Public Health in Practice 2 (2021) 100182

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Public Health in Practicejournal homepage: www.sciencedirect.com/journal/public-health-in-practiceCommentaryLessons from COVID-19’s impact on medical tourism in Cambodia
Makoto Kosaka a, b, Yurie Kobashi c, d, *, Kensuke Kato e, Manabu Okawada f,
Masaharu Tsubokura ca

Internship, Kitahara International Hospital, Hachioji City, Tokyo, JapanThe University of Tokyo, Bunkyo City, Tokyo, Japanc
Department of Radiation Health Management, Fukushima Medical University School of Medicine, Fukushima City, Fukushima, JapandKitahara International Hospital, Hachioji City, Tokyo, Japane
Department of Neurosurgery, Sunrise Japan Hospital Pheon Penh, Pheon Penh, CambodiafDepartment of Pediatrics, Sunrise Japan Hospital Pheon Penh, Pheon Penh, Cambodiab

A R T I C L E I N F O

A B S T R A C T

Keywords:
COVID-19Cambodia
Medical tourism

Making medical tourism a more valuable healthcare system is a significant public health issue. However, little
discussion has been conducted on what lessons can be learned from the impact of COVID-19 on medical tourism.
This study aimed to discuss the issues and barriers faced by patients unable to seek medical tourism, and themedical care experience at private general hospital in capital, Cambodia. First, when patients seeking medical
tourism were unable to go abroad due to the pandemic or other reasons, some of them could not easily visit
domestic health care facilities. Second, even if patients received medical care in the home country’s hospitals dueto the interruption of medical tourism, sharing the patient’s medical information between domestic and overseas
medical institutions was difficult. The third problem in medical tourism is that dependence on overseas medical
resources might hinder the development of medical professionals, facilities, and other environments in thecountry of origin. This experience revealed the need to encourage patients who were unable to undertake
medical tourism to visit domestic medical facilities, make efforts to share patient information across countries,and to invest in developing each department in domestic hospitals. Support for patients who are unable toundertake medical tourism is urgently needed.

1. Medical tourism in Cambodia
Medical tourism is the medical care that patients seek across nationalborders. Patients seek medical tourism for various purposes; however,
medical tourism is mainly in two directions: patients from low-andmiddle-income countries (LMICs) seeking higher quality medical careand patients from high-income countries (HICs) seeking low-cost med­
ical care [1]. The host countries consider medical tourism as a source ofeconomic profits [1]. Previous research in Korea, a patient-accepting
country, concluded that the benefits of medical tourism outweigh thenegative impacts of universal health coverage and the constriction ofmedical supply [2]. Moreover, medical tourism might be a powerful tool
for reducing inequalities in healthcare worldwide [3]. Therefore, mak­ing medical tourism a more valuable healthcare system is a significant
public health issue.
However, medical tourism is greatly influenced by COVID-19. Many

countries have closed national borders, imposed isolation rules for res­idents from abroad or foreigners, and have made negative polymerase
chain reaction (PCR) results mandatory for entry into the country. For
instance, Bumrungrad Hospital in central Thailand, catering to half ofthe overseas patients, reached a 32.9% of decrease in patients in 2020
compared to the previous year [4].
Further, the effects of COVID-19 on medical tourism have continued
into 2021 [5], adversely affecting medical tourism. However, little
discussion has been conducted on what lessons can be learned from theimpact of COVID-19 on medical tourism and what improvements arerequired to make medical tourism a part of a more beneficial healthcare
system.
Cambodia, located in Southeast Asia, is a country where many pa­tients undertake medical tourism to seek high-quality medical care [6].
Cambodian people go to other countries for medical checkups, surgicaltreatment, and chronic disease treatment. Many people have sought* Corresponding author. Department of Radiation Health Management Fukushima Medical University School of Medicine Fukushima City, Fukushima 960–1295,Japan.
E-mail address: yurie-s@umin.ac.jp (Y. Kobashi).
https://doi.org/10.1016/j.puhip.2021.100182
Received 22 July 2021; Accepted 30 July 2021
Available online 27 August 2021
2666-5352/© 2021 The Authors. Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

M. Kosaka et al.

Public Health in Practice 2 (2021) 100182

medical tourism to date; for instance, 3,837 patients made more than 10,000 trips to Thailand for medical care in 2010 [7]. Medical tourism is
not only meant for wealthy people, but also for people of middle eco­nomic status in Cambodia, due to the concern for their health and theease of traveling across the border to neighboring countries. Thus,medical tourism is an essential part of Cambodia’s healthcare. More­over, patients have less trust in domestic medical care owing to theextremely sparse number of medical professionals who emerged under
the Khmer Rouge regime of 1975–79; the number of doctors was esti­
mated to be 6,550 in 2016, approximately 0.4 doctors per 1,000 people[8].
In Cambodia, the total number of people infected with COVID-19
surged in April 2021 and reached 13400 on April 30, 2021, in spite ofmeasures such as quarantining of people entering the country, lock­downs, and community residents’ education to protect them frominfection. Due to restrictions on travel as a countermeasure of infection
prevention, some patients who sought medical tourism are now visiting
public and private hospitals in Cambodia. One such private hospital isSunrise Japan Hospital Phnom Penh (SJH), which was established bySunrise Healthcare Service, a joint venture between Japanese privatecompanies (JGC Japan Corporation, Innovation Network Corporation ofJapan, Kitahara Medical Strategies International) in 2016. It currently
has 50 beds and provides medical care in 14 departments, including
neurosurgery, pediatrics, and emergency medicine. In SJH, the numberof patients varies each month, and the patient characteristics havechanged since the COVID-19 pandemic.
This study aimed to discuss the issues and barriers faced by patientsunable to seek medical tourism, and the medical care experience at SJH.
We discussed the improvements required to make medical tourism a partof a more beneficial healthcare system.

sharing information between overseas treatment institutions and family
physicians was discussed to ensure the continuity of treatment in med­ical tourism [10]. In the field of medical tourism, it is necessary to pay
more attention to the sharing of medical information and provide
explanation to patients to ensure continuity of medical care. Changes topolicies and regulations might be required to accelerate the sharing ofpatient’s medical information crossing border.
The third problem in medical tourism is that dependence on overseas
medical resources might hinder the development of medical pro­fessionals, facilities, and other environments in the country of origin.
Although there is a neurosurgery department at SJH, several brain
tumor patients had gone abroad before the COVID-19 pandemic; how­ever, the majority of the brain tumor patients came to the capital hos­pital after the pandemic. A previous study reported barriers in medical
oncology, surgery, radiotherapy, imaging, pathology, and palliative care
departments for cancer patients who discontinued medical tourism dueto the COVID-19 pandemic and went back to their countries; coopera­tion between these departments is needed [11]. Thus, to provide
high-quality medical care tailored to each individual, the developmentof various sectors and cooperation between departments is required.
Investment in medical facilities and human resources to break the vi­
cious cycle of distrust in the home country’s medical care that promotes
medical tourism is required.
3. Conclusion
In this COVID-19 era, many patients are affected due to the loss of
medical tourism. In Cambodia, where the obvious problem of providing
medical care to people in own country as part of lifeline has not yet beensolved, medical tourism has become a tentative solution that has pre­vented fundamental solutions to the problem. The COVID-19 pandemic
has forced Cambodia to confront this problem by making medical
tourism unfeasible. This experience revealed the need to encourage
patients who were unable to undertake medical tourism to visit domestic
medical facilities, make efforts to share patient information acrosscountries, and to invest in developing each department in domestic
hospitals. Support for patients who are unable to undertake medical
tourism is urgently needed. Furthermore, medical tourism for profit­
making purposes might have a negative impact on sustainable health­care, which needs to be reconsidered.

2. The issues and barriers to seek medical tourism under COVID19 influenceFirst, when patients seeking medical tourism were unable to go
abroad due to the pandemic or other reasons, some of them could noteasily visit domestic health care facilities. In the case of Cambodia,
during the pandemic of COVID-19, some patients whose medical
tourism was interrupted due to COVID-19, did not visit a domestic
medical institution for more than a year, some purchased over-thecounter medicines in Cambodia without visiting hospitals or clinics,
worsening their pre-existing conditions. Besides, medical tourism will bediscontinued, not only due to the risk of pandemics like COVID-19, butalso because of the high price of medical tourism itself. A previous study
showed that 43% of medical tourists in the Maldives, an LMIC patient
sending country, were forced to bear destructive household burdens [9].
Considering that medical tourism from Cambodia has an aspect of flightfrom domestic healthcare, similar phenomena may occur in Cambodia.
This indicates that even if the pandemic is over and things return tonormal, there will be patients who will have to give up medical tourism
midway. For such patients to be able to visit domestic hospitals andclinics smoothly, establishing a system that allows them to easily accessinformation on suitable domestic medical institutions is required. Be­
sides, it is necessary to educate people on the importance of treatment
continuity and cooperation between foreign and domestic hospitals.
Second, even if patients received medical care in the home country’s
hospitals due to the interruption of medical tourism, sharing the pa­
tient’s medical information between domestic and overseas medical
institutions was difficult. Some patients who discontinued medical
tourism and visited SJH did not have complete documentation of their
medical information and did not provide exact details of their disease.
Thus, they had to perform all the tests again. They were unable to seek
the best treatment because the doctors could not access the patient’s
medical history. This problem might be partly caused due to patients’
low literacy level, and language barriers, causing miscommunication
between the doctor and patient. In a previous study, the necessity ofFunding
This study did not receive any specific funding.
Ethical approval
Not required.
Authorship contributions
MK, YK, KK, MO and MT contributed to writing the papers. All au­thors reviewed the present paper and contributed to the discussion ofthis work.
Declaration of competing interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgements
We would like to thank Yoshifumi Okada, Mihoko Nakayama, andSunrise Japan Hospital Phnom Penh staff for helping with this research.
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Public Health in Practice 2 (2021) 100182

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