International Journal for Quality in Health Care 2005; Volume 17, Number 4: pp.

277279

10.1093/intqhc/mzi059

Editorial

Globalization in health care:

is international standardization
of quality a step toward outsourcing?
Though different in many respects from other types of services,
health care services are also impacted by globalization. For
example, some countries, especially developing ones, can
attract customers by offering high quality health care at a
lower cost than is available in their home country. And
although this practice is relatively uncommon at the present
time, our hypothesis is that, within a short time, this practice
will greatly expand, partly due to the development of global
standards of quality and the rise of processes of accreditation,
both in health care and medical education.

the mutual recognition of medical degrees that accompanied

that integration [1]. Another emerging phenomenon is the
development, in less developed countries, of medical curricula that have been adapted to North American or Western
European standards and are offered in English, allowing such
programs to negotiate a higher level of recognition worldwide
and to provide a financially competitive education for students from wealthier countries.

A new trend: the circulation of patients

Globalization is characterized by the circulation of goods and

services between countries in response to criteria of efficiency. Such multilateral agreements between countries,
unfortunately, often function to the detriment of the countries
with less developed economies. Nevertheless, trade can also
benefit developing countries. Outsourcing is one situation in
which developing countries that are able to adopt standards,
processes, and language of developed countries can benefit
from the liberalization of the movement of goods and services. By undertaking some or all components of production
or service provision for clients/consumers in the developed
country, some economic benefits may occur to the developing country where the outsourced service is provided.
But what, we might ask, is the impact of the process of
globalization generally and outsourcing more particularly in
the health care sector?

The movement of patients is a more recent phenomenon.

Though still marginal, so called medical tourism is becoming
more important. Treatments offered in western Europeans
countries attract infertile couples from United States because
they cost half or one third of those provided in North America.
Elective surgery offered in highly sophisticated Indian hospitals
tends to cost only 1020% of identical treatment in western
countries.
There is also a shift from personal initiatives to national
incentives. Tunisia, for example, organized a conference at
the beginning of December 2004 to attract health care
purchasers from abroad. Purchasers, even those belonging to
public systems can potentially be interested, when a reduction
of costs by as much as 5080% can be realized. A recent report
shows that the issue has also been debated in Canada [2].

Will the development of international

standards result in an explosion of health
care outsourcing (Table 1)?

The circulation of health professionals

The movement of professionals in general tends to be detrimental to poorer countries. There are two aspects to this. The
most classic is the settlement of young professionals, originally from less developed countries, in more developed countries from which they have graduated with professional
credentials. A second phenomenon is the policy of some rich
countries, who because they lack doctors and nurses, try to
recruit recently trained graduates from poorer countries. The
movement of professionals in this way is facilitated by systems that recognize degrees internationally. This issue has
arisen recently, for example, in light of the ascension of
Poland and the Czech Republic to the European Union and

We would argue that the development of international standards, increasingly proposed by professional bodies, both in
the domain of quality of care (Alpha Program [3] and International Joint Commission [4]) and in medical education (IIME,
World Federation for Medical Education [5]) could potentially result in a significant increase in the movement of
patients and health professionals across national boundaries.
This will arise as external procedures accepted worldwide for
the recognition of quality (in health care or in education)
promise an equivalence of service.
If this scenario comes to be, insurance companies will offer
cheaper premiums (as will countries which are less and less
able to finance the health care of their populations at least for

International Journal for Quality in Health Care vol. 17 no. 4

The Author 2005. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved

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Globalization: economic issues

Editorial: Segouin, Hodges and Brechat

Table 1 International Quality Standards and Globalization

Services offered by different
countries

Services bought by individuals

Quality/accreditation

.......................................................................................................................................................... ..................................................................

Hospital care

Care offered at lower price in a

wide range of countries:
elective surgery, aesthetic
surgery, fertility treatment,
and so on
Medical education Courses in English for
pregraduate training

Europeans people (especially

French) in Tunisia for aesthetic
surgery, US people in Europe
or South Africa for infertility
treatment, and so on
Medical school places offered in
Poland, Czech Republic to
citizens of other western
countries, and so on

What are the issues?

We foresee at least two issues that should be considered. The
first is the potential of such developments to improve the
quality in health care within the world. The second relates to
issues of access to health care and the ethical dimensions
associated [6].
Developing international standards in medical education
and health care delivery can help improving quality in health
care all over the world. Nevertheless, two questions remain.
To what extent can one be sure that international standards
can be created that will fit the cultural, social, and economical
contexts of very different countries? It is often assumed that,
simply demonstrating compliance with quality processes, will
lead to a result (of the education or of the treatment) that will
be the same, whatever the country or the professionals
involved. But to what extent can we be sure that applying, for
example, North American (or European, or for that matter
African or Asian) procedures and quality rules in other countries will lead to adequate quality?
The second question is will adopting such universal standard contribute to the improvement of access to health care

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around the world? Simplistically, one might argue that simply

lowering the cost of health care would give wider access to
care (health care delivery would benefit a wider range of
people and/or a wider range of care would be offered to
people). But this has to be nuanced.
We have to consider who might benefit most from this
new situation. Firstly, the patient may have little to say in
where, when, and how their care is provided, given the priority of financial issues in the strategy of health care organization. Additionally, we can ask, how will we know if he or she
really receive equivalent care at a lower price?
Further, ethically speaking, it is not acceptable to exclude
the local population from the benefits of care that is provided
in their country for rich strangers, even if this organization
allows less rich countries to develop employment in the
health care sector. Finally, there is an inevitable and negative
impact on employment in the health care sector of the rich
countries who export their patients.

Conclusion
It is the turn of health care delivery to be globalized. Nevertheless, health cannot be assumed to be the same as other
basic goods. Linked to health care are many complex ethical,
cultural, and human resource issues that we have only begun
to name. Further, it is the duty of health professionals to
promote health as a global human right. Global public
goods [ 7 ], and, for this reason, we all must be very careful
before launching headlong into the globalization of health
care and health professional education, taking care to be certain that if we do, it will be for the benefit of all around the
world.
Christophe Segouin
University Paris 7, Medical School, Public Health, Paris
and Assistance Publique-Hpitaux de Paris
Public Health, Paris, France

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elective and costly procedures), for care provided by countries that are accredited and competitive. As difficult as it
might be for us to imagine today, this phenomenon might
also affect medical education. There are at least two reasons
why this might occur. Firstly, medical education costs are
soaring, and the promise of lower cost of education might be
very attractive in an open educational marketplace. Secondly,
the opportunity for students to train in the same places that
patients from their countries are receiving care might be seen
as both educationally sound and a bonus for patients who are
being treated abroad. Eventually, we might imagine that
countries that have welcomed international medical students
for training might also like to recruit them to stay in order to
provide care for patients who have come from the same
countries of health care.

Development of international
standards of accreditation of
health care organization: Joint
Commission International, Alpha
program (Isqua), and so on
International standards: World
Federation for Medical
Education, International Institute
for Medical Education,
Confrence Internationale des
Doyens de Mdecins d
Expression Franaise, and so on

Globalization in health care

Brian Hodges
Centre Research on Education, University of Toronto
Toronto, Ontario, Canada
Pierre-Henri Brechat
Assistance Publique-Hpitaux de Paris, Public Health
Paris, France

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