A realist synthesis of transborder patient movement from low and middle income countries to similar or higher income countries

Patient movement from high income to middle income countries for healthcare is well documented, with patients seeking treatments that are cheaper or more readily available than at home. Less well understood is the movement of... [ view full abstract ]

Patient movement from high income to middle income countries for healthcare is well documented, with patients seeking treatments that are cheaper or more readily available than at home. Less well understood is the movement of patients from low income countries to the same or higher ones. In this paper, we present a realist review that was undertaken to explore this patient movement. This paper presents a realist synthesis that aimed to address the questions: Why and how do patients from low- and middle-income countries cross international borders for healthcare? What are the contextual factors which influence this choice? In this way, our paper is novel in that we examined a social phenomenon rather than an intervention per se. We undertook a realist synthesis because we knew from our initial scoping of the literature that the available research was primarily qualitative and we wanted to go beyond describing patterns of trans-border health-seeking practices to understand context-mechanism-outcome configurations. We also felt that the realist synthesis methodology was well suited to the study of social phenomena such as trans-border healthcare seeking because such practices occur within a complex system, in diverse contexts and in the process of seeking healthcare, patients interact within a network of relationships and with range of different players.

In order to understand this phenomenon, we conceptualised health services as a market place and specifically a market place that spanned national borders. In this sense, health was a commodity to be bought and sold, and we drew initially on the theory of neoclassical free-markets. As we continued with our synthesis however, we found this had limited explanatory power in relation to cross-border patient movement, and turned instead to the sociology of markets and the work of Pierre Bourdieu to understand the interplay between context, material and non-material capital and cognitive processes in decisions to cross borders for healthcare. In this paper, we reflect on how we incorporated theory into our syntheses and consider the ways in which it enhanced our understanding as well as the challenges and limitations we experienced. We also illustrate how the outcome of one context-mechanism-outcome-configuration, provided the context for the next.