Medical tourism

Medical tourism or health tourism is the travel of people to another country for the purpose of obtaining medical treatment in that country. Traditionally, people would travel from less developed countries to major medical centers in highly developed countries for medical treatment that was unavailable in their own communities,^[1][2] The recent trend is for people to travel from developed countries to third world countries for medical treatments because of cost consideration, though the traditional pattern still continues. Another reason for travel for medical treatment is because some treatments may not be legal in the home country, such as some fertility procedures.

The medical treatment which some people seek and obtain in a foreign country include elective procedures as well as complex specialized surgeries such as joint replacement (knee/hip), cardiac surgery, and cosmetic surgeries. Some people go abroad for dental surgery or fertility treatments.^[3] The main reasons for fertility tourism are legal regulation of the some procedure in the home country, or lower price. In-vitro fertilization, donor insemination and surrogacy are major procedures involved. People with rare genetic disorders may travel to another country where treatment of these conditions is better understood. However, virtually every type of health care, including psychiatry, alternative treatments, convalescent care and even burial services are available.

Over 50 countries have identified medical tourism as a national industry.^[4]

History

The first recorded instance of people travelling to obtain medical treatment dates back thousands of years to when Greek pilgrims traveled from all over the Mediterranean to the small territory in the Saronic Gulf called Epidauria.^{[citation needed]} This territory was the sanctuary of the healing god Asklepios.

Spa towns and sanitariums may be considered an early form of medical tourism. In 18th century England, for example, patients visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis.^[4]

Description

Factors that have led to the increasing popularity of medical travel include the high cost of health care, long wait times for certain procedures, the ease and affordability of international travel, and improvements in both technology and standards of care in many countries.^[5] The avoidance of waiting times is the leading factor for medical tourism from the UK, whereas in the US, the main reason is cheaper prices abroad.

Many surgery procedures performed in medical tourism destinations cost a fraction of the price they do in the First World. For example a liver transplant that costs $300,000 USD in America costs about $91,000 USD in Taiwan.^[6] A large draw to medical travel is convenience and speed. Countries that operate public health-care systems are often so taxed that it can take considerable time to get non-urgent medical care. Using Canada as an example, an estimated 782,936 Canadians spent time on medical waiting lists in 2005, waiting an average of 9.4 weeks.^[7] Canada has set waiting-time benchmarks, e. g. 26 weeks for a hip replacement and 16 weeks for cataract surgery, for non-urgent medical procedures.^[8]

Medical tourists come from a variety of locations including Europe, the Middle East, Japan, the United States, and Canada. Factors that drive demand for medical services abroad in First World countries include: large populations, comparatively high wealth, the high expense of health care or lack of health care options locally, and increasingly high expectations of their populations with respect to health care.

In First World countries like the United States medical tourism has large growth prospects and potentially destabilizing implications. A forecast by Deloitte Consulting published in August 2008 projected that medical tourism originating in the US could jump by a factor of ten over the next decade. An estimated 750,000 Americans went abroad for health care in 2007, and the report estimated that 1.5 million would seek health care outside the US in 2008. The growth in medical tourism has the potential to cost US health care providers billions of dollars in lost revenue.^[9]

An authority at the Harvard Business School recently stated that "medical tourism is promoted much more heavily in the United Kingdom than in the United States".^[10]

Additionally, some patients in some First World countries are finding that insurance either does not cover orthopedic surgery (such as knee/hip replacement) or limits the choice of the facility, surgeon, or prosthetics to be used. Medical tourism for knee/hip replacements has emerged as one of the more widely accepted procedures because of the lower cost and minimal difficulties associated with the traveling to/from the surgery.

Popular medical travel worldwide destinations include: Argentina, Brunei, Cuba, Colombia, Costa Rica, Hong Kong, Hungary, India, Jordan, Lithuania, Malaysia, The Philippines, Singapore, South Africa, Thailand, and recently, Saudi Arabia, UAE, South Korea, Tunisia, Ukraine, and New Zealand.^[4]

Popular destinations for cosmetic surgery include: Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Mexico, Turkey, Thailand and Ukraine. According to the "Sociedad Boliviana de Cirugia Plastica y Reconstructiva", more than 70% of middle and upper class women in the country have had some form of plastic surgery. Other destination countries include Belgium, Poland, Slovakia, Ukraine and South Africa.^[11]

Some people travel for assisted pregnancy, such as in-vitro fertilization, or surrogacy,^[12] or freezing embryos for retro-production.^[13]

However, perceptions of medical tourism are not always positive. In places like the US, which has high standards of quality, medical tourism is viewed as risky. In some parts of the world, wider political issues can influence where medical tourists will choose to seek out health care.

Health tourism providers have developed as intermediaries which unite potential medical tourists with provider hospitals and other organisations. Companies are beginning to offer global health care options to enable North American and European patients to access world health care at a fraction of the cost of domestic care. Companies that focus on medical value travel typically provide nurse case managers to assist patients with pre- and post-travel medical issues. They may also help provide resources for follow-up care upon the patient's return.

Process

The typical process is as follows: the person seeking medical treatment abroad contacts a medical tourism provider. The provider usually requires the patient to provide a medical report, including the nature of ailment, local doctor’s opinion, medical history, and diagnosis, and may request additional information. Certified physicians or consultants then advise on the medical treatment. The approximate expenditure, choice of hospitals and tourist destinations, and duration of stay, etc., is discussed. After signing consent bonds and agreements, the patient is given recommendation letters for a medical visa, to be procured from the concerned embassy. The patient travels to the destination country, where the medical tourism provider assigns a case executive, who takes care of the patient's accommodation, treatment and any other form of care. Once the treatment is done, the patient can remain in the tourist destination or return home.

International healthcare accreditation

International healthcare accreditation is the process of certifying a level of quality for healthcare providers and programs across multiple countries. International healthcare accreditation organizations certify a wide range of healthcare programs such as hospitals, primary care centers, medical transport, and ambulatory care services.^[14]

The oldest international accrediting body is Accreditation Canada, formerly known as the Canadian Council on Health Services Accreditation,^[15] which accredited the Bermuda Hospital Board as soon as 1968. Since then, it has accredited hospitals and health service organizations in ten other countries.

In the United States, the accreditation group Joint Commission International (JCI) has been inspecting and accrediting health care facilities and hospitals outside of the United States since 1999.^{[citation needed]} Many international hospitals today see obtaining international accreditation as a way to attract American patients.^[16]

Joint Commission International is a relative of the Joint Commission in the United States. Both are US-style independent private sector not-for-profit organizations that develop nationally and internationally recognized procedures and standards to help improve patient care and safety. They work with hospitals to help them meet Joint Commission standards for patient care and then accredit those hospitals meeting the standards.^[17]

QHA Trent Accreditation, based in the UK, is an active independent holistic accreditation scheme.^[18][19]

The different international healthcare accreditation schemes vary in quality, size, cost, intent and the skill and intensity of their marketing. They also vary in terms of cost to hospitals and healthcare institutions making use of them.^[20] A forecast by Deloitte Consulting regarding medical tourism published in August 2008 noted the value of accreditation in ensuring quality of healthcare and specifically mentioned JCI, ISQUA and Trent.

Increasingly, some hospitals are looking towards dual international accreditation, perhaps having both JCI to cover potential US clientele, QHA Trent for potential British and European clientele, and Accreditation Canada. As a result of competition between clinics for American medical tourists, there have been initiatives to rank hospitals based on patient-reported metrics.^[21]

Other organizations providing contributions to quality practices include:

• The United Kingdom Accreditation Forum (UKAF) is an established network of accreditation organisations with the intention of sharing experience good practice and new ideas around the methodology for accreditation programmes, covering issues such as developing healthcare quality standards, implementation of standards within healthcare organisations, assessment by peer review and exploration of the peer review techniques to include the recruitment, training, monitoring and evaluation of peer reviewers and the mechanisms for awards of accredited status to organisations.^[22]

Risks

Medical tourism carries some risks that locally-provided medical care does not.

Some countries, such as India, South Africa, or Thailand have very different infectious disease-related epidemiology to Europe and North America. Exposure to diseases without having built up natural immunity can be a hazard for weakened individuals, specifically with respect to gastrointestinal diseases (e.g. Hepatitis A, amoebic dysentery, paratyphoid) which could weaken progress and expose the patient to mosquito-transmitted diseases, influenza, and tuberculosis. However, because in poor tropical nations diseases run the gamut, doctors seem to be more open to the possibility of considering any infectious disease, including HIV, TB, and typhoid, while there are cases in the West where patients were consistently misdiagnosed for years because such diseases are perceived to be "rare" in the West.^[23]

The quality of post-operative care can also vary dramatically, depending on the hospital and country, and may be different from US or European standards. Also, traveling long distances soon after surgery can increase the risk of complications. Long flights and decreased mobility associated with window seats can predispose one towards developing deep vein thrombosis and potentially a pulmonary embolism.^[24] Other vacation activities can be problematic as well — for example, scars may become darker and more noticeable if they sunburn while healing.^[25]

Also, health facilities treating medical tourists may lack an adequate complaints policy to deal appropriately and fairly with complaints made by dissatisfied patients.^[26]

Differences in healthcare provider standards around the world have been recognised by the World Health Organization, and in 2004 it launched the World Alliance for Patient Safety. This body assists hospitals and government around the world in setting patient safety policy and practices that can become particularly relevant when providing medical tourism services.^[27]

If there are complications, the patient may need to stay in the foreign country for longer than planned or if they have returned home, will not have easy access for follow up care.^[28]

Legal issues

Receiving medical care abroad may subject medical tourists to unfamiliar legal issues.^[29] The limited nature of litigation in various countries is one reason for the lower cost of care overseas. While some countries currently presenting themselves as attractive medical tourism destinations provide some form of legal remedies for medical malpractice, these legal avenues may be unappealing to the medical tourist. Should problems arise, patients might not be covered by adequate personal insurance or might be unable to seek compensation via malpractice lawsuits. Hospitals and/or doctors in some countries may be unable to pay the financial damages awarded by a court to a patient who has sued them, owing to the hospital and/or the doctor not possessing appropriate insurance cover and/or medical indemnity.^[30]

Ethical issues

There can be major ethical issues around medical tourism.^[29] For example, the illegal purchase of organs and tissues for transplantation had been alleged in countries such as India^[31][32] and China^[33] prior to 2007. The Declaration of Istanbul distinguishes between ethically problematic "transplant tourism" and "travel for transplantation".^[34]

Medical tourism may raise broader ethical issues for the countries in which it is promoted. For example in India, some argue that a "policy of 'medical tourism for the classes and health missions for the masses' will lead to a deepening of the inequities" already embedded in the health care system.^[35] In Thailand, in 2008 it was stated that, "Doctors in Thailand have become so busy with foreigners that Thai patients are having trouble getting care".^[36] Medical tourism centered on new technologies, such as stem cell treatments, is often criticized on grounds of fraud, blatant lack of scientific rationale and patient safety. However, when pioneering advanced technologies, such as providing 'unproven' therapies to patients outside of regular clinical trials, it is often challenging to differentiate between acceptable medical innovation and unacceptable patient exploitation.^[37][38]

Employer-sponsored health care in the US

Some US employers have begun exploring medical travel programs as a way to cut employee health care costs. Such proposals have raised stormy debates between employers and trade unions representing workers, with one union stating that it deplored the "shocking new approach" of offering employees overseas treatment in return for a share of the company's savings. The unions also raise the issues of legal liability should something go wrong, and potential job losses in the US health care industry if treatment is outsourced.^[39]

Employers may offer incentives such as paying for air travel and waiving out-of-pocket expenses for care outside of the US. For example, in January 2008, Hannaford Bros., a supermarket chain based in Maine, began paying the entire medical bill for employees to travel to Singapore for hip and knee replacements, including travel for the patient and companion.^[40] Medical travel packages can integrate with all types of health insurance, including limited benefit plans,^[41] preferred provider organizations and high deductible health plans.

In 2000 Blue Shield of California began the United States' first cross border health plan. Patients in California could travel to one of the three certified hospitals in Mexico for treatment under California Blue Shield.^[42] In 2007, a subsidiary of BlueCross BlueShield of South Carolina, Companion Global Healthcare, teamed up with hospitals in Thailand, Singapore, Turkey, Ireland, Costa Rica and India.^[43] A 2008 article in Fast Company discusses the globalization of healthcare and describes how various players in the US healthcare market have begun to explore it.^[44]

Destinations

Africa and the Middle East

Israel

Israel is a popular destination for medical tourism.^[45] In 2010, Israel treated 30,000 medical tourists, mostly from the former Soviet Union.^[45] There are reports that these medical tourists obtain preferential treatment, to the detriment of local patients.^[45] Some people come to Israel to visit health resorts at the Dead Sea,^[45] and on Lake Kinneret.

Iran

Iran is also among the 12 countries with biological medicines technology and can serve as a health tourism center.^[46] 30,000 people come to Iran each year to receive medical treatment (2012).^[47]

Jordan

Jordan is an emerging medical tourism destination, with related revenues exceeding one billion dollars in 2007.^[48] More than 250,000 patients from other countries sought treatment in Jordan that year. This included an estimated 45,000 Iraqis and approximately 25,000 patients each from Palestine and Sudan. An estimated 1,800 US citizens, 1,200 UK citizens, and 400 Canadians also sought treatment in Jordan that year. Treatment costs can be as low as 25 percent of costs in the US.^[48] The kingdom was rated as number one in the region and fifth in the world as a medical tourism hub in a study by the World Bank.^[48]

United Arab Emirates

Hospitals in Dubai and other emirates have expressed an intent to develop in medical tourism.^[49] Some have American-sourced international healthcare accreditation, while others are looking towards the UK, Australia and Canada for accreditation services. For example, QHA Trent has now accredited several hospitals in the UAE.

South Africa

South Africa is the first country in Africa to emerge as a medical tourism destination.^[50] It offers medical and dental care.^[51]

The Americas

Countries in the Americas that are treating foreign patients include Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Dominican Republic, Guatemala, Mexico, Panama, Peru, Turks and Caicos Islands and Uruguay.

Brazil

Brazil has long been known as a destination for cosmetic surgery. For non-cosmetic procedures, Brazil is only now entering the global market. However, Albert Einstein Jewish Hospital in São Paulo was the first JCI-accredited facility outside of the US,^[52] and more than a dozen Brazilian medical facilities have since been similarly accredited.^[53] Brazil requires visas for US citizens based on a reciprocal arrangement since Brazilians are required to obtain a visa to visit the US. Unlike in the U.S and other countries where medical procedures are simply done in an office, Plastic surgery in Brazil is done only in specialized clinics or hospitals.^{[54] [55]}

Canada

Canada has entered the medical tourism field. In comparison to US health costs, medical tourism patients can save 30 to 60 percent on health costs in Canada.^[56]

Colombia

Colombia is most likely the most underestimated destination for Global Healthcare in the Americas. Struggling with security and drug-related issues more than 15 years ago, Colombia is today one of the most thriving economies in South America and safe for tourists.^[57] Colombia's major cities like Bogota, Medellin, Cali and Cartagena are already receiving more than 1.45 million tourist each year and the numbers are increasing.^[58] Global Healthcare has been identified as one of the main drivers for economic growth in the medical sector. Patients from the Caribbean already know Colombia as a first class destination for medical procedures and cosmetic treatments. Now hospitals and facilitators are beginning to successfully convince also US-Americans of the quality of medical services provided in the country. An independent platform to compare the quality and prices of medical and cosmetic services is being supported by the government's export agency and regional initiatives.^[59] Colombia is overcoming its stigma and becoming a major player in Global Healthcare, serving needs of patients all over the Americas.

Costa Rica

Costa Rica's popularity in the medical tourism industry has been growing steadily over the years. Currently there are 3 Joint Commission International accredited (JCI) Hospitals all of which are in San Jose, Costa Rica. Recently announced by JCI accredited Clinica Biblica, is a $40 million hospital in Guanacaste designed to target the influx of medical tourism arriving in the Liberia International airport every year. This will make for a total of over six major private hospitals and 22 public hospitals. When the World Health Organization (WHO) ranked the world’s health systems in the year 2000, Costa Rica was ranked as no. 36, which was higher than the U.S., and together with Dominica it dominated the list amongst the Central American countries.^[60]

Costa Rica offers these levels of care ranging from Intermediate Life Saving capabilities, Complex Life Saving Treatment Capabilities, Advanced Life Savings Treatment Capabilities, and Life Style Treatment Services (Full range of dental work and cosmetic surgery).^[61]

Costa Rica's proximity to the U.S. helps attract over 48,000 patients a year.^[62] The Deloitte Center for Health Solutions, in their 2009 report "Medical Tourism Consumers in Search of Value" reported cost savings average of between 30-70% of US prices.^[63]

Cuba

Cuba has been a popular medical tourism destination for more than 40 years. Thousands of patients travel to Cuba, particularly from Latin America and Europe, attracted by the "fine reputation of Cuban doctors, the low prices and nearby beaches on which to recuperate."^[64] In 2006, Cuba attracted nearly 20,000 medical tourists.^[65]

Medical treatments included joint replacement, cancer treatment, eye surgery, cosmetic surgery and addictions rehabilitation. Costs are about 60 to 80 percent less than US costs.

Cuba has hospitals for Cuban residents and others that focus on serving foreigners and diplomats. In the 2007 American documentary film, Sicko, which criticizes the US healthcare system, producer Michael Moore leads a group of uninsured American patients to Cuba to obtain more affordable medical treatment. Sicko has greatly increased foreigners' interest in Cuban healthcare. A recent Miami Herald story focused on the high quality of health care that Canadian and American medical tourism patients receive in Cuba.^[66]

The Cuban government has developed Cuban medical tourism to generate income for the country. Residents of Canada, the UK and most other countries can travel to Cuba without any difficulty, although a tourist visa is generally required. For Americans, however, because of the US trade policy towards Cuba, travelers must either obtain US government approval, or, more frequently, travel to Cuba from Canada, Mexico, the Bahamas, To date no Cuban facility has achieved JCI Accreditation.^[53]

Cayman Islands

Mexico

Americans, particularly those living near the Mexican border, now routinely cross to Mexico for medical care.^[67][68] Popular specialties include dentistry and plastic surgery. Mexican dentists often charge one-fifth to one-fourth of US prices,^[69] while other procedures typically cost a third what they would in the US.^[68]

In Texas, legislators explored the possibility of allowing health maintenance organizations to operate on both sides of the border. However, physicians in south Texas lobbied against the changes, arguing that local doctors could not compete with the lower costs in Mexico".^[70] US doctors point out that the Mexican legal system makes it almost impossible to sue Mexican doctors for malpractice.^[69]

However, many who travel to Mexico for care report that they are satisfied.^[70] According to a report commissioned by Families U.S.A., a Washington advocacy group for health-care issues, "About 90 percent [feel] the care they had received in Mexico had been good or excellent. About 80 percent rated the care they had received in the United States as good or excellent".^[68]

Indeed "some U.S. dentists ... have conceded to the competition and begun a 'reverse migration' opening offices in Mexico to take advantage of lower costs".^[69] More American insurers are providing coverage for travelers, as the out-of-pocket costs to them are much lower. "With healthcare costs in the United States continuing to rise, many employers in Southern California are turning to insurance plans that send their workers to Mexico for routine care, plans that are growing by nearly 3,000 people a year."

Tijuana has proven to be a convenient center for 'medical tourism'. Due to its strategic geographic location, patients from California and much of the west coast have turned to Tijuana for elective procedures as well as for others such as chemotherapy, among others. According to the San Diego Union Tribune, about 1 million Californians go to Mexico for healthcare, and most of these patients go to Tijuana.^[71] Many of these patients seek weight loss, and plastic surgery, in addition to alternative cancer treatments.^[72] According to the Secretary of Tourism of Baja California, in 2009, close to 8 million people went to Tijuana for some type of healthcare.^{[citation needed]}

In addition to dental and plastic surgery, Mexican hospitals are popular for bariatric surgery for weight loss, considered an elective procedure that is not covered by some US insurers. A popular bariatric procedure, lap band surgery, which was approved by the FDA in the US in 2001, has been performed for longer by Mexican surgeons.^[73]

Some clinics may also offer alternative medicine therapies that have been proven ineffective or are banned in the United States.^[74] The Mexican government has shut down some of these in recent times, in response to controversial cases like that of Coretta Scott King.^[75]

Panama

In Panama, health and medical tourism is growing rapidly. Factors drawing medical tourists include Panama's tourist appeal, position as a hub for international travel, and use of the American dollar as the official currency. Many of Panama’s doctors are bilingual, board certified, and accustomed to working with the same medical equipment and technology used in the United States and Europe. On most procedures, Panama offers savings of more than 50% compared to the US and Europe.^[4]

Turks and Caicos Islands

Turks and Caicos Island provide Medical Tourism in the private-public-partnership hospital in Providenciales. Focus of the service is orthopedic surgery. The hospital is accredited by Accreditation Canada. Revenues from medical tourism contribute to the National Health Plan. Surgical services are provided by Canadian and American orthopaedic surgeons.^[76][77]

United States

A McKinsey and Co. report from 2008 found that between 60,000 to 85,000 medical tourists were traveling to the United States for the purpose of receiving in-patient medical care.^[78] The same McKinsey study estimated that 750,000 American medical tourists traveled from the United States to other countries in 2007 (up from 500,000 in 2006).^[79] The availability of advanced medical technology and sophisticated training of physicians are cited as driving motivators for growth in foreigners traveling to the U.S. for medical care,^[78] whereas the low costs for hospital stays and major/complex procedures at Western-accredited medical facilities abroad are cited as major motivators for American travelers.^[79] Also, the decline in value of the U.S. dollar is offering additional incentive for foreign travel to the U.S., although cost differences between the US and many locations in Asia are larger than any currency fluctuations.

Several major medical centers and teaching hospitals offer international patient centers that cater to patients from foreign countries who seek medical treatment in the U.S.^[80] Many of these organizations offer service coordinators to assist international patients with arrangements for medical care, accommodations, finances and transportation including air ambulance services.

Many locations in the US that offer medical care comparable in price to foreign medical facilities are not Joint Commission Accredited. ^{[citation needed]}

Uruguay

Uruguay recently entered the medical tourism market. A private medical tourism initiative, Uruhealth,^[81] has been created with support from the Ministries of Tourism^[82] and Public Health.^[83] The initiative involves the infrastructure, human resources and experience of two healthcare companies: MP Personalized Medicine (Montevideo)^[84] and SEMM-Mautone Hospital (Punta del Este).^[85]

Asia/Pacific

In 2007, Asia held almost 13 percent of the global medical tourism market, receiving 34 billion USD.^[86]

China

China is fast emerging as a desirable destination for individuals seeking medical care in a wide range of medical specialties, including cardiology, neurology, orthopedics and others. A number of private and government hospitals in major cities have established international departments. Many leading hospitals provide treatments integrating Traditional Chinese Medicine with Western medical technology and techniques.^[87] China is home to leading stem cell research and treatment hospitals that offer Westerners who want to take advantage of stem cell treatments that are still considered experimental or have yet to be approved in their home country.^[88][89]

Hong Kong

As of 2006, Hong Kong had 12 private hospitals and 39 public hospitals, providing 3,124 and 27,755 beds respectively. A wide range of health care services are offered. All 12 of Hong Kong's private hospitals have been surveyed and accredited by the UK's Trent Accreditation Scheme since early 2001.^[90] This has been a major factor in the ascent of standards in Hong Kong's private hospitals. The Trent scheme works closely with the hospitals it assesses to generate standards appropriate to the locality (with respect to culture, geography, public health, primary care interfaces etc.), and always uses combinations of UK-sourced and Hong Kong-sourced surveyors. Some of Hong Kong's private hospitals have now gone on to obtain dual international accreditation, with both Trent and JCI (and have therefore attained a standard surpassing some of the best hospitals in Thailand and Singapore). Others are looking towards dual international accreditation with Trent and the Australian group. Hong Kong public hospitals have yet to commit to external accreditation.

India

India’s medical tourism sector is expected to experience an annual growth rate of 30%.^{[citation needed]} The Indian government is taking steps to address infrastructure issues that hinder the country's growth in medical tourism.^{[citation needed]}

South Korea

Listed on CNN.com as one of the “hot destinations” for medical tourism, South Korea is quickly establishing itself in the field of medical tourism.^[91]

However, The Korea Times reported in a series of articles that Korean hospitals have adopted a discriminatory pricing policy, charging foreigners two to three times more than the full-fee for locals.^[92] The paper revealed that the price disparity in medical fees for foreign patients is extremely high, considering that the difference between the lowest and highest fees for the most-sought-after procedures exceeds more than 10 times on average.^[93]

It claims the government is overlooking soaring medical fees on foreign patients, who are unprotected from malpractice, discriminatory charging, overpricing and patient privacy rights under the Korean Medical Law.^[93][94]

In 2008, Korea had 27,480 foreign-based patients and the Korean health ministry expects that number to increase to 140,000 by 2015.^[95] Due to legislation passed in May 2009, state-licensed clinics and hospitals are now allowed to directly seek out foreign patients through various promotional activities.^[96] In 2009, South Korea had a total number of 60,000 medical tourists. In 2010, the number had risen to 80,000. The South Korean Ministry of Health has set the target for 2015 to up to 300,000 medical tourists.^[97] Areas such as Seomyeon medical street have catered to the tourism by building tourist information centers and providing guides.^{[98][99][100][101]}

Korean hospitals and clinics provide a variety of medical services for medical tourists including comprehensive health screening, cancer treatment, organ transplantation, joint/rheumatism care, spinal treatment, ophthalmology, dental care, infertility treatment, otorhinolaryngology, and Korean traditional medicine. Currently, the most popular treatments for medical tourists are cosmetic procedures such as eyelid surgery, nose jobs, facelifts, and skin lightening.^[91]

Over 30 South Korean hospitals and clinics are member providers under the Council for Korea Medicine Overseas Promotion (CKMOP). Among these facilities are the “Big Four” – Seoul National University Hospital, Samsung Medical Center, Asan Medical Center, and Yonsei Severance Hospital.^[95]

Malaysia

Malaysia is ranked in the top five destinations for health tourism.^[102]

The majority of the foreign patients seeking medical treatments in Malaysia are from Indonesia, Singapore, Japan, and West Asia.^[103] In 2012, Malaysia received 671,727 patients from around the globe.^[104]

Medical tourism started to be given prominence by government of Malaysia after Asian Financial crisis as an economic diversification.^[105] The National Committee for the Promotion of Medical and Health Tourism was formed by the Ministry of Health in January 1998.^[106] In 2009, Ministry of Health Malaysia had set up Malaysia Healthcare Travel Council (MHTC) to be the primary agency to promote and develop the country's health tourism industry as well as position Malaysia as a healthcare hub in the region.^[107]

New Zealand

In 2008, it was estimated that on average New Zealand’s surgical costs are around 15 to 20% the cost of the same surgical procedure in the USA.^[108] Companies had been set up to promote the use of New Zealand's private medical facilities by American customers through emphasizing the familiar culture and English language along with New Zealand's scenic beauty.^[108]

Pakistan

Pakistan has mentioned its keenness on working towards medical tourism and has considered it as a key element in its recent tourism policy.^[109] Despite facing security and infrastructure-related challenges, medical tourism in Pakistan has been arranging potential trips for many medical health and care procedures. Pakistan has been said to have a "huge potential" in becoming a regional medical tourism hub, comparable to many other countries in its neighbourhood.^[110] A number of modern hospital facilities exist in major cities such as Islamabad, Karachi and Lahore which are fully equipped and facilitated.^[111] Many doctors and surgeons in Pakistani hospitals tend to be foreign qualified. A number of patients from neighbouring countries have traveled to Pakistan for treatment. Other patients, mainly of Pakistani origin, especially from the Middle East, United Kingdom and United States, also travel to Pakistan to seek a range of treatments which they cannot otherwise get in their resident countries either due to expensiveness or lack of insurance cover there; common treatments that these patients seek include cardiac surgery, infertility treatments and cosmetic surgery. In the past, a sizable number of global patients traveled to Pakistan for kidney transplants although these cases have dropped ever since a legislation came into place that sought to regulate the illegal trade of selling kidneys.^[110] According to Pakistani medical experts, medical tourism is still an untapped market that can be turned into a huge opportunity if the government "focuses on key issues".^[110]

Philippines

The Philippines has been growing as a destination for medical tourism. The US Medical Tourism Association magazine reported that this services sub-sector grew 8.0% in 2007.^[112] The number can be expected to grow as American health-care costs rise, or if pending legislation results in an increase in patient wait times for surgical procedures (as has been seen in other countries where care has been nationalized), due to the traditional political, economic and cultural connections between the United States and the Philippines. International accreditation of hospitals has increased, and QHA Trent has now accredited hospitals in the Philippines.

The Philippines is one of a few countries that sends qualified nurses, physicians and dentists to the US, the thousands serving in American medical facilities being a testament to its quality of medical education.^[113][114] Many also work in the UK. According to year 2000 WHO rankings of the world's health systems, the Philippines takes its position on no.60.^[115]

Singapore

Singapore has a dozen hospitals and health centers with JCI accreditation.^[116] In 1997 (published 2000), the World Health Organization ranked Singapore's health care system sixth best in the world and the highest ranked system in Asia.^[117] In 2000, Singapore received 410,000 medical tourists. By 2012, the Singaporean government aims to attract one million international patients annually.^[118]

Patients come from neighboring countries, such as Indonesia and Malaysia, and patient numbers from Indochina, South Asia, the Middle East and Greater China are growing. Patients from developed countries such as the United States and the UK are also beginning to choose Singapore as their medical travel destination for relatively affordable health care services in a clean cosmopolitan city.

Singapore recently launched the region’s first cardiology clinic catering especially for the needs of women. This is in recognition of the fact that cardiovascular disease (heart disease and stroke) is the top killer among women in Singapore and in many other countries in the Asia Pacific. The Women’s Heart Health Clinic is located in the National University Hospital. Its emphasis is on prevention as well as treatment. Women are treated by an all-women team comprising a cardiologist, dietician (heart-healthy diet), occupational therapists (lifestyle management) and physiotherapist (exercise prescription).^[119]

Taiwan

The Taiwanese government has declared its determination for the country to become a medical tourism center. In 2007, the Department of Health launched a campaign to promote inbound medical tourism, focusing on integrating the resources of the government and academia to build Taiwan's brand as a medical tourism destination.^[120] Costs for procedures remain comparatively low. Taiwan is known for liver transplants, joint replacement surgery, bone marrow transplants, and reconstructive and plastic surgery.

Thailand

See also Medical tourism in Thailand

Medical tourism is a large and growing sector within Thailand’s extensive tourism and healthcare industries. The country is extremely attractive to potential medical tourists and international patients for a number of important reasons: it has many internationally accredited hospitals, including 30 JCI-accredited hospitals; it has experienced, often Western-trained medical professionals; it has the latest medical technology; and it has significantly lower costs of treatment when compared to corresponding procedures in the West. Taken together, all these factors – plus the country’s reputation as a popular tourist destination – have made Thailand one of the world’s top medical tourism destinations.^[121]

Thailand has the largest private hospital in Asia: Bumrungrad International Hospital.^[122] Thailand was also the first Asian country to achieve the prestigious Joint Commission International (JCI) accreditation in 2002.^[123]

In 2005, one Bangkok hospital took in 150,000 treatment seekers from abroad. In 2006, medical tourism was projected to earn the country 36.4 billion baht.^[124] In 2007, the Thailand Tourism Association's Tourism Investment Department reported that 1.42 million foreign customers used medical care services in Thailand worth 37,300M Baht ($1.2B USD).^[125]

Nearly 2.5 million medical tourists from countries around the world came to Thailand for medical treatment in 2012,^[126] with these numbers poised to show continued growth through 2013 and beyond. The Kingdom’s medical tourism industry’s rate of growth is approximately 16% per annum, with the country projected to generate some 100 billion Thai baht in annual revenue by the year 2015.^[121]

The Kasikorn Survey Center found that 60% of Thailand’s tourists – 1.48 million persons – visited Thailand in 2012 with the intention of receiving medical care or treatment. 45% of these medical tourists – 670,000 patients – had a 1:1 ratio of accompanying party traveling with them; i.e., an additional 670,000 visitors to Thailand. It is estimated that Thailand’s medical tourism industry generated at least 140,000 million Thai baht in the year 2012.^[127]

Medical tourists to Thailand from abroad have doubled from 2008-2012, the leading source countries for these visitors being the UK, the US, the Middle East (UAE, Kuwait, and Oman), Germany, Australia, Japan, and Thailand’s fellow ASEAN countries. ^[128]

The primary destinations for medical tourism in Thailand include, but are not limited to, Bangkok, Chiang Mai, Hua Hin, Koh Samui, Pattaya/Chonburi, and Phuket.^[129]

Treatments for medical tourists in Thailand range from cosmetic, organ transplants, cardiac, and orthopedic treatments to dental and cardiac surgeries. Treatments also include spa, physical and mental therapies, as well as procedures that are considered more along the lines of alternative medical practices.^[130] One patient who had coronary artery bypass surgery at Bumrungrad International hospital in Bangkok said the operation cost him US$12,000 (8,200 Euros), as opposed to the $100,000 (68,000 Euros) he estimated the operation would have cost him at home.^[131]

Japan

To promote medical tourism, the Japanese government issues six-month entry visas to travelers entering Japan to receive medical care, double the duration of regular tourist visas. An estimated two percent of foreign visitors to Japan came for medical care. Japan's medical system is reportedly strong in the area of cancer treatment.^[132]

Europe

Countries in Europe that have active medical tourism sectors include Turkey, Romania, Cyprus, Germany, Hungary, Estonia, Lithuania, Malta, Poland, Portugal, Czech Republic, Slovakia, Spain, Bulgaria and Ukraine.

In 2006 it was ruled that under the conditions of the E112 European health scheme, UK health authorities had to pay the bill if one of their patients could establish urgent medical reasons for seeking quicker treatment in another European union country.^[133]

Bulgaria

Bulgaria is a member of European Union since 2007,^[134] which helps medical tourists from Europe reduce their travel costs. Bulgarian standard of living is lower in comparison with other developing European countries. However, this fact is significant for its lower prices for providing health care services. On the other hand, Bulgarian physicians are highly qualified and have specialized in renowned Bulgarian and international universities. There are a number of modernly equipped hospitals, clinics and medical centers, therefore, health services in Bulgaria offer excellent combination of high value and state of the art medical care offered at competitive pricing.

The biggest private hospital in Bulgaria Tokuda Hospital Sofia, which is a member of Tokushukai Medical Corporation, have served over 10,000 international patients^[135] EU, Russia and the former republics, and the Middle East for the past five years.

The unique combination of highly qualified medical care at competitive price and the numerous places of interest in Bulgaria give the opportunity to combine travel for health reason with recreational, balneological, historical, religious, pilgrim, adventurous tourism and many others. Spa tourism in Bulgaria is very well developed, thanks to the great number of mineral and thermal springs and the modern facility infrastructure of Bulgarian tourism.

Czech Republic

Czech Republic has built its medical tourism on spas and medical care equalling the world standards (for example Ostrava University Hospital). The Czech Republic is well known for its affordable and high quality medical treatment. The most of Czech doctors studied at Charles University in Prague which was founded in 1348. Back in the 14th century it was the first university in Central Europe region and currently it is one of the oldest universities in Europe. The study demands enormous attention to practical training in combination with a broad theoretical knowledge. As a result the medical education in Prague is honored abroad as one of the top in the world.

Cyprus

Cyprus is actively developing its medical tourism industry. Currently very few hospitals have independent accreditation.

Estonia

Estonia is particularly popular among Scandinavians for medical tourism. The medical tourism industry achieves world standards and has to comply with EU regulation since it joined the EU in 2004. Estonia is known for its good medical care and scored particularly high in the Health Consumer Powerhouse report, produced on behalf of the European Union.^[136]

France

British NHS patients have been offered treatment in France to reduce waiting lists for hip, knee and cataract surgery since 2002.^[137] France is a popular tourist destination but also ranked the world's leading health care system. This ranking reflects the expertise offered by doctors and surgeons to patients cared for in France. The French National Authority for Health (HAS) issues high-level quality requirements for French health care, with which clinics and hospitals must comply in order to be accredited.^[138] European Court of Justice said that National Health Service (England) has to pay back British patients ^[139]

Germany

Germany is a destination for patients seeking advanced medical technology, high standards, safety, and quick treatment.^[140] All German citizens have health coverage,^[141] resulting in a high hospital density, with twice as many hospitals per capita as the United States.^[142] The high hospital density results in shorter waitlists for treatment. Costs for medical treatment compete well with other developed European countries and are commonly 50% of those in the USA.^[141]

Germany is an attractive destination for patients from the Middle East since traveling to the USA has become more difficult for them since the September 11 attacks. US citizens sometimes travel to Germany to seek treatments such as artificial cervical disc replacement that are not US Food and Drug Administration (FDA) approved.

Hungary

Because of an advantageous geographical location thermal water can be found with good quality and in great quantities on over 80% of Hungary's territory. Approximately 1,500 thermal springs can be found in Hungary. There are approximately 450 public baths in Hungary.

The Romans heralded the first age of spa in Hungary, the remains of their bath complexes are still to be seen in Óbuda, to this day. The spa culture was revived during the Ottoman occupation of Hungary who used the thermal springs of Buda for the construction of a number of bathhouses, some of which are still functioning (Király Baths, Rudas Baths).

In the 19th century the advancement in deep drilling and medical science provided the springboard for a further leap in bathing culture. Grand spas such as Gellért Baths, Lukács Baths, Margaret Island, and Széchenyi Medicinal Bath are a reflection of this resurgence in popularity.

The capital Budapest is a destination for economical dental treatment.^[143][144] The town of Mosonmagyaróvár, near the Austrian border, has been a popular dental tourism destination for decades, and has 150 practices for its 33,000 residents.^[145]

Lithuania

Lithuania is one of several countries actively promoting medical tourism.^[146] Treatments involve cosmetic surgery, eye surgery, and other services.^[147]

Poland

Since 2004, when Poland joined the European Union, it has become another locale for people seeking cheaper medical treatments.^[148] The quality of care in Poland must comply with EU standards.

Romania

Romania is a member state of the European Union. Medical tourism services in Romania varied but cover a large scope. The quality of services is implemented by both national and EU bodies of accreditation. Medical tourism in Romania is quality driven as outlined in the Medical Tourism Magazine, issue 18.^[149]

The private healthcare system in Romania is amongst the most dynamic in the country in terms of investments and growth. Market reports state that growth can still be expected in the private system in the years to come.^[150]

There are facilitators in Romania helping traveling patients access services, both medical and touristic services.

Turkey

Turkey attracts medical tourists from Europe and the Balkans, the United States, Eurasia and the Middle East, hosting about 200,000 patients annually.^[151]

Over 34 hospitals and medical institutions have achieved Joint Commission International accreditation.^[152]

In Turkey, all medical tourism activities will be distributed to all the activities to which the Ministry of Health participate overseas and within the country, to the culture and tourism directorates in provinces and to the offices in the country by Culture and Tourism Ministry, to all the activities held abroad and in the country the Medical Tourism Association and OHSAD (Private Hospitals and Medical Institutions Association ) take part to, to the representatives of TUMSIAD^[153] in the United Kingdom, Germany, France, Belgium, Holland, Denmark, Austria, Iran, Jordan, Syria, Kosovo, Macedonia and Bosnia, with a view to promote the Turkish health services.

United Kingdom

National Health Service (England) is public but some private hospitals and clinics in the United Kingdom are medical tourism destinations, especially London.^[154][155] Nevertheless, as at the present time very few UK private hospitals have gone through independent international accreditation (they only have the mandatory registration with the UK's watchdog, the Care Quality Commission), so they have not as yet measured themselves against the best clinics and hospitals elsewhere in the world.

See also

• Wellness tourism

References

• Businesses May Move Health Care Overseas (Washington Post)
• CBC News on "Medical tourism: Need surgery, will travel"
• A Cut Below: Americans Look Abroad for Health Care (ABC News)
• 's Medical Tourism, 60 Minutes (CBS News)

External links

Wikivoyage has a travel guide for Medical tourism.

• Listings of medical tourism websites - Open Directory Project

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