that this might be an underestimation since most people tend not to report problems, so it does not decrease their chances of receiving outbound medical treatment again. However, almost the same number of complications was observed in a UK study. 25,26 A 2010 study by Alghamdi et al showed that transplant tourists experienced a higher rate of acute rejection within the first 12 months compared with those who choose local transplantation (27.9% versus 9.9%, P = 0.005). 24 It should also be noted that orthopedics was the most popular specialty for which Kuwaitis sought overseas medical care; this was in keeping with the Omani study. 25 A most interesting fact about Oman's study was that 15% of the respondents did not seek local medical care before going abroad for medical care, yet the number of Kuwaitis who conducted this same behavior was almost double that of the Omanis. 25 Although it is difficult to measure intent and behavioral reasons for seeking overseas treatment, [29][30][31] there is a small number of people among the Kuwaiti population who have a sense of entitlement reflected in the reasons the participants selected other than the 1.87% who wanted to go for tourism. Attitudes like the waiting times are too long (27.3%), fear of medical errors reported in social media platforms (19.3%), short consultation time (10.7%), and nepotism 3.9% are attitudes that require further examination as well as the shortcomings of the healthcare system itself, as was done in the United Arab Emirates, which is now showing promising economic growth from inbound medical tourism. 32

Limitations
A major limitation of this study was the scarcity of statistics and data on patients who sought medical care overseas, because the governing authorities did not release the exact number of patients who received medical treatment abroad. Another limitation was the scarcity of scientific literature on medical tourism in the Arabian Gulf and Arab countries.

Conclusion
A lot of money is invested in Kuwait's healthcare systems, but the nationals have become victims of political corruption that has led to national debt with other countries. The majority of Kuwaiti nationals who seek healthcare overseas distrust the healthcare system in Kuwait, but half of them are open to alternatives if they were made available in Kuwait. This

What Is Already Known?
Medical tourism has been increasing exponentially in Kuwait and effecting the training of Doctors, and the financial status of the health sectors, however reasons of this is clearly known.

What This Study Adds?
This study provides a clear insight to medical tourism from the patients point of view and to develop a plan to increase the trust of the patients to system and the health sector.
Research Highlights study provides feedback to major stakeholders in Kuwait's healthcare system to develop the best strategies addressing the direct healthcare needs of this country.

Recommendations
The issues raised in this Kuwaiti study can be tackled using two different recommendations, namely, community approach and public health sector approach. The goal should be to create awareness among the members of the public using different media in order to sensitize them to medical tourism and its impact on families, countries, communities, and individuals. The authors of this study also recommend that standards should be set to regulate the medical tourism industry in both the country of origin and the country of destination. Medical tourism companies should be accredited, and such accreditation should be reviewed regularly. The country should also invest in its healthcare system by inviting visiting doctors to treat the public and teach the residing staff.