11 24 25 In this review, our basic premise is that when domestic healthcare markets are imperfect, some patients seek healthcare in international markets. Our contention is that health

markets in LMICs are unable to scale up the supply of healthcare goods and services to meet demand; that they www.selleckchem.com/products/Roscovitine.html are unable to meet the demand for a range of healthcare goods and services patients seek, for example, non-communicable diseases; and that the prices for healthcare goods and services are unpredictable.10 The range of factors that characterise health market failure, and the underlying mechanisms and circumstances in which patients seek healthcare in alternative international markets, will be identified. Study outcomes will be used to identify strategies for interventions to increase utilisation of domestic health markets. Methods and analysis A rapid realist review, as proposed by Saul et al,26 will be undertaken. The study will be conducted in the following iterative steps. We will begin by describing the initial hypotheses, or relevant candidate theories, before undertaking a more thorough search of the literature for pertinent papers, and then extracting and synthesising the data based on our theoretical

framework. Identifying candidate theories To identify initial candidate theories, we have undertaken a preliminary exploration of the theory of how healthcare markets work, and what contributes to healthcare market failure in LMICs. The scoping review revealed a number of key elements on which a domestic healthcare market may thrive or falter. If these elements, whether stand-alone, or in conjunction, are (or perceived to be) insufficient, patients may seek alternative services,

which could include going abroad. A healthcare market is an interactive socioeconomic institution that works through the process of interactions of demand and supply.10 23 24 27 28 Healthcare markets should work by stimulating choice and competition so that providers continually work to improve their efficiency and products, and meet consumer demand.10 23 28 When operating under conditions of perfect competition and perfect information, rational market players respond to price signals, and this price-regulated, money-based exchange ensures Cilengitide efficiency and equilibrium between supply and demand.10 11 29 Markets, however, often work imperfectly, leading to market failure.10 11 29 What constitutes ‘health system failure’ is not, however, clear cut.30 Despite this, we have identified in the literature a number of health system features that may have adverse implications for health, including six health systems performance themes, namely accessibility and responsiveness; quality; outcomes; accountability, transparency and regulation; fairness and equity; and efficiency, identified by the WHO.