Medical tourism

Medical tourism refers to people traveling to a country other than their own to obtain medical treatment. In the past this usually referred to those who traveled from less-developed countries to major medical centers in highly developed countries for treatment unavailable at homes.[1][2] However, in recent years it may equally refer to those from developed countries who travel to developing countries for lower priced medical treatments. The motivation may be also for medical services unavailable or illegal in the home country.

Medical tourism most often is for surgeries (cosmetic or otherwise) or similar treatments, though people also travel for dental tourism or fertility tourism.[3] People with rare conditions may travel to countries where the treatment is better understood. However, almost all types of health care are available, including psychiatry, alternative medicine, convalescent care, and even burial services.

Medical tourists are subject to a number of risks, such as deep vein thrombosis from air travel or poor post-operative care.

Health tourism is a wider term for travel that focus on medical treatments and the use of healthcare services. It covers a wide field of health-oriented, tourism ranging from preventive and health-conductive treatment to rehabilitational and curative forms of travel. Wellness tourism is a related field.

History

The first recorded instance of people travelling for medical treatment dates back thousands of years to when Greek pilgrims traveled from the eastern Mediterranean to a small area in the Saronic Gulf called Epidauria.[4] This territory was the sanctuary of the healing god Asklepios.

Spa towns and sanitaria were early forms of medical tourism. In 18th-century Europe patients visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis.[5]

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.[6][7] 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 other countries. For example, in the United States, a liver transplant that may cost $300,000 USD, would generally cost about $91,000 USD in Taiwan.[8] A large draw to medical travel is convenience and speed. Countries that operate public health-care systems often have long wait times for certain operations, for example, an estimated 782,936 Canadian patients spent an average waiting time of 9.4 weeks on medical waiting lists in 2005.[9] Canada has also set waiting time benchmarks for non urgent medical procedures, including a 26-week waiting period for a hip replacement and a 16-week wait for cataract surgery.[10]

In First World countries such as 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.[11]

An authority at the Harvard Business School stated that "medical tourism is promoted much more heavily in the United Kingdom than in the United States".[12]

Additionally, some patients in some First World countries are finding that insurance either does not cover orthopedic surgery (such as knee or hip replacement) or limits the choice of the facility, surgeon, or prosthetics to be used.

Popular medical travel worldwide destinations include: Canada, Costa Rica, Ecuador, India, Israel, Jordan, Malaysia, Mexico, Singapore, South Korea, Taiwan, Thailand, Turkey, United States.[13]

Popular destinations for cosmetic surgery include: Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Ecuador, 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.[14]

Some people travel for assisted pregnancy, such as in-vitro fertilization, or surrogacy,[15] or freezing embryos for retro-production.[16]

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 organizations. 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.

Circumvention tourism is also an area of medical tourism that has grown. Circumvention tourism is travel in order to access medical services that are legal in the destination country but illegal in the home country. This can include travel for fertility treatments that aren’t yet approved in the home country, abortion, and doctor-assisted suicide.[17] Abortion tourism can be found most commonly in Europe, where travel between countries is relatively simple. Ireland and Poland, two European countries with highly restrictive abortion laws, have the highest rates of circumvention tourism. In Poland especially, it is estimated that each year nearly 7,000 women travel to the UK, where abortion services are free through the National Health Service.[18] There are also efforts being made by independent organizations and doctors, such as with Women on Waves, to help women circumvent draconian laws in order to access medical services. With Women on Waves, the organization uses a mobile clinic aboard a ship to provide medical abortions in international waters, where the law of the country whose flag is flown applies.[19]

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.[20] There are a number of accreditation schemes available based in a number of different countries around the world.

The oldest international accrediting body is Accreditation Canada, formerly known as the Canadian Council on Health Services Accreditation,[21] which accredited the Bermuda Hospital Board as soon as 1968. Since then, it has accredited hospitals and health service organizations in ten other countries.

JCI Gold Seal, an example of international hospital standard accreditation
JCI Gold Seal, an example of international hospital standard accreditation

In the United States, the accreditation group Joint Commission International (JCI) was formed in 1994 to provide international clients education and consulting services.[22] Many international hospitals today see obtaining international accreditation as a way to attract American patients.[23]

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.[24]

A British scheme, QHA Trent Accreditation, is an active independent holistic accreditation scheme, as well as GCR.org which monitors the success metrics and standards of almost 500,000 medical clinics worldwide.[25]

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.[26]

Increasingly, some hospitals are looking towards dual international accreditation, perhaps having both JCI to cover potential US clientele, and Accreditation Canada or QHA Trent. As a result of competition between clinics for American medical tourists, there have been initiatives to rank hospitals based on patient-reported metrics.[27]

Risks

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

Some countries, such as 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.[28]

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.[29] Other vacation activities can be problematic as well — for example, scars may become darker and more noticeable if they sunburn while healing.[30]

Also, health facilities treating medical tourists may lack an adequate complaints policy to deal appropriately and fairly with complaints made by dissatisfied patients.[31]

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.[32]

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.[33]

Receiving medical care abroad may subject medical tourists to unfamiliar legal issues.[34] 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.[35] Issues can also arise for patients who seek out services that are illegal in their home country. In this case, some countries have the jurisdiction to prosecute their citizen once they have returned home, or in extreme cases extraterritorially arrest and prosecute.[17] In Ireland, especially, in the 1980s-90s there were cases of young rape victims who were banned from traveling to Europe to get legal abortions. Ultimately, Ireland’s Supreme Court overturned the ban; they and many other countries have since created "right to travel" amendments.[17][36]

Ethical issues

There can be major ethical issues around medical tourism.[34] For example, the illegal purchase of organs and tissues for transplantation had been methodically documented and studied in countries such as India,[37][38] China,[39][40] Colombia[41] and the Philippines.[42] The Declaration of Istanbul distinguishes between ethically problematic "transplant tourism" and "travel for transplantation".[43]

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.[44] 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".[45] 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.[46][47]

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.[48]

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.[49] Medical travel packages can integrate with all types of health insurance, including limited benefit plans,[50] preferred provider organizations and high deductible health plans.

In 2000, Blue Shield of California began the United State's 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.[51] 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.[52] 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.[53]

Destinations


Africa and the Middle East

Jordan

Jordan through their Private Hospitals Association, managed to attract 250,000 international patients accompanied by more than 500,000 companions in 2012, with a total revenues exceeding 1B US$.[54] Jordan won the Medical Destination of the year award in 2014 in the IMTJ Medical Travel Awards.[54]

Israel

Israel is a popular destination for medical tourism.[55] Many medical tourists to Israel come from Europe, particularly the former Soviet Union, as well as the United States, Australia, Cyprus, and South Africa. Medical tourists come to Israel for a variety of surgical procedures and therapies, including bone marrow transplants, heart surgery and catheterization, oncological and neurological treatments, orthopedic procedures, car accident rehabilitation, and in-vitro fertilization. Israel's popularity as a destination for medical tourism stems from its status as a developed country with a high-quality level of medical care, while at the same time having lower medical costs than many other developed countries. Israel is particularly popular as a destination for bone marrow transplants among Cypriots, as the procedure is not available in Cyprus, and for orthopedic procedures among Americans, as the cost of orthopedic procedures in Israel is about half that of in the United States. Israel is a particularly popular destination for people seeking IFV treatments. Medical tourists in Israel use both public and private hospitals, and all major Israeli hospitals offer medical tourism packages which typically cost far less than comparable procedures than in facilities elsewhere with a similarly high standard of care. In 2014, it was estimated that roughly 50,000 medical tourists came to Israel annually.[56][57][58][59] There are reports that these medical tourists obtain preferential treatment, to the detriment of local patients.[55] In addition, some people come to Israel to visit health resorts at the Dead Sea,[55] and on Lake Kinneret.

Iran

In 2012, 30,000 people came to Iran to receive medical treatment.[60] In 2015, It is estimated that between 150,000 and 200,000 health tourists came to Iran, and this figure is expected to rise to 500,000 a year.[61]

Iran has low endemicity for Hepatitis B virus and Hepatitis C virus infections and there is a unique experience of control of these infections that can be presented to people in Middle East countries. The pharmaceutical companies in Iran produces the drugs needed for control of HCV and HBV infection such as Tenofovir disoproxil, Peg Interferon, Sofosbuvir/daclatasvir and Ledipasvir with very low prices and high efficacy. Sadeghi F, Salehi-Vaziri M, Almasi-Hashiani A, Gholami-Fesharaki M, Pakzad R, Alavian SM. Prevalence of Hepatitis C Virus Genotypes Among Patients in Countries of the Eastern Mediterranean Regional Office of WHO (EMRO): A Systematic Review and Meta-Analysis. Hepat Mon. 2016;16(4):e35558.

South Africa

South Africa is the first country in Africa to emerge as a medical tourism destination.[62]

Americas

Brazil

In Brazil, Albert Einstein Hospital in São Paulo was the first JCI-accredited facility outside of the US,[63] and more than a dozen Brazilian medical facilities have since been similarly accredited.[64]

Canada

In comparison to US health costs, patients can save 30 to 60 percent on health costs in Canada.[65]

In the early 1990s, Americans illegally using counterfeit, borrowed, or fraudulently obtained Canadian health insurance cards to obtain free healthcare in Canada became a serious issue due to the high costs it imposed.[66]

Costa Rica

In Costa Rica, there are two Joint Commission International accredited (JCI) Hospitals. Both are in San Jose, Costa Rica. When the World Health Organization (WHO) ranked the world’s health systems in the year 2000, Costa Rica was ranked as no. 26, which was higher than the U.S., and together with Dominica it dominated the list amongst the Central American countries.[67]

The Deloitte Center for Health Solutions reported a cost savings average of between 30-70% of US prices.[68]

Cayman Islands

Cuba

United States

A McKinsey and Co. report from 2008 found that between 60,000 and 85,000 medical tourists were traveling to the United States for the purpose of receiving in-patient medical care.[69] 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).[70] 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,[69] 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.[70] Also, the decline in value of the U.S. dollar between 2007 and 2013 used to offer additional incentives 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.[71] Many of these organizations offer service coordinators to assist international patients with arrangements for medical care, accommodations, finances and transportation including air ambulance services.

Asia and the Pacific Islands

China

Ctrip's 2016 Online Medical Tourism Report indicates that the number of travelers who enroll in the oversea medical tourism through its platform increased fivefold over the previous year, and more than 500,000 Chinese visitors are expected to go on medical tourism. The top 10 medical tourism destinations are Japan, Korea, the U.S., Taiwan, Germany, Singapore, Malaysia, Sweden, Thailand, India.[72] Regular health checks made up the majority share of Chinese medical tourism in 2016, representing over 50% of all medical tourism trips for tourists originating in China.[73]

Hong Kong

All 12 of Hong Kong's private hospitals have been surveyed and accredited by the UK's Trent Accreditation Scheme since early 2001.[74]

India

Medical tourism is a growing sector in India. India is becoming the 2nd medical tourism destination after Thailand. Chennai is regarded as "India's Health City" as it attracts 45% of health tourists visiting India and 40% of domestic health tourists. India’s medical tourism sector was expected to experience an annual growth rate of 30% from 2012, making it a $2 billion industry by 2015.[75][76] As medical treatment costs in the developed world balloon - with the United States leading the way - more and more Westerners are finding the prospect of international travel for medical care increasingly appealing. An estimated 150,000 of these travel to India for low-priced healthcare procedures every year. Cosmetic surgery, bariatric surgery, knee cap replacements, liver transplants, and cancer treatments are some of the most sought out medical tourism procedures opted by foreigners.

Malaysia

Medical tourism in Malaysia

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.[77]

Pakistan

Singapore

Singapore has a dozen hospitals and health centers with JCI accreditation.[78] In 2013 medical expenditure generated from medical tourists, mostly from more complex medical procedures, such as heart surgery, was S$832 million, a decline of 25% from 2012’s S$1.11 billion, as the hospitals faced more competition from neighbouring countries for less complex work.[79]

Thailand

Thailand has 39 JCI-accredited hospitals. In 1994 The Thai Dental Council was established and is the premier governing body of dental practices in Thailand, and has now formulated uniform competency requirements for dental practitioners, thus directly influencing the medical and dental teaching programs. The Ministry of Public Health plays an important role in developing healthcare to promote scientific based education.[80] In addition, the Thai government has placed a more important role in public health programs for its citizens. Foreigners seeking treatment for everything from open-heart surgery to gender reassignment have made Thailand a popular destination for medical tourism, attracting an estimated 2.81 million patients in 2015, up 10.2 percent.[81] In 2013, medical tourists pumped as much as US$4.7 billion into the Thailand's economy, according to government statistics.[82] The development of Thailand's sex reassignment surgery has expanded the country's medical tourist industry throughout the years. Through the portrayal of kathoey, transgender women, represented in the media, Thailand has become one of the leading countries with a growing number of medical tourism per year.[83]

Europe

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.[84]

The European directive on the application of patients’ rights to cross-border healthcare was agreed in 2011.[85]

Finland

On December 9, 2013 the City of Helsinki decided, that all minors under the age of 18 and all pregnant mothers living in Helsinki without a valid visa or residence permit, are granted the right to the same health care and at the same price as all citizens of the city. This service will be available sometime early year 2014. Volunteer doctors of Global Clinic have tried to help these people, for whom only acute care has been available. This means that the Finnish health care system is open for all people coming outside of the European Union. The service covers special child health care, maternity clinics and specialist medical care etc. practically for free. It is still unclear if this will increase so called health care tourism, because all you have to do is come to Helsinki as a tourist and let the visa expire.

The Global Clinic in Turku offers health care for all undocumented immigrants for free.[86]

France

British NHS patients have been offered treatment in France to reduce waiting lists for hip, knee and cataract surgery since 2002.[87] France is a popular tourist destination but also ranked the world's leading health care system by the World Health Organization.[88] European Court of Justice said that National Health Service (England) has to pay back British patients.[89]

At this moment, the number of patients is growing, and in 2016, France has scored # 7 in the Medical Tourism Index.[90]

Serbia

Serbia has a variety of clinics catering to medical tourists in areas of cosmetic surgery, dental care, fertility treatment and weight loss procedures.[91] The country is also a major international hub for gender reassignment surgery.[92]

Turkey

The cost of medical treatments in Turkey is quite affordable compared to Western European countries. Therefore, thousands of people each year travel Turkey for their medical treatments.[93] Turkey is especially becoming a hub for hair transplant surgery.[94]

United Kingdom

The National Health Service is publicly owned. It attracts medical tourism principally to specialist centres in London. Some private hospitals and clinics in the United Kingdom are medical tourism destinations.[95][96] Very few UK private hospitals have gone through independent international accreditation (they 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.

It is alleged that health tourists in the UK often target the NHS for its free-at-the-point-of-care treatment, allegedly costing the NHS up to £200 million.[97] A study in 2013 concluded that the UK was a net exporter of medical tourists, with 63,000 UK residents travelling abroad for treatment and about 52,000 patients getting treatment in UK. Medical tourists treated as private patients by NHS trusts are more profitable than UK private patients, yielding close to a quarter of the revenue from only 7% of volume of cases. UK dental patients largely go to Hungary and Poland. Fertility tourists mostly travel to Eastern Europe, Cyprus and Spain.[98]

In the summer of 2015 immigration officers from the Border Force were stationed in St George's University Hospitals NHS Foundation Trust to train staff to identify “potentially chargeable patients”.[99] In October 2016 the trust announced that it planned to require photo identity papers or proof of their right to remain in the UK such as asylum status or a visa for pregnant women. Those not able to provide satisfactory documents would be sent to the trust's overseas patient team "for specialist document screening, in liaison with the UKBA (border agency) and the Home Office.” It was estimated that £4.6 million a year was spent on care for ineligible patients.[100]

See also

Notes

  1. ↑ Horowitz, Michael D.; Rosensweig, Jeffrey A.; Jones, Christopher A. (2007). "Medical Tourism: Globalization of the Healthcare Marketplace". MedGenMed. 9: 33. PMC 2234298 Freely accessible. PMID 18311383.
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  4. ↑ "History of Medical Tourism". Discovermedicaltourism.com. Discovermedicaltourism.com. Retrieved 2015-11-03.
  5. ↑ Gahlinger, PM. The Medical Tourism Travel Guide: Your Complete Reference to Top-Quality, Low-Cost Dental, Cosmetic, Medical Care & Surgery Overseas. Sunrise River Press, 2008
  6. ↑ Laurie Goering, "For big surgery, Delhi is dealing," The Chicago Tribune, March 28, 2008 Archived April 1, 2008, at the Wayback Machine.
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  8. ↑ Tung, Sarah (July 16, 2010). "Is Taiwan Asia's Next One-Stop Plastic-Surgery Shop?". Time.
  9. ↑ The Private Cost of Public Queues in 2005, Fraser Institute
  10. ↑ Wait times shorter for some medical procedures: report., Canwest News Service
  11. ↑ Linda A. Johnson, "Americans look abroad to save on health care: Medical tourism could jump tenfold in next decade," The San Francisco Chronicle, August 3, 2008
  12. ↑ Lagace, Martha "The Rise of Medical Tourism", Harvard Business School Working Knowledge, December 17, 2007. Retrieved July 1, 2008.
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  14. ↑ "Medical tourism: Need surgery, will travel" CBC News Online, June 18, 2004. Retrieved September 5, 2006.
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  16. ↑ Jones C (2007). "Ethical and legal conundrums of post-modern procreation". Int J Gynaecol Obstet.
  17. 1 2 3 Cohen, Glenn (2012). "Circumvention Tourism". Cornell Law Review. 97 (1309).
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  19. ↑ "Ship campaigns". Women on Waves. Women on Waves.
  20. ↑ Joint Commission International Accreditation & Certificationweb, Joint Commission International, archived from the original on 22 July 2011, retrieved 19 July 2011
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  34. 1 2 "Medical Tourism: Ethical Pitfalls of Seeking Health Care Overseas". Ahcpub.com. Retrieved 2011-10-29.
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  36. ↑ Spreng, Jennifer (2004). Abortion and Divorce Law in Ireland. Jefferson, NC: McFarland & Company, Inc. p. 150. ISBN 0786416750.
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  38. ↑ Chopra, Anuj (February 9, 2008). "Organ-transplant black market thrives in India". The San Francisco Chronicle.
  39. ↑ "Transplants and Ethics in San Francisco". The Epoch Times. 2007-05-23. Retrieved 2011-10-29.
  40. ↑ David Kilgour, David Matas (6 July 2006, revised 31 January 2007) An Independent Investigation into Allegations of Organ Harvesting of Falun Gong Practitioners in China (free in 22 languages) organharvestinvestigation.net
  41. ↑ Lee Mendoza Roger (2010). "Colombia's organ trade: Evidence from Bogotá and Medellín". Journal of Public Health. 18 (4): 375–384. doi:10.1007/s10389-010-0320-3.
  42. ↑ Roger Lee Mendoza (2010). "Price deflation and the underground organ economy in the Philippines". Oxford Journal of Public Health. pp. 101–107.
  43. ↑ Participants in the International Summit on Transplant Tourism and Organ Trafficking convened by The Transplantation Society and International Society of Nephrology in Istanbul, Turkey, 30 April to 2 May 2008. "The Declaration of Istanbul on Organ Trafficking and Transplant Tourism". Kidney International. 74 (7): 854–59.
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  45. ↑ "Medical Tourism Creates Thai Doctor Shortage". NPR. Retrieved 2011-10-29.
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  48. ↑ Union Disrupts Plan to Send Ailing Workers to India for Cheaper Medical Care, The New York Times
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  50. ↑ "Mini-Meds: Limited benefit plans provide cost-effective compromise" Houston Business Journal,
  51. ↑
  52. ↑ Bruce Einhorn, "Outsourcing the Patients", BusinessWeek, March 13, 2008
  53. ↑ Greg Lindsay,"Medical Leave" Fast Company, May 2008. Retrieved October 15, 2008.
  54. 1 2 "IMTJ MEDICAL TRAVEL AWARDS 2014". Retrieved 2014-04-25.
  55. 1 2 3 Health Ministry to probe Israel medical tourism industry following Haaretz exposé, Haaretz, Nov. 18, 2010
  56. ↑ https://www.imtj.com/articles/update-medical-tourism-development-israel/
  57. ↑ http://www.timesofisrael.com/israel-ranks-as-a-top-medical-tourism-destination/
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  59. ↑ http://www.zendette.com/2015/04/14/medical-tourism-why-israel/
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References

Wikivoyage has a travel guide for Medical tourism.
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