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Medical tourism

Medical tourism (also called medical travel, health tourism or global healthcare) is a term initially coined by travel agencies and the mass media to describe the rapidly-growing practice of travelling across international borders to obtain health care. It also refers pejoratively to the practice of healthcare providers travelling internationally to deliver healthcare[1][2].

Services typically sought by travelers include elective procedures as well as complex specialized surgeries such as joint replacement (knee/hip), cardiac surgery, dental surgery, and cosmetic surgeries. However, virtually every type of health care, including psychiatry, alternative treatments, convalescent care and even burial services are available. As a practical matter, providers and customers commonly use informal channels of communication-connection-contract, and in such cases this tends to mean less regulatory or legal oversight to assure quality and less formal recourse to reimbursement or redress, if needed[citation needed].

Over 50 countries have identified medical tourism as a national industry.[3] However, accreditation and other measures of quality vary widely across the globe, and there are risks and ethical issues that make this method of accessing medical care controversial[citation needed]. Also, some destinations may become hazardous or even dangerous for medical tourists to contemplate.

In the context of global health, "medical tourism" is a pejorative because during such trips health care providers often practice outside of their areas of expertise or hold different (i.e., lower) standards of care[4][5]. Greater numbers than ever before of student volunteers, health professions trainees, and researchers from resource-rich countries are working temporarily and anticipating future work in resource-starved areas[5][6]. This emphasizes the importance of understanding this other definition.


[edit] History

The concept of medical tourism is not a new one. The first recorded instance of medical tourism 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. This territory was the sanctuary of the healing god Asklepios. Epidauria became the original travel destination for medical tourism.

Spa towns and sanitariums may be considered an early form of medical tourism. In eighteenth 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.[3]

[edit] 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.[7]

Medical tourists can come from anywhere in the First World, including Europe, the Middle East, Japan, the United States, and Canada. This is because of their 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. 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".[8]

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 a million and a half 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]

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.[10] 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.[11]

Additionally, patients are finding that insurance either does not cover orthopedic surgery (such as knee/hip replacement) or imposes unreasonable restrictions on 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. Colombia provides a knee replacement for about $5,000 USD, including all associated fees, such as FDA-approved prosthetics and hospital stay-over expenses. However, many clinics quote prices that are not all inclusive and include only the surgeon fees associated with the procedure.[12]

According to an article by the University of Delaware publication, UDaily:

' The cost of surgery in India, Thailand or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost $200,000 or more in the US, for example, goes for $10,000 in India--and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the US costs $500 in India, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth $3,700 in the US is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the US runs about $1,250 in South Africa.[12] '

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 and New Zealand.[3]

Popular cosmetic surgery travel destinations include: Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Mexico and Turkey. In South America, countries such as Argentina, Bolivia, Brazil and Colombia lead on plastic surgery medical skills relying on their experienced plastic surgeons. In Bolivia and Colombia, plastic surgery has also become quite common. 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. Colombia also provides advanced care in cardiovascular and transplant surgery.

In Europe Belgium, Poland and Slovakia are also breaking into the business. South Africa is taking the term "medical tourism" very literally by promoting their "medical safaris".[13]

A specialized subset of medical tourism is reproductive tourism and reproductive outsourcing,[14] which is the practice of traveling abroad to undergo in-vitro fertilization, surrogate pregnancy and other assisted reproductive technology treatments including freezing embryos for retro-production.[15]

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 to unite potential medical tourists with provider hospitals and other organisations. Companies are beginning to offer global health care options that will 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 also help provide resources for follow-up care upon the patient's return.

[edit] 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 medical doctors 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.

[edit] International healthcare accreditation

Because standards are important when it comes to health care, there are parallel issues around medical tourism, international healthcare accreditation, evidence-based medicine and quality assurance.

The oldest international accrediting body is Accreditation Canada, formerly known as the Canadian Council on Health Services Accreditation, 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 best known accreditation group is the Joint Commission International (JCI). They have been inspecting and accrediting health care facilities and hospitals outside of the United States since 1999.[16] Many international hospitals today see obtaining international accreditation as a way to attract American patients.[17]

Joint Commission International is a relative of the Joint Commission in the United States. Both are 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.[18]

QHA Trent Accreditation, based in the UK, is an active accreditation scheme.[19] Prior to that, the Trent International Accreditation Scheme was a key player.

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.[11]

Increasingly, some hospitals are looking towards dual international accreditation, perhaps having both JCI to cover potential US clientele, 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]

[edit] Organizations and Associations

Medical Tourism Association (MTA), the first for-profit trade association for medical tourism, is made up of international hospitals, healthcare providers, medical travel facilitators, insurance companies, and other affiliated companies and members with the common goal of promoting medical tourism in a global environment. The Association promotes the interests of its healthcare provider and medical travel facilitator members. The MTA has three tenets: Transparency, Communication and Education.[23] The goal of these types of associations is often to raise awareness of medical tourism in the hopes of expanding the industry.

HealthCare Tourism International (HTI) is a 501(c) non-profit organization that is complementary to the Joint Commission International accreditation group. Health care organizations can apply for self-certification or accreditation on the HTI website.[24]

[edit] Risks

Medical tourism carries some risks that locally-provided medical care does not. Some countries, such as India, Malaysia, 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, 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.[25]

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. However, JCI and Trent fulfill the role of accreditation by assessing the standards in the healthcare in the countries like India, China and Thailand. Also, traveling long distances soon after surgery can increase the risk of complications. Long flights and decreased mobility in a cramped airline cabin are a known risk factor for developing blood clots in the legs such as venous thrombosis or pulmonary embolus economy class syndrome. Other vacation activities can be problematic as well ' for example, scars may become darker and more noticeable if they sunburn while healing.[26] To minimise these problems, medical tourism patients often combine their medical trips with vacation time set aside for rest and recovery in the destination country.

Also, health facilities treating medical tourists may lack an adequate complaints policy to deal appropriately and fairly with complaints made by dissatisfied patients.[27]

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.[28]

[edit] 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]

[edit] Ethical issues

There can be major ethical issues around medical tourism.[29] For example, the illegal purchase of organs and tissues for transplantation has 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 centred 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]

[edit] 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]

[edit] Subfields

[edit] Dental

Dental tourism involves individuals seeking dental care outside of their local healthcare systems.

[edit] Fertility

Fertility tourism is the practice of traveling to another country for fertility treatments.[45] The main reasons for fertility tourism are legal regulation of the sought procedure in the home country, or lower price. In-vitro fertilization, donor insemination and surrogacy are major procedures involved.

[edit] Destinations

[edit] Africa and Middle East

Countries in this region involved in medical tourism include Saudi Arabia, South Africa, and Tunisia.

[edit] Israel

See also: Medical tourism in Israel

Israel is emerging as a popular destination for medical tourists.[46] In 2006, 15,000 foreigners travelled to the country for medical procedures, bringing in $40 million of revenue.[46]

Medical tourists choose Israel for several reasons. Some come from European nations such as Romania where certain procedures are not available. Others come to Israel, perhaps most commonly from the US, because they can receive quality health care at a fraction of the cost it would be at home, for both surgeries and in-vitro fertilization treatments.

Other medical tourists come to Israel to visit the Dead Sea, a world-famous therapeutic resort.[46] The Israel Ministry of Tourism and several professional medical services providers have set out to generate awareness of Israel's medical capabilities.[47]

[edit] 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]

[edit] 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.

[edit] 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 and Uruguay.

[edit] 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,[50] and more than a dozen Brazilian medical facilities have since been similarly accredited.[51] 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 in specific plastic surgery only hospitals[52]

[edit] 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.[53]

[edit] 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 currently located in San Jose, Costa Rica. For a total there are over six major private hospitals and 22 public hospitals.

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).[54]

Because of Costa Rica's close proximity to the USA, the country is able to attract over 20,000 US patients a year.[55] It is also the prices of medical services that are quite attractive to consumers seeking quality care at an affordable price. 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.[56]

[edit] 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."[57] In 2006, Cuba attracted nearly 20,000 health tourists.[58]

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.[59]

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, Jamaica or the Dominican Republic. Cuban immigration authorities do not stamp the passports of US visitors so that Americans can keep their travels a private matter.

To date no Cuban facility has achieved JCI Accreditation.[51]

[edit] Mexico

Americans, particularly those living near the Mexican border, now routinely cross to Mexico for medical care.[60][61] Popular specialties include dentistry and plastic surgery. Mexican dentists often charge one-fifth to one-fourth of US prices,[62] while other procedures typically cost a third what they would in the US.[61]

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".[63] US doctors point out that the Mexican legal system makes it almost impossible to sue Mexican doctors for malpractice.[62]

However, many who travel to Mexico for care report that they are satisfied.[63] 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".[61]

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".[62] 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."

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.[64]

[edit] 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.[3] No Panamanian hospitals currently have international healthcare accreditation, whether through US, British, Australian or Canadian sources.

[edit] United States

Although much attention has been given to the growing trend of uninsured Americans traveling to foreign countries, a McKinsey and Co. report from 2008 found that a plurality of an estimated 60,000 to 85,000 medical tourists were traveling to the United States for the purpose of receiving in-patient medical care;[65] 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).[66] 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,[65] 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.[66] Also, it has been noted that the decline in value of the U.S. dollar is offering additional incentive for foreign travel to the U.S., although, costs differences between the US and many locations in Asia far outweigh 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.[67] 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.

[edit] Uruguay

Uruguay recently entered the medical tourism market. A private medical tourism initiative, Uruhealth,[68] has been created with support from the Ministries of Tourism[69] and Public Health.[70] The initiative involves the infrastructure, human resources and experience of two healthcare companies: MP Personalized Medicine (Montevideo)[71] and SEMM-Mautone Hospital (Punta del Este)[72].

[edit] Asia/Pacific

Many Asian Pacific countries are medical tourism destinations.

[edit] 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.[73] 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.[74][75].

[edit] 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.[76] 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.

[edit] India

India's medical tourism sector is expected to experience an annual growth rate of 30%, making it a Rs. 9,500-crore industry by 2015.[77] Estimates of the value of medical tourism to India go as high as $2 billion a year by 2012.[78] Advantages for medical tourists include reduced costs, the availability of latest medical technologies and a growing compliance on international quality standards, as well as the fact that foreigners are not likely to face a language barrier in India. The Indian government is taking steps to address infrastructure issues that hinder the country's growth in medical tourism.

Most estimates claim treatment costs in India start at around a tenth of the price of comparable treatment in America or Britain.[7][79] The most popular treatments sought in India by medical tourists are alternative medicine, bone-marrow transplant, cardiac bypass surgery, eye surgery and orthopedic surgery. India is known in particular for heart surgery, hip resurfacing and other areas of advanced medicine.

Ministry of Tourism India(MoT) is planning to extend its Market Development Assistance (MDA) scheme to cover Joint Commission International (JCI) and National Accreditation Board of Hospitals (NABH) certified hospitals. A policy announcement of this effect is likely soon.[80]

The south Indian city of Chennai is regarded as the healthcare captal of India.[81]

[edit] Korea, Republic of

Listed on CNN.com as one of the 'hot destinations' for medical tourism, Korea is quickly establishing itself in the field of medical tourism.[82].

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.[83]

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.[84]

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.[84] [85]

In 2008, Korea had 27,480 foreign-based patients and the Korean health ministry expects that number to increase to 140,000 by 2015[86]. 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[87].

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[82].

Over 30 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[86].

[edit] Malaysia

Malaysia is well on its way to develop itself as a medical tourism hub. The country has excellent hospitals, English is widely spoken, and many staff have been trained to a high level in the UK or in the US. There is a highly active Association for Private Hospitals of Malaysia working to develop medical tourism.[88] However, while Malaysia has a national accreditation healthcare scheme (MSQH) and many Malaysia's hospitals are currently firmly on the way to achieve international healthcare accreditation.

Malaysian hospitals International Specialist Eye Centre, Penang Adventist Hospital and many others such as Gleneagles Hospital Kuala Lumpur [12] have or are going to be JCI accredited. The Ministry of Health has launched a medical tourism page[89] with medical tourism portals such as Wellness Visit.[90]

[edit] New Zealand

New Zealand is a relatively new destination to medical travel. It has all the hallmarks of a very successful destination especially for North American based patients. This includes being a first world, developed economy with a sophisticated and comprehensive medical system. It is first and foremost English speaking with a rich heritage of producing world class doctors and medical research.

Many of its private hospitals are internationally accredited, state of the art and offer an integrated package of care. The surgeons in New Zealand are trained both in New Zealand and abroad, usually spending years of their training in either North America or Western Europe.

While New Zealand is aligned medically and culturally to North America, the cost of the surgical care is significantly cheaper. On average it is considered that New Zealand's surgical costs are around 15 to 20% the cost of the same surgical procedure in the USA[91]. One patient who had his prosthetic hip replaced in New Zealand said the total cost including travel, lodging and the surgery at a private hospital was $20,000, as opposed to the $80,000 - $140,000 he was told the operation would have cost at home.[92]

Added to this the personalized level of medical care, the world renown natural beauty and tranquility, the fact that New Zealand is one of the safest[93] places in the world and only 12 hours direct flight from the west coast of North America, then New Zealand as a medical travel destination looks set to develop.

[edit] Pakistan

Pakistan has mentioned its keenness on working towards medical tourism and has considered it as a key element in its recent tourism policy.[94] Despite suffering several blowbacks, due to insecurity and instability in the region, medical tourism in Pakistan has been arranging potential trips for many medical health and care procedures. A number of modern hospital facilities exist in Islamabad, Karachi and Lahore which are fully equipped and facilitated.[95] Many doctors and surgeons in Pakistani hospitals tend to be foreign qualified. A number of patients from neighbouring Afghanistan and Iran have traveled to Pakistan for treatment.

[edit] 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.[96] 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.

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.[97][98] According to year 2000 WHO rankings of the world's health systems, the Philippines takes its position on no.60.[99]

[edit] Singapore

Singapore has a dozen hospitals and health centers with JCI accreditation.[100] 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.[101]

"SingaporeMedicine"[102] is a multi-agency government-industry partnership committed to strengthening Singapore's position as a medical hub and promoting Singapore as a destination for advanced patient care. 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.

[edit] 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.[103] Costs for procedures remain comparatively low. Taiwan is known for liver transplants, joint replacement surgery, bone marrow transplants, and reconstructive and plastic surgery.

[edit] Thailand

Medical tourism has been a growing segment of Thailand's tourism and health-care sectors. 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.[104]

Treatments for medical tourists in Thailand range from cosmetic, organ transplants, cardiac, and orthopaedic treatments to dental and cardiac surgeries. Treatments also include spa, physical and mental therapies. 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.[105] Bumrungrad treated approximately 55,000 American patients in 2005 alone, a 30% increase from the previous year.[106]

Hospitals in Thailand are a popular destination for other Asians. Bangkok Hospital, which caters to medical tourists, has a Japanese wing, and Phyathai Hospitals Group has interpreters for over 22 languages, besides the English-speaking medical staff. When Nepal Prime Minister Girija Prasad Koirala needed medical care in 2006, he went to Bangkok.[107]

Many Thai physicians hold US or UK professional certification. Bumrungrad International hospital states that many of its doctors and staff are trained in the UK, Europe and the US. Bumrungrad International was accredited most recently in 2005 by the Joint Commission.[108] Some of the country's major hospitals have also achieved certification by the International Organization for Standardization's ISO 9001:2000. However, ISO 2000 is not an accreditation scheme.

The World Health Organization's 2000 ranking put the Thai healthcare system at number 47, below the USA's ranking at 37 and the United Kingdom's ranking at 18.[109]

Serious political problems during late 2008, including mass demonstrations and the complete closure of major airports, have made travel to Thailand less appealing than in the past, and the US State Department has issued a travel alert for the country.[110]

[edit] Europe

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

[edit] Czech Republic

Czech Republic has built its medical tourism on spas and medical care equalling the world standards (for example Ostrava University Hospital).

[edit] Cyprus

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

[edit] Germany

Germany is a destination for patients seeking advanced medical technology, high standards, safety, and quick treatment.[111] All German citizens have health coverage,[112] resulting in a high hospital density, with twice as many hospitals per capita as the United States.[113] 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.[114]

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.

[edit] Poland

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

[edit] Turkey

Turkey has since many years attracted medical tourists from Europe and the Balkans, the United States, Eurasia and the Middle East.[115]

The Turkish private healthcare system is striving to become a strategic global health service provider manufacturing center. Web site www.healthinturkey.org [13] has been established by the DEä�K-Foreign Economic Relations Board of Turkey Healthcare Committee and the Accredited Hospitals Association of Turkey. The site contains information on prices and hospital statistics, information about the healthcare, pharmaceutical and insurance environments as well as an international patient guide.

Turkey has the highest number of JCI accredited healthcare institutions in the world except for the US.[citation needed] The German Hospital in Istanbul operates the country's first ISO-certified IVF center, while Memorial Hospital was the first private hospital to receive American JCI accreditation.[citation needed] Since then, over 34 hospitals and medical institutions have achieved Joint Commission International accreditation.[116]

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