Cross-border assisted reproduction care in Asia: implications for access, equity and regulations.
Medical care (Quality management)
Medical care (Analysis)
|Publication:||Name: Reproductive Health Matters Publisher: Elsevier Science Publishers Audience: General Format: Magazine/Journal Subject: Family and marriage; Health; Women's issues/gender studies Copyright: COPYRIGHT 2011 Reproductive Health Matters ISSN: 0968-8080|
|Issue:||Date: May, 2011 Source Volume: 19 Source Issue: 37|
|Geographic:||Geographic Code: 90ASI Asia|
Abstract: This paper gives an overview of the global commercialised
market in assisted reproduction treatment in low-resource countries in
Asia and raises concerns about access and equity, the potential
commercial exploitation of the bodies of subaltern women to service the
demand for donated ova and surrogate pregnancy, and the need for
protections through regulations. A lack of systematic data about
cross-border reproductive care is a significant obstacle to debate and
policy intervention. Little is known about the extent, experience or
conditions of cross-border reproductive care outside of Europe and the
United States. Further research is needed in Asia on the local effects
of this trade upon local health systems, couples seeking care, and those
women whose body tissues and nurturing capacities facilitate it. More
attention needs to be paid to the provision of publicly funded
reproductive health services to address the inequitable distribution of
treatment and to investigate means to regulate this trade by
governments, international NGOs, professional organisations and civil
society groups in developing countries. The global trade in assisted
reproduction challenges us to balance the rights of individuals to
pursue health care across national borders with the rights of those
providing services to meet their needs, especially vulnerable groups in
situations of economic disparity.
Keywords: cross-border reproductive care, reproductive tourism, assisted reproductive technologies, commercialisation, Asia region
Cet article donne un apercu du marche mondial de la procreation medicalement assistee dans les pays a faibles ressources d'Asie. Il s'inquiete de l'acces et l'equite, la potentielle exploitation commerciale du corps des femmes subalternes qui satisfont la demande de dons d'ovules et de meres porteuses, et la necessite de reglementations de protection. Un manque de donnees systematiques sur les soins genesiques transfrontaliers est un obstacle majeur au debat et aux interventions politiques. On sait peu de choses de l'etendue, de l'experience ou des conditions des soins genesiques transfrontaliers hors de l'Europe et des Etats-Unis. De nouvelles recherches sont necessaires en Asie sur les consequences de ce commerce sur les systemes locaux de sante, les couples demandant des soins, et les femmes dont les tissus corporels et les capacites porteuses les facilitent. Il faut accorder davantage d'attention a la prestation de services de sante genesique finances par les pouvoirs publics pour corriger la repartition inequitable des traitements et prospecter des moyens de faire reguler ce commerce par les gouvernements, les ONG internationales, les organisations professionnelles et les groupes de la societe civile dans les pays en developpement. Le commerce mondial en procreation assistee nous met au defi de concilier les droits des individus a rechercher des soins de sante a travers les frontieres avec les droits de ceux qui assurent des services pour repondre a ces besoins, en particulier les groupes vulnerables se trouvant dans une situation de disparite economique.
En este articulo se expone una vision general del mercado comercializado internacional en el tratamiento de reproduccion asistida en paises asiaticos de bajos recursos, y se plantean inquietudes en cuanto al acceso y la equidad, la posible explotacion comercial del cuerpo de mujeres subalternas para atender la demanda de ovulos donados y maternidad subrogada y la necesidad de protecciones mediante reglamentos. La falta de datos sistematicos sobre el turismo reproductivo es un obstaculo significativo para el debate y la intervencion de politicas. No se sabe mucho acerca del alcance, la experiencia o las condiciones del turismo reproductivo fuera de Europa y Estados Unidos. Aun es necesario realizar mas investigaciones en Asia sobre los efectos de este comercio en los sistemas de salud locales, en parejas que buscan atencion medica, y en aquellas mujeres cuyo cuerpo y capacidad para nutrir lo facilitan. Se debe prestar mas atencion a la prestacion de servicios de salud reproductiva financiados publicamente, a fin de eliminar la injusta distribucion de tratamiento e investigar los medios para la regulacion de este comercio por gobiernos, ONG internacionales, organizaciones profesionales y grupos de la sociedad civil en paises en desarrollo. El comercio mundial en reproduccion asistida nos reta a sopesar los derechos de las personas de buscar servicios de salud en otros paises y los derechos de los prestadores de servicios de atender sus necesidades, especialmente grupos vulnerables en situaciones de disparidad economica.
THE last decade has seen a rapid expansion of international cross-border trade in medical services, chiefly providing care for mobile patients who have the personal resources to travel. In the past, medical travel was associated with travel to wealthy nations for specialised health care unavailable elsewhere, but now it has expanded to include travel by wealthy patients to developing countries. Trade in medical services to foreigners is promoted as a new export opportunity for developing economies to generate foreign revenue, investment capital and tax revenue. (1) It was estimated to be worth US$60 billion in 2008 and is expected to grow to US$100 billion by 2020. (2)
The growth of this market has become intertwined with the trade policies of many countries as an economic strategy for developing economies, linked into the overall trade in services ratified under the General Agreement on Trade in Services (GATS) (1995) governed by the World Trade Organization (WTO). (3) Economic pressures such as the Asian economic crisis of 1997 have encouraged governments in a number of low-resource countries to find additional sources of revenue and resources to sustain health service provision in their own countries. The trade is facilitated by the growth of private corporate hospitals, the ease of international travel and global communication, and the increasing portability of health insurance.
One category of this trade involves the movement by patients across international borders to undertake assisted reproduction treatments and surgery. It was first described by Knoppers and LeBris in 1991 as "procreative tourism" to describe patients exercising "their personal reproductive choices in other less restrictive states". (4) This includes travel for IVF (in vitro fertilisation), ICSI (intracytoplasmic sperm injection) and associated procedures, such as PGD (pre-implantation genetic diagnosis), gamete and embryo donation and surrogate pregnancy. Throughout this paper, I use the term cross-border reproductive care consistent with the standardised definition proposed by the European Society of Human Reproduction and Embryology (ESHRE), (5) rather than "reproductive tourism" or "infertility tourism" (6,7) to avoid an association with touristic activities. (8)
Petchesky (9) has argued that neo-liberal, market-oriented approaches to delivering reproductive health services are failing to deliver real progress in addressing the reproductive and sexual health needs of the majority, and that the lack of public accountability within the "free market" endangers standards of quality, access and the protection of human rights. In this paper, I suggest that the development of cross-border reproductive care in Asia for export diverts resources and personnel towards those able to mobilise the financial resources to travel, while the majority of infertile couples continue to have little or no access to treatments. The second issue that this paper examines is the potential for the exploitation of subaltern women in Asia to service the demand for gametes and surrogacy within the global reproductive trade. Finally, I summarise the prospects for regulation of this trade.
This overview is informed by work completed for a broader anthropological study of the use of assisted reproductive technologies in Thailand across seven months' fieldwork in 2007-2008. The broader study involved interviews and observations in three private clinics and two public infertility clinics, and interviews with 31 patients and staff, which included six foreign patients/ couples who had travelled to Thailand. (8)
Recent trends in reproductive medical travel
Although no accurate statistics on the numbers of patients travelling cross-border for reproductive care exist, particularly in developing countries, (10) survey evidence suggests the market is growing. In 2010 approximately 6% of Canadian IVF patients went to the United States for treatment, 80% of them for anonymous donor eggs, while 4% of IVF patients in the United States were from other countries. (11) In Europe, major hubs for assisted reproduction treatment include Spain, Belgium, Cyprus, and the Czech Republic. A 2010 European Society of Human Reproduction and Embryology (ESHRE) survey of 44 clinics in six European countries estimated that 11,000-14,000 patients sought treatment in other European countries annually. (5) Jordan, Israel and South Africa are important hubs in the Middle East and Africa.
In Asia, India and Thailand are major hubs for international assisted reproductive care, and as such are the focus of this paper, although Singapore, Malaysia and South Korea are increasingly important as destinations, especially for regional patients. These services have usually evolved through a combination of sophisticated medical infrastructure and expertise, particular regulatory frameworks (or the lack of them), and lower wage structures, which allow for lower, competitive costs. In addition, good tourist infrastructure and visa requirements, government policies supportive of medical travel in general, and the availability of translators, religious affiliation (for example Muslim patients may prefer to travel to Malaysia for care) all play important roles in determining the popularity of these sites. (12)
The internet is the primary site of advertising by clinics offering assisted reproductive services and an important source of information and online social networking for people seeking information. In addition, many patients utilise medical facilitation companies specialising in cross-border reproductive care. These usually have commercial links with specific clinics or hospitals and arrange all inclusive packages, including airfares, accommodation, clinic services, and concierge services. For example, a company based in Singapore called Asian Surrogates contracts surrogates from countries in the region for people from Canada, US, France, Belgium, Germany and Denmark. (13) Thailand Fertility.com facilitates travel to clinics offering "family balancing" and ova donation.
Thailand's first IVF birth occurred in 1987 and there are now at least 30 clinics providing full clinical services for assisted reproduction. (14) Of these, approximately six clinics service a significant international clientele. In 2004 the Thai government launched a deliberate strategy to encourage foreign medical travel to Thailand, promoting its sophisticated hospitals, well-trained medical staff and significant cost differential. The foreign patient trade is forecast to be worth US$4.3 billion in 2012. (15) A full cycle of IVF at most of the leading private hospitals in Thailand ranges in price from 80,000 baht (US$2,000) to 160,000 baht (US$4,000). Although exact figures of the number of patients travelling for reproductive care to Thailand is unknown, approximately 400,000 foreign patients travel to Thailand each year for medical treatments. (1) Thailand has become a popular destination for non-medical sex selection through pre-implantation genetic diagnosis and microsorting. Until recently, assisted reproduction in Thailand has been largely self-regulated. The introduction of a new Reproductive Health Bill will affect the trade in Thailand, as it will include legal restrictions on clinical practices, such as the banning of nonmedical sex selection and commercial surrogacy.
Since the advent of legalised commercial surrogacy and egg donation in India in 2002, a number of clinics in Gujarat, Delhi and Mumbai now specialise in providing commercial surrogacy and ova donation services oriented primarily towards foreign clients from the United States, Britain and elsewhere, including expatriate Indian couples. Indian Council for Medical Research guidelines dictate that surrogates do not provide the eggs for couples when donated ova are required; these must be supplied by a different donor. (16) As will be discussed below, new legislation was introduced in 2010 which promotes legally enforceable contracts and a few other protections for surrogates, and introduces restrictions against same-sex couples, but India continues to have a highly permissive legal environment. As with Thailand, there are no accurate figures available of the numbers of people travelling for assisted reproductive services in India.
Why infertility is a reason for cross-border travel
A meta-analysis of fertility studies suggests that approximately 9% of couples across the world are infertile (defined as infertile for at least 12 months). (17) Demographic changes such as later ages of marriage, delayed childbearing and other factors such as obesity and untreated sexually transmitted infections are contributing to the demand for assisted reproductive technologies. (18) This includes a high demand for biomedical interventions, with an estimated 56% of infertile couples seeking some form of care. (17,19)
Other factors include the lack of expertise and services in some countries. Only 48 out of 191 member States of the World Health Organization have IVF facilities. (19) For example, residents of many Pacific nations do not have access to IVF services and may seek them in Australia, New Zealand, the United States and Asia. Other people travel in search of privacy and some transnational migrant couples return to their countries of origin for treatment in a linguistically and culturally familiar setting close to extended family. (20)
Cost is also an important factor. In many countries without publicly funded access to these services, medically assisted reproductive services are expensive, forcing couples to seek more affordable care. Within the United States, not all states mandate full or partial insurance cover for assisted reproductive technologies, requiring couples to pay the full expense. (19) The International Federation of Fertility Societies (21) notes that essentially half of the countries surveyed have no third party reimbursement by any national health plan or private health insurance company for assisted reproductive treatment.
One of the prime reasons for seeking cross-border reproductive care is to evade legal restrictions on treatment in home countries. The ESHRE found this to be the major motivator for cross-border travel to European clinics. (5) Individual countries may prohibit specific services for religious or ethical reasons, or on the grounds that a service is not considered sufficiently safe. (22,23) The International Federation of Fertility Societies (21) lists a range of clinical practices which carry differing regulations in various jurisdictions. These include: definitions of eligibility for treatment, number of embryos transferred, cryopreservation, the availability of posthumous insemination, sperm and egg donation, the micromanipulation of sperm (ICSI) and embryos (assisted hatching and cytoplasmic transfer), requirements regarding anonymity of donors, pre-implantation genetic diagnosis, and IVF surrogacy (particularly restrictions on commercial surrogacy). Regulations in home countries may prohibit certain categories of individuals from receiving a service due to age, marital status or sexuality, especially at public expense. For example, British women over 40 may not access publicly-funded IVF services (due to the low success rates for women over this age) and there are long waiting times for appointments within the public system. (24)
Equity and access issues for low-income countries
A range of potential benefits and negative effects have been described for the international trade in health services for low-income countries. (25) Benefits include the generation of foreign exchange, the creation of job opportunities through linkages with tourism, insurance, hotel and service businesses, the utilisation of existing excess capacity among private hospitals, and the retention of some specialists who might otherwise move abroad for work.
For low-income countries, a primary concern is that the development of the foreign patient trade in health services will have a detrimental effect upon the public health systems of these countries, by encouraging the further development of inequitable, two-tiered health systems, where elite, technologically sophisticated hospitals, catering to wealthy foreign clients, stand beside poorly resourced public hospitals. (26) The privatisation of health systems generally carries negative consequences for public health systems. (27) The trade in health services, encouraged by WTO trade agreements, has differing effects upon national public health systems, depending upon the degree of privatisation already existing in a country, whether there is excess capacity within the private sector, and the degree of government control, subsidisation and regulation exerted over the private health sector. (25) Within many developing countries, few have sufficiently developed regulatory environments to forestall negative impacts. (27)
Negative effects generated by the development of the international trade in health services in low-income countries include a local "brain drain" of skilled medical staff from the public health system into private, elite hospitals, affecting access for the local population. For example, a recent review of human resources for health notes the effects in Thailand of the international trade in health services, which requires highly specialised staff. The resources needed to provide services to one foreign patient are estimated to be equivalent to those used to provide services for 4-5 Thais. (28) In particular there has been a large shift in specialist medical staff from the public sector to private hospitals. (15) In 2008, staff at a public infertility clinic at a major university hospital in Bangkok spoke to me of the difficulties in recruiting specialist nursing and laboratory staff when public sector wages cannot compete with those offered at private clinics and hospitals.
Currently, the international trade in assisted reproduction services does little to improve local equity and access to treatment for local populations in low-resource countries. In developing countries, assisted reproduction treatment for infertility remains inaccessible for most couples experiencing infertility. (19) In 2001 the WHO called for innovative approaches, such as the development of low-cost treatments and technology for low-resource settings. (17,19) Yet even as these strategies are being implemented, a number of developing countries are involved in the global trade in assisted reproductive care, while their local populations still struggle to afford these technologies.
In-vitro fertilisation costs are approximately 50% higher than the gross national income per capita in many developing countries, including India, Indonesia, China and Malaysia. (18) One possible strategy proposed by health policy analysts to address the distortions in public health systems exacerbated by the international trade in medical services is that a proportion of the profits of the hospitals involved in cross-border health services be used to subsidise public health care and access for poorer local patients, (16) but this requires a sophisticated regulatory system that does not exist in many countries in Asia.
Commercialisation of reproduction and exploitation
Another concern with regard to cross-border reproductive care is the global commercialisation of the body and of reproduction which it entails. (29) In particular, the trade in transnational commercial surrogacy and commercial gamete donation services raises questions about the conditions under which ova and sperm are exchanged and women hired to carry a pregnancy for others, and the protections required for vulnerable groups providing these services, particularly poorer women from developing countries. There are diverse opinions as to the effects and ethics of commercial surrogacy arrangements; however, the growth of a global trade in commercial surrogacy in developing countries warrants particular attention, particularly in countries where the lack of regulation offers little protection to women who act as surrogates. (30)
Commentators suggest that in globalised commercial exchanges, the effects of extreme poverty and patriarchal pressures create a "bioavailable" population of women ready to act as surrogates or as egg donors in developing economies. (31) The degree of exploitation involved in such transactions depends upon whether there is undue inducement, given the unequal economic position of women donors/surrogates, the level of control and coercion imposed upon them, their subordination within the arrangement, the degree of protection of their rights throughout the treatment process or pregnancy, and the extent of protection of their physical and mental health. Feminist ethicist Donchin (32) argues that the structural conditions under which poor women live renders their choice to become surrogates an "adaptive preference" rather than a fully free autonomous decision. Under conditions of gender inequality which restrict their opportunities in the paid workforce they have limited choices and make pragmatic decisions. Donchin argues that the global, commercialised market exploits both impoverished women who sell their bodily resources and vulnerable people crossing borders for these services. She suggests there is a need to improve the conditions under which paid surrogates "work" and to address the unequal distribution of power and wealth that generates exploitative relationships. (32) In order to address these inequalities within international surrogacy arrangements, Humbryd (33) calls for the establishment of "fair trade international surrogacy", in which the arrangements are regulated, focusing upon minimising the potential harms to all parties involved and ensuring fair compensation to surrogate mothers.
Commercial surrogacy and commercial ova donation are banned in a number of countries. Such bans, combined with the difficulty in locating altruistic surrogates and ova donors, is fuelling the cross-border trade in international commercial surrogacy and ova donation. Same-sex couples constitute another significant group seeking commercial surrogacy and ova donations, who often do not have access to surrogacy services in their home countries. Although commercial surrogacy and ova donation are permitted in some states of the United States, their prohibitive costs put them beyond the means of many couples.
Since legalising commercial surrogacy in 2002, India has become an important hub of commercial surrogacy and ova donation, able to offer services at a significantly lower cost and advertising a plentiful supply of surrogates and donors. Ethnographic work in Indian surrogacy clinics and Indian civil society groups raises concerns about the conditions under which commercial surrogacy and ova donation is undertaken. (34-36). The research notes that the women preferred by clinics for surrogacy and ova donation are poor and illiterate, and are portrayed as having clear economic motives for undertaking surrogacy without emotional complications. In a study conducted with 42 surrogates in Anand in India in 2006-2008, (34) the median family income of the surrogates was reported at US$60 per month, meaning that 34 of the 42 women were below the poverty line.
These researchers and activists question whether women in such dire financial need are free to make choices about the risks they undertake in ova donation or pregnancy. The amounts of money involved for surrogates were significant in local terms--they were paid approximately 300,000 Rupees (US$7,500)--around one-third of the fees paid by contracting parents. Such commercial inducements may entice women to disregard the risks involved and face pressure from their family to be involved. (34) A number of surrogates report having no contracts and no third party legal representation. (35,36) While they receive medical care for the term of their surrogate pregnancies, this is not offered for any of their own subsequent pregnancies, despite the increased risks to their health. Similar concerns are raised as regards commercial ova donation in developing countries, and whether women donors are fully informed of the risks involved or whether financial inducements encourage them to overlook the risks, including the possible over-stimulation of their ovaries to maximise egg production.
In response to concerns over surrogacy conditions in India, the Assisted Reproductive Technologies (Regulation) Bill 2010, awaiting approval by the Law Ministry at this writing, contains some protections for surrogates. It sets an upper age limit for surrogates at 35, allows no more than five live births, limits the number of times a woman can undergo embryo transfer for the same couple, and forbids clinics from sending Indian women abroad to act as surrogates. Importantly, it will also make surrogacy contracts legally enforceable. Nevertheless, India will continue to have one of the most permissive laws on surrogacy in the world. (37)
In other developing countries, commercial arrangements for surrogacy or ova donation may occur with little scrutiny, either due to the illegal nature of these transactions, or a lack of regulation. This is particularly the case for women who move between countries to act as surrogates or ova donors. (38) In some cases such movement is voluntary, but in others, it involves the trafficking of women. For example, in February 2011, the media reported a police investigation in Thailand involving 14 Vietnamese women, seven of whom were pregnant, who had been trafficked to act as surrogates for a Taiwanese company. (39) Because such trade occurs across borders, it is very difficult to detect or regulate, or provide legal protections to the women, children, or contracting parents involved.
The prospects for regulation
Across the world there is great diversity in the regulatory frameworks governing assisted reproductive technologies, and it is this diversity which encourages the movement of patients seeking to avoid restrictions on certain practices. (22,40,41) It is clear that a number of developing countries in Asia are struggling to regulate the rapidly growing assisted reproduction market within their jurisdictions, as well as the complexities of the international trade. For example, although commercial surrogacy was legalised in 2002 in India, it has taken eight years before legislation mandating enforceable contracts and some degree of protection for contracting parents, surrogates and donors has been enacted. Despite a large foreign trade in Thailand, the new Reproductive Health Bill to regulate assisted reproductive technologies has awaited ratification for years due in part to the instability of the government. Meanwhile, the lack of regulation has produced a lucrative international trade. For foreign patients, there is little legal protection in cases of malpractice across borders.
Policy researchers note the difficulties in achieving consensus over the degree to which international medical travel should be subjected to control and the appropriate balance between individuals' autonomy and the need to ensure adequate protections. (22) Discussing the issue from a US perspective, Cortez (42) provides a useful framework of the various policy and legal approaches available to a state for regulating medical travel, including cross-border reproductive care. Unilateral options include efforts to: regulate patient travel, regulate referral networks (for example, by licensing brokers or restricting referrals), regulate health insurers, provide oversight through agencies to monitor the movement of patients, and provide codes of practice and guidelines. As Cortez notes, some of these are impractical to implement (such as regulating individual travel, or regulating advertising on the internet) and legal precedents in each jurisdiction will have consequences for what can be achieved. Multilateral approaches include cooperation between countries to regulate providers and intermediaries, and cooperation to standardise accreditation, clinical practices, and outcomes reporting. (42)
Although there have been some recent successes in brokering multilateral agreements on global health issues, such as international organ transplantation and tobacco control, even within the European Union, agreements on cross-border trade in health core have proven practically impossible to broker. (43) International harmonisation of laws is unlikely. (22) Two countries have made the highly controversial move to enact legal sanctions against citizens involved in certain forms of cross-border reproductive core. (41) In 2010, Turkey banned cross-border travel for assisted reproduction services involving third party donation of sperm or eggs, under item 231 of the Turkish Penal Code, according to which it is illegal to "change or obscure a child's ancestry", with a punishment of 1-3 years imprisonment. (44) Two Australian states, New South Wales (45) and Queensland, (46) have legislated to ban residents from being involved in any commercial surrogacy arrangements, including overseas, on the grounds of consistency with state laws which only allow altruistic surrogacy. However, it is not clear how such laws might be enforced, and whether such coerced conformity is justified. Such bans may simply act to reinforce discrimination against certain groups of patients, or force cross-border commercial surrogacy or gamete donation to go underground, while turning some parents or infertile couples into criminals.
Civil society organisations, including medical professional associations, patient and health consumer groups have important roles to play in monitoring the effects of cross-border reproductive care and to lobby governments for increased protections for those involved. For example, the European Society for Human Reproduction and Embryology (ESHRE) has a Task Force on Cross-Border Reproductive Care, whose aim is to gather reliable data on the number of patients who cross European borders to access assisted reproductive technologies, and the reasons why they travel. (5) International umbrella organizations for patients, such as International Consumer Support for Infertility (iCSi), (47) have a useful role to play in the dissemination of information and to present patients' perspectives in order to influence legislation and guidelines on assisted reproduction services transnationally. There is also a need for representation of the people who provide the services, such as gamete donors and surrogates.
A lack of systematic data about cross-border reproductive care is a significant obstacle to debate and policy intervention. Little is known about the extent, experience or conditions of cross-border reproductive care outside of Europe and the United States. Further research is needed in Asia on the local effects of this trade upon local health systems, couples seeking treatment and services, and those women whose body tissues and nurturing capacities facilitate it. More attention needs to be paid to the provision of publicly funded assisted reproduction services, to address the inequitable distribution of treatment and to investigate means to regulate this trade by governments, international NGOs, professional organisations and civil society groups in developing countries. (43)
Cross-border reproductive core raises questions concerning the limits of individuals' reproductive autonomy and rights to seek desired treatment options and recognition of ethical pluralism and social justice within the context of global capitalism. (22,32) Cross-border reproductive care challenges our current regulatory regimes and poses questions over the rights of states to regulate the reproductive lives of citizens. Within the process of neoliberal economic globalisation, national systems of health governance are being reconfigured as health core is increasingly framed as a tradeable commodity rather than a "public good". (48) There is a need to interrogate more carefully the particular historical conditions and trajectories involved in such travel and recognise that structural influences of face, ethnicity and class are involved in the relationships between cross-border patients, their clinicians, donors and surrogates. In sum, although mobility in pursuit of health core is celebrated by some as the ultimate neoliberal consumer "choice" and "freedom", not all travel is equal and more work is needed to probe the economies, politics, practices, relations and assumptions that underpin this trade.
I wish to thank the World Health Organization Centre for Health Development for permission to draw upon commissioned work undertaken for the "Workshop on the movement of patients across international borders--emerging challenges and opportunities for health care systems", Kobe, 24-25 February 2009. Thanks also to participants of that workshop for their discussion of these issues. This paper does not reflect the views of WHO or its member states. This work also draws upon research undertaken for an Australian Research Council Discovery Project, funded by the Australian government (DP1094895).
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Associate Professor, School of Population Health, Faculty of Health Sciences, University of Queensland, Herston Qld, Australia. E-mail: firstname.lastname@example.org
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