Medical Tourism in Colombia: Tourists or International Patients?

CAJIAO, MEDICAL TOURISM IN COLOMBIA, VOICES IN BIOETHICS, VOL. 9 (2023)

* Ximena Cajiao, LLM Georgetown University Law Center, Bioethics Certificate Columbia University

© 2023 Ximena Cajiao. This is an open access article distributed under the terms of the

Creative Commons Attribution License, which permits unrestricted use, distribution, and

reproduction, provided the original author and source are credited.

Medical Tourism in Colombia: Tourists or International Patients?

DOI: 10.52214/vib.v9i.11941

Ximena Cajiao*

Keywords: Medical Tourism, Healthcare, Coverage, Medical Visa, Colombia, Medical Benefits, Equal Access

INTRODUCTION

Medical tourism should contribute to developing a more robust healthcare system that acts in the best

interests of patients and ensures equal access to healthcare. This paper examines medical tourism in

Colombia and argues that developing a system that aligns with bioethical principles is necessary. People

traveling for care should have access to the Ministry of Health rather than only the Ministry of Industry and

Tourism, emphasizing their purpose as patients seeking medical procedures or treatments rather than

tourists engaging in leisure activities. Additionally, in the interest of justice, Colombian patients should

benefit from the revenue derived from medical tourism. It is crucial to recognize that both patients traveling

for care and people in the destination country can derive benefits from medical tourism. The Colombian

government can protect the rights and well-being of patients seeking care and ensure that any benefits are

distributed fairly among Colombian citizens.

I. Background

Medical tourism refers to people traveling to foreign countries to obtain health care.

1

Many individuals

from high-income countries seek health care in less developed countries to take advantage of the lower

costs. Destination countries are increasingly showing interest in becoming medical tourism hubs due to the

significant financial potential of this multi-billion dollar industry. The global medical tourism market is

projected to reach $207.9 billion by 2027.

2

This growth not only generates income but also creates

employment opportunities and business prospects for local residents in sectors such as tourism,

pharmaceuticals, and infrastructure. By establishing themselves as medical tourism destinations, countries

can stimulate economic development and enhance their healthcare structure.

CAJIAO, MEDICAL TOURISM IN COLOMBIA, VOICES IN BIOETHICS, VOL. 9 (2023)

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Colombia is among the fastest-growing medical tourism destinations in the world. It has become a popular

destination for medical tourists due to its advanced healthcare infrastructure, biotechnology, and highly

skilled physicians who cater to international patients at affordable prices.

3

The healthcare entities in

Colombia offer a wide range of medical procedures, including cardiovascular, bariatric, orthopedics,

cosmetic surgery, dental care, and fertility treatments.

4

The Colombian government has actively promoted medical tourism to position the country as a destination

for world-class medical services.

5

Through strategic economic policies, effective regulation, and digital

marketing, medical tourism has emerged as a significant contributor to Colombia’s income. The Colombian

Ministry of Industry and Tourism, which regulates medical tourism in Colombia, forecasts at least 2.8 million

health tourists and a revenue of at least $6.3 billion by 2032.

6

Colombia intends to have medical tourism play a significant role in its economy. However, ethical issues

exist. The Colombia Ministry of Industry and Tourism is more involved in medical tourism than the Ministry

of Health is. Additionally, the government has not been held accountable for the shortcomings in the

medical tourism industry. There should be an organization advocating for the rights and well-being of

medical tourists. Furthermore, using public funds to attract international patients may divert funds from

local communities. Last, the negative impacts of medical tourism on Colombian patients deserve attention.

This paper aims to explore these ethical issues from two perspectives: that of medical tourists and that of

Colombian citizens. I argue that the benefits of medical tourism outweigh the harms but that those traveling

for health care deserve protection.

II. Patients: Are They International Patients or Tourists?

When medical tourists seek hospitals and physicians in a destination country, facilitators may direct them

to non-licensed practitioners and questionable facilities. These facilitators, who receive commissions, may

not act in the patient’s best interest. Rather, like travel agents, they base their referrals on the referral fees

that hospitals or physicians pay.

7

International patients risk getting lower-quality health care from

unregulated hospitals or providers. This can interfere with informed consent and increase the risk of

infections. There may be an absence of medical malpractice coverage from physicians. Unregulated or

unlicensed medical care may even lead to patient fatalities. Therefore, it is crucial for international patients

to carefully evaluate the risks associated with “booking” their healthcare options.

To mitigate these risks, it is important for international patients to thoroughly assess the accreditation

status of the hospital or clinic they plan to visit. The Joint Commission International (JCI) accreditation can

provide patients with an external quality assessment and assist them in making an informed decision.

8

International patients should proactively seek out certified and reputable healthcare providers and

institutions to ensure both their safety and a high quality of care. Colombia has five hospitals and clinics

with JCI accreditation.

9

Colombia is the third most-used destination for plastic surgery in the world; the first is Brazil, and the

second is Turkey. In Colombia, one out of every three plastic surgery patients is an international patient.

10

The Colombian Association for Plastic Surgery advises all patients to check the hospital's accreditation.

Patients should check the website of the local Secretary of Health in each city and see if the physician

conducting the plastic surgery is listed.

11

Institutions and doctors must fully comply with requirements,

including describing the procedure and obtaining informed consent from patients. It is very common to

read in the media plastic surgeries conducted in what is known in Latin America as “clinicas de garage”

CAJIAO, MEDICAL TOURISM IN COLOMBIA, VOICES IN BIOETHICS, VOL. 9 (2023)

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(garage clinics) with negative results and deaths.

12

Official data covers plastic surgeries conducted at

accredited institutions with registered doctors. There is a lack of data on garage clinics.

There are a few things the government can do to make medical tourism safer. First, the Ministry of Health’s

website should maintain a list of healthcare providers with JCI accreditation. In each city, the local Secretary

of Health is responsible for providing patients with information about the quality of care of the hospitals in

its region. Second, the government should take responsibility for providing accurate and comprehensive

information to international patients, enabling them to make fully informed decisions regarding their

medical procedures. In the context of informed consent, patients may have trouble understanding due to

language barriers, terminology, and the complexity of the risks involved in medical procedures. Lastly,

Congress should enact a legal framework that determines the responsibility of all parties involved in

medical tourism.

13

In the unfortunate event that a medical tourist requires intensive care, it becomes imperative to determine

who will bear the responsibility for their well-being and any potential financial implications. Medical tourists

are not protected from errors and failures of medical procedures because the Colombia Constitution

specifies that the healthcare system exclusively caters to its citizens, while coverage for foreigners is limited

to emergencies only. The US State Department recommends that those traveling to Colombia have

international health insurance.

14

International patients can sue doctors in Colombia for medical

malpractice, referred to as medical liability.

15

The government should take responsibility for certifying medical institutions and issuing medical visas with

specific requirements and regulations specific to medical tourism.

16

A new medical visa system is in place.

Changing the terminology may help the government see those traveling for care as medical patients rather

than medical tourists. That may lead to a different mindset and spur the government to protect them and

ensure high-quality care. It may also help those traveling avoid tourism industry facilitators and find

reputable surgeons and hospitals.

III. Are Colombian Patients and the Local Healthcare System Benefiting from Medical Tourism?

The main reason for the growth of medical tourism from developed countries to developing countries like

Colombia is the excessive cost of treatment in wealthier nations.

17

Other reasons include the long queues

for certain types of medical services in the home country, the availability of better technologies abroad,

inadequate (or absence of) health insurance, and the unavailability

18

(or prohibition) of certain medical

services in the home country.

19

The Colombian Constitution recognizes health as a fundamental right for all citizens.

20

Pursuant to the

Constitution’s health mandate, Colombia designed a mandatory universal social health insurance system in

1993. It aims to achieve a fair distribution of resources, opportunities, and services while holding the

government accountable.

21

Before 1993, less than 25 percent of the population had coverage; now,

between 94 and 99 percent have it, regardless of income level or employment.

22

However, universal care

does not entitle Colombian citizens to many of the modern surgical centers, technology, and doctors that

tourists access. Local wealthy Colombian citizens tend to purchase private insurance that allows them many

more healthcare options.

23

The OECD reports that only 41 percent of Colombian citizens were satisfied with

the availability of the quality of care, while the OECD average is 67 percent. According to the OECD, the

out-of-pocket health expenditure in Colombia is 14 percent, which is lower than the OECD average of 18

percent. Despite its recognized right to health care, the current system is not providing the quality of care

that the people would prefer.

CAJIAO, MEDICAL TOURISM IN COLOMBIA, VOICES IN BIOETHICS, VOL. 9 (2023)

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Those traveling to Colombia for care are not covered by universal social health insurance and must pay for

their health care

24

out of pocket or through their private insurers using international coverage.

25

Like local

supplemental private insurance, medical tourists and their insurance plans tend to pay more for their care

than the rate that the universal system would pay the providers for care provided to the general Colombian

population. This situation often leads to higher revenue from medical tourists than local patients unless the

local patients have supplemental private insurance. The mismatched payment schemes leave the local

population with unequal access to healthcare resources

26

since healthcare providers prefer to cater to

patients paying more than the government-subsidized insurance pays. Medical tourism “threatens to result

in a dual market structure”

27

characterized by a higher-quality, expensive segment that serves wealthy

nationals and foreigners alongside a lower-quality segment that caters to the poor, most of whom are

covered by universal healthcare coverage.

28

Medical tourists should pay taxes or a special premium to improve the local healthcare system. While the

medical tourism industry arguably generates tax revenue,

29

some additional money should flow from the

medical tourists to the healthcare outlets that the local people use. Then, the country can benefit even

more from promoting medical tourism while ensuring that the government and the healthcare system

follow the principles of justice, beneficence, and public welfare.

30

In Colombia, Fundación Cardioinfantil, a private non-profit hospital known as “La Cardio,” is a good example

of a regional leader committed to providing clinical excellence to both national and international patients.

31

About 20 years ago, La Cardio, well known for its cardiovascular health care, aimed to become the top

hospital in the region (Latin America and the Caribbean) to obtain financial resources for improving its

facilities. It became the first hospital in Colombia to achieve the JCI accreditation, attracting patients from

countries with inadequate cardiovascular healthcare systems.

32

Foreign governments covered their

citizens’ medical expenses, allowing La Cardio to fund system improvement. Currently ranked as the fifth-

best clinic in Latin America and having won the Gold Award for Corporate Social Responsibility, La Cardio

has received recognition for its dedication to serving economically disadvantaged Colombian patients.

33

This example demonstrates how introducing a high-paying market has not led to neglecting local patients,

as resources from medical tourists are used to enhance the healthcare system for the local population.

CONCLUSION

The Colombian government needs to recognize that international patients are seeking medical services,

not tourism or vacation experiences. Therefore, a new policy should categorize international patients

separately from the tourism sector and treat them purely as patients. The introduction of medical visas

may help this. Once establishing international patients are patients and not tourists, the Colombian

government could impose taxes on them and allocate the funds generated to reinvest in the healthcare

needs of its citizens, ensuring justice and promoting awareness of the ethical rights of international

patients. At the same time, home country governments directing patients to a destination country should

conduct thorough due diligence of the ethical principles applied to international patients as well as the

accreditation of the destination country’s hospitals. Colombia may be aware of the implications of the

difference in terms but unwilling to modify the language due to the associated costs, liabilities, and risks

involved.

1

Gaines, J., Lee, C. V. (2019). Medical tourism. Travel Medicine, 371–375. https://doi.org/10.1016/b978-0-323-54696-6.00039-2

https://www.sciencedirect.com/science/article/pii/B9780323546966000392

CAJIAO, MEDICAL TOURISM IN COLOMBIA, VOICES IN BIOETHICS, VOL. 9 (2023)

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2

Forecasted Evolution of Medical Travels, 2023-2027: A Segmental View. ReportLinker. (2023, December).

https://www.reportlinker.com/p06473784/Medical-Tourism-Market-Size-Share-Trends-and-Analysis-by-Region-Service-Provider-

and-Segment-Forecast.html

3

Forecasted Evolution of Medical Travels, 2023-2027: A Segmental View. ReportLinker. (2023, December).

4

Arias-Aragonés, F.J.A., Payares, A.M.C., & Jiménez, O.J. (2020). Characterization of the healthcare tourism in the city of Bogotá

and the District of Cartagena. Clío América, 14 (28), 486-492. https://doi.org/10.21676/23897848.3941

5

Arias-Aragonés, et al. (2020).

6

Arias- Aragones, et al. (2020). https://www.colombiaproductiva.com/ptp-sectores/historico/turismo-salud (citing the

Colombian Production Transformation Program (PTP))

7

Glenn Cohen, Patients with Passports Medical Tourism, Law, and Ethics. New York Oxford University Press, 2015, p. 25

8

Glenn, Cohen. (2015), p. 23-24.

9

A Global Leader for Health Care Quality and Patient Safety. Joint Commission International.

https://www.jointcommissioninternational.org/ (The five Colombian hospitals and clinics with JCI accreditation are two hospitals

in the capital city Bogota (la Cardio and Fundación Hospital Universitario Santa Fé de Bogotá), one hospital in Cali (Clinica

Inbanaco), one hospital in Medellín (Hospital Pablo Tobón), and one clinic in Florida Blanca (Fundación Cardiovascular de

Colombia). Nearby countries such as Venezuela and Trinidad Tobago do not have any accredited hospitals or clinics. Ecuador and

Panamá have one each, Perú has eleven, and Brazil has seventy-one.)

10

International Society of Aesthetic Plastic Surgery ISAPS (2023), ISAPS International Survey on Aesthetic/Cosmetic Procedures

performed in 2022, p. 52. https://www.isaps.org/discover/about-isaps/global-statistics/reports-and-press-releases/global-survey-

2022-full-report-and-press-releases/ (most frequently cited countries of foreign patients in Colombia are the US, Spain, and

Panama.)

11

Why choose a member of the SCCP. (2023). Colombia Plastic Surgery Association (SCCP). https://cirugiaplastica.org.co/porque-

elegir-un-miembro-de-la-sccp/ See also: To Find a Surgeon. (2023). Colombia Plastic Surgery Association (SCCP).

https://cirugiaplastica.org.co (This website is helpful for checking the list of members of the SCCP.)

12

Cosmetic Surgeries Performed in Garage Offices can Become a Public Health Problem. Concejo de Bogotá D.C. (2022).

https://concejodebogota.gov.co/cirugias-esteticas-practicadas-en-consultorios-de-garaje-se-pueden/cbogota/2015-07-

17/100100.php (There are many cases of deaths resulting from illegal plastic surgeries. The local government in Bogota is aware

of the deaths, as reported in the Bogota Counsel (2015)). See also Travel.State.Gov, US Department of State, Bureau of Consular

Affairs. (August 17, 2023). https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-

Information-Pages/Colombia.html (There is a warning that says: “Although Colombia has many elective/cosmetic surgery

facilities that are on par with those found in the United States, the quality of care varies widely. If you plan to undergo surgery in

Colombia, carefully research the doctor and recovery facility you plan to use. Make sure that emergency medical facilities are

available, and that professionals are accredited and qualified. Share all health information (e.g., medical conditions, medications,

allergies) with your doctor before surgery.")

13

Arias-Aragonés, F.J.A., Payares, A.M.C., & Jiménez, O.J. (2020), p. 490. (report “the absence of regulation and a legal framework

that determines the responsibilities of each link in the production chain” as a difficulty that affects competitivity to become a

leader in medical tourism in the Latin American region.) See also: Trujillo, M. A. (2023, November 24). Colombia’s New Bill on

Regulating Cosmetic Surgeries. BNN Breaking. https://bnn.network/breaking-news/health/colombia-to-regulate-cosmetic-

surgeries-a-step-towards-patient-safety/ (On November 22, 2023, as a response to rising cases of death and injuries associated

with plastic surgeries, a bill was introduced in the Colombian House of Representatives to regulate the practice of cosmetic

surgeries and protect the integrity of patients)

14

U.S. Department of State, Travel.State.Gov, Colombia. (August 17, 2023). Traveler’s Checklist,

https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html

15

U.S. Department of State, Travel.State.Gov, Colombia. (August 17, 2023). Traveler’s Checklist. See also: Medical Tourism and

Elective Surgery. The Department of State informs that “U.S. citizens have suffered serious complications or died during or after

CAJIAO, MEDICAL TOURISM IN COLOMBIA, VOICES IN BIOETHICS, VOL. 9 (2023)

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having cosmetic surgery or other elective surgery“ and “the legal options in cases of malpractice are very limited in Colombia,”

https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html

See also: The law firm Alvarez Gonzalez Tolosa Attorneys. (August 8, 2023). Medical Malpractice in Colombia, includes medical

malpractice as one of the areas of expertise of the firm. https://www.agtattorneys.com/blog/medical-malpractice-in-colombia/

16

Colombia recently enacted a new visa regulation (Resolution 5477 from July 22, 2022, issued by the Ministry of Foreign Affairs)

effective as of October 22, 2022. No data currently exists about a "medical treatment" visa because it is a new legislation. Even

though the regulation refers to the visitor as a patient and includes requirements such as (1) a letter from the medical institution

explaining the treatment and approximate duration, (2) a letter explaining costs and who will pay for the treatment, (3) insurance

policy, and (4) the general requirements for tourists, the regulation specifically explains that this kind of visa is considered as a

TOURISM visa (art 37).

17

Glenn, Cohen. 2015

18

Frequently Asked Questions. Bioxcellerator. https://www.bioxcellerator.com/faqs (For example, Bioxellerator stem cell

therapies conducted in Medellin, Colombia, are not FDA-approved.)

19

Vovk, Viktoriia, Lyudmila Beztelesna, and Olha Pliashko. (2021). "Identification of Factors for the Development of Medical

Tourism in the World" International Journal of Environmental Research and Public Health 18, no. 21: 11205.

https://doi.org/10.3390/ijerph182111205

20

Colombian Constitution. (1991). art. 49

21

Ministry of Health and Protection. Columbia Ministry of Health. (2023).

https://www.minsalud.gov.co/English/Paginas/Ministry.aspx

22

“Does Colombia’s Health System Need an Overhaul?” (March 2, 2023). The Dialogue, Latin America Advisor.

https://www.thedialogue.org/analysis/does-colombias-health-system-need-an-overhaul/

23

Health at a Glance 2021 Colombia Country Note. OECD. (2023). https://search.oecd.org/colombia/health-at-a-glance-

Colombia-EN.pdf

24

Travel.State.Gov, US Department of State, Bureau of Consular Affairs.

https://travel.state.gov/content/travel/en/international-travel/International-Travel-Country-Information-Pages/Colombia.html

25

Glenn, Cohen. (2015). p. 2-9.

26

Banco de la República. (2023). Regional Health Inequalities in Colombia. https://www.banrep.gov.co/en/regional-health-

inequalities-colombia (The Central Bank of Colombia (“Banco de la República”) in reports that despite having relatively high

health coverage compared with other countries, empirical results show persistent inequalities in the healthcare system. The aim

is to reduce and eventually eliminate such inequalities.)

27

Glenn, Cohen (2015), p. 158-160, citing Rupa Chanda, an Indian business professor, Trade in Health Services, 80 Bull. World

Health Org. 158, 160 (2002).

28

Banco de la República. (2023). Regional Health Inequalities in Columbia. https://investiga.banrep.gov.co/es/be-1233. (Under

Colombian law, it is mandatory for all employees and employers to pay 4 percent and 8 percent of the applicable salary,

respectively, to the universal healthcare system (EPS) to obtain coverage for the employee and family members. This is known as

the contributive system, and the funding is known as parafiscal. The unemployed obtain coverage through the government-

subsidized system known as SISBEN (System of Identification of Beneficiaries of Social programs), funded with taxpayers’ money,

known as fiscal funding. According to the Central Bank of Colombia (Banco de la República), “in recent years, the healthcare

sector has faced financial and administrative problems that have increased the need for fiscal resources for its financing and that

could affect its sustainability. Regarding the composition of the outflow, it is worth noting the cost of ensuring the contributory

and subsidized regime, which on average explains 80 percent of the total system expenses during the period 2011-2022.”

“Additionally, pressures derived from the Covid-19 pandemic, Venezuelan migration” and expenses derived from the increase in

the subsidized system due to the high rate of unemployment and informal employment are negatively impacting financing of the

healthcare system in Colombia. Additional fiscal resources are needed because the health care Colombians receive costs more

than what beneficiaries pay.)

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29

Statista. (2023). Revenue of the medical tourism sector in Colombia from 2019 to 2024

https://www.statista.com/statistics/1156551/colombia-revenue-medical-tourism/

30

Glenn, Cohen. (2015), p.218 (The beneficence principle is the general moral obligation to act for the benefit of others, and

some of those acts are obligatory, as is the government’s obligation concerning healthcare.)

31

Hospital Cardioinfantil Bogotá, Colombia. https://cardioinfantil.org

32

Hospital Cardioinfantil https://cardioinfantil.org (Trinidad and Tobago, Aruba, Curacao, and Panamá were the first countries

with international agreements with La Cardio.)

33

Hospital Cardioinfantil Bogotá, Colombia. https://www.lacardio.org/historia/