BackgroundThe resolution adopted in 2006 by the World Health Organization on international trade and health urges Member States to understand the implications of international trade and trade agreements for health and to address any challenges arising through policies and regulations. The government of Maldives is an importer of health services (with outgoing medical travelers), through offering a comprehensive universal health care package for its people that includes subsidized treatment abroad for services unavailable in the country. By the end of the first year of the scheme approximately US$11.6 m had been spent by the government of Maldives to treat patients abroad. In this study, affordability, continuity and quality of this care were assessed from the perspective of the medical traveler to provide recommendations for safer and more cost effective medical travel policy.ResultsDespite universal health care, a substantial proportion of Maldivian travelers have not accessed the government subsidy, and a third reported not having sufficient funds for the treatment episode abroad. Among the five most visited hospitals in this study, none were JCI accredited at the time of the study period and only three from India had undergone the National Accreditation Board for Hospitals (NABH) in India. Satisfaction with treatment received was high amongst travelers but concern for the continuity of care was very high, and more than a third of the patients had experienced complications arising from the treatment overseas.ConclusionSource countries can use their bargaining power in the trade of health services to offer a more comprehensive package for medical travelers. Source countries with largely public funded health systems need to ensure that medical travel is truly affordable and universal, with measures for quality control such as the use of accredited foreign hospitals to make it safer and to impose measures that ensure the continuity of care for travelers.Electronic supplementary materialThe online version of this article (10.1186/s12992-018-0375-4) contains supplementary material, which is available to authorized users.

BackgroundUniversal health coverage (UHC) is difficult to achieve in settings short of medicines, health workers and health facilities. These characteristics define the majority of the small island developing states (SIDS), where population size negates the benefits of economies of scale. One option to alleviate this constraint is to import health services, rather than focus on domestic production. This paper provides empirical analysis of the potential impact of this option.MethodsAnalysis was based on publicly accessible data for 14 SIDS, covering health-related travel and health indicators for the period 2003–2013, together with in-depth review of medical travel schemes for the two highest importing SIDS—the Maldives and Tuvalu.FindingsMedical travel from SIDS is accelerating. The SIDS studied generally lacked health infrastructure and technologies, and the majority of them had lower than the recommended number of physicians in a country, which limits their capacity for achieving UHC. Tuvalu and the Maldives were the highest importers of healthcare and notably have public schemes that facilitate medical travel and help lower the out-of-pocket expenditure on medical travel. Although different in approach, design and performance, the medical travel schemes in Tuvalu and the Maldives are both examples of measures used to increase access to health services that cannot feasibly be provided in SIDS.InterpretationOur findings suggest that importing health services (through schemes to facilitate medical travel) is a potential mechanism to help achieve universal healthcare for SIDS but requires due diligence over cost, equity and quality control.

BackgroundAccess to tertiary care is a problem common to many small states, especially island ones. Although medical treatment overseas (MTO) may result in cost savings to high income countries, it can be a relatively high cost for low and middle income source countries. The purpose of this study was to estimate the costs of overseas medical treatment incurred by the households of medical travelers from Maldives and assess the burden of medical treatment overseas on the government and on households.MethodsA survey was conducted of inbound Maldivian medical travelers who traveled during the period June – December 2013. Participants were stratified by the source of funds used for treatment abroad. Three hundred and forty four government-subsidized and 471 privately funded Maldivians were interviewed. Self-reported data on the utilization and expenses incurred during the last visit abroad, including both expenses covered by the government and borne by the household, were collected using a researcher administered structured questionnaire.ResultsThe median per capita total cost of a medical travel episode amounted to $1,470. Forty eight percent of the cost was spent on travel. Twenty six percent was spent on direct medical costs, which were markedly higher among patients subsidized by the government than self-funded patients (p = <0.001). The two highest areas of spending for public funds were neoplasms and diseases of the circulatory system in contrast to diseases of the musculoskeletal system and nervous system for privately funded patients. Medical treatment overseas imposed a considerable burden on households as 43 % of the households of medical travelers suffered from catastrophic health spending. Annually, an estimated $68.9 million was spent to obtain treatment for Maldivians in overseas health facilities ($204 per capita), representing 4.8 % of the country’s GDP.ConclusionsOverseas medical treatment represents a substantial economic burden to the Maldives in terms of lost consumer spending in the local economy and catastrophic health spending by households. Geographical inequality in access to public funds for MTO and the disproportionate travel cost borne by travelers from rural areas need to be addressed in the existing Universal Health Care programme to minimize the burden of MTO. Increased investment to create more capacity in the domestic health infrastructure either through government, private or by foreign direct investment can help divert the outflow on MTO.

Background Shortages in resources for health and health service delivery in small island states make it inevitable for islanders to seek medical treatment out of the country. This study aimed to assess the changes in access to treatment overseas and its disparities before and after universal health care was introduced in 2012 in the island state of Maldives. Methods Using primary and secondary data, two analyses were performed: 1. Analysis of beneficiary data on public subsidy for medical treatment overseas 2010–2013; 2. A comparative analysis of two independent cross-sectional surveys conducted in 2010 and 2013. Public subsidy, financial protection, usage, and costs of medical treatment overseas were analyzed using descriptive statistics and the concentration curve and index. Results Number of beneficiaries subsidized for treatment overseas has increased by 199% and the average expenditure per beneficiary has increased by 49.7% during 2010–2013. Average number of visits abroad in a year has slightly decreased from 1.6 in 2009 to 1.4 visits in 2013, but among travelers who made more than one trip abroad, average visits remained at 2.7 per year. Median medical costs have increased by 26.9% and the proportion of household spending on overseas treatment in annual household spending has remained around 20% over the years. The proportion of travelers belonging to average households (household spending below $650) has increased by 107%, and the concentration index decreased from 0.08 in 2009 to 0.04 in 2013 indicating a change towards a more uniform distribution of MTO use. Conclusions Despite the fact that the objectives of the two surveys differed which may have led to differences in measurements, it can be concluded that UHC has narrowed the gap between the rich and poor in utilizing medical treatment overseas. However, median out of pocket spending on MTO has increased over the years indicating the need to broaden the benefit package of the UHC program. Further research is needed on the most deprived populations who have not accessed care abroad despite the change in the health financing system in the country.