International retirement migration (IRM), also known as international long-stay tourism, originated as sun-seeking moves from Northern to Southern Europe in 1960s become a global phenomenon [1]. There are many factors promoting IRM. Trade agreements, as seen in the example of North American Free Trade Agreement (NAFTA), contributed to expansion in the number and type of US retirees in Mexico [2]. The rise of internet and air access made IRM much easier. With the global growth of the elderly population IRM has been deemed as a growing industry in recent years [3, 4].
Thailand has emerged as a popular residential destination due to the government’s long-stay tourism promotion policy since 2001 as part of the national development strategy [4]. Tourism Authority of Thailand (TAT) defines “Long Stay” as staying in the country for more than 30 days and not for sightseeing activities or working but with a purpose of living with the intention to return to the home countries [5]. Special renewable one-year visas called O-A visa have been widely provided for people aged 50 years and above who fulfill certain financial criteria. Though the exact number of long-stay retirees is unknown due to the variety in types of stay and visa[6, 7], the Immigration Bureau statistics suggest considerable increase in the number of people staying in Thailand over a year using the retirement visas, which reached 68,000 in 2016, up from around 10,000 in 2005 [8, 9]. In order to further promote retirement migration in competition with neighboring countries such as Malaysia and Philippines, Thailand introduced a new 10-year retirement visa (exactly, 5 years and extension for another 5 more years) named O-X visa for more affluent people from 13 Western countries and Japan in 2017 [10]. As evidenced by the selected nations of the new visa, Japan, the world’s most aged country, is a primary target of Thai long-stay tourism [13, 15]. Thailand became Japan’s second-most popular long-stay destination following Malaysia[11] with at least 3,800 Japanese staying for over a year using the retirement visas in 2016, up from less than 900 in 2005 [8, 9]. The availability of medical services is one of the major pull factors to Thailand [12], in addition to the low cost of living, short flight time from Japan, warm weather, and availability of a long-term visa [13].
Thailand is among top medical destinations of Asia with 62 private hospitals and clinics accredited by Joint Commission International (JCI), while the number is 9 in Singapore and 16 in Malaysia [14]. The deliberate targeting of patients from abroad began after the 1997 financial crisis as private hospitals were losing their domestic patients. The government further strengthened this movement by introducing its medical hub policy in 2003 with an overall strategy to make Thailand an international medical hub in four areas: (1) medical service hub; (2) wellness hub; (3) academic hub, and (4) product hub. In this connection, not only TAT but also Ministry of Public Health (MOPH) takes part in retirement tourism promotion issuing a guideline for developing “Long Stay for Health in Thailand”. The MOPH regulation requires all new or extending long-stay visa applicants, either 1-year (since 2019) or 10-year type (since 2017), to show proof of private health insurance with coverage not less than 400,000 baht per year for inpatient care, and not less than 40,000 baht per year for outpatient care [10, 15]. As of July 2020, 14 Thai private insurance companies provide such insurance which can be purchased online at https://longstay.tgia.org/[16]. An overseas insurance policy is also acceptable as long as it meets the minimum requirements. One of the remaining challenges is that many of the Thai and oversea private medical insurance companies imposes an age limit or medical exclusions.
The expectation on the growing economic benefits from the foreign retirees to healthcare service sector is seen globally. For example, Malaysia also places importance on the provision of healthcare specifically aimed at the elderly and retirees from overseas [17], and there are substantial numbers of potential care-oriented migrants who consider care for themselves in the near future [18]. However, the healthcare use by long-stay retirees in destination countries is not well understood. Previous studies on IRM are dominated by describing and analyzing the motivations for moving, push and pull factors [6, 19–22] or the way of lifestyles adjustment [7]. There are few studies focusing on healthcare issues of long-stay retirees. While increasing in recent years, most such studies are qualitative examining the long-stay retirees’ healthcare experience abroad [23–29]. Our recent quantitative study revealed the healthcare service use of Japanese long-stay retirees was limited as they prefer going back to Japan for treatment of chronic or serious diseases [30]. Another quantitative study reported the favorable attitude of Japanese long-stay retirees towards Thai medical services [31]. A qualitative study of Japanese retirees in Malaysia identified that health beliefs, medical symptoms, health insurance, language barriers, voluntary health repatriation to Japan, and psychological support influence healthcare service use among Japanese retirees [26]. To inform IRM promotion strategies, this study explored the barriers and incentives to the use of health services in Thailand by Japanese long-stay retirees.