The number of foreign patients who visited Korean hospitals for medical treatment was a record 81,789 in 2010, up 36 % from the previous year, says the Ministry of Health and Welfare. Total revenue from treatment on foreign patients nearly doubled. (Note: These are not exclusively medical tourists – see below on how foreign patients are defined.)
The number of foreign patients has been on a sharp increase, with the government actively promoting medical tourism. It recorded 7,901 in 2007, 27,480 in 2008 and 60,201 in 2009.
The 2010 number for foreign patients was calculated based on data submitted by 1,686 hospitals and clinics nationwide. Yonsei University Severance Hospital attracted the largest number of foreign patients, followed by Samsung Medical Center, CheongShim International Medical Center, and Asan Medical Center.
The numbers do not equate to actual medical tourist numbers as they include all foreigners who are non-Koreans who receive no benefits from medical insurance. This includes American soldiers based in the country, plus holiday and business travellers and expatriates treated in the country. The total number is an exaggeration as even the ministry admits that they have assumed all non-nationals visited Korea for medical purposes and did not adjust the numbers for other categories such as general tourists, who fall ill during their trip. According to the Ministry of Health and Welfare, the total of 60,201 foreign patients in 2009 included 4,576 American soldiers based in the country.
The analysis of data on foreign patients shows the number of outpatients was 64,777, accounting for 79.2 percent of all foreign patients, and 11,653, or 14.2 %, came to receive medical checkups. The number of inpatients recorded was 5,359 which may reflect a small number of patients who travel to Korea for elective surgery requiring a hospital stay.
In 2010 female patients outnumbered male patients, being 57.2 %. Female patients from Japan and China accounted for 79 % and 71 % respectively of the total, strongly suggesting that the main areas are cosmetic treatment and cosmetic surgery undertaken on an outpatient basis. By nationality, patients were in order from the U.S. China, Japan, and Russia. The number of Japanese patients dropped slightly from the previous year, coinciding with the overall decrease of Japanese tourists. The US figures include soldiers, holidaymakers, resident expatriates, business travellers and diplomats.
14% received skincare-related treatment and cosmetic surgery while 13.5 % received internal medical treatment. Another 13.1 % visited total medical checkup centres. 43 % went to local medical centres while 20.5 % visited general hospitals and another 23.5 % chose to go to clinics.
In a recent seminar, Lee Chul of Yonsei University Medical Center said that more than 2,000 medical facilities in Korea are capable of attracting foreign patients; the US, China, Japan and Russia are primary targets; with the Seoul metropolitan region as the main destination. But he also identified problems, including fierce competition with too many places across Korea seeing medical tourism as a growth industry, even though many hospitals have not set up the medical care infrastructures expected by foreigners. He sees communication skills as a primary concern, with a lack of foreign language capability among most healthcare providers. He pointed out that Korea’s national health care system permits doctors an average of 3 minutes per patient, which is efficient but lacking in physician-patient interaction; that is a totally unacceptable practice in dealing with foreign patients who are paying with an expectation of service, and few places accept foreign credit cards.
Critics of the local medical tourism industry point out that there is no centralized governance of this industry and minimal regulatory support, so there is a lack of standardization. Under current national law, hospitals may only allot a maximum 5 % of the total bed capacity to non-citizens. The law also forbids domestic hospitals from operating on a for-profit basis, though this is currently under review.

According to a recent (but very small) survey by International Board of Medicine and Surgery (IBMS) of medical providers and medical tourism agencies worldwide, medical tourism will continue to grow substantially over the next few years in spite of the uneven global economy.
With a mere 39 responses, the survey is really a trade version of a vox-pop man–in-the-street interview. Apart from lack of statistical viability, answers from people active in promoting medical tourism will tend to be positive; so answers have to be read with care. With those caveats:• All agreed that medical tourism revenues will rise, with 75% anticipating moderate to strong growth. 54% say that medical tourism will not belong merely to the relatively wealthy.• 80% believe that medical tourism growth is significantly correlated to patient travel costs. 50% characterize the correlation as strong or very strong. On a common-sense level, it would seem hard to argue against this.• Survey participants believe that global economic volatility; rising fuel costs etc. will not inflate travel costs to levels deterring patient travel.• Most rely on the internet to promote medical tourism.
Most of the survey respondents were doctors and when asked what they wanted in a medical tourism agency partner-answers were broadly similar for;• Favourable financial incentives.• Previous professional relationship.• Professional reputation/testimonials.• International certification.• Global reach with several customers in several countries.
When asked to weigh the most significant obstacles to growth – • Inadequate patient knowledge of international treatment options.• Inadequate or inconsistent credentialing, standards and certification of providers.• No government help in promoting medical tourism.• Insurance indemnification problems
The International Board of Medicine and Surgery (IBMS) is a USA based organization seeking to sell certification services to healthcare providers whose credentials have been reviewed. There are five levels of certification-entry, ruby, silver, emerald and gold. IBMS certification launched in 2009 reviews national licensure, specialty certification and hospital affiliation but it is not a JCI type hospital accreditor with set standards and the organization does not certify by audited visits to hospitals. The site lists hundreds of dentists, doctors and surgeons but at present it only lists around 30 as being certified. Although IBMS claims not to be an agency for medical travellers, the website lists services offered as “co-coordinating pre and post medical evaluation and/or treatment”.

Regional unrest is affecting several Middle East countries on trade, travel and medical tourism. According to Fawzi Hammouri, former Private Hospitals Association president, due to unrest in their home countries, the number of Arab patients seeking treatment in the Kingdom’s hospitals this year has fallen dramatically. Private hospitals have reported a drop in the number of Libyan, Yemeni, Sudanese, Bahraini and Syrian patients, who make up the bulk of the patients from across the world and who receive treatment at the Kingdom’s private hospitals. The decline has been seen as setback for Jordan as it is the largest medical tourism destination in the region.
Figures Hammouri indicated a 90 % drop in Libyan patients, 60 % drop in Syrian patients, while Yemeni and Bahraini patients both witnessed 50 % declines. The number of patients from Sudan has dropped by 30 % since the beginning of the year, "Although we are currently targeting markets such as Chad, Iraq and Saudi Arabia, our major markets have been the ones which have been hardest hit."
In 2010 Jordan attracted more than 220,000 Arabs and foreigners, 45,000 of whom were admitted to hospitals, according to the Private Hospitals Association (PHA). In 2009 210,000 patients from around 48 Arab and foreign countries were treated in Jordanian private hospitals, clinics and medical centres. Iraqis represented the largest number of foreign patients seeking treatment in the kingdom, accounting for 19 %, followed by Palestinians (16%) and Saudi Arabians (15 %). Yemeni patients were fourth, constituting 14 %of the total, followed by Sudanese and Libyan patients at 13 % and 9 % respectively.
The effect on Jordan’s figures for 2011 will depend on how quickly, or if, local unrest ends; and if circumstances are changed temporarily or permanently. The fall could be as much as 50,000 over the year.
Despite political turmoil in several Arab and North African countries, countries in the region are continuing to promote medical tourism. Each country has a different take on developments as while some are benefiting from rivals no longer in a position to be serious medical tourism destinations, some are also suffering as outbound medical tourism from some of the affected countries has stopped or is down to a trickle. According to reports in Gulf News, doctors and investors at the flagship of medical tourism in the UAE’s Dubai Health Care City, hope the newly established Heath Care Authority will be able to deliver what the previous two managements of the city failed to achieve. They said the situation was highly critical and unless the new authority moved quickly to correct failures, the project as a whole would become deserted. They said red tape, poor communication with clients and high rents were the three main issues working against the popularity of the city. Speaking to Gulf News, doctors said the city has failed to attract new clinics and international brands have pulled out due to high costs. Doctors and investors said clinics were also pulling out due to the high rents and maintenance fees. Restaurants and pharmacies have also closed. The economic downturn has also hit DHCC badly as the centre flagship 400-bed University Hospital has been put on hold and may never be completed.
In Oman, Starcare Hospital, managed by Starcare Health Systems has opened. Starcare Hospital in Muscat is a state-of-the-art facility built according to American architectural standards designed by a Belgian architect, and run by a UK company. Starcare is a new generation 50-bed multi-specialty hospital catering to the people of Seeb, wider Muscat and the entire Sultanate of Oman. It offers primary and secondary care in all specialties and tertiary care in selected specialties. Dr. Sadik Kodakat of Starcare Hospital comments, "We look to set new bench marks in the private healthcare sector combining legendary Omani hospitality with Western quality systems. The hospital has embraced international accreditation standards from the design stage itself and in its operational plans. The aim is to reduce the dependence of Omanis and expats on hospitals abroad for high quality treatment. The most important thing is to create confidence among local patients about the facilities in the country and to ensure access to treatment without delay.
Starcare plans to open another 150-bed hospital, 10 polyclinics and a chain of 15 pharmacies in different parts of the sultanate in two-to-four years. The company also plans to enter the healthcare sector in Saudi Arabia & UAE in the near future. Starcare Health Systems Limited is based in Manchester, UK with operations in UAE and Oman. The company is planning a major expansion into the Middle East and India in the next few years.

A study for the Missouri Hospital Association into domestic medical tourism suggests that medical travel created over 3,000 jobs and generated $124 million in non-medical travel expenditures in 2009. The US state of Missouri’s travel industry sees inbound medical travel as something the Division of Tourism can promote for the state.
The study "Behind the Big Blue H" used Missouri Division of Tourism statistics on travel expenditures to estimate the impact of medical travel on non-medical services and products. In 2009, nonresidents receiving medical care in Missouri hospitals included 84,885 inpatients and 769,567 outpatients, according to the study, which was prepared by the Community Policy Analysis Center, University of Missouri–Columbia. Most medical tourists to Missouri are from neighbouring states, including Illinois, Kansas, Arkansas and Oklahoma. The study estimated that non-resident inpatients daily spend averaged $143 to $164, including $66 to $88 for accommodation, $66 for meals, and $11 for fuel. Outpatient daily spending averaged $77.
Study authors, Thomas G. Johnson, Shriniwas Gautam and James D. Rossi, say that the economic impact of medical tourism goes beyond expenditures for healthcare because medical travelers, including patients and traveling companions, buy services and goods from retail businesses, hotels, restaurants and fuel stations. The report on medical tourism is part of a larger study conducted by the hospital association to demonstrate healthcare’s impact on Missouri’s overall economy.
The St. Louis region led the state in medical tourism, attracting 49% of non-resident outpatients and 57% of non-resident inpatients. Kansas City followed with 26% of outpatients and 18% of inpatients. Springfield was third, with 8% of outpatients and 10% of inpatients. Missouri hospitals, on average, charged $2220 and $39,140 for out-of-state outpatient and inpatient services, respectively.
The report suggests that Missouri can benefit by marketing to medical tourists and working with the healthcare community to inform patients and their companions about the opportunities Missouri offers in the state’s largest cities – St. Louis, Kansas City and Springfield. Opportunities extend to include wellness travel as Missouri offers 10 spas in different regions of the state. Missouri’s Division of Tourism currently does not target medical travellers.
Other US cities, including Orlando, Las Vegas and Miami, are promoting inbound medical travel. According to market research group HealthLeaders-InterStudy, Oklahoma City is becoming the medical tourism destination for oncology care in the USA. According to the recent Oklahoma City Market Overview, health systems in Oklahoma City are offering proton cancer therapy treatments that are only available in a handful of locations nationwide. OU Medicine will open a cancer center offering proton therapy in late 2011, positioning itself to compete with market leaders ProCure Proton Therapy Center. Patients from 23 states, as well as international patients, have already sought treatment at INTEGRIS.
While most cities concentrate on domestic medical tourism, New York also gets international medical travellers. Manhattan cosmetic surgeon David Shafer has launched a New York City based medical tourism website, with iPad, iPhone and Android applications. He previously created the world’s first interactive cosmetic surgery themed iPhone application, The Shafer Plastic Surgery app. The website gives patients worldwide access to information and the ability to book appointments. It has instant translation of website information into twelve languages; access to Skype video conference consultations; and social media Facebook and Twitter. It also has accompanying iPhone, iPad and Android applications that offer mobile and smartphone users the ability to tap into all resources on the go. The site also offers the option to take a self-portrait with a personal phone, attach it to an email and send to Dr. Shafer for an initial consultation.
Dr. David Shafer has established a global patient base with more than 50 % of his patients travelling from Europe, the Middle East, Asia and Australia to seek out personalized service at his New York City practice. Dr. Shafer created Medical Tourism NYC as a response to the frustration of patients who travel to developing countries in search of cheap cosmetic surgery only to end up in his office in need of surgical revisions or worse, emergency treatment; mostly due to substandard techniques and training. Medical Tourism NYC focuses on travel to obtain the highest level of medical care, giving consumers access to top doctors, the leading hospitals and the resources of New York City.

A new authority will oversee Dubai Healthcare City and seek to boost the UAE as a medical tourism destination. The Dubai Healthcare City Authority (DHCA) has been set up to also attract a whole spectrum of complementary industries ranging from drug manufacturers, research laboratories to pharmacies. The law specifies DHCA’s objectives, which include promoting Dubai as a global medical and healthcare destination. The law also states that the government of Dubai will not be responsible for any debts or obligations of third parties associated with the authority, Healthcare City or its affiliates, and that the authority will be solely responsible for its debts and obligations.
The new law gives the DHCA full financial and administrative autonomy. The 4.1 million square feet healthcare city includes two hospitals and 90 medical facilities including outpatient clinics and diagnostic laboratories. Home to many international healthcare brands, several overseas owned clinics have either closed or not opened. Launched in 2002 to offer high quality healthcare, the third management structure is the latest attempt to attract medical tourists from the USA, Europe, North Africa and Middle East. So far it has fallen well below any set targets, and most of the current business is from locals or expatriates or travellers, rather than medical tourists. DHCC received over 400,000 patients in 2010 compared with 220,000 in 2009.No breakdown for 2010 is available, but in 2009 only 10% were from outside the UAE and that 10% included expatriates, holiday and business travellers as well as medical tourists; so the actual number of medical tourists could be as low as 20,000.
The healthcare city has helped attract medical tourists from neighbouring Gulf states who seeking a range of services from cosmetic surgery to treatment using alternative medicine. However due to visa restrictions, the UAE has experienced a 5 to 10 % drop in arrivals in 2011 from Libya, Egypt, Lebanon and Syria. Visa restrictions for Libyan tourists have also led to a decline in medical tourism and local tourism companies suggest that although Libyans were big spenders in the medical tourism sector when they went to the UAE, with the current turbulent events in Libya, there is a decrease of more than 60 % in medical tourists from there as visas become harder to get, airports are closing down and people are feeling less safe to travel at the moment.
One of the mandates of the new authority is to attract top specialists to the emirate. It will have to work hard since there is a huge shortage worldwide of nurses and specialist doctors. The new law stipulates that the authority’s mandate includes establishing either by itself or in partnership with other entities, medical colleges and universities, nursing schools and a wide range of research, diagnostic, rehabilitation, nutrition and physiotherapy centres.
The DHCA will also oversee all transactions involving land within Dubai Healthcare City, including the ownership, sale, leasing and mortgaging of properties and facilities under its ownership.
New rules within Law No. 9 of 2011 include-• Employees exempt from any taxes.• Institutions can freely transfer profits outside.• Tax exemption status is granted for 50 years (can be renewed for another 50 years subject to approval).• No customs duties on products developed, manufactured, imported or used in the DHCA.• Products and goods exported from the city for first time will be subject to standard levies.• No measures restricting private ownership of organisations in the DHCA.• Organisations or individual operations will not be subject to laws and regulations of Dubai Municipality or Dubai Department of Economic Development.• Laws and regulations concerning public health, safety and environment will apply to all entities and individuals.
Dubai Healthcare City has launched ’Patients beyond Borders: Dubai Edition’, in collaboration with Healthy Travel Media. The 156-page guidebook, published in English and Arabic for international distribution, offers an in-depth overview of JCI-accredited hospitals, select health travel agents, accommodation, and essential medical travel information in Dubai. Dubai Healthcare City has successfully broadened its delivery of healthcare solutions in 2010 through attracting new service providers in various specialties, including ENT, ayurvedic medicine, obstetrics and fertility treatment. A second phase will feature a dedicated wellness cluster comprised of wellness centres, nutrition centres, resorts, spas, and sports medicine clinics.
Despite the development of the healthcare city and other progress in the UAE health sector, many UAE residents still prefer to go abroad for surgery, according to international healthcare providers exhibiting at a recent Arabian travel market. Residents of the Gulf have become targets for clinics in Thailand and elsewhere in Southeast Asia. Attracted by short flight times and a high disposable income amongst residents in the region, Thai medical service providers are upping their profile in the Gulf. Apiwat Ourairat of medical tourism agency RSU Healthcare, reports that a majority of his clients come from the Middle East, with the majority coming from Oman, followed by the UAE, Saudi Arabia, Kuwait and Bahrain.

The Hungarian government has agreed to provide a substantial sum for the development of health tourism in Hungary. Prime minister Viktor Orban signed a cooperation agreement with Laszlo Sz?cs of the Medical Tourism Office, focused on dental tourism.
Dental tourism is crucial for Hungary’s economy, generating 227million Euros in revenue each year Viktor Orban said, “Hungary is able to tap into its advantage in dental tourism and show Europe how it can get back on its feet”. Health tourism, especially spa and dental tourism, also receive special attention with the government planning support worth 117 million Euros. The state will finance the sector’s development including market expansion, cost optimalisation, technical upgrade and incentives to keep dentists in Hungary and prevent their migration. The programme will aim at increasing dental services to foreigners two-fold in three years and three-fold in five years.
The government claims that Hungary’s share of dental tourism in Europe is around 40 %, but with many EU rivals who have no accurate figures on dental tourism, that figure seems too high. Hungary needs promotion to keep its market lead ahead of fierce Polish, Turkish, Bulgarian and Czech competition.
To raise standards and attract more health tourists Serbia is drafting a new spa law. Vladan Veškovi?, of the Serbian Spas and Resorts Association says “The most important objectives of the new law are criteria regulation for spa certification and recertification, environment protection, as well as regulation for the use of the natural medicines. The implementation of a sustainable spa law will have a positive influence on the attitude of the relevant institutions in Serbia and encourage them to define spa tourism and promote it as a strategic tourist product of Serbia.”
Many spa centers in Bulgaria, especially in the capital city of Sofia, are housed in basements, garages and similar premises, which are rather unsuitable for relaxation. However, according to the newly passed amendments to the Tourism Act, managers of spa and relaxation centers will no longer be allowed to house their businesses in such inappropriate premises. Hissarya mayor Georgi Piryankov says, ’Many spas in Bulgaria fail to meet the latest criteria regarding their clients’ relaxation and health recovery. The amendments require that all managers and owners of spa and wellness centers provide their clients with relaxation conditions corresponding to the certificates that they have obtained. In addition, hoteliers will be obliged to inform their guests if the water that their spa centers use is mineral or it comes from the tap.”

A new price survey from medical tourism agency Avantis Health suggests that the Irish Republic is one of the most expensive countries in the world for dental and medical treatment.
The Global Health and Dental Price Index shows that savings of up to 70 % can be made by seeking some elective treatments in other countries. The index compares the cost of treatment for a range of procedures including dental care, and elective surgeries such as knee replacement, eye and cosmetic surgeries.
The survey compares 12 countries in each category, but the 12 countries vary. Those looked at include – Ireland, UK, Spain, Norway, Germany, Austria, Portugal, Hungary, Lithuania, Croatia, Latvia, India, Italy, Czech Republic, Australia, Tunisia, Brazil, Thailand, Belgium, Cyprus, South Africa, Greece, Malaysia and Turkey.
The study clearly shows the difference in cost between countries and that all are cheaper than Ireland for a range of procedures including dental, elective surgery, eye care and cosmetic surgery.
It shows that the cost of a tooth extraction is highest in Ireland; the average fee for the treatment was 90 Euros, in comparison to 82 Euros in Portugal, 75 Euros in the UK, 39 Euros in Hungary and 21 Euros in India. A dental examination and consultation is priced at 65 Euros in the Republic, while other European countries charged a lot less; the average fee in Italy was just 27 Euros, compared to 55 Euros in the UK.
The price index confirms that fees for other dental treatments, including crowns, wisdom tooth extraction, dental X-rays and dental implants are considerably higher in Ireland than most of the other countries included in the index. Even within Ireland there are savings of up to 30% available by shopping around.
According to the index, a patient could save more than half of the cost of cruciate-ligament repair by having it done in Germany as opposed to the Republic. The average cost of the treatment in Ireland is 5,514 Euros, while the cost in Germany is only 2.700 Euros. The cheapest place in the EU where the treatment is available is Lithuania where it costs just 1652 Euros. A full knee replacement, which costs 17,049 Euros in Ireland, costs 11,400 Euros in the UK and just 5,676 Euros in Poland.
Orla Fahy of Avantis Health says, "Irish patients can make significant savings on their health and dental care, by merely shopping around in Ireland with substantial savings possible if they are willing to travel abroad for treatment .For example, patients requiring a simple dental implant can save over 50% by undergoing the treatment in another European country. Patients requiring common but more invasive procedures, such as knee replacements or cruciate ligament repair, can make similar savings in the same way. Savings in cosmetic surgery are also particularly evident. A tummy tuck procedure can cost 79% less without even traveling outside Europe, while breast augmentation could cost 54% less by taking a flight to Belgium.”
The prices do not include travel and accommodation costs or quality comparisons.
The Irish health minister James Reilly says a study is currently underway into the true cost of medical procedures in Ireland as neither the actual cost nor the wide disparity are acceptable.

Finnish spas should develop their offering to meet changing customer preferences, according to new research. The popularity of health tourism is on the rise, according to research by the Innovations and Learning in Spa Management project (ILIS), coordinated by the Turku University of Applied Sciences. The range of spa and wellness travel services has increased rapidly in central Europe but Finnish spas have been slower to develop their offering. The ILIS Project has examined the views of both spa management and customers on how the sector should be developed, and compiled the results into virtual educational modules.
The research says that future growth areas in the travel sector will include health tourism. According to the Finnish Tourist Board, Finland’s strengths include opportunities for relaxation in calm surroundings, enjoying physical exercise in scenic nature, and the sauna. These are the main elements on which the current offering of basic wellness holidays and the health and exercise holidays are based.
Recent years have also seen the emergence of pampering holidays on the market. According to the ILIS Project, the customers’ interest in being pampered seems to have lessened and demand is now directed more towards treatments promoting good health. Responding to this trend requires closer cooperation between the spas and research centres, and the utilisation of multidisciplinary know-how.
Health tourism was defined by the International Union of Tourism Organisations in 1973 as the provision of health facilities utilising the natural resources of the country, in particular mineral water and climate. Since this definition the development of health tourism and spa tourism as its main sector has been rapid with a dramatic growth of supply and service differentiation. Natural resources (mineral water, salt, mud) are still in use, but integrated provision of body and mind is the trend including a wide spectrum of wellness, fitness, and medical wellness products and services. At the same time a broader population is being introduced to spa services.
ILIS project has defined a spa as: "A designated place of services in the continuum of health, wellbeing, relaxation and body styling (nutrition, gym, physical activities, cosmetic surgery, beauty care), which are offered holistically by skilled professionals often with aid of healing water."
Spa tourism is widely acknowledged as a core element of the health and wellness movement, which covers a broad spectrum of holistic, curative and preventative activities. The experience of spa goers is variable in the nature of treatments offered, the standards of service provided and the training that spa managers and the operatives delivering the treatments have experienced.
The ILIS project ended in 2010, but the final reports to the EU have only just been released. ILIS sought to- • Develop an understanding as to the nature and regional characteristics of spa products and services as an integral part of health tourism offered within the EU and of the demand characteristics for these products and services in each of the regions represented in this project.• Determine the extent to which each region is meeting the demand for skilled operatives, middle and senior management in the spa tourism industry.• Create common vocational training and virtual educational modules (including language and cultural skills) in cooperation with participating higher education and industry enterprise partners.

London & Partners, a new single agency with a remit to attract tourism, inward investment and international students to the UK capital has been launched to take over the work carried out previously by Visit London, Think London and Study London. London currently welcomes 25 million visitors every year. London & Partners aims to deliver a single strategy for the promotion of London both domestically and abroad by working with both the private sector and many specialist organizations. The agency will also be able to take on activities that fell between the previous organisations, such as promoting medical tourism, but probably not until after the Olympic Games in 2012.
London & Partners is a not-for-profit company limited by guarantee that will work with other organisations in the capital and across the world to ensure that London is globally recognised as the ’best big city on earth’. In an ever more competitive global economy, it has never been more important to promote leisure and business tourism, foreign direct investment and business growth as well as attracting major events, conferences, meetings and overseas students- especially with London gearing up for the 2012 Olympic Games.
Many London hospitals do already attract substantial numbers of medical tourists as private patients. They come because London offers treatments they may not have at home, top quality and the option for their partners and, from the Middle East an entire accompanying party, to enjoy the attractions of London.
Spire Healthcare is one of the largest private hospital groups with 40 hospitals and clinics across the UK, including 3 in London. Spire International, co-coordinates and delivering the healthcare needs of patients who are travelling from abroad for medical treatment. Spire International welcomes patients from all over the world with a wide range of services .It works closely with medical referrers / sponsors including country embassies, country health offices and military offices, sports teams, private corporate companies, and consultancy companies handling international medical care.
HCA International has six hospitals and four outpatient treatment centres in London including: the Harley Street Clinic, London Bridge Hospital, the Lister Hospital, the Portland Hospital, the Princess Grace Hospital, the Wellington Hospital and Harley Street at UCH. It has 727 beds in London. It has 11 overseas referral offices that deal with everything from booking to aftercare. The international office in London offers a wide range of services including special arrangements for government sponsored or company funded treatment. The Wellington Hospital in North London, the country’s largest private hospital, has taken delivery of the latest £ 1.5 million version of the Da Vinci surgical robot, the Da Vinci SI, which allows surgeon to see 3D/HD images of the surgery site ensuring greater accuracy than ever before and will be used for major operations ranging from prostrate surgery, the repair of heart valves, to complex liver and kidney surgery.

Iran expects final medical tourism figures for 2012 to be 200,000. 85,670 medical tourists arrived in Iran during the first half of the Iranian year (started March 20), showing an increase of 135% compared with the corresponding figure of last year. Manouchehr Jahanian, of Iran Cultural Heritage, Handcrafts and Tourism Organization for tourism, says the figure is expected to exceed 200,000 by the year end in March 2013, and that the country earned $600 million in revenue through medical tourism during the period. This represents a revenue per head of only $300.
According to Jahanian, the majority of medical tourists arrived in the country from Azerbaijan, Iraq, Turkmenistan, Afghanistan and Kuwait, “Tehran, Khorasan Razavi, Gilan, East Azarbaijan and Ardebil provinces hosted the largest number of medical tourists during the period. 50,000 medical tourists arrived in Iran during the previous year, generating $150 million for the country. Iranian achievements are due to the capabilities of its doctors, high level of medical knowledge, modern medical equipment and low cost of treatment.
Thanks to the efforts made by Iran Chamber of Commerce, Industries, Mines and Agriculture, ICHHTO and health and foreign ministries, a half price visa is offered to medical tourists. T-Visa is only for those who travel to Iran for treatment. The period of the visa’s validity depends on the diagnosis of the doctor, type of surgery and the time required for treatment. 10 hospitals in Iran, including Razavi Hospital of Mashhad, accept such visas. Razavi Hospital is one of the medical institutions supervised by Astan Quds Razavi. It was established by Imam Reza University in 2003, and now has 320 beds. It is considered to be one of the most advanced hospitals in the region.
Medical tourists can travel to Iran with tours designed for the purpose or through hospitals approved by the Foreign Ministry. Planned changes include special privileges for tour and travel agencies that attract medical tourists to the country.
In the past many Iranian patients went to foreign countries for treatment, but with improvements to local medical services, outbound numbers have fallen drastically.

While most African countries are seen as suppliers of medical tourists, several are looking at becoming regional hubs of inbound medical tourism.
Zambia, in south-central Africa, is the continent’s biggest copper producer. The country has been peaceful and generally trouble-free, compared to most of the eight neighbours with which it shares a border. There are private hospitals in Zambia’s larger cities that cater to foreigners and also to affluent Zambians.
Health tourism will attract local and international tourists in areas such as Mambwe and Mfuwe, says local politician Emmanuel Mwamba, “Government is working on health sector reforms that will incorporate health tourism to attract more local and international tourists. In Mambwe and Mfuwe, which receive thousands of both domestic and international tourists in a year, this could boost domestic tourism. We need to add value by putting in place a sound infrastructure, creating unique products and quality service.”
In an effort to boost the budding tourism sector that brought in much needed foreign exchange in 2012, Rwanda is considering medical tourism, mainly in the region, as another option to increase foreign exchange earnings in a country with a $1,2 billion trade deficit. The country is striving to rebuild its economy, with coffee and tea production being among its main sources of foreign exchange. Nearly two thirds of the population lives below the poverty line.
Rica Rwigamba of the Rwanda Development Board says, "The government is courting investors to set up advanced medical facilities to make our country a regional tourism hub. Medical tourism is something that requires a different approach to attract health investment like Dr. Agarwal’s Eye Hospital. It is also about attracting people with quality medical services at affordable rates. Rwanda is in a good location in terms of climate, the security and quiet environment, which patients need when going through the process of healing."
Rwanda’s problem is that many patients with complications that local doctors cannot handle are referred for medical attention abroad, mostly to India or South Africa. This is especially for people suffering from heart defects and health complications like blood cancer, brain tumour and plastic surgery for deformities or acid attack victims.
The government accepts that to develop medical tourism it would need world-class medical facilities, and a pool of specialists, an expensive venture that the government to cannot afford. So it needs overseas investors to build hospitals.
The Ministry of Health admits that it does not know statistics on the number of people who fly in or out of the country for treatment or the amount of money the state loses in terms of foreign exchange – as individuals do not have to say why they are flying in or out of the country.
Recently, Dr. Agarwal’s Eye Hospital opened in Kigali, making it the first foreign specialist establishment, which is most likely to become a regional eye referral centre. This could mean that Rwanda will earn more foreign exchange from patients. The specialist hospital handles all complicated eye cases that were once referred abroad. This will help the country save its hard currency that would have been used abroad. Rwanda is a poor rural country with 90% of the population engaged in subsistence agriculture so is never going to be a targeted market for other countries, or become a major medical tourism destination.

A high unemployment rate coupled with an influx of refugees from Iraq and Syria has resulted in challenges for the Jordanian government to provide healthcare for all, states a new report by healthcare experts GlobalData.
The new report “Healthcare, Regulatory and Reimbursement Landscape – Jordan” states that while Jordan’s economy is developing, and the country’s medical care and welfare programs are expected to grow considerably in the future, political instability is hindering this development.
Jordan’s healthcare expenditure is higher than anywhere else in the Arab world in terms of GDP and the government provides its citizens easy access to healthcare facilities either free-of-cost or at subsidized prices. A growing elderly population and various supportive government initiatives are driving Jordan’s healthcare system to develop even further.
Treating war victims and refugees from several nearby countries, has already turned Jordan’s medical tourism business into a medical war tourism one. The pressure on limited healthcare resources may increase, as problems worsen in Syria and Iraq, while the other two neighbours, Israel and Saudi Arabia, also have their own internal and external troubles. Other countries that are sources of patients for Jordan include Sudan, Yemen, Palestine and Chad; all with varying degrees of political and war problems.
Persuading other medical tourists to go to Jordan, even if it has the spare capacity, may prove difficult if they end up in hospitals full of refugees and war victims.
Enacting a medical accountability law is essential for Jordan’s medical tourism industry as it would attract more patients from abroad for treatment, argues health minister Abdul Latif Wreikat. The government and the Jordan Medical Association have been arguing over the new legislation since 2007, and last year the doctors rejected the latest version of the draft law because it did not clarify the party responsible for paying damages to patients or their families found to have been the victims of medical error. It is very doubtful that any new law will increase medical tourism numbers, as checking medical liability law is far from the minds of most medical tourists.
Abdul Latif Wreikat confirms that in the last three years Jordan has treated tens of thousands of wounded and sick Arabs and provided them with specialized medical services, and that places a significant burden on the private hospital sector in Jordan.
Jordan plays a key role in the Middle East, especially about the Israeli-Palestinian peace process and the ongoing Syrian crisis. Syria and the influx of refugees to Jordan is the most pressing issue, which could affect the country’s stability. The United States has helped through the sending of USD 52 million in aid, as Jordan has never been as essential for US foreign policy in the Middle East as now. For medical tourism this is a double-edged sword as some African and Arab countries become more anti-American.

International tourist arrivals grew by 4% in 2012 to reach 1.035 billion, according to the latest UNWTO World Tourism Barometer.
The reasons for travel are:• 51% leisure/recreation/holiday• 27% visit family and friends/health/other• 15% business/professional• 7% not specified
Emerging economies regained the lead over advanced economies, with Asia and the Pacific showing the strongest results. Growth is expected to continue in 2013 only slightly below the 2012 level.
With an additional 39 million international tourists, up from 996 million in 2011, international tourist arrivals surpassed 1 billion (1.035 billion) for the first time in history in 2012.
By region, Asia and the Pacific (+7%) was the best performer, while by sub-region, South-East Asia, North Africa (both at +9%) and Central and Eastern Europe (+8%) topped the ranking.
Taleb Rifai of UNWTO comments, “The sector has shown its capacity to adjust to the changing market conditions and, although at a slightly more modest rate, is expected to continue expanding in 2013. Tourism is one of the pillars that should be supported by governments around the world as part of the solution to stimulating economic growth.”
UNWTO forecasts international tourist arrivals to increase by 3% to 4% in 2013.By region, prospects for 2013 are stronger for Asia and the Pacific (+5% to +6%), followed by Africa (+4% to +6%), the Americas (+3% to +4%), Europe (+2% to +3%) and the Middle East (0% to +5%).
International tourist arrivals to Europe, the most visited region in the world, were up by 3%.Total arrivals reached 535 million, 17 million more than in 2011. By sub-region, Central and Eastern Europe destinations (+8%) experienced the best results, followed by Western Europe (+3%). Destinations in Southern Mediterranean Europe (+2%) consolidated their excellent performance of 2011 and returned in 2012 to their normal growth rates.
Asia and the Pacific (+7%) was up by 15 million arrivals in 2012, reaching a total 233 million international tourists. South-East Asia (+9%) was the best performing sub-region. Growth was also strong in North-East Asia (+6%), as Japanese inbound and outbound tourism recovered, while it was comparatively weaker in South Asia (+4%) and in Oceania (+4%).
The Americas (+4%) saw an increase of 6 million arrivals, reaching 162 million in total. Leading the growth were destinations in Central America (+6%), while South America, up by 4%, showed some slowdown as compared to the double-digit growth of 2010 and 2011. The Caribbean (+4%), on the other hand, is performing above the previous two years, while North America (+3%) consolidated its 2011 growth.
Africa (+6%) recovered well from its setback in 2011 when arrivals declined by 1% due largely to the negative results of North Africa. Arrivals reached a new record (52 million) due to the rebound in North Africa (+9% as compared to a 9% decline in 2011) and to the continued growth of Sub-Saharan destinations (+5%). Results in the Middle East (-5%) improved after a 7% decline in 2011, yet the region recorded an estimated 3 million international tourist arrivals less in 2012 in spite of the clear recovery in Egypt.
Among the top ten tourist destinations, receipts were up significantly in Hong Kong, USA, UK and Germany. At the same time, a significant number of destinations around the world saw receipts from international tourism increase by 15% or more – Japan (+37%), India and South Africa (both +22%), Sweden and the Republic of Korea (both +19%), Thailand (+18%) and Poland (+16%).
Although the highest growth rates in expenditure abroad among the ten top markets came from emerging economies – China (+42%) and Russia (+31%) –expenditure on international tourism by Germany held well at +3%, while the UK (+5%) returned to growth after two flat years. In the Americas, both the USA and Canada grew at 7%. On the other hand, France (-7%) and Italy (-2%) registered declines in travel expenditure.
Smaller markets with significant growth were Venezuela (+31%), Poland (+19%), Philippines (+17%), Malaysia (+15%), Saudi Arabia (+14%), Belgium (+13%), Norway and Argentina (both +12%), Switzerland and Indonesia (both +10%).
Any organization in medical tourism has to understand where people are going from and to, and the trends in all tourism sectors.

While the overall level of health across the WHO European Region has improved, European health statistics show inequities within and between countries, according to “The European Health Report 2012”. Medical tourism is partly driven by such inequalities. The report covers 53 countries and 900 million people, revealing that people are living longer and healthier lives. Life expectancy has risen by 5 years since 1980 to 76. People over 65 will account for more than 25% of the total population in the region by 2050. Diseases of the circulatory system (ischemic heart disease, stroke) account for 50% of all deaths, followed by cancer causing 20% of deaths.
Migrants living in Europe are estimated to number 73 million (52% of whom are women) and account for nearly 8% of the total population. Migrants are usually younger, less affluent and more likely to become ill, and have less access to health services than the general population. Although it does vary by what universal healthcare or compulsory health insurance is offered in each country, evidence suggests that migrants have a greater tendency to go back to their country of origin for treatment than people born in the country; the downside being that this group can least afford to be medical tourists.
The European Health Report 2012 focuses on well-being, which forms an integral part of the new European health strategy, Health 2020, adopted by the 53 European member states. Health and wellness tourism in Europe is much bigger than medical tourism, and an increased awareness of health and wellness as prevention, as opposed to medical treatment as a cure, is important for medical tourism.

Hopes that the EU cross-border healthcare directive would increase patient flows across borders are fading as reports show cash strapped hospitals denying legitimate treatment to travellers and migrants.
Despite the increasingly anti EU rhetoric of many British politicians, the UK has a strong track record of complying with EU directives on time, and usually adding to the bare minimums required for compliance. Germany, Belgium and The Netherlands have similar track records, while France tends to pass the laws on time and enforce those areas that are beneficial to the French. Some countries such as Spain have a dismal record, on average being two years past any deadline, passing laws reluctantly and not enforcing them.
Hospitals in Spain, Italy and Portugal are reluctant to honour existing EU agreements on free treatment for travellers. Their logic is “We cannot properly treat our own residents, so why should we treat foreigners for free? “The European Commission is far from happy but there is little in practice that can be done as doctors, hospitals and local politicians are effectively saying “You forced our government to make huge austerity cuts that hurt our people badly and have done nothing to repair the economy, so you must now live with the consequences.”
The chances of cross border directive laws being passed this year – or at all – in Spain, Italy, Portugal and Greece look increasingly slim. And after the recent problems in Cyprus, any law may be irrelevant.
The European Commission has warned Spain that it could take formal legal action, known as an "infringement procedure", after receiving complaints from various EU nationals about the refusal of EHIC cards.
Spain is not alone in blocking EHIC usage. Travellers in Greece and Portugal have also experienced problems. Both countries’ health systems are under pressure following the crisis in public finances.
The Spanish health system is complex. It has state hospitals and private hospitals, and a third hybrid sector, which is run by private management but provides state-funded treatment. The EHIC card may not be accepted in private hospitals but should be valid in the other two categories. Problems of refusal have largely arisen in this third hybrid sector, where the card should be accepted. Worse still, the private managers are increasingly employing debt collectors to pursue outstanding bills after travellers have returned home.
Austerity measures have a devastating impact on healthcare services, resulting in rising xenophobia in Greece and Spain, reports the humanitarian group Doctors of the World.’ Access to healthcare in Europe in times of crisis and rising xenophobia’ covers data collected in 14 cities across seven countries.
Dr Nikitas Kanakis from Doctors of the World Greece said xenophobia and healthcare always go together. In Greece, the entire public health system is under enormous pressure due to austerity measures. In Spain, the government has legally restricted access to care for undocumented migrants. Dr Alvaro Gonzales from Doctors of the World in Spain said that cuts have led to a dismantling and a destruction of the welfare state and the public healthcare system.

Alsace is fast becoming the new spa centre of Europe, both literally and because of the increasing number of hotels offering spa facilities. The region, the smallest in France and situated right in the centre of Western Europe, is home to a new organisation known as “Spa in Alsace”. Seven independently, family run hotel-restaurant complexes, situated all over Alsace, are members of the new organisation. Each of them adheres to a special Spa in Alsace charter covering the quality of the facilities, the treatments provided and the training of spa personnel. All member hotels have restaurants offering menus in keeping with Alsace’s reputation for fine food and serving a selection of the region’s world famous wines.
Members of the new organisation include the Hostellerie des Chateaux at Ottrott Le Haut in the heart of the region and set amongst vineyards and forests. The Pur Attitude spa is dedicated to guests’ well-being and relaxation. A hot sesame oil wrap perfumed with organic patchouli essential oil is a signature treatment of the Hostellerie La Cheneaudiere, a member of Relais et Chateaux chain of luxury hotels. Next year a new well-being complex will be opening to complete the hotel’s existing spa facilities.
At the gateway to the Voges du Nord nature park in northern Alsace, La Source des Sens offers a spa, a Zen garden and sensory trail. Also in the north, La Clairiere bio and spa hotel offers Sassis dei volcano treatment with hot and cold basalt stones. The Hotel Julien and spa is in the Bruche Valley in western Alsace. Next year Hotel Julien will be opening a new spa. The Asiane Spa at the Le Parc Hotel at Obernai offers a mixture of treatments from India, Japan, Morocco as well as Alsace. Les Violettes Hotel and Spa is in the south of the region, midway between Mulhouse and Colmar. The hotel’s LeSpa is naturally Zen, with Swedish massage for total relaxation.

Rwanda wants to become a medical tourism destination to boost foreign earnings. But it has few world-class medical facilities, and those are provided by overseas investment.
Rwanda is revamping its creaking health sector in the hope of attracting African patients from across its borders to galvanize its tourism industry. The tourism sector is slowly growing and the government sees medical tourism as a niche product that could help expand it. In 2012, Rwanda hosted 1,075,829 visitors compared to 908,001 in 2011, which represents an increase of 22%.
“The government is courting investors to set up advanced medical facilities in the country; to help make our country a regional medical tourism hub,” says Rica Rwigamba of the Rwanda Development Board. She is optimistic that tapping into medical tourism would improve foreign currency earnings that are badly needed to bridge the country’s trade deficit, which currently stands at over $1.2 billion.
The Ministry of Health admits it does not know how many Rwandans go abroad for treatment and how much the government loses in foreign exchange as a result. It is not just the medical costs, but also the travel and hotel costs of the patient and any companions.
Rwigamba adds “Medical tourism requires a different approach to attract world class health investors. It is also about wooing people to provide quality medical services at affordable rates. Rwanda is in a good location in terms of climate, security and a quiet environment, which patients need when going through the process of healing.”

Dr Agarwal’s Eye Hospital recently opened its doors in Kigali, making it the first foreign-owned specialist establishment in the country, which is likely to become a regional eye referral centre. The Asian firm has so far invested $6 million and plans to invest more in the next few years. “We have spent time with the ministry of health and Rwanda Development Board to see how we can expand this sector,” explains Farooq Siddiqui of Dr Argarwal Eye Hospital.
The new specialist hospital handles many complicated eye cases that were once referred abroad. The aim of this hospital is to stop any referrals for eye treatment outside Rwanda.
Before Rwanda can promote medical tourism it needs better hospitals, better-trained medical personnel and specialist skills. Above all it needs foreign investors prepared to build and run those new hospitals. It also needs to build confidence in local patients that local healthcare is better than going abroad. There is a shortage of doctors, while waiting time for non-urgent treatment is often long. A substantial number of women leave the country just to give birth. The country has little medical training and no pharmaceutical industry; so it has to import high priced drugs that attract heavy tax duties. State-of-the-art medical equipment is expensive and requires trained staff to operate it, and there are few of either in the country.
For medical tourism to succeed it will need more than a few overseas investors with new hospitals. There needs to be synergy between government, healthcare and insurance providers, industry and academia create a decent local healthcare system before trying to sell the concept to visitors.
Rwanda is never going to attract huge numbers of medical tourists but there has to be an improvement in the local health infrastructure boosted by the public and private investments in specialised hospitals and state of the art medical equipment.

King Faisal Hospital, Rwanda’s leading state-owned healthcare provider, wants to become a regional referral hospital in East Africa and attract patients from Burundi, Congo, Uganda and Kenya. In 2012 the hospital received 3755 foreign patients from across the region and Congo sent the biggest number of 1850.
There is an increased flow of patients to Rwanda. Uganda and Kenya. While the elite may still prefer to travel to Europe for treatment, the rising importance of local culture means that more Africans prefer to seek treatment within Africa rather than go to Asia. Outsiders may dismiss inter-African medical tourism as little more than a fantasy- and although it may take 20 or 30 years to happen- the regional African market will eventually be important. Tourism was once dismissed as a fantasy, but most African countries now do rather well out of a fast expanding tourism market.

Wellness Tourism Worldwide has produced an interesting new report ’U.S. Vacationers: Health, Happiness & Productivity – The Essential Report for Travel, Hospitality & Wellness Industries.’ This report offers a perspective on what American leisure travelers seek, desire and expect during a vacation.
As Americans have increasing challenges to stay healthy, the manner in which leisure time is used is critical to well-being. Vacations offer time to connect, decompress, learn new skills and experience life differently. One of the great challenges in the US workforce is the ability for employees to take a vacation. Wellness Tourism Worldwide believes that promoting leisure travel as a personal strategy for wellness and as a business strategy for economic growth benefits individuals, communities and travel-related businesses.
For any hospitality and tourism business wanting to grow, there is a premium placed on outcome driven programmes and services to improve the customer experience, which are often tied to the guest’s sense of wellbeing. Epidemic levels of stress and obesity, sleep problems and lack of balance between home and work have caused a surging interest in wellness, affecting change in the way hotels, airlines and destinations operate.
Camille Hoheb of Wellness Tourism Worldwide explains, “I have been speaking on the subject now for several years and the report is culmination of research, interviews and a U.S. consumer survey. This report will be of interest to any travel related business interested in attracting U.S. consumers with a specific interest in wellness.
Contents:• Demographics/segmentation: age, sex, marital status, education, household income, residence.• Psychographics.• Travel purchase patterns: how, when, who and what.• Trip planning and trip behavior.• Activity preferences.• Preferred destinations – past and future.• Barriers to travel: domestic and abroad.• Consumer motivations and perceptions.• Role of health, productivity and happiness.• Levels of involvement in wellness activities and overlapping tourism products.

The concept of domestic (within a country) medical tourism is not unique. Leading UK health insurer Bupa is expanding the non-insured self pay surgery, and has quietly been targeting both non-residents in the UK, and people from overseas.

Bupa On Demand is pay as you go private treatment. It is for anyone, not just existing Bupa insurance customers; and people do not even have to have any health insurance. Customers tell the specialist unit what type of treatment they are looking for and Bupa arranges the rest.
Customers get a dedicated personal adviser to explain the steps, advise on any diagnostic tests needed, and provide price certainty once treatment has been identified. They then search local quality checked hospitals and Bupa recognised consultants, and quickly book appointments at convenient times. A 24/7 helpline staffed by GPs and nurses is on hand to answer questions or concerns about medical care. The concierge service guides and supports customers through every stage of the healthcare journey
Bupa On Demand is open to everyone over 18, regardless of whether they live permanently in the UK or not.
Many people travel to the UK to benefit from the excellent healthcare available, and Bupa advisers are familiar with the needs of those visiting the country for medical treatment. Bupa On Demand is a self-pay option for private treatment and is open to international customers or those living in the UK temporarily.
It offers a broad range of private treatments and services to everyone from a hip replacement to a hysterectomy. Popular treatments include maternity care including elective caesarean sections; hernia repair; cataract surgery; varicose veins treatment and hip replacement.
It does not offer cancer cover, but that may be added in the future. At present cosmetic surgery is limited to removal of a skin lesion, but there are plans to offer many more cosmetic procedures.
Bupa On Demand was first launched as a pilot a year ago covering 70 treatments, and has been so successful that it now been increased to over 450 treatments. It effectively functions as a domestic and inbound international medical travel agency, with a quality of service that small medical tourism agencies will struggle to compete with.
Despite limited marketing and advertising, it made 10,000 bookings in the first half of 2013. Many of the procedures would not be covered by most private medical insurances. It particularly appeals to younger and less affluent customers.
The leading British hospital groups have decided to promote self-pay by making it much easier for potential patients to see what price they pay for treatment, with fully inclusive packages increasingly being on offer. Most private hospitals offer all-inclusive prices guaranteed to include all fees, an ensuite room, all medicines, inpatient consultations and aftercare.

The Nuffield Health offering promises to match any comparable price from an alternative private hospital in the local area.

Spire International hospital group has over 50 UK hospitals and clinics that treat more than a million patients a year. The group has a dedicated unit for international patients; Spire International welcomes patients from all over the world and works closely with medical referrers / sponsors including country embassies, country health offices and military offices, sports teams, private corporate companies, companies specialising in repatriation to the UK, and consultancy companies handling international medical care.
Health insurer Westfield Health is supporting a local hospital with substantial donations towards The Children’s Hospital in Sheffield, which needs to raise £20million to support a £40million transformation to provide a world class environment at the hospital, making the hospital even better. The Children’s Hospital is part of Sheffield Children’s NHS Foundation Trust and is one of only four of its kind in the country. More than 245,000 patient journeys are made to the hospital from all over the UK and from overseas every year.
The UK is a ’hidden gem’ of medical tourism, for both domestic and international patients. It has long experience in inbound medical tourism, and despite limited support from tourism and other authorities is a market leader in Europe.

In response to John Connell’s report on the prospects for medical tourism in the Caribbean, The Jamaican Promotions Corporation (JAMPRO) argues that what may be true elsewhere is not true in Jamaica.
Connell argues that plans for medical tourism supported by the "legendary reputation of Jamaican doctors and nurses in the United States, United Kingdom, and Canada,” forget that these doctors and nurses have moved overseas, leaving local skill sets bare. He adds that Jamaican health facilities lack international accreditation and have a myriad of structural, institutional and behavioral barriers that impede the development of high-quality health-service programmes, plus a public health sector that is ailing and creaking.
JAMPRO argues that a viable health and wellness market, rather than medical travel, could be only three or four years away. A JAMPRO committee is expected to produce a concept paper on health and wellness by December 2014.
The state agency points out recently announced investments by American Global and plans by Negril International Hospital to give Jamaica two medical tourism facilities, but not before 2017.
American Global’s plan is to develop Jamaica’s first five-star medical tourism facility in Montego Bay. In the first phase, a 50 to 75-bed facility will offer cosmetic surgery, bariatric services and dental treatment. In the early stages, it will focus on non-invasive surgery and by the fourth phase all procedures planned will be on offer. The project is likely to be completed in four years.
The 100-bed Negril International Hospital aims to provide medical treatment that specializes in emergency care, and surgical procedures. The target is Jamaican nationals, the million tourists that visit Negril each year, and medical tourists. There are no private hospitals in Negril and the Negril International Hospital aims to fill this void.
Connell refers to an existing location – MoBay Hope Medical Centre – as an example of failed cosmetic surgery tourism. Hospiten Jamaica, the subsidiary of Spanish company Grupo Hospiten International, which owns MoBay Hope, says it no longer operates a medical tourism facility. Nicola Francis of Hospiten Jamaica explains,” Medical tourism is not our company’s focus or service offering. Our company assists and cares for clients who are already on vacation here on the island. We do not offer a tourist package.”
Jamaica is more geared up for health tourism than medical tourism. Jamaica Coalition for Service Industries (JCSI), the Jampro affiliate responsible for devising growth strategies for the service sector lists-• 40 independent boutique and private spas in Kingston.• 20 spas in tourism areas.• 25 hotel and destination spas and wellness centres in the larger hotels• 15 other establishments.• Traditional spas including Milk River, Bath, Rockfort and Black River.
JSCI acknowledges that the traditional spas are generally in poor condition and service mainly a small local market rather than health tourists.
Jampro has a target date of 2016 to design the framework for medical tourism and wellness facilities. A JCSI report,’ Three-Year Service Sector Strategies and Expansion Plans” by economist Michael V. Julien in February 2013, indicates there is very little base data around from which to formulate policy.
Following the report, JAMPRO is working on:• The development and adoption of a private hospital accreditation standard and certification system based on international best practice.• Amendments to legislation to oversee medical facilities• Developing medical liability insurance.
Infrastructural improvements, such as the construction of Highway 2000 which links the south and north coast of the island, and the revamping of the island’s airports and seaports, will help the future development of health, wellness and medical tourism.

Thailand needs to be wary of emerging rivals such as Singapore and Malaysia, if it wants to maintain its position as the regional hub for medical tourism in the long term.
Pongsakorn Chindawatana at Bangkok Dusit Medical Services, in a recent speech, warned the country not to become complacent, as local rivals are more than ready to pick up business, “The major barrier is politics. If political demonstrations become chaotic to the point of closing airports, this will undermine patients’ confidence, and they might decide to go elsewhere. So far, there have been no cancellations of trips as the political scenario is relatively calm. But we must keep monitoring the situation closely over the next few months.”
Doctor Chindawatana says that Thailand is second to no other country in the region for the quality of its medical services. The country’s medical advancement is also internationally recognised for its high standards. It is essential for the government and private sectors to make a joint effort to promote this service on the global stage.
Thailand is a hub, but only geographically. So far, there is no clear evidence to show that any country in the region, whether Singapore, Malaysia or Thailand, will succeed in the goal of becoming such a hub permanently. All three nations are still scrambling to adopt marketing strategies to publicise their services and claim status as the regional medical-service destination.
Singapore has a competitive edge as a nation with a high number of Chinese speakers, which makes it attractive to the large number of affluent mainland Chinese. The island nation has earned a reputation for its medical services established by Britain during its colonial period, boosting patients’ confidence. Most important, it has in the past marketed these services aggressively, and could do so again.
Singapore is a rich country that will expand its service regionally, especially into Thailand, by establishing hospital networks or other forms of medical services, after the opening of the Asean Economic Community (AEC) in 2015.
Malaysia, as a Muslim nation, has an edge over Singapore and Thailand when targeting Arab patients.
Thailand has a price advantage that it is often 10% to15% cheaper than those other two nations. But cost savings may not be a key factor for some foreign tourist groups when they decide where to go. They will choose to go to the country where they feel most comfortable, especially in terms of culture and language. Thailand is rich in natural tourism resources where patients can recuperate after their treatments. Friendly service and good hospitality are also magnets.
Pongsakorn made the point that Thailand should keep its focus on the Asian market, which shows big potential, especially after the AEC opening- and not get diverted into trying to attract what may be hypothetical large numbers from the USA or Europe. There is more long term profit to be made in targeting local countries that are far less advanced medically, “The number of people from Myanmar, Laos and Cambodia going to Thailand for treatment is on the rise .We have no need to adjust ourselves much to serve people from Myanmar, Laos and Cambodia because they share similarities with Thai culture."
The Ministry of Public Health has launched its latest medical tourism strategy, a four-year plan to cement Thailand as the leading medical hub in Asia, with a target of annual income of $6 billion per year by the end of 2017. To counter criticisms that medical tourism is taking doctors and nurses away from the public health sector, the ministry plans to train more doctors and nurses to meet public health care staffing shortages.
Medical tourism adds an estimated 0.4% to Thailand’s economy every year, which raises income for the medical services sector, concluded Anchana NaRanong and Viroj NaRanong in a 2011 World Health Organisation study of the impacts of the industry.

The Russian Federation is determined to expand the medical tourism market with a conference to discuss medical tourism having been held in Moscow. 13 countries and over 40 tourism companies were represented. Sergei Shpilko of the Russian Tourist Industry Union says, “Medical tourism is a very interesting direction in the development of the tourist sector, however, it is just beginning to develop in Russia.” Organizers of the conference add, “The goal of this conference is to encourage the development of medical tourism in the Russian market, attract attention of tourist companies to this kind of tourism, promote the expansion of possibilities of rest and treatment for people who suffer from different ailments and need special services.”
According to the UN World Tourism Organization (UNWTO), Russia has the 9th largest outbound tourism market in terms of expenditure, and it is increasing by 14% per annum. MITT, the 18th Moscow International Travel & Tourism exhibition, is Russia’s number one exhibition for the travel industry and one of the top five travel exhibitions in the world. MITT takes place every year in March Last year, the medical tourism sector proved a popular attraction for visitors and it returned this year. The medical Congress, MHTC, complemented the exhibition and featured presentations by key representatives of the sector. Medical tourism is one of the fastest-growing sectors of the Russian travel industry, as the ever more health-conscious population seeks more advanced technology, better healthcare, or faster medical services abroad.
Residents of Ukraine and Russia are choosing foreign clinics for a number of reasons. This includes the continuing growth of medical costs in their homelands, and also concerns over low qualification of the doctors, which leads to uncertainty in the diagnoses and in the quality of the locally offered services. Russians are traveling to Israel for operational and sanatorium treatment of various diseases, which vary from cardio-vascular diseases to oncology, dermatology, orthopedic, IVF, and others.
Although inbound Russian medical tourism is still new, neighbour Ukraine is more developed. Medicare Europe has a new partnership with the largest cardiology centre in Ukraine and Eastern Europe – Kyiv Municipal Heart Centre. Medicare Europe Ltd is a British based medical tourism agency specializing in Central and Eastern Europe. State-of-the-art Kyiv City Heart Centre is the largest and most modern cardio hospital in Ukraine, founded in 2007. The hospital offers procedures including heart valve replacement, heart transplant, coronary bypass, and cardiac procedure for heart and valve diseases. Pavel Oltarzhevskyy of Medicare Europe says, “Ukraine has more than 30 000 medical tourists a year.”

Poland is one of Europe’s most popular medical tourism destinations. Having investigated the potential of American medical tourists, the Polish Association of Medical Tourism (PSTM) has decided that the costs of promoting to the US, compared to the returns, are not worthwhile. So it will continue to concentrate on European medical tourists, particularly those from Germany, Scandinavia and the UK.
According to the Polish Tourism Organisation the number of tourists travelling to Poland is expected to rise by 6% in 2011, from 12.4 million to 13.2 million. The figures come from the World Tourism Organisation. Poland has launched a two-year campaign to promote the country abroad. It will be mainly targeted at Germans, the French and the British. Germans are the largest group of tourists who go to Poland. In 2011, 4.8 million of them will visit Poland, and in 2010 there were three Germans for every British tourist, Britain being the second highest provider.
Within the increased numbers are higher numbers of medical tourists. According to PSTM’s Artur Gosk, 280,000 patients will go to Poland in 2011. "We expect the sector’s revenues to reach PLN 780 million," Both tourism bodies suggest that the political turmoil in North Africa and Middle East, and rising oil prices affecting air fares, will result in more Europeans travelling within Europe rather than venturing further afield.
Medical tourism is to receive financial aid from the Ministry of the Economy as part of support for Polish export products. Subsidies are to come from two sources – a national scheme for the promotion of chosen segments of the economy, equally divided between 15 sectors, giving medical tourism PLN 4.1 million- and a second scheme of PLN 150 million distributed unevenly.
Polish organizers of medical tourism has been looking for partners. In January, PSTM invited representatives of One Global Med, a US agency sending US citizens for medical treatment to South America and Asia. Americans visited Szpital Damiana hospital, Medicover Hospital, Carolina Medical Centre, Mavit Medical Centre, Rehabilitation Centre in Konstancin and the European Health Centre in Otwock. But Dariusz D?browski at PSTM says the costs of acquiring patients from the USA are too high,” American partners expect us to spend US 75,000 per year for promotion”. They also want hospitals to spend considerable sums on international accreditation that most EU hospitals find irrelevant to the EU market. One debate is whether US agencies demand too large a commission from hospitals.

The use of social media and a resurgence in luxury travel are two tourism trends that medical tourism must take note of.

Euromonitor has released a new free white paper by Caroline Bremner, Head of Travel and Tourism.
One of the most notable trends amongst 21st century travellers is an increase in online bookings. The US and Western Europe remained the largest online travel markets in 2012, with online travel sales reaching US$185 billion and US $170 billion, respectively. These same markets will grow at least until 2017. BRIC markets (Brazil, Russia, India and China) are each expected to grow between 10 and 20% until 2017.
Mobile technology has greatly affected travel bookings and will continue to grow, driving the increasingly important real-time social conversation between the newest travelling consumer, the millennial, and consumers and travel brands. Millennials are those born from the early 1980s to the early 2000s- ages from 18 to 35.
Because few are married, own a home or even own a car-they spend their money on other things, of which travel is important.
According to Pew Research Center, 81% of US consumers between the ages of 25 and 35 have smart phones and 37% own a tablet. Marketing strategies must adapt to incorporate gaming, apps and user-generated content to reach this generation, since they are sceptical of traditional marketing.
Collaborative consumption, or the act of consumers and producers coming together through activities like lending, exchange and bartering, is becoming increasingly popular. Tourists are keen to rent less expensive lodging options and homeowners struggling to pay mortgages are more willing to rent their spaces.
Luxury travel has made a comeback. Despite its decline in 2009, luxury hotels and premium air travel grew between 5-10% per year over 2010-2012. With ever-rising annual disposable incomes, middle class consumers are becoming more sophisticated, boosting demand for luxury hotels worldwide. Luxury guests have also embraced technology, with social media playing an important role for brands.
Caroline Bremner comments, “These trends need to be addressed by travel companies to maintain or increase their share in the marketplace. Technology is changing the direction of travel and tourism and it is imperative to capitalise on social media to reinforce a positive brand image, reach key demographic segments and create a conversation with prospective tourists.”
Other research companies have been looking at millenials and some interesting conclusions include-
•40% have no landline phone.
•80% sleep next to their mobile.
•Most will give you personal information-in return for a discount.

– See more at:http://blog.euromonitor.com/2013/11/white-paper-understanding-the-new-21st-century-traveller.html#sthash.BS2bb25c.dpuf

Swiss hospitals and clinics are increasingly looking for patients from countries where the wealthy want high standards of medical care. Particularly attracted to Switzerland are medical tourists from Russia and the Middle East/Gulf States. China and other Far Eastern countries are future targets. The number is increasing, say hospitals, but no exact national figures exist. Up to 30,000 foreigners seek hospital treatment in Switzerland every year, making up two per cent of all patients. A further 150,000 travel for health-spa holidays.
Gregor Frei of Swiss Health says, “There are an estimated 30,000 foreign patients who come to Switzerland every year for medical care, not counting people from the border areas. These customers demand top standards across all medical sectors.” Swiss Health was set up in 2008 by the Swiss trade promotion umbrella organisation Osec, to promote Swiss healthcare providers abroad. Swiss Health encourages its members to increase their visibility through participation in medical conferences – for example in Saudi Arabia, Russian and Oman – and by collaborating with Swiss embassies, chambers of commerce, foreign health ministers and specialists in the health sector. Jérôme Puginier of Ars Medica with two clinics in the Lugano area in the southern canton of Ticino says, “Foreign patients account for more than five per cent of all our customers, a percentage that keeps rising compared with previous years. Our foreign patients mainly come from northern Italy, but for several years the number coming from Russia has been increasing. In addition to taking part in conferences and collaboration with foreign doctors who refer their patients, the best advertising is definitely the excellent service, as happy patients will carry out word-of-mouth advertising among their friends and family, which is efficient publicity. There are two types of health tourism, one based on getting good value for money and the other based on getting the best quality. Switzerland is already known for having one of the best health services in the world – excellent care, cutting edge infrastructure, almost total lack of waiting lists – we must still strengthen this position as a high-level health destination.”
Ars Medica has set up a centre for preventive medicine for foreign clients. The day-long health status assessment includes biological and genetic analysis, diagnostic imaging, functional testing, physiotherapy and dietary consultancy and a final report with personalised recommendations. The basic package costs around SFr3,000.
With rapidly increasing health costs, even public hospitals are seeing the benefits of this lucrative source of income – those in Zurich, Bern, Basel and Geneva are all members of Swiss Health. Conrad Engler from the Swiss Hospital Association comments, “The decisive argument in attracting patients is Switzerland’s leading-edge services, especially in the university hospitals. What counts is the reputation for quality: for example, the international reputation of the oncologist Franco Cavalli brings patients from all over the world to Ticino.”
Private Swiss clinics advertise surgery in in-flight magazines while medical tourism agencies offer a deluxe service covering everything from interpreters to visas. Wellness resorts offer a healthy living experience, involving mineral baths, massage and all kinds of relaxation and beauty therapies. Eveline Lanz Kaufmann author of a 2002 book on wellness tourism in Switzerland, ’Wellness tourism: to decide on how to invest and improve quality’, comments,“ People who come on these visits are not usually ill. On the contrary they are still healthy and feel that they should do something to maintain their health. It is mostly women in the 40 to 60-year-old age bracket although the average age is falling. It is predominantly a German-speaking trend. Most foreign visitors who come specifically for spa breaks are from Germany and Austria.”
Jan Sobhani of medical agency Swixmed explains,"Some people choose Switzerland because they have long waiting lists for surgery in their own country, or they have a good healthcare system which is lacking in certain specialities. This latter category includes increasing numbers of couples coming from Italy for fertility treatment. They like to travel to canton Ticino because there is no language barrier." Agencies find patients through a network of referring doctors, hospitals and health authorities as well as family representatives.

Temos, the German-based quality Certification Company and Turkish medical assistance company Marm Assistance have become partners to co-assess selected private hospitals and clinics in Turkey.
Temos has an expanding quality certification system while Marm Assistance has local knowledge of the Turkish healthcare market. In mixed teams, Marm Assistance doctors and Temos quality experts will visit hospitals seeking the Temos certificates and quality seals on patient care and medical tourism.
In the USA, European quality system DNV Healthcare has been approved by the US Centers for Medicaid Services (CMS) to accredit US hospitals for another six years, the maximum allowed by law.
First approved by CMS in 2008, DNV Healthcare has now accredited more than 300 US hospitals ranging from major urban medical centres to rural critical access hospitals. The NIAHO accreditation standards employed by DNV appeals to a growing number of hospitals seeking an alternative approach to hospital accreditation. DNV is the only programme that integrates CMS requirements with the ISO 9001 Quality Management System. The result is an accreditation process that hospitals find less onerous but at the same time more supportive of their quality and patient safety initiatives.
Yehuda Dror of DNV Healthcare explains, “Our whole philosophy centres on the idea of freeing hospitals to innovate, and to use their own talents to not only comply with CMS but to create continual improvement throughout their organizations.”
Based in Cincinnati, Ohio, DNV Healthcare is part of Det Norske Veritas, a global independent foundation dedicated to safeguarding life, property and the environment. DNV accredits acute care and critical access hospitals, and also provides specialist primary stroke centre certification.

Mount Sinai Hospital in New York City is the latest to get Medical Travel Commission international patient certification, as the hospital’s international patient services department seeks to attract more overseas medical tourists. In addition to providing high quality healthcare, it offers international patients seeking medical treatment concierge services that include travel and visa coordination and translation services. Mount Sinai’s new premium patient floor Eleven West offers hotel-level accommodation with gourmet meals in private rooms and suites with 24-hour concierge service.

Austerity measures are harming EU economies and seriously damaging public health, says influential European health group European Health Forum Gastein.
This is important for medical tourism as it confirms other evidence that millions of Europeans are struggling financially so are delaying medical treatment, dental treatment and even buying medicines.
As the public supply of health care decreases, the private health industry can step in to fill the gaps. There is evidence that those who can afford private healthcare are increasingly doing so across Europe.
Professor Martin McKee of the London School of Hygiene and Tropical Medicine told the forum “Europe’s politicians have to realise that stringent austerity policies are harming their economies as well as the health of their populations.”
There is growing evidence of the direct negative effects the crisis and austerity policies are having on people’s health and healthcare systems, said McKee, who is finalising research on the impact of the economic crisis for publication later this year.”
Professor Helmut Brand added “The subject of health is given much too little attention in the discussion of the financial and economic crisis. But it could offer a window of opportunity at European and at national level to implement reforms that would otherwise not be possible without the crisis, including a reform of the EU health mandate.”
In many European countries, austerity measures are having a dramatic effect on health budgets. The current OECD Health Data 2012 report shows that, in 2010, after years of increases in health expenditures, deep cuts were made in a number of European countries: minus 7.6% in Ireland, minus 7.3% in Estonia, minus 6.5% in Greece. Other studies show a 25% reduction in the health budget in Latvia between 2008 and 2010, and a cut of 30% for the Czech Republic.
The cuts on 2011, 2012 and beyond are much more severe than in 2010, with some counties looking to cut health expenditure by 20%.
It also effects who is entitled to local healthcare. Spain has used a royal decree to change entitlement to health care from residence to employment. Thus young people who have never been employed – as is the case with almost half of all youth – and undocumented migrants risk being excluded from healthcare.
In Portugal increases in the rate of co-payment for many services has meant the cost of attendance at an emergency department in a major hospital has doubled to 20 Euros. Initial reports indicate that the death rate began to rise at the beginning of 2012 as a result of this measure.
In Italy a reduction in the number hospital beds from 4.5 to 4 per 1,000 population has been introduced, while co-payments are now required for visits to a specialist or an emergency department.
Professor McKee concludes, "Some of the measures that have been taken to reduce health expenditures in response to the crisis can be justified, where they have streamlined a previously inefficient system. However, in many cases, such as the introduction of co-payments, where there has been a failure to discriminate between medically necessary and unnecessary utilisation, reforms are not supported by evidence. The full consequences of the various cuts in health care systems can still not be properly foreseen. But it is clear that people with chronic illnesses, such as hypertension, diabetes or cancer are being particularly affected. A breakdown in the supply of essential medicines could be fatal. The silence from health ministers on the human consequences of austerity is shocking.”
Health services in Europe need to have greater private sector involvement said Antonio Durán of Técnicas de Salud, "It is unlikely that European States will be able to fund healthcare systems – including new required capital investment – as they have in recent decades. The limits to the direct state provision of health care are marked by the limited investment capacity of governments, in particular in situations of tight budgets and fiscal crises. The public sector needs to concentrate on what it does better: financing and regulation. A majority of funding should be public in order to promote equity. The future health system function may be substantially, but never only, private. Service provision finally may be privatized extensively if socially agreed and if adequate regulation is provided."
Dr Thomas Czypionka, of the Vienna Institute for Advanced Studies, added, “Pressure to cut costs in times of recession can create opportunities to accelerate reforms in the health sector. Demand for health services does not depend on the economy. Crises can mean that change has to be implemented which might otherwise not happen till years later. But many European countries have reacted by simply making cuts, even abandoning reforms which had already been put in train, or increasing the burden on individuals for using basic services, either by imposing extra costs or lengthening waiting-lists. The consequences will be felt for many years to come.”
Five trends will cause a complete revamping of hospitals in the near future: concentration on the patient as a whole instead of on individual organs, a multidisciplinary approach, continuous care and system integration, and the search for interventions that are highly effective despite involving minimal resources. Health care systems in many countries around the world are facing a sea change. Many changes will be evident in hospitals over the next five years.
Dr de Roodenbeke explains: “Until now we have concentrated on treating individual organs or diseases. An approach focusing on the condition of the patient as a whole is more effective and more affordable in the long run. The emphasis in the future will also be on greater continuity in health care, on many areas of specialization collaborating together, on the integration of different systems and on services involving maximum effect and minimal costs. The hospitals that make progress with such measures will fare the best in the long run whereas those whose areas of specialization continue to work on parallel tracks without cooperating will suffer from the changes.”
Understanding what is happening within Europe is vital for medical tourism agencies and hospitals to decide what they offer, to whom and where.

Iran has become a destination for Omani nationals needing medical treatment. The number of Omanis visiting Iran for medical tourism is on the rise with 5,000 Omanis seeking treatment in the country every year, according to the Iranian Embassy in Muscat.
A third of Iranian visas issued in Muscat are for medical tourism. Abdul Majid al Borzi of the Iranian Embassy in Oman explains, “We offer care at a fraction of the cost when compared to other destinations. GCC nationals who were previously seeking treatment in Europe, South Asia and South East Asia are being drawn to Iran. With daily flights from Muscat to Tehran, an express service at the embassy which issues visas to Omani nationals in a day or two at the most, increased interest from travel agents who specialise in medical packages and an abundance of top level medical specialists in Iran, the statistics from our visa section show a sharp increase in applications for medical reasons.”
Iran has seen a noticeable increase in Omani patients in Iran. In the past, the majority of GCC patients went to Shiraz for eye surgery as it is closer to the GCC than Tehran, but by promoting Iran’s medical capabilities in different fields and facilities for Omani patients, there has been an increase of patients in Tehran and Mashhad.
Iranian hospitals that hold a medical tourism license from the Ministry of Health arrange airport transfers as well as accommodation. In addition, a nurse can be assigned to each patient.
Shookoofeh Dehkordi for the private Moheb Hospital in Tehran adds, “ In addition to the GCC, many patients come from Azerbaijan, Turkey, Iraq and India. Iranian ophthalmologists are renowned throughout the region, we also have speciality services in cardiology, kidney transplants, urology and general surgery.”
Moheb Hospital is an Iranian pioneer in treating foreign patients as a planned service. Since 2004, there have been patients from overseas for kidney transplantation and urology non-invasive surgeries. After a while, Moheb increased the range of services. In Iran, private kidney transplants are legal.
Iran accepts that is pointless trying to attract Americans or Western Europeans. Pressure continues to mount on Iran over its nuclear programme; and the presence of US and EU warships off the coast, is hardly conducive to attracting American or European medical tourists.

A tourism minister in Indonesia has stated that Indonesia has the potential to become a health tourism destination. Yet in 2012, a record number of 600,000 Indonesians travelled overseas for medical treatment. Two out of three go to Malaysian hospitals and clinics. This makes Indonesia the biggest outbound global medical tourism country source.
The number of Indonesians seeking medical treatment abroad in 2012 saw a significant increase from 2006 when nearly 350,000 people went overseas and spent $500 million. In 2012, it is estimated that 600,000 Indonesians spent $1.4 billion on medical treatment overseas. The increase suggests that they go overseas for quality and availability of care as much as for cost reasons. This is why the key destinations are Malaysia and the now high priced Singapore, with very few going to low priced India.
While Singapore is still a favourite medical destination for the well-heeled Indonesian, the majority of Indonesians, especially from Sumatra favour Malaysia. Indonesians from Sumatra form the majority of overseas patients at Mahkota Medical Centre in Malacca and Penang Adventis Hospital. The Malaysia Health Travel Council (MHTC) website is available in Bahasa Indonesian, and Malaysia targets the country.
Tourism minister Mari Elka Pangestu claims that Indonesia can become an international health destination because of its abundant natural beauty, with a huge potential to attract tourists looking for low-cost health and medical care, “Indonesia’s potential to become a health tourism destination is big because Indonesia has many attractive places. Indonesia has geographical proximity to many wealthy countries, such as Australia and China. There is much local and traditional wisdom on healing all measure of ailments. Indonesia has been named as the best spa destination in the world. A well-established health tourism industry can bring in revenue not only from foreign health tourists but also from our people who travel abroad to seek medical treatment.”
The response of health minister Nafsiah Mboi to the record number going overseas for medical treatment was, “We will start with action. We will immediately set up working groups and an action plan. The government has identified four hot spots in which to begin developing health tourism: Bali, Jakarta, Makassar and Manado.The four areas were chosen not only because the health facilities there are already advanced but also because there are many things to see. As well as spas, Indonesia also has potential in the medical sector. The country boasts many specialist doctors with good international reputations, but many people are not aware of that due to a lack of promotion. To attract patients from overseas, the government will have to collaborate with travel agents and increase cooperation between hospitals, clinics and spas. More Indonesian hospitals need international accreditation from the Joint Committee International.”
If medical tourism potential is large, why are 600,000 Indonesians going overseas? Nafsiah Mboi’s answer is: “Attitudes need to change so that those Indonesians seeking medical treatment will make the effort to find that treatment at home. I often wonder why Indonesian people like to get check-ups in Singapore. What is it that we don’t have? It turns out the answer is because of the service and the mental attitude. We don’t have any pride to serve. In Singapore, doctors are willing to spend time to listen to patients’ complaints and discuss the various medical procedures that are available.”
The Ministry of Health and the Ministry of Tourism have signed an agreement for the development of health tourism. The government will work with public and private stakeholders, including hospital representatives, spa providers, and health associations, to create the Indonesia Wellness and Healthcare Tourism (IWHT) working team, which will jointly design a work plan to follow up the agreement.

On February 28, the European Council formally passed the draft directive that gives medical patients the mobility to seek cross-border health care from other EU states, while still receiving compensation through their own national health care system. The Council approved the amendments made by the European Parliament.
In line with article 294 of the Lisbon Treaty, the cross-border healthcare directive has now been adopted. Member states will have 30 months to transpose the directive’s provision into national legislation. The new directive provides clarity about the rights of patients who seek healthcare in another member state and meets the Council’s wish to fully respect the case law of the European Court of Justice on patients’ rights in cross-border healthcare while preserving member states’ rights to organise their own healthcare systems.

The Lanka Hospitals Corporation is looking to increase capacity and expand into regions beyond Colombo. It is also exploring partnerships with investors. Lakith Peiris of Lanka Hospitals says, “Capacity increase at the current premises is being discussed and we will add 100 more rooms and new theatres and clinics this year. We are discussing with other parties and investors the possibility of partnerships or joint ventures to build new hospitals in the country. These discussions are at the early stages and we are still exploring the possibilities. On April 1 the first preliminary care centre will be opened in Malabe. This will house an outpatient department, laboratory, pharmacy, emergency care and also preliminary care. We will open six such centres in the Colombo suburbs this year.”
The hospital has plans to open an international patient care centre in a bid to cater to foreign patients. It will start to promote medical tourism this year, as it believes Sri Lanka is well on its way to be recognised as a medical destination. The former Apollo Hospital was rebranded as Lanka Hospitals in November 2009.
Another company believes that the country has potential. Ashok Pathirage of Softlogic Holdings adds, “ Sri Lanka has a well developed healthcare sector and the country should promote health tourism where there is a huge potential in the international market. The country’s medical sector is highly qualified and is capable of providing specialized treatment. Sri Lanka could be promoted as a health tourism destination with the expected influx of tourists. We could offer specialized services as the country has international standard hospitals and medical staff. Not only ayurveda treatment but western medication could be provided for the foreigners thereby earning foreign exchange. The focus should be to become a treatment centre similar to services offered by Singapore. The authorities should encourage modern private healthcare institutions to attract foreign patients. The sector needs incentives to upgrade its hospitals to be on par with international standards.”
Local conglomerate Softlogic Holdings plans to set up a state-of-the-art hospital in Kandy with a substantial investment. This hospital is at the design stage and will have 100 beds. The fully equipped hospital will be ready for the public in 30 months. The company also plans to set up a specialist cancer treatment centre and negotiations are currently underway. The company is getting ready to cater to the international market. Softlogic acquired shares in Asiri Hospitals in 2006 and in Asiri Surgical Hospitals in 2007.It has now controls the Asiri group of 4 hospitals consists of 4 hospitals and the newly planned one will be the largest private hospital in Colombo.

The number of Russians going to Finland for medical care or a wellness holiday is expected to increase substantially in the next few years.

Finpro has launched Finland Care to promote health tourism from Russia to Finland. It also seeks opportunities for Finnish companies to offer healthcare services in Russia.
Finland Care is implemented by Finpro’s office in St. Petersburg. Finpro is a public-private organization, part of the ministry of employment, seeking to promote the internationalization of Finnish companies and foreign investment in Finland.
Recent interest in Finnish health care and its export potential has brought new players in the sector. New companies have been set up specifically to provide travel arrangements. One of them is a health broker Nordic Clinic, established to develop a health-oriented tourism to Finland. It owns a healthcare hotel in Helsinki. The number of patients from Russia is set to increase greatly within a few years and health tourism in Finland will be a booming business, according to Tero Silvola of Nordic Clinic. "It is now predicted that over the next ten years the Russian healthcare market will grow. Private markets can grow up to three-fold from the current level. In the market in question there is not a great deal of trust in the quality of health services, and a large part of that demand will turn to the Nordic countries."
Every year, thousands of Russians seek treatment abroad and the number is expected to grow. A recent Finpro survey showed that at least 100,000 Russians went abroad in 2011 to seek treatment; but only 1,000 sought treatment from Finland.
The key problem highlighted by Finpro was language and unless advertising, marketing and all contact are all in Russian, then the Russians will not go to that country. Eero Toiviainen of Finland Care explains, "One big obstacle has been language. The problem has largely been remedied, as more health care providers add Russian language skills to their repertoire.”
The Russian language website of Finland Care aims to attract Russians to Finland for treatment. The website acts as a platform for any Finnish company seeking to offer Finnish private treatment, care or welfare to Russians.
Partner companies already signed up to Finland Care include; Docrates Hospital, Orton Orthopaedic Hospital, Hospital Neo, Heart Center Tampere, Ovumia, Coxa Hospital, Nordic Clinic, Clinic Helena, Hyksin, Arte-Doctors, and Med Group.
Specialist cancer treatment is offered at Docrates Hospital in Helsinki. Orton Orthopaedic Hospital in Helsinki and Hospital Neo in Turku offer orthopedic treatment. The Heart Center Tampere University Hospital specialises in heart disease. Ovumia is a private fertility clinic in Tampere. Coxa Hospital in Tampere specialises in joint replacements. Clinic Helena is a specialist breast cancer clinic in Savonlinna. Hyksin is a new company that is offering a wide range of private treatment from 2013 at the University Hospital of Helsinki for patients from Russia, Sweden and the UK. Arte-Doctors runs clinics in Lahti and Heinola.Med Group has five dental clinics.
Hospital Orton has brought foreign patients to Finland since the 1990s. The overwhelming majority come from Russia. The number of overseas patients has risen steeply in the last few years. Juha Aarvala of Orton comments, "In the last three years the number has grown 60 to 70 % each year. The impact is around 5 to10 % of our turnover. The need and potential is noticeably bigger than what we have at this moment realised."

A new Buffalo based medical tourism agency is the latest to target Canadians seeking healthcare in the USA as lengthy wait times force more and more people south of the border for treatment.

Cross Border Access has been helping Canadians book appointments and negotiate fees for a variety of procedures in upstate New York since May. Unlike most rival Canadian or US based agencies, this US agency charges a $200-a-year membership fee and connects patients directly with service providers, rather than taking a cut of the fee paid to the hospital, getting an introduction fee from hospitals, or charging commission on top of the hospital fee, based on the amount paid.
Company founder Ed Meyer says, “Because of our experience in the American health care delivery system, we can do a better job of getting good prices and screening the provider to make sure they are qualified. As U.S. healthcare is a free-market system, the same diagnostic imaging scan can cost anywhere from $900 to $2,000. Most Canadians may not know that these great price differentials exist as they are focused on alternatives to waiting months for a CT scan, cancer treatment or knee replacement in Canada.”
Cross Border Access has relationships with diagnostic facilities, hospitals and physicians in Buffalo and Niagara Falls, New York, and targets Canadians from southwestern Ontario and the Toronto area seeking quality affordable care. Ed Meyer says, "We don’t take any money from health care providers in the U.S. and we don’t give any money to Canadian health care providers who refer patients to us. Our only source of revenue is the membership fees from patients so we don’t get into any ethical grey areas about sending people to specific providers or facilities."
A competing agency Timely Medical Alternatives of Canada makes its money by charging a markup and pays Canadian doctors for referring patients. Richard Baker explains, “This is done in the best interest of patients -and doctors who do not want the marketing fee — about $1000 for a hip replacement patient, for example — can have it donated to a medical charity of their choice. A lot of our business comes from doctors who refer their patients to us because their hands are tied as far as being able to get them surgery." The agency has helped thousands of people secure treatment since opening for business in 2003, most of them from Alberta, British Columbia, Ontario and Saskatchewan. The agency has partnerships with 22 hospitals in 10 US states and because the agency pays them directly for medical services up front, they are happy to get business they would not otherwise receive and offer their best rates. Timely Medical Alternatives do not charge a separate fee for their services and says, “ In almost every case, the care giving facility pays our fee and, in fact, we rebate a portion of our fee to our clients. There are surgical facilitators within Canada, who charge up to $180/hour for their time. This is on top of the cost of the surgery .we are NOT one of these firms. The exception is for urgent procedures, which are not elective such as cancer treatment, and cardiac procedures. We are frequently asked to expedite these procedures in the US-which we can certainly do. The reality is, however, that in many provinces, these procedures are readily available with short waiting times. Almost invariably, once we have organized treatment for these clients, they obtain a date in the public system and cancel their US appointment. Overtime, our US providers have come to take our requests for cancer or cardiac procedures less seriously. For this reason, we have had to put in place a $500 advance payment charge for requests of this nature. Should the US procedure take place, this pre-payment is credited to the cost of the procedure.”
Some Canadian doctors and organizations are concerned at the growth of agents targeting Canadians, particularly if offering innovative techniques in South America that are not approved in the USA or Canada. They accuse agencies of exaggerating the waiting times and problems of Canadian healthcare, and have concerns about continuity of care and the appropriateness of treatments.
While some agencies are well-run businesses, people desperate for treatment that they cannot get or have to wait a long time for in Canada, are vulnerable to rogues. Some new agencies simply fail due to lack of business, leaving hospitals and patients out of pocket.
A more extreme case is of a short-lived agency, where Windsor police are investigating the founders of short-lived agency EcuMedical Resources International that closed without warning, leaving behind a still-furnished office. The police press release says, “A Windsor couple is facing numerous fraud charges after a lengthy investigation conducted by the Windsor Police Financial Crimes Unit. A cheque had been written by the owner of Ecumedical Resources International (ERI) to a Michigan hospital for medical services provided to a patient. The financial institution reported that the cheque had returned NSF and that the cheque had been written on an account that had previously been closed. A local media outlet reported that a woman had paid ERI over $19,000 for medical treatment she had received at a hospital in Michigan. The woman learned that ERI had not paid her medical bills and presently, the hospital is seeking payment from her. To date, seven victims have contacted the WPS Financial Crime Unit to report similar occurrences involving failed payment by ERI to medical facilities in Michigan. ERI functioned as a go- between service for Canadian patients seeking health care in the United States but primarily in Michigan. ERI would arrange for medical procedures for their clients and in turn, their clients would pay all medical fees in advance to ERI including ERI’s 40-50% fee. The clients were assured by ERI that the fees paid would cover the costs for their treatment in the United States. Clients of ERI are now receiving invoices from medical practitioners and hospitals located in the United States as a result of ERI’s failure to pay as promised. These clients are not only subject to the loss of money paid to ERI but are now facing medical bills from creditors on behalf of the Michigan medical facilities. Tracy Bevington and Deborah Bevington are charged with six counts of fraud over $5000 and two counts of fraud under $5000."

In the tiny country of Luxembourg, 5% of residents, five times the European average, prefer to receive medical treatment across the border. By 2013, it is predicted that some 25,000 Grand Duchy residents who are regularly treated abroad will have an easier life if the European directive on the application of patients’ rights in cross border health care has then become national law everywhere.
If prior authorisation from a Luxembourg medical professional remains mandatory, the state’s insurance is obliged to reimburse medical costs, but only to the pre-determined maximum amount. For example, treatment in France might cost half of what it costs in Luxembourg, but travel expenses could bring the total to a similar figure. It is assumed, based on this, that Grand Duchy citizens who travel abroad for treatment are usually seeking long-term or complicated procedures.
The lack of a national health scheme has dramatically reduced the number of Cypriots who could benefit from the EU directive on cross-border healthcare. National politician Athena Kyriakidou says the directive is of vast importance and offers a legal framework for the protection of patients’ rights, in the event that they opt to seek treatment abroad. “All member states are obliged to implement this directive within 30 months from when it is approved by the European Commission. We must implement it as soon as possible so we can re-evaluate it and improve any inefficiency that may appear. We could create a strategic alliance with local private hospitals so that patients can opt for treatment locally, meaning money does not have to leave the state. Patients on long waiting lists, as well as those seeking specialist treatment that is not available in Cyprus, stand to benefit the most. However, only those who are entitled to free health care in Cyprus will be able to seek free treatment abroad.” Fellow politician Stella Mishaouli adds, “Not all Cypriots will benefit from this directive, because we are the only state in the EU that does not have a NHS. So not all Cypriots are covered through the directive, only beneficiaries to free health care. Others will need to be approved by a special ministerial committee, in order to seek treatment abroad. If the criteria isn’t fulfilled, they will have to be treated locally.”
There are mixed reactions among Slovenia healthcare institutions to the recent adoption of a EU cross-border healthcare directive paving the way for EU residents to seek health services in any member state. The Health Ministry views the directive as an opportunity for Slovenian health institutions to gain business.
The Committee of the Regions (CoR) is calling on the European Commission to come forward with formal proposals for simplifying the rules that determine how regional and local authorities can establish a joint secretariat to manage common projects and public services across borders. Since 2006, neighbouring regions in different member states have been able to set up a joint entity with a legal personality using a unique instrument called the European Grouping for Territorial (EGTC). 16 EGTCs have already been set up in European border areas- including between France and Belgium (Lille-Kortrijk-Tournai), France and Germany (Strasbourg-Ortenau), or Spain and Portugal (Galicia-North of Portugal). Supporters of EGTCs claim that closer cooperation among neighbouring authorities can encourage economic development and bring real benefits to people living in border regions. The existing partnerships are already managing joint projects and delivering healthcare services. Mercedes Bresso, of the Committee of the Regions (CoR) says, "National borders should not be an issue when two neighbouring regions want to run a hospital together."

Reproductive tourism, people crossing international borders to purchase assisted reproductive technologies is a multi-million dollar industry. But there are legal and ethical problems when citizens of wealthy countries travel to poorer countries to purchase the services of a surrogate mother.
The fastest growth country for ART, and certainly the largest market for providing surrogate mothers is India. Some reports value the Indian ART industry between $500 million and $3 billion.
In an academic paper, "Ethical concerns for maternal surrogacy and reproductive tourism" in the Journal of Medical Ethics, Professor Raywat Deonandan of the Interdisciplinary School of Health Sciences at the University of Ottawa, with students Samantha Green and Amanda van Beinum, identify specific ethical challenges posed by this emerging new industry.
The authors identify the tension between business ethics and medical ethics as being at the heart of the industry’s ethical problem, along with an insufficiently broad definition of “informed consent.” When desperately poor, illiterate and vulnerable village women are entering into complicated contracts to sell their reproductive health to wealthy foreigners, some physical and social risks are not fully communicated to them, such as their risk of estrangement from their communities, or the risk of domestic unease with their spouses and existing children.
The research points out that there is no ethical framework for establishing rights and responsibilities; In a business deal each party is only concerned about their own best interests only; but in a a medical deal, the clinic is morally responsible for everyone’s interests, including both the surrogate’s and the client’s.
The extent to which Indian ART clinics cater to the needs of non-Indians has always been difficult to determine, as is any sort of measurement of how many foreigners travel to India specifically to seek out ART services, especially maternal surrogacy services.
In another recent paper, “Measuring reproductive tourism through an analysis of Indian ART clinic websites” in International Journal of General Medicine, Professor Deonandan and students Mirhad Loncar, Prinon Rahman and Sabrina Omar analyzed the official websites of 159 Indian ART clinics to determine how many were actively seeking a foreign clientele. 86% of the clinics made some mention of reproductive tourism services, with 47% offering surrogates to clients.

According to Awni Bashir of Jordan’s Private Hospitals Association (PHA), "Patients from 102 countries went to Jordan for treatment in 2010. The number of Arab and foreign patients who received treatment in Jordan increased by 10 % in 2010 compared to 2009, to 230,000.The medical tourism industry’s potential for growth is limited by the number of hospitals in the country. Available hospitals cannot cope with the rising number of patients seeking treatment in the country, and there is a need for more investment in the sector. There are just 61 private hospitals in the country with only two more under construction. The lack of a medical accountability law means US health insurance companies will not refer patients to Jordanian hospitals. We treated patients from the US last year, but they came personally without being referred by insurance companies.
A draft medical accountability law for Jordan was formulated in early 2010, but has yet to be forwarded to the Lower House for consideration. According to the latest report issued by PHA, medical procedures on Arab and foreign patients included organ transplants, open-heart surgeries, infertility treatment, laser vision corrections, bone operations and cancer treatment.”

MASholidays, the travel arm of Malaysia Airlines is expanding its health screening packages currently offered to customers through an existing collaboration with HSC Medical Center, a diagnostic centre in Ampang, Malaysia.
Under the new arrangement, HSC will offer executive health screening, heart screening, heart and stroke screening, and heart, stroke and cancer screening options to MASholidays at attractive rates. MASholidays will then incorporate these screening programmes into its all-inclusive travel packages and promote them to customers who wish to experience Malaysia’s affordable world-class medical facilities.
HSC Medical Center (HSC) is one of the few centres in the world to have designed and offered comprehensive health screening packages for heart diseases, stroke, and cancer, to detect some of today’s life threatening diseases. HSC also provides advanced medical and cardiac therapeutic services, such as coronary angiogram, balloon angioplasty, and stent implantation.
Through these packages, Individuals will be given a choice of economy or business class return travel exclusively on Malaysia Airlines, 3 nights’ accommodation in a 3 to 5-star hotel, daily breakfast and a roundtrip private transfer from the hotel to HSC for the free health-screening. This package includes a preventive care programme.
Dr. Amin Khany of Malaysia Airlines explains, “MASholidays introduced a health screening package in 2005 with HSC Medical Center as an expansion of the Malaysia stopover programme. Healthcare is now more affordable in Asian countries and Malaysia boasts a high number of specialists with extensive international qualifications. This is the national carrier’s contribution to make Malaysia the preferred medical tourism destination”. Dr. Lim Yin Chow of HSC Medical Center adds, “In spite of being one of the established healthcare industry players in the country, we realise that in order to grow, we have to take advantage of the booming international medical tourism market. This partnership between a Malaysian private medical centre and an airline marks a significant development in HSC’s effort to reach out to medical tourists from around the globe, in line with the government’s effort to develop Malaysia into a global medical tourism hub. Since moving to our own building in early this year, we have put in place various mechanisms to cater to international patients. HSC is just 1 hour away from Kuala Lumpur International Airport (KLIA) via a direct highway. This makes us a fitting and convenient medical destination for foreign patients travelling with Malaysia Airlines.”
The deal is in line with the Ministry of Health’s aim in becoming the leader of healthcare services destination in the region. The Malaysia medical tourism industry’s revenue is anticipated to grow by 16% a year between 2011 and 2014.
TMC Life Sciences is targeting medical tourism to be a major contributor its revenue in the next three years as it seeks to become profitable. The group is targeting medical tourists and wants them to account for 30% of its patients within the next three years. TMC Life Sciences is offering a range of services from diagnosis to cardiac and orthopedic surgery. The group expects the 30% to contribute 40% of TMC’s revenue. At the moment, less than 5% of TMC’s patients are foreigners, and it has been making losses over the last 2 years.
The target markets are Indonesia, Bangladesh, and Indo-China, mainly using TMC’s flagship hospital, Tropicana Medical Centre in Kota Damansara. The hospital is 15 minutes away from the Sultan Abdul Aziz Shah Airport in Subang. Tropicana Medical Centre has 120 beds and is adding another 30. It has an international patient centre (IPC) with staff fluent in English, Chinese, Tamil and Malat, while interpreters for other languages can be pre-arranged.

Medical service providers, hotels and travel agents are establishing their own association to develop and promote Thailand as a medical tourism destination, and particularly to attract medical tourists from high-spending markets including the Middle East, Russia, Western Europe, China and Japan.
Prapa Wongphet, president of the Thailand Medical Tourism Cluster, who will become president of The Thailand Federation of Medical Tourism Association, explains that the association which is in the process of being registered with the Commerce Ministry, will be officially launched by the end of this year, "We are now ready to move forward after working closely with our partners to design the master plan to develop and promote Thailand as a world-class medical tourism destination."
It will take over from the Thailand Medical Tourism Cluster that was set up a year ago by the Institute of Small and Medium Enterprises Development, and now has 15 travel and medical services associations as members. Among the cluster’s membership are the Thai Hotels Association, the Society of Aesthetic Plastic Surgeons of Thailand, the Thai Clinical Physicians Association, the Association of Thai Travel Agents, the Thailand Incentive and Convention Association and the Thai Spa Federation. The major stakeholders in medical tourism, the hospitals, have joined forces with supporting organizations, including hotel/rehabilitation facilities, travel agents, nurses, ambulance operators, medical specialists, Thai traditional medicine specialists, spa operators, and the Translators and Interpreters Association. Government agencies and educational institutes support the collaboration. It aims to enhance the quality of medical tourism in Thailand and assist foreigners seeking medical services in Thailand.
Under the promotion plan, the cluster had organised business matching between local medical service and tourism operators and overseas travel agents and insurance companies, especially from Russia, Iran and China. Producing booklets and conducting road shows in key markets also formed part of the initiative. The new association plans to build on this good start.
Prakit Chinamornpong of the Thai Hotels Association says that better-promoted medical tourism will enable hotels and other accommodation businesses to enjoy longer stays by foreign visitors who want to travel and experience Thai hospitality as well as receiving medical treatment or being a health tourist. The Tourism Authority of Thailand says medical tourism is an area where visitors tend to spend more and stay longer than normal tourists.
Although recent flooding has caused problems in and North of Bangkok, it is likely to cause local difficulties only for a few weeks.

Although each country can only count the number of true medical tourists, (excluding treatment for holidaymakers, business travellers, expatriate workers and spa/health tourism) each year as a few hundred, both Australia and New Zealand remain hopeful of attracting medical tourists. Current estimates for New Zealand are around 500 to 700 people a year, mostly from nearby islands with poor medical facilities. The only real attempt at estimating Australian figures came in a report from a now defunct organization that made a rough guess at 7,000 a year, but could neither define what they meant as a medical tourist nor provide any basis for that figure; industry information suggests the real numbers are much lower.
The global recession has hit both countries hopes of attracting medical tourists in real numbers, as their prime target market of the USA has been the worst hit economically. Attempts to build the market are driven in both places by a handful of pioneers and believers, as neither government has shown any inclination to promote or invest in their country as a destination. In New Zealand, no official body, and few hospitals, have shown any interest in even discussing medical tourism. In Australia, efforts have been driven by Matt Hingerty of the Australian Tourism Export Council, “We have contended for a long time that the service of health is globalising, and if we do not play in that space then we are going to lose our best people offshore.”
Australian health professionals have been one of the loudest critics of medical tourism, with regular protests about the risks of people going to Malaysia, Singapore and Thailand for dental and cosmetic surgery at much less than they pay in Australia. This makes it difficult for any medical professional to support those who now argue that the future for Australian inbound medical tourism is the Asian middle classes seeking elective and cosmetic surgery. Australia’s pitch to the Asian market is based on promoting superior health care, which is in itself particularly difficult to support in comparison to Singapore and the chance to recuperate on holiday. Australia is more expensive than the Asian countries it wants to attract business from. The Singaporean government has poured large sums into building the infrastructure and marketing medical tourism, the Australian government has not invested in developing an Australian industry. Another problem for Australia is that one area where is well regarded is cosmetic surgery, is a key market for those very same Asian countries it targets. A recent press report claimed that a leading proponent of medical tourism in Australia believed that Singapore has reached its capacity so Australia should be positioning itself to capture the medical tourists Singapore can no longer accommodate. There is no evidence of capacity problems in Singapore as the country is rebuilding inbound numbers as the global economy recovers. Australia does have one niche, including in vitro fertilisation (IVF), where it is held in high regard worldwide. Matt Hingerty believes that Australia’s climate and landscape make it an attractive destination, “We have spare capacity in our private health system. We have world-class medical specialists in a range of fields, a clean environment, an open economy, a well-understood legal system and we are a safe destination.”
A medical tourism agency set up to promote New Zealand as a destination for medical tourists is using backing from Sir Stephen Tindall to attract Americans with healthcare prices at what it claims are as little as a third of what they pay in the United States. Medtral has opened an office in California and began a marketing campaign targeting Americans in search of cheap elective surgery through Auckland-based Ascot Hospital and Clinics. A heart bypass is on offer via Medtral for US$37,000 including flights and insurance, as little as 30 % of the cost of the procedure alone in the United States, according to the firm’s promotional material.
Sir Stephen Tindall bought a 25% stake in Medtral last year via his angel investment company K One W One. Edward Watson of Medtral says, "Stephen Tindall is an investor with a long view. To have any chance in the States, you need a long-term view. We have struggled to get much traction in the United States since launching before the global financial crisis, with the battle compounded by healthcare reforms. The environment has been extremely difficult – people are switched off and more worried about keeping their own job." With a new office in California, Medtral is making a new push to attract hundreds of patients to New Zealand, from the current handfuls. The most it thinks it could cater for is 5,000 a year. Medtral’s California unit, Ascot Hospitals International, offers self-insured American businesses a free review of their elective health benefits packages in a bid to attract patients to New Zealand, and is promising to lock in savings of as much as 40 % for 12 months, including travel and accommodation. Medtral promotes ”High quality, affordable medical tourism and treatment in a first world, English speaking country.”

Mercury Healthcare International (MHI) has selected Practice Fusion, the fastest growing electronic medical record community in the USA, for its electronic medical records system within its globally integrated health delivery system.
Electronic medical records used properly with other information technology can improve communication and patient safety if fully implemented in hospitals as they can help reduce medication errors, avoid the need to repeat diagnostic testing, and improve continuity of care.
Practice Fusion currently has iPhone and Android applications in private beta testing. When the stable release comes out, the mobile solutions will provide MHI people a lightweight and secure way to stay connected to a global network of providers and other medical advisers on the go.
MHI’s network includes over 6,000 pre-screened and inspected hospitals, more than 4,300 of which are in the USA, along with over 750,000 vetted doctors, clinics, dialysis centres, physical therapy and rehab centres, labs, imaging and hearing centres, plus substance abuse and mental health clinics. MHI operates several offices worldwide where staff work to operate a health travel and medical tourism logistics hub, conduct patient safety reviews and use medical records to conduct extended outcomes measurements for health travel and medical tourism patients seeking care in a location other than their home town.
MHI’s core business is to provide employees of self-funded / self-insured companies and individual consumer members the opportunity to access clinically coordinated health and wellness services.
MHI uses innovative and well-developed outcomes measurement tools originally developed by Rand Corporation to monitor, measure, and report functional, clinical and patient satisfaction outcomes over a 36-month period and to document continuity of care. Maria Todd of MHI says, "Practice Fusion will make our operations flow more efficiently and lower the cost.”
MHI clients and members can access affordable hearing aids as well as free hearing exams, walk in free battery replacements, and savings on hearing aids throughout the USA. TruHearing has developed a discount hearing services programme. MHI clients who enroll in this plan can receive hearing benefits for their plan participants, but also for members of their immediate and extended family. Hearing loss is a condition that affects 12 % of the American population. There are 1500 TruHearing centres throughout the USA and Canada.
MHI clients and members can access prescription discounts at most local chain and independent pharmacies throughout the USA. For members of self-funded health benefit plans pharmacy copays are more than $25 and some medications may not be covered at all. The new deal can save money on any prescription where the copay is more than $10. Some members have already saved up to 90% at Walgreens, CVS, Costco and Sam’s Club.MHI members get the prescription savings at more than 54,000 pharmacies as a free added bonus of membership.
MHI clients and members can access affordable diagnostic imaging tests at more than 3900 locations throughout the USA. Maria Todd explains, "Almost every medical tourism case that we have coordinated in the last five years has required some pre-procedure testing in the form of MRIs and CTs especially for shoulder, knee and hip surgeries, or in the case of cancer patients, PET. These tests have been available to medical tourism patients at a cost of generally $1000 or more. If they go to a hospital to have it done, they are charged a radiologist fee for the interpretation and a facility fee. Now they can go to a small private free-standing location, be treated with respect for their time, the pain they may be in, and the hard-earned money in their pockets."

Diatri is a diagnostic imaging network and scheduling/referral service. MHI can now offer client employers and insurers a way to control their health spending for diagnostic services such as MRI, CT, Arthrograms, and PET. It is estimated that 10-15% of employees will need an MRI, CT or PET scan in the next 12 months.

In analyzing alternate development strategies for health care tourism, Estonia concluded that it needs a much better understanding of what consumers in target countries want.
The Estonian Development Fund commissioned a report “Healthcare Services 2018,” as part of a wider project on developing Estonia’s service economy. This report analyzes opportunities for Estonia’s export of health and wellness services over the next decade, outlines choices for a strategy, and makes recommendations for action.
The report first asked whether or not Estonia has the potential for becoming a health and medical tourism destination. The answer was that it could be as there will be a global growth in healthcare services, as Estonia’s healthcare system and services is good, and the country has the intention of develop a knowledge-intensive, predominantly service-based export-oriented economy.
The report agreed that the country has potential. But it reported varying opinions on the size and growth of health and medical tourism globally, and in Europe, and the actual potential for Estonia. Part of the problem is defining and measuring the target market for cross-border health care by individual country, and differentiating between real information and hype.
Although the report looked at other health care service and product export opportunities, it concluded that there is real potential in health tourism. It concluded that the drivers for individual healthcare tourism in Europe are one or a combination of factors- a search for better service quality, lower prices and shorter queues. It said that this may also apply in the longer run to national health systems and insurers, but while individual health tourism can be proved to exist, it is more of a future possibility for state or insurer driven health tourism, than current fact.
A survey conducted in the course of the report says that two out of three managers of Estonian healthcare institutions and businesses expect that European consumers will increasingly seek healthcare in other EU states, and that that younger and more educated people are most likely to use services outside their home country.
The Estonian healthcare system provides a good base for health tourism. It has state-of-the-art technology, high-quality expertise and price advantages over many EU countries. 30 % of all health providers in the country already deal with international patients and there are a few health businesses in Estonia where most of the business is from other countries.
The report attempted and failed to find any reliable figures or estimates on either the value of or numbers of foreign patients treated in Estonia, let alone any figures for health tourism. The managers surveyed believe that exports of healthcare services would increase in the near future, although the majority of them do not make any active effort to achieve this growth. In the short term, the shortage of staff and, in some cases, facilities that do not meet the standards, are inhibiting factors.
The report concludes that even those working in Estonian healthcare say that marketing of services to foreigners is poor. There is a desperate need for attractive, foreigner-oriented marketing and sales that will bring customers into Estonia. This problem goes wider than for health care, as it also applies to tourism. Estonia has an image problem as few in Europe know much about the country or what it has to offer, so until this image problem is solved, it is hard to market healthcare. Health tourism appears to be a logical way to continue developing tourism, because it would be much easier to offer value-added healthcare services to people who have already been to Estonia as tourists.
After analyzing the report, the Estonian Development Fund suggests that a possible model for Estonia to systematically develop health tourism is to set up a public-private partnership agency to develop cooperation between the different players and devise ways of marketing what is on offer. Experts from the fund say that in developing health tourism, Estonia can choose between different strategies, or even mix them. The fastest growth could be achieved by taking full advantage of the synergy of tourism, wellness and health services. The report pointed to health related challenges of neighboring EU countries – alcoholism, obesity, elderly related care. The experts suggest offering innovative service packages for these. All strategy choices will require a willingness to make targeted and long-term investments in Estonian medical services and related fields.
When selecting target markets, the report says that there are no countries where Estonia can export its healthcare services with little effort and fast profit. International experience shows that usually it is more likely to be successful in neighboring countries and that for Estonia, Finland may be the best bet as it is easier to enter than other markets, but its size is not so large when compared to Sweden or Norway that both have higher barriers to entry. North West Russia, where poor healthcare outcomes leave great problems for the local population, has growing potential. So have Latvia, Germany, and the United Kingdom, but in these countries there are different negative factors to consider: limited market and purchasing power in Latvia; and in Germany and UK, Estonia is relatively unknown and the distances are greater.
The report concludes that for Estonia, it is possible to develop health tourism but only if it makes serious efforts on developing a clear strategy focus, cooperation between different parties and with a willingness to make longer-term commitments. And before any of that can happen, a public-private health tourism promotional body must be set up.

The Ministry of Public Health in Lebanon seeks to improve the quality of primary health care in Lebanon. Accreditation Canada International has begun training on quality improvement and the accreditation process, as well as help in the development of the skills of health care professionals in different regions. This project began with a group of 20 Lebanese primary care centers going through an initial assessment of their services, to help identify opportunities for improvement and provide the impetus to improve the quality of care provided to the population. This second phase of the primary health care strategy follows Accreditation Canada International’s successful review and revision of existing Lebanese primary health care standards, and the pilot testing of the revised standards in three local health organizations.
Sébastien Audette of Accreditation Canada International says,” The Ministry of Public Health is using a staged and sound approach that builds consensus within the primary care community and instills confidence that significant improvements can be achieved. The level of engagement has a direct impact on results, and the progress being made is commendable.”

There are already signs that the winds of change in the Middle East will affect medical tourism, but in each country the effects may differ.
Traditionally, the Middle East /Gulf region has been a source of medical tourists for other countries, particularly Germany, the USA and UK. After 9-11, travel restrictions and anti-Arab sentiment, meant that the US became less popular. Recent US moves to increase inbound travel may alter that. Countries such as Belgium have targeted Kuwait, Saudi Arabia and the UAE; some Asian destinations have fared less well in attracting this market. The building of new hospitals in the region is struggling to keep up with demand, so outbound medical tourism is still expanding. Meanwhile, several places, particularly Dubai and Jordan have been promoting themselves as medical tourism destinations.
Once you discount the expatriate and business or vacation traveller who becomes sick, the Middle East/Gulf country has made few inroads in attracting people from Europe or North America. Partly this is due to cost, but increasingly it is due to the increased political tensions in the region. Unfortunately for those places that are peaceful and safe, the average European or American does not discriminate between places but just regards the region as one. It is likely to be many years before this changes, so those places promoting medical tourism are effectively competing among themselves for regional custom.
Regional custom is also being affected by politics. Saudi Arabia’s Prince Alwaleed has warned that changes will affect every Arab state, “The winds of change that are now blowing in the Middle East will eventually reach every Arab state.” In Saudi Arabia, the number of people who travel overseas for the purpose of medical tourism is around 200,000, mainly to the USA, UK, Germany and France. South Korea wants to take some of that business. The minister of health of Saudi Arabia, and the ministry of health and welfare of Korea, recently signed a co-operation agreement. As well as treating Saudis in Korea, Korean hospitals will be given the opportunity to be part of a new medical city, which is a national project of the Saudi government. Saudi patients are going to foreign countries for organ transplants, cancer treatment, organ transplant and chronic disease care, and it is this lucrative market that Korea wants.
Turkey is targeting several Middle East countries, the latest being Yemen. The Yemeni Ministry of Health sent over 200,000 patients to Jordan and Egypt in 2011. Turkey’s goal is to receive at last 10% of this amount in 2012 from Yemen and 50% in the future. With one neighbour Syria effectively fighting a civil war, and the other one, Egypt, embroiled in a struggle between protestors and the military, tourism to Jordan is being affected. The Yemen government is looking at alternative medical tourism destinations, and Turkey can offer cheaper treatment than Jordan in a peaceful region. But the Yemen is another country with problems.
Jordan hopes for an increase in medical tourism in 2012, but local political problems may make this unlikely. Local hospitals promoting medical tourism are reluctant to say how many international patients are actually medical tourists. Libya has been the main source of business in recent years, and local hospitals are now seeing Libyan business again. There are 20,000 Libyans in Jordanian hospitals, but these are mostly casualties of war, not medical tourists. There are so many Libyans that a committee of representatives from different branches of the health sector will be formed to regulate the distribution of Libyan patients to local hospitals. The committee will have a base at Queen Alia International Airport where Libyan patients can get a preliminary diagnosis and be referred to hospitals according to the specialisations available. During the Libyan civil war, many Jordanian hospitals treated war casualties for free, but the numbers still coming mean that they cannot afford to keep doing this. The Jordanian government has agreed to use public hospitals to treat Libyans. More importantly, the new Libyan government has agreed to pay treatment costs.
In the past, Qataris preferred to seek medical treatment in Europe, and some still do. But aggressive medical tourism promotions by Thai tourism operators and the Tourism Authority of Thailand in the Middle East means Qatari arrivals in Thailand increased from 14,052 in 2007 to 15,138 in 2008, 15,913 in 2009, and 22,341 in 2010. Regency Travel & Tours in Qatar, with 35 offices in Qatar, says 30-35% of clients select Thailand with the rest preferring Europe, particularly Germany and the Czech Republic.
Bahrain’s $1.6bn Dilmunia Health Island is a step closer to becoming a reality, with a call for tenders for the project’s initial infrastructure phase. Development manager Ithmaar Development Company (IDC) says phase 1 infrastructure works will take 24 months to complete, and rather ambitiously expects the first hospitals, hotels and clinics to be open by mid-2014. The aim is to turn Bahrain into a world-class health tourism destination. The artificial island is off the northeast coast of Muharraq. It will be a mix of residential, leisure and commercial sub-developments, surrounding core health and wellness facilities.
Whether Dilmunia will ever be more than a fantasy is debatable as political tensions in Bahrain have almost destroyed the local tourism industry, with violent crackdowns on dissenters, plus doctors and nurses being imprisoned for treating dissidents. In the Gulf kingdom the Shia Muslims are in the majority, but the kingdom is ruled by a royal family from the Sunni minority, who also happen to occupy most government posts. The country may have difficulty attracting investors, medical tourists or medical staff for Dilmunia.

Accreditation Canada International is expanding the adoption of its Qmentum International accreditation programme to hospitals in Oman and Slovenia.

Pro Cardiaco Hospital in Rio de Janeiro, Brazil is the first international organization to earn an Accreditation Canada International stroke services distinction, awarded to health organizations that meet or exceed the best standards of stroke care.

Hygeia Hospital Tirana is the first Temos certified hospital in Albania. It has been awarded the Temos Certificate “Quality in International Patients’ Care” for its high class medical, non-clinical and technical services offered for national and international patients.
Areti Souvatzoglou of Hygeia says, “The onsite inspection and Temos certification are important for our hospitals, since they offer us the possibility of accessing an extensive network of healthcare providers in the medical tourism market, with the ultimate aim being to expand our customer base and attract foreign patients. Medical tourism is also very important for Albania, which will evolve another line of tourist business not yet developed in the country”.
From January 2013, academic medical centres accredited by Joint Commission International (JCI) will be accredited under a new set of standards; the Joint Commission International Standards for Academic Medical Center Hospitals. These hospitals will also be recognized separately on the JCI website listing of all accredited organizations.
Paul van Ostenberg of JCI explains, "These new standards were developed to recognize the unique resource such centres represent for health professional education and human subject research in their communities and countries. They were also developed to present a framework for including medical education and human subject research into the quality and patient safety activities of academic medical centre hospitals. Unless deliberately included in the quality framework, education and research activities often are the unnoticed partners in patient care quality monitoring and improvement."
The new standards are divided into two chapters — medical professional education, and human subject research programmes – as medical education and clinical research are most frequently organized and administered separately within academic medical centres. These new standards will be integrated into the evaluation process for the accreditation of hospitals. For example, when the on-site evaluators are reviewing patient care in a clinical unit, they will also evaluate the contribution of medical trainees to care processes in that unit, and the integration of clinical research protocols into the care provided on the unit and the quality monitoring processes.
Not every hospital with students or conducting research is considered an academic medical centre hospital under these new standards. JCI will evaluate hospitals under the academic medical centre hospitals requirements when the hospital:• Is organizationally or administratively integrated with a medical school;• Is the principal site for the education of both medical students and medical specialty residents from the medical school noted in the previous criterion; and• Conducts academic and/or commercial human subject research involving patients of the hospital.

Dr. Yahya Öztel, the owner of Turmed, a medical tourism agency operating in Russia and Ukraine says that growth of health and medical tourism in Turkey will be led by visitors from Russia and the Ukraine. Dr. Öztel explains, “Unfortunately the health system in Ukraine is not highly subsidized therefore Ukrainian doctors do not always have the necessary modern technology or equipment to diagnose or treat patients. The same is true in parts of Russia. So health tourism mobility from Russia and Ukraine will provide Turkey with more business.”
Turkey offers thermal and spa-wellness tourism, tourism, and medical tourism. Turkey’s geographical advantage will increase numbers in all three areas.

Antalya Medical Park International hospital also sees potential in other Eastern Europe countries Almost very week it gets cancer and organ transplant patients from Kazakhstan and Kyrgyzstan.
Turkey aims to create special health zones to target health tourism, including hospitals, rehabilitation centres, thermal spa facilities and care facilities for the elderly and holiday villages.

The Ministry of Health has a new legal code that helps it develop health tourism and improve the inflow of foreign investment in healthcare. Which companies have been awarded the contracts to manage and develop the new zones will be announced in December; while investment, building and zoning operations will begin in 2013.
A holiday provider who promises not to beaten on price or value is anticipating that health tourism will help to increase the number of bookings for Turkey holidays next year. Holiday Mate says, “Investment in health tourism could provide a great boost to general tourism across Turkey. Plans to develop niche health zones could signal a rise in the demand for holidays to Turkey and flights to Turkish resorts.”

Cosmetic surgery in ArgentinaIn Argentina, the Federal Public Revenue Administration has pointed out that, based upon the number of breast implants imported into Argentina for use by its cosmetic surgeons, the country is not receiving corresponding amounts of tax revenue. The value of implants imported into Argentina from Brazil, France and the United States totalled some US$15m in 2008-09, so the total billed cost of the operations using them should have been at least US$150m. Given that the total taxable income declared by cosmetic surgeons and clinics was much less, the Revenue Administration has put the due tax not received at some US$10m. The tax authorities suggest that 80% of all cosmetic surgery undertaken in Argentina remains undeclared. The same tax authorities estimate that health tourism is a significant source of income for local cosmetic surgeons, as this type of treatment accounts for the majority of the estimated 1,000 foreigners in Argentina every month for surgery of all types, because of both lower treatment prices and medical expertise. The tax authorities are looking for ways to ensure they get due taxes, and a medical tourism service tax is one proposal.

Medical tourism in Cost RicaThe Costa Rican National Tourism Chamber (Canatur) estimates that more than two million tourists visited the country in 2010. In 2009, the number of visits was 1.9 million, compared to 2 million in 2008. Juan Carlos Ramos of Canatur explained “The tourism sector recovered this year after suffering a significant drop in 2009.” It was helped by more airline routes from the US and Europe. Medical tourism continued to deliver numbers throughout 2010. Though no official data exists, an estimated 50,000 to 100,000 medical tourists visited Costa Rica in 2010.
The local medical tourism industry is worried that the central government’s new tax proposal will hit hard at medical tourism. Unless lawmakers exempt foreign patients from the proposed value added tax, the cost of medical services in Costa Rica will be 15 % higher than they are now. That amount may be enough to deter customers completely, or effectively force them to go to other countries instead. The government is proposing a value added tax that covers professional services. These services are not covered now by the existing 13 % sales tax, although certain materials used by professionals do carry a sales tax. The value added tax would cover all professional medical services, including dental as well as hospital stays. The goal of the administration is to raise taxes equal to 2.5 % of the gross national product, substantially more than citizens pay now. The value-added tax is just one of the several new levies that the administration seeks.

New medical tourism services in MexicoIn Puerto Vallarta, Mexico, Casa Velas has expanded its medical programme, combining advanced elective procedures with a luxurious recuperation stay. The adults-only all-inclusive boutique hotel and ocean club in Puerto Vallarta works in conjunction with the board-certified, bilingual doctors of AmeriMed, a network of hospitals in Mexico adhering to US healthcare standards. The hotel supplements its existing wellness programme with elective surgery and cosmetic procedures. Treatments include facelifts, tummy tucks, rhinoplasties, mammoplasties, gastric bypass, Botox, and varicose vein treatments. Following procedures, Casa Velas provides a restful and relaxing retreat for recuperation where patients receive personal attention 24-hours a day from the staff as well as visits from qualified medical personnel to attend to post-surgery needs. For overall health and wellness, Casa Velas offers a week of wellness package, which includes a medical consultation and physical exam upon arrival; two acupuncture treatments, Yoga sessions, curative spa treatments, and unlimited use of the spa’s hydrotherapy area. The package also provides personalized holistic menus to heal, rejuvenate, and energize the body and mind.

Avantis Health has launched a new self-funded healthcare product that allows Irish consumers to control, fund and manage their own healthcare spending. Consumers effectively self-insure; paying for their own medical costs and offering a reliable alternative to ever increasing health insurance premiums. Consumers save for their healthcare requirements using health savings accounts in mainstream banks. Risk management products such as a critical illness policy, or hospital cash policies can be added to manage the financial risk of serious illness. Avantis Health is a professional healthcare purchaser that sources and purchases any treatment required on behalf of the patient at substantial discounts.
Orla Fahy of Avantis Health says, "Self-funded health care is an international norm. With the cost of health insurance policies rising to unsustainable highs, this is an important alternative for Irish consumers and businesses. Avantis Health has a proven track record across Europe of sourcing quality, cost effective medical treatment in a transparent, efficient way. Unlike health insurance, our service allows consumers to remain in control of their heath spending and have a say in how their money is being spent. Our research shows Irish patients are paying more for a range of medical treatments than anyone else in Europe. With Avantis Health, Irish consumers can enjoy the same value for money enjoyed by their European counterparts."
As well as working with Irish hospitals and clinics, Avantis Health also offers access to a global network of treatment providers in eleven countries which can result in significant savings on elective treatments, cosmetic surgery, dental care, laser eye treatments, IVF and hundreds of other procedures.
Once a treatment is required, Avantis members can request the treatment either in Ireland or abroad. Avantis Health will seek quotations from its global provider network on the patient’s behalf. Considerable discounts can be achieved through bulk buying for all members. Following consultation with their doctor/medical advisor, the member then selects the quotation that best meets his/her requirements. Avantis Health then draws up an agreement between the hospital/dental provider and the patient to purchase the treatment.
Avantis Health is a wholly owned Irish company established in Dublin in 2007, and already offers self-funded healthcare products across Europe. The Avantis Health Network is made up of hundreds of quality healthcare providers worldwide, including health centres, hospitals, healthcare suppliers and dental and medical professionals. The customer gets quotations for the chosen treatment that includes: price quoted, date available, provider details and aftercare arrangements. The expanding network currently offers treatment in Ireland, the UK, USA, Argentina, Australia, Brazil, Cyprus, Egypt, Estonia, Hungary, India, Norway, the Philippines, Poland, Portugal, South Africa, Spain, Switzerland, Turkey and the UAE.
The offering is timely for Ireland that only has three main health insurers, all regulated so they can only offer the same price to customers however old or sick they are. State owned VHI healthcare has just raised prices between 15% and 45%, and the Irish government has been ordered by the EU to sell or privatize the company. Of the other two insurers, Quinn Healthcare is a trading name of an insurance company under administration, where the future will depend whether or not the new owners want to offer health insurance. The Irish economy is in turmoil, with elections due soon, as well as dental and hospital prices rising very fast.
A little publicized part of the proposed EU directive is that it will not just apply to state healthcare systems, but also private health and related insurances across the EU. Irish people who have been waiting years for medical treatment or who suffer from rare diseases are the most likely to gain from the new Cross-Border Healthcare Directive agreed by the European Parliament. This will give Irish patients on a waiting list the right to travel abroad for treatment and be reimbursed, and this will be especially useful for patients in Galway, Donegal or Sligo who could be eligible for treatment in Northern Ireland, which is part of the UK.

The Korea Tourism Organization has unveiled “MediApp Korea,” a medical travel application to provide international visitors and foreign residents access to Korea’s medical tourist information and services.
MediApp Korea provides detailed information on medical travel in Korea, and introduces major hospitals and medical travel packages and provides tailored searches based on preferred doctors or clinics. It is designed to guide users through their journey to Korea from prior to arrival and on through to after departing. Useful information, such as medical and travel news as well as various coupons and promotional events, is updated in real time and the application is available in four languages: English, Japanese, Chinese and Russian.

Inje University Haeundae Paik Hospital, in Busan, is gaining business from medical tourism, with its cutting edge medical technology and highly skilled doctors. But it believes that the success comes from its emphasis on custom-tailored medical services and care for patients. Spokesman Hwang Tae-gyu says, “People from different countries have different needs, having various difficulties and conditions. So it is important to provide them with customized services, and fully understand their cultural background and private needs. For the success of medical tourism, the best medical service should be provided, but at the same time, it is also crucial to combine it with various tourists’ attractions such as restaurants, hotels, historical sites and shopping districts. Government, travel agencies, hospitals and other related bodies need work together. “We aim to challenge the traditional image of hospitals-associated with inconvenient facilities, lack of space, uncomfortable rooms, and so on. But our hospital offers a nature-friendly environment that can help patients.” Patients can also get easy access to an alkaline seaside hot spring water as all the 1,004 rooms are supplied with spring water,
Busan is particularly popular with Japanese and Chinese who want to have cosmetic surgery. The hospital opened an International Health Care Center last November led by a team of medical professionals and translators fluent in foreign languages to help non-Korean patients feel comfortable and at ease.

Seoul Wooridul Hospital has received accreditation from the Joint Commission International (JCI) as the first specialized hospital in Korea. It is the eighth hospital to receive JCI accreditation in South Korea. To be certified by JCI, hospitals must receive get at least 90% scores, and the hospital received a high mark of 99.7 points on average. It got 100% from almost every area including international patient safety goals.
Seoul Wooridul Hospital commented, "JCI Accreditation is not just about promoting international patients. This is to provide the best medical services to patients in a safe environment by improving medical services up to the international standards. We hope this could be a great opportunity for many patients in the world, who suffer from spinal and joint diseases, to visit us and get treatment."

Medical tourism could be about to grow in Iceland, as two new private hospitals, Iceland Healthcare in Reykjanesbaer and PrimaCare in Mosfellsbaer, are being built. Both will offer specialized surgery and treatment, joint replacement, and other services. Dental implant clinic Nordic Smile, owned by two Swedes, has opened in a new building by the Reykjavík seaside. Nordic Smile offers dental implant treatments at low prices, but with the best quality in material and technique in accordance with strict Scandinavian health standards. The goal is to offer services for 30% of the normal price for similar services in the UK. A dental implant treatment for one jaw, upper or lower, costs 5800 Euros, including implant screws, abutments, high quality titanium bridge, new teeth, x-rays, consultation etc. Nordic Smile has negotiated a special price for their customers on airfares and accommodation.
Nordic Health Pro, owned by Icelandic doctors, is looking into the possibility of attracting patients to Icelandic clinics and hospitals. Patients are already being flown in from Greenland and Faroe Islands to the Landspítali national hospital in Reykjavík in accordance with agreements with the authorities in those countries.
Magnus Orri Schram of the Association of Health Tourism in Iceland believes there are many opportunities for tourism from overseas patients going private hospitals, as it is common for partners to accompany patients on these trips. He estimates that patients usually stay at a hospital and hotel for two weeks after surgery. Iceland has much to offer in terms of bathing, exercising, rehabilitation and an overall lifestyle change where the country’s nature and image fits in well with health-related tourism. Although it does get a few medical tourists, attempts over the last five years to increase numbers have mostly failed.
PrimaCare is an Icelandic private limited liability company founded in June 2008 to develop, build, operate, and market a state-of-the-art- medical resort destination. The medical focus is orthopedic joint replacement (knee and hip), and other less invasive orthopedic procedures. It will be a surgical specialty hospital with an elegant boutique-style hotel and after-care facility. This resort environment will help rehabilitation and healing. PrimaCare is medical tourism destination offering a package of: extremely high quality medical care and delivery; rehabilitation management; focused customer service including serving as a liaison with referring physicians and third party payers; medical continuity and follow-up s; and vacation/tourism packages for the friends and families of patients.
A new private hospital run by Iceland Healthcare, owned by entrepreneur Robert Wessman, hopes to open this August in the military hospital at the old US Naval Air Station at Keflavík that has been vacant since the US military left the base in 2006. Modification work is scheduled to begin soon and finish in mid-2011. The hospital aims to target patients form overseas, particularly the UK and Norway, with specialized treatments, joint replacements and gastric bypass surgery along with rehabilitation. It will also offer rehabilitation for cardiac patients and behavioral treatment for obesity patients. Keflavík Airport Development Corporation (Kadeco) is a co-owner with other investors of Seltún, a new company that owns and runs the site. The company estimates that it will have to invest $9 million to upgrade the hospital to modern private patient use. Iceland Healthcare has a 25-year lease and is also renting two apartment complexes in the vicinity for a hospital hotel.
Kadeco is offering real estate investors the opportunity to invest in medical tourism at what is has been known as the Asbru Enterprise Park since 2006. Asbru Enterprise Park wants to become an international centre for health and relaxation. The park, which was formerly the NATO base in Iceland, has several properties available for purchase, including the fully operational Icelandic Health Hotel – which opened in 2009 as Detox Health Center to offer therapies developed in Poland. Properties for sale cater for companies looking for service, industry and residential development locations. The Icelandic Health Hotel specialises in health and wellness programmes, where people stay for two weeks and eliminating alcohol, drugs, caffeine and learn how to lead a healthy lifestyle.
The Reykjanes Health Association, set up in 2009, aims to promote Reykjanes as a health destination, by marketing Iceland for health and medical tourism. Whether these renewed attempts to attract businesses and medical tourists will succeed is debatable. For the best part of five years, the owners of Asbru Enterprise Park have been attempting to promote the site, with regular stories that it is about to open with a range of health providers. That it is urgently seeking investor partners suggests that Kadeco does not yet have enough funds to rebuild the hospital. In February 2010 Kadeco assured Iceland Healthcare that construction and renovations to the hospital would begin in the second quarter of 2010 but work was not begun in 2010, so even if the new dates are met, it may not be ready for patients until 2012. The hospital will have three operating theatres and 35 hospital beds, but can only treat 4000 patients a year. In 2010 Kadeco promised that the hospital would get 2000 patients per year, with the first medical tourists arriving in the second quarter of 2011. We will have to wait and see if / when it opens, whether it can attract sufficient medical tourists to make investment worthwhile.

’The company that solved healthcare’ is the ambitious title of a new book by John Torinus Jr., chairman of Wisconsin-based Serigraph, a 61-year-old plastic printing firm with 450 U.S. employees, but 1,700 worldwide in India, China and Mexico. This does make them very different to most US companies in their healthcare employee needs.
The book claims to be a blueprint for solving the biggest problem in health care: runaway costs. Torinus describes how the company engaged its employees in managing their health and health costs and how innovations at other companies were sought out and put to work. Serigraph has had only three small premium increases in the last seven years and has held in increases to less than 3% annually.
Changes emphasized consumer responsibility, centres of excellence, and a prime role for primary care. Previous efforts (wellness programs, some rationing, participating in a buying group, and cost-shifting to employees) had accomplished little. The firm is now self-insured, with costs now split 80/20 with its employees. Included in the health plan, but in a tangential rather than central capacity, is a medical tourism programme both domestically in the USA and using places including India and Costa Rica, that offers companion travel. Serigraph employees now shop for care to reduce their co-pays and share of overall costs. Torinus feels that there is no relationship between health care costs and quality, however measured, and that the key to controlling costs is attention to detail and total employee involvement. BridgeHealth Medical arranges the medical tourism.
Torinus comments, “ When Serigraph employees found out that they will see no premium increases for health care in 2011, they were elated. They know that it was their efforts, person by person, that made the difference. Health cannot be improved and health costs cannot be lowered without the full engagement of the participants in the plan. Each employee at the company received a copy of the book, as their stories of battling the hyperinflation in health care are included in the book. With inflation running at about 7% this year, we will have to work even harder as intelligent consumers if we are to avoid a premium increases again in 2012. But we know it can be done, because we’ve managed that feat five times in eight years.”
America’s health care problems are so extensive that they are incapable of being solved by any one company or any one approach. But the book is worth reading for anyone interested in the US market and Torinus is amazed that hospitals make it so difficult to compare what are often huge price differences between almost identical hospitals in different US towns and cities. House Republicans hope to make good on a campaign promise to undo the healthcare reform law by scheduling an early vote to repeal it. Such a repeal vote would be largely symbolic, as the prospects of a repeal bill making it through the Senate, where Democrats cling to a narrow majority, is much less likely. Democrats are preparing for a fight to defend the reform, noting that consumers already are benefiting from changes made under reform. They argue that undoing the law would increase the number of uninsured; put insurers back in control of health insurance, allowing them to increase premiums at will; and lead the federal budget deficit to grow quicker. Torinus comments, “The Senate won’t agree to repeal, and, even if it did, the president would veto. Nor will they replace key provisions for the same reasons. However, good principles that were overlooked in the passage of the law could be injected into it. Transparent prices could be ordered. Consumer driven principles could be included as an option in all health plans.“
Part of the new healthcare legislation has come into effect from 2011. For rate increases of ten percent or more in the individual and small group markets filed in a state on or after July 1, 2011, or effective on or after July 1, 2011, insurers will be required to publicly disclose and justify the proposed increases and the increases would not be presumed unreasonable. For rate increases filed in a state for 2012 and thereafter, a state-specific threshold will be set for disclosure of rate increases. The threshold would be determined using state-specific cost data and trends. Torinus comments,” It is an admission that costs/prices are still soaring out of control — 10% or more in many cases. The answer is an army of consumers equipped with good information on health care value — quality metrics, transparent all-in prices and service. Why would anyone pay $50,000 for a hip replacement when a good one can be bought for $20,000 in the same regional market? They do, because there is no transparency on all-in prices.”

Mercury Advisory Group has put together 30 key findings from global research on medical tourism.
Maria Todd of Mercury explains, “Our consultants and technical advisors have gathered the findings when benchmarking medical tourism market initiatives throughout the world. We hope these findings will help new market entrants and to make it easier for people in their medical tourism strategy.”
The findings include;• All leading medical tourism destinations have developed a clear vision and strategic objectives and set specified goals with specific timeframes.• Co-operation and co-ordination among relevant authorities is a must. Singapore, Korea, Malaysia, Turkey, and Lebanon have formed national medical tourism councils bringing together relevant parties.• Many destinations work to attract foreign and national investments by using tax incentives for the development of the sector.• Medical tourism clusters have mostly failed.• Most destinations offer transparent pricing for their surgical and diagnostic services, often as packages. But what is in or out of the package is often poorly described and puts off potential customers.• More countries are trying to monitor health and medical tourism numbers.• International safety and quality accreditations have become a prerequisite for any hospital or clinic.• Some countries have also developed their own ISQua-accredited national accreditation system.• Many doctors have international professional qualifications and are fluent in several languages.• India, Thailand, and Malaysia have special visas for long-stay medical tourism.• Airlines such as Lufthansa, Malaysian Airways, Turkish Airlines, and Etihad offer medical tourism packages.• Some hotels work with hospitals to accommodate companions and recovering patients.• A national marketing strategy is essential.
Overall, what the research shows is that for any country to be successful, it has to be organized and pro-active at national and international level.
Gone are the days that any country can develop medical or health tourism with a hands-off approach where hospitals and clinics spend as much time competing with each other as with other countries.
Customer expectations in packaging, quality of care, language skills and service are growing all the time.
Countries have to train doctors, hospitals, nurses, therapists and others in language and service skills.
What is interesting is within the 30 detailed topics that we are only able to give an indication of here; there is no mention of low price or international medical tourism bodies, and little mention of medical tourism agencies.

More foreigners are seeking medical treatment in Thailand each year, with 2012 expecting to see 2.53 million foreign patients generating Bt121.6 billion in income. Most popular treatments are for orthopedics, heart surgery, cosmetic surgery and dental work.
Department of Health Service Support chief Somchai Pinyopornpanich reported the growing trend – 1.37 million foreigners in 2007 generated Bt41 billion; 1.38 million in 2008, Bt50.9 billion; 1.39 million in 2009, Bt63.3 billion; 1.98 million in 2010, Bt78.7 billion; and 2.24 million in 2011 generated Bt97.8 billion. The top five countries were Japan, USA, UK, Middle East and Australia.
Somchai said the three main groups of foreigners seeking medical treatment were – foreign residents (41.4 per cent), tourists who use some medical services during their stay (32 per cent), and visitors seeking specific medical treatments here (26.6 per cent). He said a medical hub campaign (focusing on medical treatment, Thai spa, Thai traditional medicine and Thai herbs) would improve Thai medical services in general.
Previously, both the health and tourism bodies have stuck firmly to much higher figures, and not even admitted what local doctor bodies argued, that at least 30% of ’medical tourists’ were expatriates or holidaymakers.
The long used figures from The Tourism Authority of Thailand (TAT) and the Department of Export Promotion (DEP) for the number of medical tourists to Thailand, with no source given for the figures, other than ’reliable estimates’ were as follows:
• 2001 550,161• 2002 630000• 2003 973000• 2004 1 million• 2005 1.25 million• 2006 1.45 million• 2007 1,373,807• 2008 1.3 million• 2009 1.2 million• 2010 1.5 million estimate• 2011 1.5 million estimate
These new figures are interesting as they are the first official confirmation of what many in the medical tourism industry have argued, and others have denied, that most “ medical tourists’ are actually expatriates resident in Thailand or holidaymakers. There are still concerns that even the new figures are inflated by including outpatient use such as use of hospital pharmacies.
Applying 26.6% to the figures for 2007 to 2011, and rounding them up, as we do not know how the % varies over time, this for the first time gives us a more accurate view of actual medical tourists;
• 2007 365,000• 2008 367,000• 2009 370,000• 2010 527, 000• 2011 596, 000• 2012 673, 000

Romanian medical tourism saw 60,000 foreign arrivals in 2011, with dental, ophthalmic and cosmetic surgery services being the most sought after, says Emilian Imbrifrom of the Ministry of Regional Development and Tourism, “Most came at the recommendation of friends. People sought cosmetic surgery, dentistry, ophthalmology, cardiac prostheses, and orthopedic prosthetic services.” Although claimed as medical tourism numbers, it is highly probable that this mixes both medical tourism and health tourism. The ministry is fuzzy on how it defines medical/health tourism, and how it calculates those numbers.
Tourist packages combining travel and medical treatment will be on offer from mid-2012. Romania is also a leading international destination for natural spa treatment. Romania is unknown to much of the world, despite offering mud baths, thermal water baths, mineral baths and asthma therapy in natural salt caves.
In Split, the first medical tourism centre in Croatia should be completed in the second half of this year. This luxury accommodation aimed at retirees from overseas will include clinics with diagnostic and specialist centres. Users will have a restaurant, an internet corner, a piano and lounge bar, a cinema and a library. On the roof there will be a green oasis with a promenade, an outdoor swimming pool with a sundeck and a wellness and fitness centre. The residence will have 54 accommodation units, 40 rooms and 14 suites, with an option to rent them out for the period of five days to 99 years, and will be able to accommodate up to 100 people, The seven-storey building will have an underground garage with 105 parking spaces and several business premises – a shop, a bank and a gift shop. The new retirement health tourism centre is in town and is only a 15-minute walk from the beach, promenade and the old town.
Qatari citizens will now be able to visit Bulgaria for medical tourism. Bulgaria’s minister of health Dessislava Atanassova has signed a memorandum for partnership with the Qatari government.
Tour operators and tourism department officials in Macedonia are expecting travellers from across the world in 2012. Compared to 2010, 2011 saw a 30% rise in the number of tourists visiting Macedonia, according to the Macedonian Chamber of Commerce. In 2011, the country that has a population of only 2 million received more than 700,000 visitors, mainly from within Europe, US and the Far East, but increasingly from Japan and China, while Qatar is the latest target market. Dental treatment and health tourism are both attracting an increasing number of visitors to Macedonia, but numbers are not known.

Many organizations assess and accredit hospitals in general, but the part of the hospital that many medical tourists come into contact with is the international patient centre. A new independent organization, The Medical Travel Commission, has been set up to offer accreditation specifically for international patient centers.
The Medical Travel Commission is based in Asheville, North Carolina, USA. Founder Jim Tate has worked as a consultant with healthcare related companies across the world, ranging from Sri Lanka and Israel to Pakistan and Peru, providing health information technology services. Having witnessed disparities in services provided to international patients, he aims to create best in class service standards that will benefit hospitals, agencies and prospective patients. The Commission has Dr. Stewart Hamilton as its Chief Medical Officer, with over two decades of experience across the world. Bambi Rose is Director of Certification, and has worked for the Certification Commission for Healthcare Information Technology.
The Medical Travel Commission team includes medical officers, hospital CFOs, published security authorities, legal experts, experienced post-acute care professionals, certification professionals and medical records managers. There is an advisory board to oversee the process.
The organization aims to create the optimal experience for international patients by the certification of international customer service standards. They believe that a transparent credentialing process for healthcare providers;
•Helps hospitals gain credibility among potential medical tourists.
•Enhances medical tourism agencies abilities to educate prospective patients.
•Delivers a quality assurance promise to patients and their care providers that minimizes cultural or communications obstacles.
The Medical Travel Commission has assembled a diverse team of healthcare advisors to establish benchmarks for the delivery of quality service, and develop reviews, audits, and recommendations. The onsite review is performed by a team that includes certification as well as clinical expertise.
It certifies hospitals that support medical travel and the care of international patients and has created an educational review process leading to certification that includes support of best practices to increase credibility in the medical travel industry through transparent and unbiased standards.
Jim Tate says that the first certifications are expected to be awarded very soon, “Final preparations are being made for the notification of the initial recipients of the 2012 Medical Travel Commission Certification. The certification is only awarded to those hospitals that have successfully met 100% of our stringent criteria."

Jeju Healthcare Town, part of Jeju Free International City Development Center (JDC), has broken ground and expects to be built by 2015 on the self-governing island off South Korea.
This will be the first medical town in Korea to provide a variety of healthcare services on one site. It will offer medical check-up clinics, rehabilitation centres, medical research and development centres, and more. Byon Jong-il of JDC explains, “A healthcare town is where everything about health is concentrated in one location. Although there are many of these in other countries, it is the very first to be built in Korea. Jeju is the perfect place for a healthcare town to be established not only because it has a great natural landscape but also because it has a clean environment and abundant natural resources. Korea is also famous for its Oriental medicine. Jeju is a great place for medical tourism because it can combine such medicine with its environment.”
Jeju Healthcare Town is being built on a 1.54 million-square-meter site, 34 % of which will be preserved as green areas. The town will have three different parks — the wellness park, the medical park, and the research park — to provide specialized services to patients and visitors. The wellness park will be a medical complex focusing on healthcare and recreation. The medical park will provide advanced medical services such as specialized hospitals and long-term care facilities. The town is one of six core projects to help the island become internationally recognized. The other five projects include a science park, global education city, resort-type residential complex, Seogwipo tourism port, and a history theme park.
The aim is to build the town into a global medical tourism site that attracts not only Korean patients but also those from abroad. Byon Jong-il adds,” We plan to attract medical tourists from abroad. We do not have a specific target, but we expect there will be many Chinese tourists in the coming decade or two. So in the short term, we will focus on attracting Asian medical tourists. The town will provide clinics for internal medicine, orthopedics, cosmetic surgery, dentistry and more. The island’s clean natural environment will be perfect for treating seriously ill patients over a long period of time.”
JDC plans to connect local hospitals with foreign ones for active exchanges of medical services and know-how. Seoul National University Hospital will be participating in the project in a development consortium with Neulproon Medical Foundation, Seowoo Co Ltd, Zhong Da Real Estate and ADI Health Care. Zhong Da Real Estate will be responsible for overseas marketing, while Neulproon Medical Foundation will become the main operator of healthcare facilities at the resort complex. ADI Health Care Co will build and operate healthcare facilities. Greenland Group from Shanghai will build facilities at the wellness park
Across South Korea, the Ministry of Health and Welfare is tracking down illegal brokers, and demands medical institutions directly explain the medical fees to the patients, to stop them charging visitors more than locals. Korea is the first country report in a new OECD series evaluating the quality of health care across OECD countries – whether care is safe, effective and responsive to patients’ needs.
The Ministry of Health and Welfare has announced Korea’s own standards in accrediting medical institutions have been accredited by the International Society for Quality in Healthcare (ISQua). Receiving accreditation from the Korea Institute for Healthcare Accreditation (KOIHA) will now mean the accredited hospital is providing medical services to international standards.

Many potential medical tourists are told that the only safe hospitals are those with international accreditation; many Americans are told that they should only ever consider JCI accredited hospitals. Within the medical tourism industry, some would argue that both views are a fallacy.
A Minnesota medical tourism agency, Soter Healthcare, has looked at national and international accreditation from a consumer viewpoint and aims to dispel some of the myths on accreditation and certification. The company says, “There is a lot of noise about accreditation in media and marketing surrounding international medical travel. With few clear voices, sorting the message from the madness is challenging.”
“Accreditation, whether regulatory or voluntary, is simply a floor above which a hospital must work. That there are no good, better, best connotations implied or expressed in existing standards. There is a significant trap awaiting patients who believe, either having come to it on their own or through promotion by medical tourism agencies, accreditation by one international body or another equals a standard of excellence.”
“The prevailing view is that international accreditation provides a comfort for international patients. Harvard Medical International cites the focus of this development on its website:” Internationally, the growth of the health care industry has resulted in increased competition, leading hospitals to attempt to differentiate themselves through accreditation and certification by internationally recognized health care evaluators.”
“We often see the comment – We only use JCI accredited hospitals – on the websites of medical tourism agencies. I always enjoy reading that statement, knowing that the company either doesn’t understand accreditation or doesn’t really believe the comment. Accreditation is a means by which the medical community evaluates administration, operations, quality and patient safety. In some cases, local or national regulatory authorities conduct accreditation inspections. In other cases, an independent third-party agency whose report the regulatory agent accepts conducts the review. In America, state health departments regulate hospitals, and the health department can either conduct its own inspections or accept those of an agency. In other countries, the national health ministry generally manages the accreditation process.”
“In medical tourism, accrediting organizations expanded internationally. International accrediting organizations involved in destination medical care fall into three groups: (a) national/domestic agencies, (b) international accreditors, and (c) medical tourism organisations that purport to offer credentialing. The best known of the international entities is the International Society for Quality in Healthcare (ISQua). ISQua does not directly accredit hospitals; rather, ISQua accredits the accreditors.“
“JCI, QHA Trent, and Accreditation Canada International are all reputable international accreditation agencies. Where a national medical system and accreditation systems are strong, such as in countries like Australia, Canada, China, France, New Zealand, the United Kingdom and the United States, international accreditation is rarely considered. There are no JCI accredited hospitals in Australia, Canada, France, Japan, Norway, or the United Kingdom, nor are there any QHA Trent accredited hospitals in the United States, Canada or Australia.”
“None of that means accreditation is not important. It is a beginning stage of reviewing hospital quality for international patients. However, accreditation is not the end point or the distinction.”

The Libyan government is no longer paying Jordanian hospitals for the treatment of Libyan patients who travel to Jordan without prior approval. Ali Bin Jalil, head of the Libyan medical committee in Jordan says: “Any Libyan who now goes to Jordan without prior approval from the government must pay his own expenses, including the cost of medical care. The decision was adopted because we cannot cover the high costs of accommodation and daily costs for those who go for treatment and stay for long periods. Some patients have been finishing their treatment and staying in Jordan as tourists – we have had to pay for their accommodation and other expenses.”
The Libyan government owes a huge sum to the Jordan government and hospitals. 58,000 Libyans have gone to Jordan since February 2011, including 48,000 for medical treatment, many with war injuries. The total cost of treating Libyan patients in Jordan is £90 million, and only $30 million has been paid.
The new Libyan government is footing the bill for people injured in the civil war that brought down Qaddafi. It has begun an audit after being charged in excess of $110 million. It accuses some Jordan private hospitals and of ordering unnecessary tests and charging double or even triple the normal cost for treatment.
Jordanian doctors have been treating tens of thousands of Libyan war wounded at private hospitals and clinics across the country. But the mission of mercy has become the object of controversy amid accusations of inflated bills and patients being turned away for lack of beds.
Yalli Abul Kassem, a representative of Libya’s interim government in Jordan, has accused Jordan’s medical sector for overcharging Libyan patients. He also accused Libyan patients of excessive spending, after reports they were using state funds for cosmetic surgery and holidays. “When I took over my job to take care of Libyan patients in Jordan I realized how big my responsibility will be due to overspending of patients and overcharging from Jordanian doctors.”
Until the new rules on prior approval, the Libyan government had no management and budgetary controls, so was paying for the medical costs and travel expenses of the war wounded as well as costs for one or two people to accompany them to Jordan, Turkey, Lebanon and other countries.
Jordan’s Private Hospitals Association (PHA) has rejected accusations of profiteering, but agreed with Libyan authorities to appoint a team of arbitrators to settle the dispute. Jordanian officials have been also accused of using their positions to take a share of the spoils. One minister is accused of taking 10% of all billed medical costs in exchange for writing and managing contracts for the Libyans with Jordan’s hospitals and serving as the legal representative of all the Libyan patients in the country.
The arguments on profiteering are threatening the hard-earned reputation of the kingdom’s private hospitals, not only among Libyans but others as well, which could hurt one of Jordan’s main earners of foreign currency. Jordanian health minister Abdul Lateef Werikat said the government was alarmed by the rising number of complaints of overcharging by Libyan patients and promised to sort out the problem. Awni Bashir of the PHA denies profiteering or manipulation of the expenses, but this does not satisfy Ali Bin Jalil of the Libyan medical committee, “There is a difference in prices charged for the same medical treatment in different hospitals and we will review the bills as part of the audit process.”
Jordanian private hospitals are a favorite medical tourism destination for patients from Yemen, the oil rich Gulf States, Sudan, Libya and other countries with a less advanced medical infrastructure. The Arab Spring badly hurt the medical tourism business, with non-war 2011 medical tourism cut to half of what it was in 2010.Jordan insists it is safe, but admits that it is surrounded by regional unrest, which makes it difficult to attract patients other than from nearby countries.

Medical tourism in Malaysia hit record levels in 2011 and is on track to achieve yet another year of healthy numbers in 2012. But with the bulk of business coming from Indonesia, attracting people from other countries is vital for long-term growth as Indonesia has a new hospital improvement plan.
Receipts from foreign patients spending on medical treatment in Malaysia in 2011 were RM 509.77 million, while foreign patient numbers were 578,403. This compares to revised figures for 2010 of 392,956.The 2012 prediction is over 600,000.
Dr Mary Wong Lai Lin of the Malaysia Healthcare Travel Council (MHTC) says the 2011 revenue grew by 34.5 %, while the number of patients went up by 47.2 % on 2010. These figures are well above the initial projection of RM 431 million revenue and 400,000 foreign patients.
MHTC was established under the Ministry of Health Malaysia as the primary agency to develop and promote the healthcare travel industry and position Malaysia as the healthcare destination of choice in the region. Medical tourism receipts are separate from tourist receipts, which are tabulated by the tourism ministry. 41 hospitals and 8 dental, eye, and health screening clinics are registered with MHTC.
Penang received the highest share of foreign medical revenue at 49 %, followed by hospitals within the Klang Valley at 21 % and Malacca, at 10 %. The Indonesian market continued to form the bulk of foreign patients in Malaysia due to its proximity and accessibility. Dr Mary Wong Lai Lin of MHTC adds, “We are targeting Japan, China, the Middle East and Bangladesh as well as countries within South East Asia such as Cambodia and Myanmar.” Foreign patients often seek very specialised treatment such as cardiac, orthopaedic, in vitro fertilization and oncology, while an increasing number are seeking cosmetic surgery and dental treatment.
Indonesia is planning to bring more hospitals up to international standards, aiming for the country to be a health tourism destination by 2015.The health ministry believes that it is unfair that Indonesia is always overlooked and even its own citizens go to Singapore, Malaysia, Thailand or India.
There are 10 state-run hospitals in Indonesia — including Cipto Mangunkusumo Hospital [RSCM] in Jakarta – currently working towards Joint Commission International accreditation. Three private hospitals, Siloam Hospital and Eka Hospital in Tangerang and the Santosa Hospital in Bandung — are the only JCI ones in Indonesia.
The Indonesian health ministry seeks to improve hospital standards at home so fewer Indonesians will travel abroad to seek medical care. Bali’s Sanglah Hospital has the most potential to be marketed as a health tourism destination, as patients can enjoy the resort island while recuperating from treatment. The ministry will ensure the affordability of medical care for Indonesians at the state-run hospitals seeking international accreditation. The plan is that the accreditation process for RSCM will finish before the end of 2012 and the others will follow soon afterwards.

A new health complex in the capital Bogota, costing between $11m and $19m, could boost health, wellness and cosmetic tourism to Colombia. The construction of the Bosque Beauty Garden hotel and medical centre is expected to begin next March. It is the result of a partnership between spa company Altos de Bosque and construction company Ricam. The health centre and adjacent hotel will cover 52,000 square feet.
Cosmetic surgery will be a major part of services on offer, with five-star accommodation for visitors alongside shops, green space and conference rooms. The complex with be the first of its kind in Colombia and will have 130 rooms and 40 doctors offices.
According to the Medellin-based cluster group of medicine and dentistry, and the Cali Chamber of Commerce, there were 18,000 health tourists in the region in 2010. 10,000 of those were foreigners, mainly from Curacao, Aruba, Suriname, the United States, and Spain. Bogota estimates similar numbers in 2010.
According to Colombia’s Ministry of Commerce, Industry and Tourism the most popular treatments sought by visitors are heart surgery (41%), general surgery (13%), gastric band surgery (10%), cosmetic surgery (10%), cancer treatment (6%), orthopedic treatment (4%, dental care (2%) and eyecare (1%).
Guillermo Rincon, the man behind its construction, says "When this is finished it will be the first in the country, meeting the needs of a rapidly growing sector in Colombia."

Following a successful start to accrediting Costa Rica clinics that desire international accreditation to help in their efforts to attract more American medical tourists, AAAHC International is now keen to expand into other countries in South and Central America.
AAAHC International, a subsidiary of the Accreditation Association for Ambulatory Health Care (AAAHC) has accredited the Luis Kaver Clínica Dental, a cosmetic dental clinic, the Hospital Clinica Metropolitana, a multi-specialty ambulatory health care clinic, and Instituto Centroamericano de Medicina ICEM-all in San Jose, Costa Rica, under the AAAHC international accreditation programme.
John Burke of AAAHC comments, “With the growth of medical tourism and the significant number of Americans living abroad, we believe it is important to offer a programme that helps ensure that ambulatory medical services in foreign countries meet high standards. By voluntarily participating in the AAAHC accreditation process, these ambulatory organizations demonstrated their commitment to the safety and quality of the care they offer patients. The AAAHC peer-based survey process makes our accreditation unique, and enable us to work closely with ambulatory centres to assess their services and assure they provide high-quality care.”
The accreditation surveys were conducted by a team of U.S.-based AAAHC surveyors who are themselves active practitioners of ambulatory health care. The first organization to be accredited by AAAHC International was the Nova Dental Center in San Jose, Costa Rica. 95% of customers of the Nova Dental Center, a full-service dental clinic that specializes in cosmetic dentistry, are from the USA. Luis Obando of Nova Dental Clinic says, "The accreditation process was a lot of work to get everything together to meet the standards, but in the end it helped to improve our clinical and administrative processes." Nova Dental received a three-year accreditation.
The association launched its international accreditation program in Costa Rica, and other clinics in that country have begun the process toward AAAHC International accreditation. The AAAHC will soon add accreditation for ambulatory organizations in other Central and South American countries. AAAHC International is a subsidiary of the Accreditation Association for Ambulatory Health Care (AAAHC). Founded in 1979, AAAHC is the leader in ambulatory health care accreditation with nearly 5,000 organizations accredited nationwide. AAAHC accredits a variety of ambulatory health care organizations, including ambulatory surgery centres, office-based surgery centres, college student health centres, managed care organizations, military health care clinics, large medical and dental practices and medical homes. Third-party payers, medical organizations, liability insurance companies, state and federal agencies and the public recognize AAAHC accreditation as a symbol of quality.
In 2012, all AAAHC accreditations will be for a standard three-year term and the less common six-month and one-year terms will be discontinued. Following an accreditation survey, there now will be only two possible outcomes: a three-year term or a denial of accreditation. The policy is effective for organizations that apply for accreditation on or after March 1, 2012, or have their surveys conducted on or after July 1, 2012.Organizations that receive accreditation but have some deficiencies will be required to submit a plan for improvement within 10 days of receiving the accreditation decision. After reviewing the plans for improvement and the survey report, the AAAHC accreditation committee will determine if an organization will require an interim survey. Organizations that demonstrate compliance with all AAAHC standards at the interim survey will maintain accreditation for the remainder of the three-year term. Organizations not in compliance may have their accreditation term revoked. In accordance with existing AAAHC policies, random and discretionary surveys of any organization also may be conducted.

To promote its themes of wellbeing, medical tourism and spas in 2011, the German National Tourist Board has published three brochures: Wellness Holidays: “Germany – Land of Wellbeing”; “Health Travel: Spas & Health Resorts in Destination Germany”; and “Medical Travel – You’ll be well-looked after in Germany”.
Wellness Holidays covers the broad characteristics of Germany’s spa resorts, treatments and the organizations responsible for ranking and critiquing the facilities. Health Travel provides detailed information about Germany’s spa towns and categorizes them by their locations, treatments and local expertise: mineral and thermal springs; peloids (mud and clay); climatic health resorts (mountains and seaside); those that offer treatments unique to Germany, such as Kneipp, Felke, Schroth, Heilstollen (air in disused caves and mines) and radon (naturally occurring gas) treatments; and Thalassotherapy, which uses genuine sea water and seaweed and massages with Ruegen’s medicinal chalk or body wraps with sea-buckthorn. Medical Travel details the various specialties and practices available to international patients and their families at university clinics.
In Medical Travel, the German National Tourist Board presents leading German hospitals that offer a broad range of treatments in various disciplines. There are over 2000 hospitals in Germany, including 37 university hospitals, 700 public sector and church-owned hospitals and 500 hospitals belonging to private networks. At least 10 % of them have a department dedicated to helping visitors from abroad. 68,000 patients from 169 countries underwent inpatient treatment in Germany in 2008.
Dresden has one of the world’s top diabetes centres, the Medical Clinic and Policlinic III in the University Clinic Carl Gustav Carus. In Mainz, the University’s endoscopy program is well advanced in detecting many pre-cancerous states. Munich is well known for several different kinds of procedures and practices. The German Heart Center in Munich (Deutsches Herzzentrum) is renowned for its minimally invasive techniques. In Hamburg, the University Heart Center of the University of Hamburg specializes in non-surgical options as well as pediatric vascular surgery. The University Clinic of Schleswig-Holstein, has a very high success rate in living donor liver transplants and also specializes in kidney and pancreas transplants even when blood type between donor and recipient are incompatible. Hamburg also has a pancreas centre and offers cancer research and surgery. In Düsseldorf, the University Clinic (Universitaetsklinikum) specializes in malignant tumors of the digestive tract, thyroid and lungs. In Nuremberg, the Neurosurgical Clinic has expertise in the surgical treatment of diseases of the brain and central nervous system. The Neurosurgical Clinic of the Charite University Clinic Berlin, specialises in neuro-oncology, vascular neurosurgery and spinal neurosurgery; while the Center for Muscular-Skeletal Surgery (CMSC) offers a wide range of treatments, including trauma surgery, an endoprosthetic center and is well known for its treatment of spinal diseases and injuries and tumors of the muscular-skeletal system. The University clinic at Muenster is known for treating children with cancer. The Technical University in Munich is a specialized breast cancer centre.
The University of Hamburg-Eppendorf is renowned for its stem cell transplant work as well as for its treatment of diseases related to the blood and lymphatic system. The University Medical Center is the largest hospital in Northern Germany. University Medical Center Hamburg-Eppendorf with 80 clinics and institutes is again attending Destination Health in the UK.

Taiwan is gearing up for more Chinese and American medical tourists. It has launched a new app service for medical travel that provides handy information on tourist attractions and healthcare facilities around the country. The app, designed by the Taiwan External Trade Development Council (TAITRA) under commission from the Department of Health (DOH), has versions for English, as well as for traditional and simplified Chinese. The service, which is free, covers information ranging from health checkups to cosmetic medicine, with a map service for each listed facility. Users can access information on the 31 medical and healthcare facilities under the DOH’s international medical programme. Now available for iPhone and iPad users, the App will expand to Android users in the first quarter of 2012.
Four major hospitals in Taiwan have signed a cooperation agreement with New Era Life Insurance Co. of the USA to provide unique medical services to American policyholders of the insurer when they choose to get medical treatment in Taiwan. New Era Life Insurance of Houston, Texas, will pay for American customers to get medical services at the Taipei Medical University Hospital, Chang Gung Memorial Hospital System (made up of hospitals in different areas in Taiwan), Changhua Christian Hospital in central Taiwan, and E-Da Hospital in southern part of the island.
New Era Life Insurance has designed a US medical insurance policy for customers who can speak Chinese. The new service will help American customers, including Taiwanese who hold U.S. passports, to get medical treatment in Taiwan – including health examinations and cosmetics surgery, which are uncommon in insurance policy contracts. The customers can also get treatment in the USA. The details are still vague but founder Bill Shun-zer Chen, a Taiwanese immigrant, suggests customers have to pay a bigger share of medical costs if treated in the USA and funding for air flights to the island for themselves and families.
The insurance group is controlled by shareholders who are primarily Asian and has 150,000 policyholders. The company makes the bold claim that they plan to sell it to 1% of the total 20 million Asian Americans. We will get 1% of the total market – is a marketing claim that turns off experienced investors as it never happens.
Keeping this deal in perspective, by the standards of US health insurers the company is tiny, the equivalent of a family retailer when compared to insurance supermarket Cigna. In any one year, if more than 5% of the 150,000 policyholders have a medical claim in any one year then the insurer would lose money. The big question is how many of these US based Asians will rather be treated in Taiwan than in the USA. Similar deals for other countries have yet to find more than a handful, if any, US policyholders prepared to go overseas even when they have overseas links. What may determine the answer is how good the incentive is for the policyholders to go to Taiwan. This is an interesting pilot, but neither the insurer nor the hospitals should expect a rush of medical tourists.

The tourism industry in Russia is expanding with health resorts a popular choice for vacations, says the Federal Agency of Tourism. Tourism is growing at a rate of 7 % a year and one in three Russians favour health resorts as their vacation destination. Grigory Sarishvili of the Federal Agency comments, "Health resorts are gaining popularity and in certain regions are fully booked all year-round.”
Russia is to spend up to $60 million on a six-year advertising campaign to bolster its image as a tourist destination, as part of the government’s programme for the development of tourism through 2018. The $60 million earmarked for advertising will be spent on subjects and programmes about Russia on federal channels, promotion on social networks, exhibitions, the organization of presentations about Russia in foreign countries, promotional campaigns and the organization of press tours.
While the campaign is directed at both domestic and foreign tourists, the total number of foreign tourists visiting in 2011 is disappointing as European economic problems are affecting the chief suppliers of visitors to Russia: Germany, France, Britain and Italy. Of the 22 million foreign visitors in 2010, only 2.1 million were tourists.

Northern Caucasus Resorts Company (NCRC) is developing a massive system of ski, beach and natural heath spa resorts covering 50,000 sq km in the North Caucasus Mountains, stretching 1,200 km from the Caspian Sea to the Black Sea and bordering Asia. It is attracting Asia-Pacific investors seeking to diversify outside their domestic markets in a new national strategy to use public-private initiatives in tourism to spur much-needed economic growth in depressed regions of the Russian Federation.
Moscow-based NCRC was established last December to drive the massive tourism project, which will create up to 300,000 new jobs. A collaboration with the federal government, the development is part of a long-term strategy to address the economic lag that underlies social tensions in the North Caucasus region. The ten-year project is anticipated to require up to $30 billion to complete all phases, including a cluster of five world-class skiing and five modern seaside resorts, as well as an array of health spas that will take advantage of the area’s legendary healing mineral and hot springs. The eventual aim is 150,000 visitors a day.
The Russian government has designated the entire 50,000-sq-km development area a special economic zone. State guarantees will cover up to 70 % of investments for three to ten years. The state will impose no corporate or transportation taxes for the first ten years, no land taxes for five years and no VAT tax will be applied on equipment imported into the SEZ. The project offers opportunities for foreign companies interested in hospitality, health and wellness, food and beverage, retail, real estate, logistics and warehousing industries.
The French state-owned banking group and long-term investor Caisse des Depots et Consignations (CDC) has signed a strategic joint venture with NCRC to provide advanced technical, legal, planning and environmental expertise to support the project. 20 French companies have already expressed interest in investing in ski lifts, hotels, airports, mountain tunnel and other construction projects.

According to a recent analysis by business experts Oxford Business Group, Jordan is fast turning medical tourism into a mainstay of the kingdom’s economy, with the sector likely to soon turn a healthy profit thanks to the high levels of public and private investment in hospitals, medical facilities and staff training,
OBG says, “Jordan is well established in the medical tourism sector, having welcomed foreign patients to its health facilities for more than two decades. According to figures issued by the Jordan Enterprise Development Corporation, the country earned $1.4bn from the medical tourism sector in 2009 from 220,000 foreign visitors seeking treatment – a 10% rise in medical tourists from 2008.”
“A breakdown of 2009 figures compiled by Jordan’s Private Hospitals Association show that Iraqis were by far the largest patient group treated in the country’s hospitals, accounting for 19% of the total. This was followed by Palestinians, who made up 16%; Saudi Arabians with 15%; Yemeni patients next with 14% and Sudanese and Libyan patients at 13% and 9%, respectively. The remaining 14% included patients from a further 36 countries, demonstrating the fact that Jordan’s medical tourism sector is currently heavily reliant on a few neighbouring states for the vast majority of its activity.”
“According to a World Bank study, Jordan is ranked first in the region and fifth globally as a medical tourism destination, though it will be facing increasing competition in the coming years, with other Middle Eastern nations looking to cash in on the potential health windfall. The revenue generated by the Jordanian health services may also come under pressure as other countries in the region, notably states such as Iraq, improve the standards of their domestic medical facilities and those of professional service providers. In recognition of the potential for the patient pool in the region to be partly drained, Jordan has begun looking further afield for clients, promoting its medical services in the US and Europe.”
“In early October, Jordan and Romania agreed to bolster cooperation in the health sector, with Bucharest offering to help train doctors in specialised emergency services, while there are also plans to export Jordanian-made pharmaceuticals to Romania. According to Romanian Health Minister Attila Cseke, there was the potential for medical tourists from his country to come to Jordan as long as the fees charged were lower than those in other countries.”
Oxford Business Group concludes, ”Jordan’s efforts to enter the Romanian market are just the latest step in a far longer campaign to broaden the scope of its medical tourism sector. In 2009, Jordan began actively promoting its medical services in the US, aiming to capture a share of the growing market for overseas health provision there. While it may be early days, Jordan has made some impact in the American market, with the US now ranked in the top 10 countries sending patients for treatment in the kingdom, though this still represents a small fraction of the total. Though some other countries in the region are trying to generate interest in their own medical tourism services, seeking to attract foreign patients while also encouraging their own nationals to utilise local care facilities, Jordan does enjoy a number of advantages. One of the strongest selling points that Jordan’s health tourism industry has is its cost factor, with the fees for many procedures being less than 25% those charged in the US. This combined with the acknowledged quality of the country’s medical facilities and staff, with most of Jordan’s hospitals having gained internationally accepted accreditation, mean that overseas patients can be treated to the highest standards but at a fraction of the cost. Jordan also enjoys the advantage over many of its regional rivals of not requiring visas for citizens of many countries, or being able to offer visas on arrival, appealing to weary travellers not in the best of health. As long as Jordan can continue to increase the numbers of US medical tourists, who represent the largest and most lucrative segment of the market, the kingdom’s health sector should be able to shrug off any losses of clients to regional rivals, further building its reputation as a service provider of the highest quality while at the same time improving the health of the economy.”

According to new academic research on medical tourists in Bangkok, service quality has a positive relationship with value, satisfaction and brand trust. And it has a direct impact on medical tourists’ behavioral loyalty.
’International Tourists’ Service Quality Perception And Behavioral Loyalty Toward Medical Tourism In Bangkok Metropolitan Area’ has been published in The Journal of Applied Business Research. The independent research was by Assistant Professor Aurathai Lertwannawit of Suan Dusit Rajabhat University, and Associate Professor Nak Gulid of Srinakharinwirot University. The Office of the National Research Council of Thailand and Suan Dusit Rajabhat University sponsored it.
This research assesses the relationship between service quality, value, satisfaction, and brand trust on the behavioral loyalty of international tourists acting as medical tourists toward private hospital medical services in the Bangkok Metropolitan area. A quantitative study was performed using 400 international tourists who used medical service from private hospitals in Thailand. Most of the respondents used services from BNH Hospital.
Medical tourists ranked several factors for deciding to use medical services at the hospital according to order of importance: medical quality, value of services, patient safety and security, location, international patient marketing, international patient management, attention to unique needs of the medical traveller, and transparency.
Service quality has a positive relationship with value, satisfaction, and brand trust -which also has direct impact on medical tourists’ behavioral loyalty. In addition, value, satisfaction, and brand trust have an effect on the relationship between service quality and behavioral loyalty. Nationality does not have any effect on the relationship between service quality and value, satisfaction, and brand trust.
The research model is an extended service quality-loyalty model by insertion of brand trust from relationship market research. The results of this study provide empirical evidence better suited to the research model in a medical tourism context, in which distance between the service provider and the customer is relatively high. The researchers suggest that brand trust plays an important role in creating loyalty and also in leveraging the relationship from service quality and value to loyalty.
Brand trust is an important mechanism in generating both attitudinal and behavioral aspects of loyalty. The main rationale that explains this phenomenon is that tourists have to travel to a distant country in order to receive medical services, which provides a direct challenge to the individual. Consequently, a high level of brand trust can reduce uncertainty. Brand trust is important when tourists travel from a developed country to use a service in a developing country where they think the overall level of technology and knowledge is relatively low.
So everybody in medical tourism should devote more effort and resources to building a strong brand trust. Medical providers are able to generate loyalty among customers; this loyalty is directly beneficial, in terms of both creating repeat purchases and positive word-of-mouth. Word-of-mouth is important in medical tourism because key informants for medical tourism have a close relationship with the consumer. Word-of mouth and Internet reviews hugely impact which country and which hotel tourists go to, and medical tourism has not yet grasped the increased importance of peer review compared to traditional advertising.

Cuba is one of the unsung heroes of medical tourism, as it has been quietly attracting people from overseas for decades. The government controls access to all local hospitals for overseas patients, and has just relaunched Servimed.
Empresa Comercializadora de Servicios Médicos de Cuba S.A., known as Servimed, is a state owned and run company that offers foreigners access to the 16 Cuban hospitals and clinics that provide more than 100 types of health services on the island, ranging from cancer treatment and drug addiction programmes, to dentistry and cosmetic surgery. As an organization, their work has been ongoing for more than 20 years, initially as Servimed; later as Cubanacan Tourism and Health, then as Tourism and Health, and now back to Servimed.
It has been hidden away, but as part of a more public international role, the for-profit medical services company relaunched itself before an international business audience at the recent International Havana Fair. The expectation that President Obama will fulfil his promise to do away with the rules that prevent most US citizens going to Cuba for tourism or healthcare is part of the reason for the new openness.
Servimed deals with private individuals but its main role is to coordinate the bigger-volume business of government-to-government services. Servimed provides for-pay medical services by Cuban personnel to governments of 15 countries; which includes medical tourism. For-pay medical services to other governments are not new. Panama announced in 2011 that it will pay for the hands-on specialty training of Panamanian doctors in Cuban hospitals. Also in 2010 Qatar agreed with Cuba to pay for an undisclosed number of Cuban doctors to work in a new 54-bed hospital in the oil-rich country. Cuba also agreed in 2010 to manage and staff eye surgery centres in hospitals in China and Algeria.
Servimed is providing services to 15 countries this year, including Algeria, China, Portugal, Jamaica, Qatar, Surinam and Ukraine. Cuban medicine has become a worldwide leader in healthcare services for people in poor and rural areas as well as in disaster zones; at least 38,000 medical workers from Cuba are currently deployed in 77 countries. Cuba is in charge of a $690 million plan to rebuild Haiti’s healthcare infrastructure. Since 1998, the Escuela Latinoamericana de Medicina (ELAM) in Havana has been training 7200 students from all over the world, and graduates 1500 doctors per year.
Many of these programmes are funded by Venezuela, and others by countries such as South Africa, Brazil and Norway, but many are subsidised by Cuba. Cuba has proposed to the European Union and Canada that its doctors and medical services could be part of triangulated aid service provided in developing countries; so far, no agreement has materialized.
Venezuela is paying at least $5 billion in oil and cash per year for the services of Cuban doctors and for training of Venezuelan and third-country medical students in Cuba. Venezuela has also funded Operación Milagro, a billion-dollar programme led by Cuba that has given free eye surgery to hundreds of thousands of low-income Latin Americans.
Now, the government wants to use Servimed to make Cuba’s public health services sustainable and more efficient by generating revenues from paid for medical services and medical tourism and investing the profits in maintenance, repair and purchase of equipment for Cuba’s public health institutions.
Servimed is spearheading a Cuban effort to increase for-profit medical exports. A Public Health Ministry document published in December 2010 said that, as part of an overhaul of Cuba’s healthcare system, medical institutions should begin to sell services to foreigners wherever possible, “The medical services will remain free for poor countries. But they will be sold to those whose economy allows it, with the goal of reducing our expenses and contributing to the development of the national health system.”
The Cuban medical system now offers medical services for Canadians. Servimed’s individual subsidiary Health Services International began in January 2007. HSI is the agency officially recognised by Turismo y Salud and the Cuban medical system. It assists and guides medical tourists. In the agreement between HSI (Servimed) and Turismo y Salud, anyone who does speak Spanish will always have a medically trained person nearby who will act as an interpreter to help the medical tourist understand test results and to help when decisions are necessary. Many doctors and nurses do speak English and some speak French, also.

Turkey is uniquely placed in the centre of the EU, Middle East and Asia. According to Recep Tayyip Erdogan, prime minister of Turkey, at the start of the new decade, “Turkey’s vibrant economy has become a source of stability and welfare with growing foreign trade, a strong banking system, and diverse and prospering small and medium-size enterprises. All of these qualities have transformed Turkey into an attractive place for business.” Health and tourism are both growth areas, but although Turkey has great potential for health tourism, it has been unable to effectively market its assets and brand due to the lack of an integrated approach, a recent report has said.
The report, ’Turkish and Global Perspective: Heath Tourism 2010 by the Health Foundation of Turkey says, “Our country is an important centre of attraction for health tourism with healthcare facilities, trained human resources, technological infrastructure and accumulation of experience. The country could explore its real potential through stronger coordination between the government, civil society and the private sector as well as through more powerful international promotion and marketing strategies. Turkey ranks among the top 10 countries in terms of tourism income. It has great potential for health tourism, taking into consideration its geographical location, natural and historical wonders, climate and current healthcare infrastructure. Nation-brand has an important effect on health tourism, so the country needs to develop a nation-brand strategy that could be clearly expressed and promoted.”
According to one of the report’s authors Y?lmaz Argüden, the brand needs to be perceived not just as an instrument of promotion but as part of a strategy, “We need to build the brand of Turkey on values that really exist. Turkey is a multidimensional country and it is not possible to promote all aspects of it. We need to select some of these dimensions and really focus on them. Selected aspects should be distinctive for Turkey.” ?pek Alt?nbasak of Bahcesehir University argues that Turkey should rid itself of the “cheap country” label and highlight its diversity and lifestyle to draw more tourists. This is a problem for health tourism as a key attraction is the low prices when compared to other EU countries.
According to data provided by the Turkish Statistical Institute and the Central Bank, 103,400 foreign patients came to Turkey for treatment in 2003, spending $91 million, while the figure was 162,480 at $282 million in 2008 and 132,680 at $225 million in 2009.TurkStat estimates for 2010 are around 165,000, placing the country at number ten in a ranking of global destinations for inbound medical tourists.
The report cites the high-quality infrastructure of hospitals, comparative price advantages, geographical location, suitable climactic conditions and tourism facilities at high standards in addition to well-trained staff with a command of foreign languages as advantages for health tourism in Turkey. It says that the lack of cooperation between the state, nongovernmental organizations and the private sector, the lack of a sufficient number of experts including doctors and nurses trained in the area of health tourism and a lack of legislation are disadvantages to Turkey in terms of health tourism.
An excellent example of the type of mutual cooperation that the report wants is when the Turkish Healthcare Tourism Development Council (THTDC) will once again exhibit at the forthcoming Destination Health Exhibition on 15 – 16 April 2011 at London’s Olympia Conference & Exhibition Centre.Emin Cakmak of THTDC said " Destination Health is the perfect forum for Turkish healthcare providers to showcase the quality of their health and medical services to UK medical tourists.” THTDC members consist of governmental institutions, hospitals, clinics, doctors, medical tourism facilitators, travel agencies, hotels and thermal hotels. Exhibitors within the Turkish pavilion will include fertility clinics, dental clinics, cosmetic surgery clinics, hospitals and health and medical spa resorts and hotels.

Although healthcare and dental costs have fallen across Ireland this year, people can save considerable sums by travelling within Ireland or going overseas, a new survey shows.
According to the second annual Avantis Health Global Health and Dental Price index, Irish health and dental charges dropped by an average of between 3% and 10% since the Spring. The survey also shows that there is a variation of up to 70% in the cost of some treatments around Ireland, and patients could also save up to 50% on some procedures if they travelled to countries such as Spain, Belgium and Germany.
The index looks at treatment costs within Ireland and globally and covers a range of elective procedures including dental treatment, eye surgery, cosmetic surgery and elective surgery. Prices for common dental procedures have fallen by as much as 21% in some cases, while cosmetic surgery procedures have seen costs decline by between 10% and 20%. Elective medical procedures have fallen in price by up to 16%. Laser eye surgery has increased in price by 21%, and the cost of nose reconstruction surgery has increased by 24%.
The survey reveals vast differences in prices throughout Ireland. Although Dublin is more expensive for some procedures, such as a tooth extraction, it is significantly cheaper for others. A simple dental implant costs 75% less in Dublin compared with some cities in Connacht or Leinster, while some cosmetic surgery procedures are 67% cheaper in the capital compared with other Irish cities.
Orla Fahy of Avantis says, “These figures show a modest reduction in health and dental prices. It also shows a startling variation in prices between Irish regions for the same procedures. Irish patients can make significant savings on their health and dental care, by merely shopping around within Ireland, with substantial savings possible if they are willing to travel abroad for treatment.”
Despite the cuts, Ireland remains one of the most expensive countries in Europe for health and dental treatments
International average cost comparisons:
Tooth extraction:• Ireland: €84• Dublin: €100• Rest of Leinster: €80• Connacht: €80• Munster: €75• Belfast €53• London €64
Laser Eye Surgery:• Ireland: €1868• Dublin: €2025• Connacht: €1700• Munster: €1750• Rest of Leinster: €1996• London: €2260• Belfast: €1785• Tunisia: €892• Hungary: €545
Breast augmentation• Ireland €2774• Munster: €5000• Leinster: €4700• Connacht: €3050• Dublin: €3000• Belfast: €4875• London: €4500• Belgium: €2256

According to Balázs Botos of the Ministry for National Economy the central message of the country for the forthcoming years will be "healing Hungary", “Hungary has all the potential to render health tourism as a breakthrough point. In the next few years, the Hungarian message will focus on physical and mental health, but with the help of gastronomy, the quality of life and tourism services will also improve. To achieve this, more support should be given to the catering industry. In order to improve the possibilities, the demand and the offer should be more balanced. Problems include the lack of restaurants offering traditional gastronomy values, fresh Hungarian ingredients are often missing from the menu and the education system is also out of date."
If you are suffering winter blues, Hungarian capital Budapest has just the solution – free spa admission for visitors to the city through March 2011. Offered as part of the city’s winter marketing campaign, the deal offers those looking to visit Budapest free entry to one of the city’s three most popular spas, as well as a free night if you visit for three or four nights. Hungary’s capital has 118 thermal springs, which were first discovered by the Romans and remain a popular tourist attraction today. Among them are the Széchenyi thermal bath, the largest medicinal bath in Europe, and the Gellért Baths and Spa, one of the most popular for visiting tourists. The Hungarian National Tourist Office says that alongside the three spas, 60 hotels are participating in the campaign by offering free guest nights, and Hungarian national carrier Malev is providing deals on flights.
The tourism office plans to position Hungary as a health tourism destination over the coming years, targeting German, Austrian and British tourists away from other eastern European health hotspots such as Poland and the Czech Republic. This is being driven by a boom in the number of spa and wellness hotels in the country – from only 24 in 2001, there are now 150.
Although private spa, wellness and dental clinics offer high quality at reasonable prices, basic state medical care has problems. Hungarians pay a healthcare premium to the government and receive free healthcare services funded by the state. However, the quality of those services is often so poor that Hungarians who can afford it choose to pay extra for private treatment. Government and trade unions blame underfunding, structural problems and, in some instances, bad management for the woes. One of the ways to improve the situation is to attract foreign customers, according to the government. Hungary hopes that health tourism will become the main driver of the sector’s growth. Foreign tourists already go to Hungarian dentists and health spas each year — but most of them are privately owned. Much restructuring and investment will be needed before foreigners start to go to hospitals and clinics run by the state. Regardless of how much money is put into the system, independent audits say that efficiency needs to improve.

The 2011 Treatment Abroad Medical Tourism Survey has attracted over 600 participants in the two weeks since it was launched. The initial 600 participants have been attracted by targeting enquirers to the Treatment Abroad family of medical tourism web sites. The research aims to find out about the experiences of patients who have gone abroad for some form of surgery or medical or dental treatment. The research is being undertaken by European Research Specialists on behalf of Intuition Communication who run Treatment Abroad, and the International Medical Travel Journal.
The research data will be provided at no charge to a Medical Tourism Research Team led by Dr Neil Lunt at the University of York and Professor Richard Smith at the London School of Hygiene and Tropical Medicine. The team recently completed a review of Medical Tourism for the OECD.
Intuition is encouraging all healthcare providers who offer services to international patients to encourage their past patients to complete the survey. Intuition is offering £100 (or €100 or $150) of Amazon vouchers to five participants drawn at random, who complete the survey in full. In addition, for every completed questionnaire, Intuition will donate £1 to Smile Train, an international charity that provides cleft palate surgery to children around the world.
Healthcare providers will get a free copy of the full report of the research, provided that more than twenty of their patients complete the survey. Providers can download an email template to send to medical tourists who have used their services.

The Indian Tourism Ministry has agreed to pay over $27,000 to 10 medical tourism service providers including representatives of hospitals, travel agents and tour operators. India’s medical tourism is now included in the Marketing Development Assistance (MDA) scheme, under which medical tourism service providers can be given financial assistance. The ministry suggested that although in 2002, only 150,000 foreign patients visited India for treatment, the estimate for 2010 is around 500,000.But it admitted that these are no more than rough estimates as there are no official figures. India has been a pioneer in medical tourism due to low prices and modern medical technology. Patients visit India mostly for heart surgery, knee transplants, cosmetic surgery and dental care.
According to Vishal Bali of Fortis Healthcare, Americans are increasingly visiting Mumbai for medical treatment. He says: “There has been a 30-35% rise in American patients being treated in Mumbai each year. And we are not including non-resident Indians. They find treatment here more affordable, and it is high quality healthcare. A cardiac surgery in India costs $13,000, including stay and travel. In the US it costs $55,000 – $75,000. “
According to a new research report from RNCOS “Indian Healthcare – New Avenues for Growth”, medical tourism is expected to create a huge opportunity for the country’s private hospitals, with a large number of patients from all over the world expected to visit India to receive first world healthcare facilities at third world prices. It is expected that the medical tourism market will grow at 31% a year during 2010-2013.
To promote medical tourism, the Tamil Nadu government is planning to bring out tourism brochures in consultation with medical institutions. Citing the availability of super speciality hospitals in the state, providing quality services affordable cost, the state’s primary objective is to make Tamil Nadu a favoured domestic and international tourist destination. Patients mostly come from the Middle East, Pakistan and some African countries.
An Indian company, Vipul MedCare, is offering expatriate Indians in Dubai an opportunity to obtain healthcare in their country of origin. Vipul MedCare, which has an alliance with Dubai-based Avita Healthcare and Global Assistance, plans to market its packages to UAE insurers that provide group health insurance benefits to companies. These packages include second medical opinions, electronic medical record management and elective surgical procedures. The mounting cost of health care has become a hot issue for the UAE insurance sector. While medical insurance continues to be profitable for insurers, they are unhappy at the high cost of healthcare. According to a regional health care report by Alpen Capital, expatriates in the GCC prefer their native countries when it comes to medical treatment as they are unhappy with the quality of medical care at government run hospitals and clinics in the GCC.Vipul Med Care’s network extends to 4000 hospitals across India. It will target companies such as those in construction and labour supply with a substantial base of Indians.

Apollo Hospitals will open standalone cosmetic clinics in Mumbai, Delhi, Chennai and Hyderabad in the next six months. Apollo has formed a subsidiary, Apollo Cosmetic Surgical Centre to run Apollo Cosmetic Clinics that will offer a range of cosmetic surgeries, including liposuction, rhinoplasty, breast enhancement, eyelid lift and beauty procedures such as botox, dermal filling and facelift. It will soon include stem cell-based cosmetic correction. Apollo’s cosmetic care initiative is to help India to be a healthcare destination for cosmetic surgery.
A range of medical treatments presently unavailable in the island will be made available to Sri Lankans in neighbouring India at an affordable cost, a newly launched health tourism company says. Manilal Fernando of Comfort Health Care explains, "Our aim is to offer high quality health care at an affordable cost to middle income families. What we are offering is a home to home service, where the patient leaves home, gets the treatment in India and comes back home safely."
Comfort Health Care, Sri Lanka will provide services from second opinions to sourcing the right medical facilities, arranging visas, and organizing travel and accommodation in addition to medical treatment. The company will also ensure a smooth handover to the patient’s local doctor for follow up and after care. Specialized treatments include transplants, cancer treatment, scans and assisted reproduction.

The Taiwan government will set up an international medical development fund aimed at promoting Taiwan’s medical services to the global community. President Ma Ying-jeou said “In recent years, the country has received about 90,000 visits annually from foreign tourists seeking medical check-ups and healthcare services. The establishment of the medical fund is expected to position Taiwan as a top medical tourism destination and help the country bring home more business opportunities from Asian countries, which currently stand at US$4.72 billion per year.”
The president has called for the formation of a cabinet-level office in charge of internationalizing Taiwan’s medical services. There are 31 domestic medical institutes providing services to medical tourists. Although the government has yet to agree details of the fund’s operations and amount of capital, the suggestion is that it could be established as a venture capital fund backed by the National Development Fund and money from the private sector. The main purpose of the fund will be to market the nation’s medical industry and boost its image abroad. The government wants visitors to move on from health checkups and simple operations to other medical procedures including heart surgery and fertility treatment.
Taiwan wants to emulate competitors Singapore and Thailand. Taiwan was slow to take advantage of the growth in medical tourism. Taiwan’s government has paid out substantial funds each year to a government-backed taskforce on medical tourism since 2007. That funding is to cover international marketing activities and operating expenses.
With restrictions on mainland Chinese tourists fast diminishing, the island could see a surge in medical tourists, with growing wealth in China. Taiwan has the attributes of a good medical tourism destination — it is safe, located a few hours by plane from other major Asian cities, and western-trained doctors who speak English. Taiwan plans to build a major medical tourism complex near Taoyuan international airport, although investors have yet to be found for the project.

The Buddhist Tzu Chi General Hospital in Hualien, Taiwan has launched a medical tourism programme in a bid to become a regional player as Taiwan seeks to expand its tourism industry. The hospital, the largest medical center in eastern Taiwan, will collaborate with travel agencies to introduce medical tourism packages for visitors from home and abroad. The hospital will put together several packages to meet the needs of tourists, including fast affordable checkups, high-technology diagnostics, cosmetic surgery, and micro-plastic surgery.
Thousands of Chinese nationals have visited Taiwan to have health checkups in the first eight months of this year, taking advantage of medical tourism offered to Chinese tourists since 2008.At least 3000 Chinese in tour groups received health checkups says the Department of Health. Chinese visitors, attracted by Taiwan’s advanced medical skill and equipment, are willing to pay as much as US$3,289 for a half-day or full-day medical examination. Some China-based Taiwanese businessmen also arrange checkups for their employees when they make trips to Taiwan.

Temos has expanded its telemedicine portfolio with new tele-care, tele-clinic and tele-monitoring services. St. Luke’s Medical Center Global City and St. Luke’s Medical Center Quezon City are the first Temos certified hospitals in the Philippines. For 6 days the Temos surveyors visited the hospitals and found very well managed hospitals with highly motivated staff, an outstanding technical infrastructure, and a high level of quality in medical and non-medical services as well as in research activities. Hospital Alemão Oswaldo Cruz in Sao Paulo, Brazil has had a successful Temos re-certification. For 3 days the Temos surveyors visited the hospital and found a very well managed hospital with a high level of quality in medical and non-medical services as well as in its research activities.
Temos has started the training of two regional collaboration partners and their teams to serve hospitals, dental clinics, practices and clients in Eastern Europe and the regions Cyprus and Greece. Dr. Claudia Mika of Temos trained 10 Temos assessors in Athens, for their assignment in Cyprus and Greece. All are medical doctors and/or quality experts in the health system and completed the training successfully. Together with its partner for Greece and Cyprus, Angeliki Katsapi, it will set up a new office in Cyprus in early 2011 to support, inspect and certify hospitals and dental clinics in Cyprus and Greece.
A partnership agreement has been signed between Levent Ba? and Temos so that he becomes Temos regional manager for Turkey. Another partnership making Dr. Marijan Gjukic the Temos representative for Croatia and neighbouring countries has been signed. A memorandum of understanding has been signed between the Croatian Medical Tourism Association and Temos on cooperation in support of association members in Croatia who intend to attract international patients.
The US Centers for Medicare and Medicaid Services (CMS) has granted deeming authority to DNV Healthcare for critical access hospitals, expanding DNV’s role as the newest provider of hospital accreditation in the USA. DNV Healthcare is a division of Det Norske Veritas (DNV), an independent German foundation with 300 offices in 100 different countries.
Just two years ago DNV became the first new organization in over 40 years to win Medicare deeming authority for the US’s acute care hospitals. With CMS’s latest approval, DNV begins offering a new version of its NIAHO accreditation program designed specifically for critical access hospitals. Yehuda Dror of DNV Healthcare says, "Critical access hospitals are an important part of the national hospital grid. Our quality-based accreditation program embraces ISO quality management standards as a means of improving patient safety and quality of care."DNV’s NIAHO program – National Integrated Accreditation of Healthcare Organizations – is based on collaboration versus inspection and is the only hospital accreditation program to integrate ISO 9001 quality protocols.
DNV accredited hospitals can now display a web-ready emblem letting staff and the community know that they have quality-driven accreditation. The blue badge signifies adherence with the Medicare Conditions of Participation. The gold emblem affirms additional accomplishment of full compliance with the ISO 9001 quality management system.

A customer survey from a collection of CNN websites has looked at global tourism. It covered 108 destinations, 60 airlines and 50 hotel chains. The survey was conducted by independent research group Synovate between May and June 2010.
The location of the consumers was: North America 14%, Latin America and Caribbean 8%, Middle East and Africa 24%, Europe 31% and Asia Pacific 23%. All those surveyed were affluent educated international travellers.70% male and 30% female.61% were mid to top managers or their partners. Average household income US $ 105,000.70% had taken one or more international leisure trips in the previous 12 months, and 50% had taken leisure and business trips.
Questioned on which type of holiday or activity was likely to be of interest for the next vacation; 21% selected yoga/spa health related tourism and 6% medical tourism. Adding up the 20 different categories gives a total of around 750%….. so it is much more a wish list of possible types to choose from. It does not mean that 6% will actually take a medical tourism holiday. It means that among the 20 categories, 6% would consider it, the same percentage as for golf. And this is also a ’may consider’ not a ’have done’ questionnaire. Such future predictive surveys are notoriously unreliable compared to what research based on what people actually do.
On attitudes to travel: 64% were happy with long-haul air travel, 18% only wanted short haul air travel, and the rest were uncertain.
Looking at travel intent on the region people would most likely go to in 2010-2011;

For people living in Asia Pacific: 59% stay in region, 19% Europe, 14% North America, 6% `Middle East/Africa and 2% Latin America /Caribbean.
For people living in Europe: 62% stay in region, 11% Asia/Pacific, 15% North America, 7% `Middle East/Africa and 5% Latin America /Caribbean.
For people living in North America: 50% stay in region, 13% Asia/Pacific, 22% Europe, 5% `Middle East/Africa and 11% Latin America /Caribbean.

Focusing on the Asia/Pacific region as a destination, considering 25 destination countries and only asking those both in and outside Asia/Europe who said they that it was their most likely next destination-top countries; Hong Kong 38%, Singapore 33%, Japan 32%, China 32%, Australia 31%, Malaysia 28%, Thailand 27%. New Zealand 24%, India 19% and South Korea 19%.
Asked which Asia Pacific destinations had the best image, on the criteria of tourist safety; Australia 66%, Japan 58%, New Zealand 60%, Hong Kong 48%, Singapore 43%.
Many of the above answers are of course not specific to medical or spa tourism. But results show how that there are huge differences between regions as to where people prefer to travel, and that several Asian countries have work to do to convince travelers that they are safe destinations. If nothing else, it illustrates that you cannot have one global marketing message or expect to be received the same everywhere. Choosing the right target and the right message will be essential to business success in 2011.

Switzerland is targeting wealthy Russians who ski at top resorts to visit the country for anything from a health check to full surgery. There are no official figures on Swiss medical tourism numbers or revenue. Jan Sobhani, of Zurich-based Swixmed, which arranges treatment for foreign patients, makes the bold claim that it is now worth US$1 billion, and by 2020 will be worth over $5 billion. This figure is said to be 60% from medical treatment and 40% from extra tourism including hotel rooms. Patients often travel with at least one relative and stay in luxury five-star hotels.

University Children’s Hospital Zurich is attracting Russians for surgery and check-ups. In 2011 Switzerland plans to broaden its target market for the luxury end of the medical tourism trade, by targeting wealthy visitors from the Arabian Gulf region. The Swiss healthcare system enjoys an excellent reputation: doctors and nursing staff are highly trained and it constantly invests in technology and a state-of-the-art infrastructure.
Tourist authorities are distributing 6,000 nine- page brochures for Russians at Swiss skiing resorts including Davos, Klosters, St. Moritz and Zermatt. The campaign highlights the high quality of Switzerland’s doctors, the “country’s reputation for quality and historical links to Russia. It is not offering cut-price treatment. Switzerland focuses on state-of-the-art procedures that may not be available elsewhere. For example, a Zurich hospital was the world’s first to use ultrasound to kill brain tumor cells without cutting open the skull. While the Swiss doctors employed a technique involving three 5-millimeter (0.2 inch) cuts, Russian surgeons would have used a more invasive procedure that involves making a 4-centimeter incision.
Antoine Hubert of Genolier Swiss Medical Network says that out of 12,000 patients admitted to hospital last year, 600 came from abroad, a much higher proportion than five years ago. But although only 5% of numbers, they are responsible for 15 % of the company’s revenue, “Foreign patients profit from our wellness offer and hotel services and often come accompanied with family members, who also stay at the clinic. Foreign patients generate more income and profit than a Swiss private patient.” Genolier’s flagship clinic, which overlooks Lake Geneva and Mont Blanc, has a new presidential suite with exclusive comfort and privacy, and prices to match.
According to United Nations comparisons, only Japan, Hong Kong and Iceland, have a longer average life expectancy than the 81.7 years of Switzerland. Hirslanden Private Hospital Group, Switzerland’s largest private health-care provider, is seeking annual growth of about 10 percent in foreign patients within the next five years. Hirslanden runs 14 clinics from Lake Constance on the Austrian border to Lake Geneva on the frontier with France, and is collaborating with hospitals in Jeddah and Dubai to attract Arab patients. Hirslanden has a new deal with the International Medical Center (IMC) in Jeddah, Saudi Arabia. The collaboration will give patients in Saudi Arabia access to the Hirslanden network, filling gaps in the medical care provided in the kingdom. The co-operation includes the referral of patients to Hirslanden, the exchange of doctors, and the transfer of knowledge at various levels of care, medicine and administration.
Switzerland’s main competitors in the luxury medical tourism market are Austria, USA, the UK and Germany. Switzerland has a long history of medical tourism, dating back to the Romans when wealthy travelers came to take the waters. In the early days, these healing mineral waters were thought to offer cures for all kinds of diseases. At the beginning of the twentieth century, patients from all over the world came to Switzerland for treatment in Alpine clinics. Today, patients from around the world travel to Switzerland for the high quality and range of these medical clinics.

The cost of facelifts, tummy tucks, liposuction and breast enlargements in the UK is set to rise by 20% after new government guidelines on Value Added Tax. Doctors performing purely cosmetic operations must register for VAT and pass the charge on to patients in a move that will boost public finances. According to the British Association of Aesthetic Plastic Surgeons (BAAPS), cosmetic surgeons in the UK in 2010 carried out 9,430 breast enlargements, 3,417 tummy tucks, 5,000 facelifts, more than 4,000 nose jobs and over 1,000 operations to correct ears that stick out. At the moment, a breast enlargement operation can cost up to £5,000, which will rise to £6,000 once VAT is added. The average cost of a facelift could rise from about £6,000 to £7,200.

HM Revenue and Customs (HMRC) argues it is only clarifying existing laws in guidance sent to trade professionals and that there is no change in government policy on VAT for cosmetic surgery; VAT is not charged on surgery for medical reasons. HMRC guidance to health professions states that services are only exempt of VAT if the purpose is to ’protect, maintain or restore the health of the person concerned’.
BAAPS says that over 90% of procedures deemed cosmetic are non-surgical treatments such as injectables and lasers, and it agrees they should be taxed with VAT. However, they warn that including surgery such as breast reductions and tummy tucks will present an ethical minefield.
Fazel Fatah of BAAPS warns, “Using blanket terminology such as ’free choice rather than medical necessity’ and ’purely for aesthetic purposes’ places a value judgment on treatment and compromises the doctor-patient relationship. Treatments carried out by cosmetic surgeons do improve the psychological as well as the physical wellbeing of patients. The subjective proposals by HMRC will potentially harm large numbers of patients. They imply that any procedure that corrects appearance rather than function is not a medical need. With surgery, we are quite literally, dealing with human lives."
Dr Samantha Gammell of the British Association of Cosmetic Doctors adds, ’When patients seek out care from doctors they expect to be treated without judgment or prejudice, putting the maintenance of their health as our primary concern. We are appalled that HMRC inspectors are demanding to review confidential patient records for proof of their medical needs. It is an obscene invasion of privacy based on a ridiculous premise that a doctor, having taken on a duty of care, could do otherwise than protect the health of their patient. There is simply no legal basis for the HMRC’s approach and we will continue to fight for patients’ rights.”
In 2009, in the USA, the authorities had the idea of charging a 5% tax on all cosmetic procedures. It failed to get through the Senate. The UK situation is different as it is not a planned legislative change but a change of interpretation by HMRC who act independently of politicians.
A number of people already travel abroad for cosmetic surgery, as it is cheaper in Eastern and Central Europe. Although it is even cheaper in parts of Asia, few travel that far for simple cosmetic work. UK cosmetic surgery associations have warned that patients ”unable to afford elevated prices in the UK, will be forced to travel abroad where standards and guidelines for cosmetic surgery are not necessarily as strictly controlled.”
If you are prepared to travel for cosmetic surgery abroad, with clinics everywhere from Brazil and Bulgaria to Thailand and Tunisia seeking UK clients, you can certainly get a much cheaper deal. In many places, the standards of surgery are as good as the unregulated UK cosmetic surgery industry.

The Quebec College of Physicians is warning multiple sclerosis patients not to seek liberation treatment at clinics outside Canada because the procedure remains scientifically unproven and may have unknown risks. It also assured MS patients that anyone who develops complications after taking part in such medical tourism would be cared for by doctors in Canada.
A growing number of Canadians with the debilitating neurological disorder are travelling to clinics in the Costa Rica, Europe, India and elsewhere for liberation treatment, which is based on an Italian vascular specialist’s hypothesis that MS is linked to blocked and twisted neck veins. Paolo Zamboni believes these vein anomalies, chronic cerebrospinal venous insufficiency (CCSVI) allow blood-borne iron deposits to damage brain cells. He argues that opening blockages in the veins with a tiny balloon can alleviate MS symptoms. MS has long been considered an autoimmune disease. But since late last year, when Zamboni’s procedure first made headlines, a number of MS patients have sought out private clinics abroad, paying thousands of dollars apiece for the treatment. Some medical tourism agencies have promoted the concept heavily in Canada.
Dr. Charles Bernard says, “I have received numerous messages from patients afflicted with multiple sclerosis and we are saying to them that we need to wait for the results of studies that are currently underway before generalizing Professor Zamboni’s treatments. In particular, we are recommending to these individuals that they refrain from consulting any medical tourism clinics offering these treatments prematurely with little regard for their effectiveness and side-effects.” Liberation therapy is not available in Canada, and the federal government is awaiting results of several studies now underway before deciding whether pan-Canadian clinical trials should go ahead. Several international studies have found that narrowed neck veins can occur in people without MS, and among people with the disease, such venous blockages are not always present when symptoms begin. So some doctors argue that the obstructions are not the cause of multiple sclerosis, as Professor Zamboni’s hypothesis suggests. Nobody knows whether blocked neck veins cause MS, are a result of MS or have no association with the disease at all. Results from North American studies funded by the Canadian and American MS societies, and now underway, should answer some of those questions and help determine how research aimed at validating the procedure should go forward.
The Italian doctor who gave multiple sclerosis sufferers hope their condition could be treated with a simple procedure and prompted many of them to cross borders and shell out thousands of dollars to receive it has now warned patients against receiving the treatment until further clinical trials have been conducted. Paolo Zamboni, a researcher at the University of Ferrara, suggested that the improper drainage of blood from the brain, termed chronic cerebro-spinal venous insufficiency, may play a part in causing MS, which is generally believed to be an autoimmune disease. Zamboni recently told an MS conference in Gothenburg, Sweden, that patients should not go ahead with such surgery, except in the case of clinical trials. He also said he does not support medical tourism of MS patients who travel overseas to clinics that will perform the surgery. Thousands of people are believed to have done this. Those who believe in the theory, argue that Zamboni’s caution is unlikely to change the minds of those who are determined to receive surgery to open their blood vessels, if they have the hope of alleviating many of their symptoms.

More than 30 million people in the United States travel to resource-limited areas of the world each year. This global mobility may contribute to the spread of infectious diseases – such as influenza, measles, and meningitis – and may also put individual travelers at risk for malaria, typhoid, dengue fever and hepatitis. Despite these potential risks, a recent study conducted by the division of infectious diseases at Massachusetts General Hospital (MGH) and published in the Journal of Travel Medicine found that 46 % of travellers to resource-limited countries did not seek health advice or vaccinations prior to departure.
The researchers surveyed 1,200 international travelers departing the United States at Boston Logan International Airport. The study was the result of a broad-based collaboration between MGH, the Centers for Disease Control and Prevention (CDC), the Boston Public Health Commission, and officials from the Massachusetts Port Authority, which owns and operates Logan International Airport. Based on the results from this work, the CDC, travel medicine experts and Logan Airport officials hope to develop better tools to educate people about the public health risks associated with global travel.
Of those surveyed, 38% were traveling to countries described as low and low-middle income by the World Bank’s World Development Report, yet 46% of these travellers did not seek health advice prior to departure. Foreign-born travelers, including those traveling to visit family and friends, and those traveling alone or for vacation, were the least likely to have researched health information. The most commonly cited reason for not pursuing health information was a lack of concern about potential health problems. Of the 54% of travellers to resource-limited countries who did seek health information, the internet was the most common source, followed by primary care practitioners.
The rapid global spread of SARS in 2002-2003 and new influenza strains in 2009 exemplified the role played by travellers in disseminating infectious diseases. More recently, dengue fever – a tropical disease found mainly in the Caribbean, Latin America and Asia – has been reported in the southern United States. In India, an epidemic of Chikungunya – a viral infection characterized by fever, headache, weakness and joint pain – was spread to Italy by travelers.
Edward Ryan of MGH says, "International travel is the primary way many infections traverse the world. What many people do not realize is that, without seeking the correct health information, they are putting themselves at increased risk of infection, as well as creating a public health risk in their home communities after they return."
The small sample may or may not have included medical travellers. What the study highlights is the need for hospitals and agents at the sending and receiving countries for medical travel, to do a better job of ensuring that the traveller and any companions are aware of the general health risks in the destination country, and have taken the right precautions. A key reason why there was the recent argument over diseases in India is that organizations have concentrated on the medical travel aspects of trips, and forgotten that the customer is also an international traveller. Medical travel agencies need to be as responsible as travel agents and tour operators are on ensuring their customers have the relevant injections before travel, and are warned on the health hazards of the country; they may be going to the cleanest hospital in the world, but are still at risk when they travel within the country on the way to and from it.

Thailand Medical Tourism Cluster (TMTC) says it will promote both domestic and international markets, claiming the wellness sector can be sold locally to domestic travellers. Prapa Wongphaet of TMTC says, “Medical tourism is much more than visiting a hospital or local doctor. We can market wellness, healthy living and spas to Thai travellers promoting the idea of turning a holiday into an opportunity to improve health. We are working with Tourism Authority of Thailand (TAT) to promote products and routes in Thailand that have a medical tourism theme for Thais.”
According to TMTC, Thailand earned Bt147 billion from 1.5 million international tourists who sought medical treatment in the country in 2010, but these are both rough estimates. Medical clients spend 12,000 baht per day, three times higher than normal visitors. Each medical client stays in Thailand between 8-15 days on average. Prommate Nathonmtong of TAT adds: “We are promoting lifestyle tourism and wellness that features meditation, healthcare and wellness and even healthy cooking classes.”
Currently, medical tourism concentrates on Bangkok, Hua Hin, Phuket, Krabi and Samui that have international grade hospitals. TMTC hopes to extend the reach to other destinations in North Thailand and the Northeast. In 2012 it plans to develop two provinces – Ubon Ratchathani and Udon Thani – to attract ASEAN medical tourism mainly from Laos. Hospitals in Chantaburi, Trat and Rayong province could draw business from Cambodia. A key problem is that most of the regional hospitals are already overcrowded, while the few private hospitals in the North, lack sophisticated diagnostic equipment found in hospitals in Bangkok, Phuket, Samui and Pattaya.
Despite being one of the most highly regulated spa industries in the world, Thai operations must be more proactive in developing better standards or else other countries could outstrip Thailand, warns Andrew Jacka of the Thai Spa Association (TSPA), "Competition is going to change radically in 2015. Thai spa operators must speed up improving their standards prior to the advent of the Asean Economic Community in order to secure the country’s position as leader in the Asia-Pacific. The global positioning of Thai spas is defined through the element of “Thai-ness”, which is an intangible quality that no one can copy. But spa treatments in Indonesia, Cambodia and Laos are very similar to those in Thailand, while in terms of numbers, Malaysia and the Philippines are the main competitors.’
Of the 75,000 spa businesses worldwide, 30% are in Asia Pacific. Thailand has 2% of the global market and is the seventh-largest employer of spa therapists. Thailand’s first spa opened in 1992 and the industry grew by 25% a year until 2005, when the rate slowed to 10% as more spas opened. Last year the industry was valued at US$400 million. 1500 spas are registered with the Public Health Ministry – including 800 day and resort spas and 700 massage parlours for health and beauty.
The TSPA and the certification body SGS (Thailand) have established the voluntary Thai Spa Excellence Quality Standard, which focuses on five areas – facilities and infrastructure, sanitation, personnel, monitoring and improvement, and operational control. A compulsory standard is the minimum requirement applied by the Public Health Ministry. A standard that would help spas expand abroad has been undergoing trials and was recently launched by SGS.

In an effort to promote health and wellness tourism to Australians, the Ministry of Health Malaysia and Tourism Malaysia held a briefing session for tour operators interested in understanding the rules and regulations required to package and promote health tourism to Malaysia. Health tourism is growing in Malaysia. From 2007 to 2009, there were around 350,000 medical tourists each year, the exact numbers still being a matter of dispute. This number is expected to grow significantly in 2010 with over 625,000 expected. Whether this is an accurate prediction or an optimistic government target, is a matter of debate.
Traditionally, most medical tourists come from ASEAN countries such as Singapore and Indonesia. However, Tourism Malaysia believes there is significant potential to grow medical tourism from the Australian market. Choy Lup Bong for the Ministry of Health Malaysia says, “Along with outstanding medical facilities and doctors, Malaysia also has English as a main language, convenient transport infrastructure, stable government and cost comparisons show that despite the high level of services, Malaysia is one of the most cost competitive countries for most procedures. The Ministry of Health has selected 35 of Malaysia’s best private hospitals for promotion and will continue efforts to help access to medical services for Australian visitors.” Shahrin Mokhtar director of Tourism Malaysia Sydney says that medical tourism is a strong potential market, “Although it is a niche market, these visitors spend more than leisure travellers, stay longer and also tend to become repeat visitors.”
A report on Malaysian tourism by analysts RNCOS, says that with increasing promotional activities and government support, tourism will increase by 8% each year from 2011 to 2013. According to “Malaysia Tourism Industry Forecast to 2012”, Malaysia has emerged as one of the top tourist destinations in the world. The research identifies that medical tourist arrivals in the country will also experience tremendous growth on the back of increased investment and infrastructural developments. The report found that Singapore, Indonesia, and Thailand are the major source countries for tourist arrival in Malaysia.

The government of the Turks and Caicos Islands has followed Dubai and Nigeria with a public declaration of the need to drastically cut government funded outbound medical tourism. While for Dubai and Nigeria it is a point of principle to improve local healthcare so patients do not have to be sent abroad, for the Turks and Caicos it is matter of dire economic necessity. Other countries that pay for citizens to go overseas for treatment either have economic problems or a desire to spend the money on improving local healthcare. This could well be the beginning of the end for government paid outbound medical tourism in these countries.
Nigeria loses an estimated £10 million annually to medical tourism to India, says Henry Mojekwu of medical tourism agency New Horizon Healthcare Nigeria Limited. He says that the trend is due to India’s ready availability of relatively cheaper healthcare, and accepts that when Nigeria has quality hospitals, the country will benefit financially. At present, patients go to India to avoid the long waiting times that patients experience in Nigeria.
The Turks and Caicos Islands interim government is seeking public input on how to reduce the cost of a two-year-old health care system that the country now cannot afford. Among a raft of budget measures that include renegotiating contracts with InterHealth Canada for operating the two local hospitals, is the intention to limit services for temporary residents.
The local economy hit the system hard by reducing the number of foreign workers who left when jobs dried up; reducing insurance contributions that help pay for the nation’s health care, according to the government’s “Health Care Funding Challenge”. The total annual cost of healthcare is $61.5 million. NHIP contributions pay for only $19 million, while the government picks up the $42 million difference. Costs include $44 million to InterHealth Canada for infrastructure, equipment and clinical services to operate the hospitals
A key target for cuts is the $9 million that the health insurance pays to get locals treated overseas. Because of tight budget constraints, the Ministry of Health has had to suspend or downsize a number of its programmes, including closing a hospice and care home.
Part of the problem is that much of the healthcare plan of the previous elected government was never implemented. A Health Regulatory Authority to govern and monitor many aspects of the healthcare delivery process has never been created, neither has primary health care been upgraded or a healthy lifestyles initiative developed. Also, a clinical services review board has been appointed but has not met, and a contract management board to deal with InterHealth Canada has been ineffective.
Although blaming their predecessors makes political points, the government needs to reduce the high cost for medical treatment overseas. While NHIP reduced the cost from $36 million for 10,000 Turks and Caicos Islanders in 2008 to $9 million for more than 30,000 beneficiaries, the cost is threatened by what the review calls “an open door, no limit policy as required by current legislation.” Also increasing costs is unlimited funding for medical care overseas for migrant workers who do not permanently reside in the TCI and unlimited funding for their dependents, regardless of the number of dependents. Illegal immigrants do not make any contributions, but they get treatment on humanitarian grounds and under international accords and agreements. Only those who are employed contribute, so 11,000 dependants are being supported by 18,000 contributors. The government suggests dramatic increases in contributions and allowing long-term residents not currently eligible for cover, such as retired persons and winter visitors, to join the program to increase contributions.
Other ways to increase income would be applying high healthcare taxes on tobacco, alcohol and high sugar content products, and encouraging health and medical tourism, although the suggestion that the government receive 50 % of revenues may not go down well.

The benefits of health tourism in Cyprus and the low cost of treatment for UK consumers will be promoted at "Health Destination Cyprus 2010", on November 21 (consumers) and 22 (business), aimed at the general public and the business community respectively. Attendance at both days is free of charge.
The public event on 21 November is a consumer exhibition aimed at increasing the number of British medical tourists looking for information about travelling to Cyprus for health and wellness treatment. It will take place at the Trios Banqueting Hall Palmers Green, London, will showcase top hospitals, clinics and spas from Cyprus and will give visitors the opportunity to meet doctors and medical specialists, get free advice and explore various treatment options on the island. The business event on the next day will showcase Cyprus as a destination for medical treatment and general preventive healthcare, and is taking place at the CBI Conference Centre.
The Health Destination Cyprus events are jointly organised by the Health Service Promotion Board, the Ministry of Commerce, Industry and Tourism and the Cyprus Tourism Organisation and will highlight opportunities for those with an interest in Cyprus as a health destination. The organizers say that comparative data shows that treatment in Cyprus offers to UK patients savings of up to 68%.
An estimated 60,000 UK residents traveled abroad for medical and dental treatment last year, attracted largely by the far lower costs of dentistry and cosmetic surgery. Infertility treatment, orthopaedic surgery and obesity therapy were also popular.
Christos Petsides of the Cyprus Health Service Promotion Board, says, “The past few years have seen the health service in Cyprus gain a reputation at least equal to that of developed European countries. There is a large and growing private health sector. Today there are more than 80 private hospitals and clinics with 2500 beds, 2250 doctors and 720 dentists. Private hospitals in Cyprus tend to be very well equipped and technologically sophisticated. The clinical staff are typically well qualified, many having trained in the UK and other English speaking countries. English is spoken fluently in all private medical and dental clinics.”

A new survey of 5,000 people suggests that 80% of NHS patients want more choice over how and where they are treated in the NHS, 79% want more choice in where they are treated and 75% want a choice of hospital consultant.
50% were totally unaware that they can, at least in theory, choose which hospital to go to for non-emergency treatment. Women and people over 55 in particular want to see more patient choice in the NHS. Nine out of 10 over the age of 55 want to have a greater say in how and where they are treated.
Under the government’s increasingly controversial modernisation plans, everyone will be able to choose, not only where, but which NHS consultant team provides their hospital care. Many in the NHS agree with the theory, but say that with limited resources this is not practical.
Health secretary Andrew Lansley comments, “There is clear evidence that patients want more choice and control over their healthcare, which is exactly what our plans to modernise the NHS are all about. Patients no longer want to settle for second best. They want what is best for them and their families and they do not want to be restricted by geographical boundaries or bureaucratic rules. Patient choice in the NHS has been very limited, but that is about to change.”
All patients now have the right to choose which hospital provider they are referred to by their GP/referrer. This legal right, which was introduced in April 2009, lets patients choose from any hospital provider in England offering a suitable treatment that meets NHS standards and costs.
Now patients can choose which hospital they are seen in, according to what matters most to them, whether it’s location, waiting times, reputation, clinical performance, visiting policies, parking facilities or patients’ comments. Patients can also choose to go to independent sector providers who have a contract with the NHS. A choice of hospital is available for most patients and in most circumstances. Exceptions include emergency and urgent services, cancer, maternity and mental health services. A patient has a legal right to be able to choose which hospital they are referred to for their first outpatient appointment, but not a legal right to specify which consultant they see.
These changes are unlikely to reduce English medical tourism as most of the treatments that people go overseas for are not offered under the NHS, very limited under the NHS, or relate to dental treatment to which separate rules apply. There has never been much evidence of British patients going overseas for surgery that is readily available under the NHS, and this increased choice may simply mean that if there are long waiting periods at one hospital, patients will go to another one. The situation is complicated as there is and probably always will be a gap between what national politicians claim and the reality on the ground in local hospitals.

According to the Council for the International Promotion of Costa Rica Medicine (Promed), medical tourism generated $295 million dollars in revenue for Costa Rica in 2010 from 36,000 medical tourists in Costa Rica. Most came with at least one companion and spent six times more than a traditional tourist.
The Council claims that the medical tourism sector is growing at a rate of 15% to 20% annually. In Costa Rica the increased demand is from Americans. 36% go for dental treatment and the rest for orthopedic and cardiovascular treatment or cosmetic surgery. Promed accepts that the country needs a higher profile to increase numbers in the face of stiff competition from other countries.
Promed is a private not-for-profit organization that coordinates the efforts carried out to ensure the quality of services provided by the private health industry in Costa Rica and their international promotion, with the intention of consolidating the country as a major destination for medical tourism. It has developed regulatory standards and promotes the certification of service providers, with the support of international bodies and the training of local certifiers. The organisation brings together health service providers, health professionals, tourism service providers, academia, and other marketers of goods and services related to health and tourism.
The following have been certified by Promed -• Clínica Bíblica Hospital• CIMA San José Hospital• UNIBE University and Clinic• Pino’s Plastic Surgery Clinic• Hospital Metropolitano• Homewatch Caregivers Latin America• La Católica Hospital Hotel• Clínica Oftalmológica 20/20• Mind and Health• Nova Dental• Especialidades Dentales Truque Argüello• New Smile Dental Group• Clinica Dental Cosmetics Costa Rica
In 2007, Costa Rica had a mere 5,000 medical tourists and by 2008 this had increased to 20,000. Promed says that by 2009 this had increased to 30,000. The industry is on track to exceed the latest target of 40,000 medical tourists a year by 2019. Nearly all come from the USA.

Costa Rican Medical Care (CRMC), a medical tourism agency only dealing with treatment in Costa Rica, has added Hospital Metropolitano to its network. In San José, Hospital Metropolitano is a leading local hospital that offers state of the art technology with very competitive prices and USA standards, being fully accredited by the Accreditation Association for Ambulatory Health Care (AAAHC). AAAHC International is now accrediting hospitals and clinics in Costa Rica, with other countries in South and Central America to follow. The hospital’s founder, Dr. Roberto Herrera, along with a group of Costa Rican investors, plans to open a number of clinics across Costa Rica.

The Health Ministry in Malaysia is working with the Home Ministry and police to investigate the allegation that a local hospital conspired in an illegal kidney trade. Dr Hasan Abdul Rahman said, “Malaysia, being a member of the World Health Organisation and a signatory to the declaration of Istanbul on organ trafficking and transplant tourism is committed to ensure such illegal practices are not undertaken in this country.”
In Malaysia, transplants from unrelated donors need to be vetted by the independent Unrelated Transplant Approval Committee before they can be carried out. Legal kidney transplants in Malaysia are carried out in Kuala Lumpur Hospital, Selayang Hospital, University Malaya Medical Centre and a few private hospitals in the Klang Valley.
Dr Hasan Abdul Rahman is seeking to distance the government from the allegation that the illegal medical tourism is happening in Malaysia, “It seems a little far-fetched that such an illegal activity, especially involving foreigners, has been carried out in any of these hospitals. However, if there is evidence that it happened, the ministry will certainly take action against those involved. The alleged transplants from unrelated foreigners from Bangladesh would have required prior approval from the ministry. Our records show that there have been no such requests or applications." His statement is slightly misleading as if they were illegally done on a cash basis the doctors and hospitals are hardly going to be dumb enough to seek official approval.
Malaysia is only one of several countries alleged to contain hospitals and/or local doctors that have taken part in illegal organ transplant tourism. Bangladesh is involved in the trade; poor people are paid for their organs, which are then sold on to foreigners prepared to pay cash to criminals to jump the queues for transplants in their home countries. Usually, the transplant is done in a remote hospital in a third country, which means that several local doctors, medical staff and administrators are in on the deal; although transplants may be done by a surgeon from another country flown in and out quickly.
The Bangladeshi police are on the trail of an international syndicate linked to illegal kidney trade across several Southeast Asian countries. Local media reports allege that a reputable international hospital group with hospitals in several countries including Malaysia has been involved in the illegal business.
The police investigations reveal that donors from remote villages in Bangladesh were flown to hospitals in several different countries to sell their kidneys, and the kidneys are fresh for an immediate operation on an anonymous foreign patient. Basically, the donors are very poor and the recipients are well off.
Bangladeshi police have detained eight people in connection with luring poor and illiterate victims overseas for the trade. One of those arrested but not yet charged is Nafiz Mahmud a manager in Bangladesh for Columbia Asia Healthcare. In a statement he said, he has nothing to do with the illegal trade. “I have not faked the identity of any kidney donor or recipient. On the kidney transplants that took place in India, all the donors were very close kin of the organ recipients. All the donors and recipients sent abroad by me were first blood relations.” Kidney transplants are illegal in Bangladesh unless the donor is a close kin, spouse, or he or she has donated it before death.
However, the Joypurhat Superintendent of Police Mozammel Haque insists that Mahmud is involved in organ trade and cites statements of people arrested earlier in this connection, “Columbia Asia Healthcare established last year keeps in touch with doctors of hospitals abroad and arranges illegal organ transplants outside the country.” The police admit that as yet they are not clear if the syndicate used or had tacit approval from Columbia Asia Healthcare, or if people who worked for the company were involved in a private capacity.
Nafiz Mahmud acknowledged that he did not obtain any permission either from the health or home ministry to set up the organisation. He said he only possesses a trade licence. He claims that Columbia Healthcare has 34 hospitals worldwide including in India, Malaysia and Indonesia and, “My business does not involve any medical treatment. It is like tourism.” A document seized by police shows that the institution provides healthcare by specialised international doctors through videoconference.
The police so far have identified around 100 people in Joypurhat who the syndicate lured into selling organs, and claim that up to 30 people in several Asian countries-including doctors – are involved in the racket.

Hospitals and clinics in Tijuana have created business groups to target potential U.S. medical tourists. The dual attraction for Americans is that Mexico is nearby and cheap. Fees for dentistry, laser eye surgery, cosmetic surgery, cancer treatment and bariatric weight-loss procedures are on average 40% to 70% lower than in the USA. Dental implants that may cost $2,000 north of the border can be as low as $800 in Mexico, while a $50,000 hip replacement can be $13,000. A marketing campaign is critical in helping Tijuana recover from a drastic drop in cross-border visitors that suffered from long delays to get into and out of Mexico and a surge in drug-related violence in the Tijuana region.
Flavio Olivieri of the Tourism Medical Association of Tijuana says, "In the past, the focus was on low cost. But in the last five years, doctors have been offering more complex treatments, hiring more bilingual personnel and doing more professional marketing."
According to the Baja California Medical Tourism Association, 250,000 people a month visit Tijuana for health products and medical services, most of them Californians. Roughly 60% are Hispanics living in the USA. The next largest group is people seeking alternative medical treatments, followed by middle-income Americans wanting high-quality low-cost care. This latter segment is the one that Mexican government and business groups are targeting. The Baja tourism office, the Tijuana Convention and Visitors Bureau, and new medical tourism business groups in Tijuana, Mexicali, Rosarito Beach and Ensenada are working on promotional strategies.
The 119 bed private Hospital Angeles Tijuana focused on medical tourists when it opened in 2004. Although the high figure of three out of patients being from the USA has fallen as more local people use it, the hospital regularly attracts 100 to 150 inpatients from the USA. Most come for weight-loss surgery, the rest for orthopedic, neurological and cardiac procedures. The hospital is seeking to raise its international standing by applying for JCI accreditation. Although it gets some foreign patients through medical tourism agencies, it feels it can do a better job than most of them, so has formed its own company to offer travel, accommodation and other services to foreign patients.
A key problem that Mexico has not solved is the variety in quality. All are low cost, but consumers struggle to tell the difference between a top-class hospital, a middle range one, and a clinic that cuts corners. The Tourism Medical Association of Tijuana is considering collecting licensing and certification information for medical tourists.

DentiCenter opened a dental clinic in Tijuana in 1991 just to serve cross-border patients. The company now has 6 clinics all along the border from Tijuana to Reynosa.The group provides affordable, US-style care within a short walking distance from a border crossing. It also offers packages that include transport, hotel stay and other services.
Many medical tourists are from border US states. US insurance companies Blue Shield, Health Net and Aetna contract with the Mexican health insurance company SIMNSA to offer plans to California companies whose employees want to cross the border for health care. Cover is restricted to providers in Mexican border cities.

The Global Healthcare Management Network of the Association of University Programs in Health Administration (AUPHA) is calling for academic papers for a special themed issue of the Journal of Health Administration Education: Global Healthcare Management.
The special issue on global healthcare management will look at the increasing globalization of health services, including medical tourism, as well as health services management in developing nations and how these developments will or should impact health administration education.
An introductory paper will be invited and will consider what is meant by global healthcare management. There has been much interest in comparative health systems and global health in recent years. Now there is interest in better managing health facilities and health systems (coordination, communication, resource development) in foreign environments, but there is little experience or information in the professional literature to draw on. These issues will be discussed in an overview of the themed issue.
Papers to be submitted should consider best models and state-of-the-art practices in international settings. Submissions that include an international team of authors will be given stronger consideration. For example, an American faculty member would need to find an international counterpart to put the value of health management practices in the perspective of an international location. This is more of an outside-in approach where an American health administration faculty will learn from key international setting examples.
All relevant papers will be considered for submission and some possible topics include:• International health services. To what extent has medical tourism been successful or not successful, and what can we learn from these experiences? Examples of how this information has been incorporated into coursework would be beneficial.• Key lessons on how to manage an international hospital/clinic in a foreign environment including partnerships with non-government agencies, government ministries, corporations and other key stakeholders. • Public health management. International hospitals in developing nations are often quite involved in community health. What are some key ways to better link hospitals/clinics and population health? What examples are there of better health outcomes as a result of strong health services management practices? What implications do these findings have for healthcare management education in North America and how can educational processes benefit from this knowledge?• What can we learn from the differences between domestic (US) and international health competencies in: a) finance/accounting, b) cross-cultural management, c) health supply chain, d) human resources management, e) accreditation, and others. What implications do these differences have for education of domestic versus international students?
A final invited conclusion paper will review key points from the invited papers and put them in the context of what global healthcare management is. It will assess the benefit global healthcare management brings to other professional pursuits of global health and the implications for health administration education.
Submissions should follow the general instructions for submitting manuscripts outlined on the AUPHA website. Manuscripts will be reviewed as they are received using the Journal of Health Administration education review process. Deadline for submission is January 1, 2012. Publication date for this themed issue is anticipated to be mid-2012.

The latest available medical tourism statistics from the Singapore Tourism Board show that visitors who went to Singapore for medical treatment or related reasons grew 13 percent to 646,000 in 2008 compared to 2007. However, these have to be interrogated to remove the distortion to the data.
370,000 visitors actually went to Singapore for medical treatment. The other 230,000 are family members of the patients who accompanied them and had no treatment. However, the combined revenues of $1.5 billion for the economy would not have come without the people going for treatment. As most countries count the number treated, and exclude family members, the true medical tourism numbers figures used for Singapore should be 370,000.
The tiny island of Singapore has long been the choice of destination for major medical care for patients from neighbouring countries Indonesia, Malaysia, Brunei, Cambodia, Vietnam, Indochina, Greater China, Russia and the Middle East. There are 15 hospitals and medical centres in Singapore that have obtained the United States-based Joint Commission International (JCI) accreditation. Singapore hospitals are also looking towards European and Asian-based hospital accreditation systems.
Asia’s economic growth and an expanding middle class have fuelled strong demand for medical tourism in Asia. The small city-state is considered a pioneer in medical tourism and has built a strong image for itself as a provider of high-quality medical treatment and complex surgery. The government has done a lot to help develop the industry. But competition in medical tourism is increasing, with more Asian countries promoting medical tourism So Singapore has to compete with Thailand, India, Malaysia, the Philippines, South Korea and Taiwan. Tan Yen Nee at the Singapore Tourism Board says, ’’We want to keep the position of Singapore as a high-quality healthcare destination well known for advanced medical care."
Singapore is increasingly becoming a springboard for Russian companies that want to expand into Asia. Russia has steadily grown in importance as a trading partner of Singapore over the years. Singapore healthcare company Sourcelink built Russia’s first private hospital in Vladivostok, and will soon build its second in Tartarstan, where healthcare facilities will be housed in the same building as retail outlets and accommodation for medical tourists. Denis Nyam of Sourcelink says, "We have been catering to the foreign sector in our market for a long time. So our advantage is that we are good at making turnaround fast, bringing in technology fast, making things efficient. We target the growing Russian middle class who have an increasing demand for private healthcare services." So Singapore is now targeting both Russians who want to come to Singapore and those who want to be treated in Russia, with the aim of encouraging medical tourists from other countries to go to Singapore owned hospitals in Russia. Sourcelink Healthcare Services has been launched to offer medical concierge services to assist foreign patients from various burgeoning markets, namely Vietnam, Indonesia and Russia, with the practical aspects of medical travel to Singapore, including visa application, ticketing and accommodation.

Baltic Bariatric Services based in Riga, Latvia has entered the fast growing weight loss tourism market with a surgical programme. The company specializes in bariatric medicine, the branch of medicine focused on solutions for obesity.
Initially targeting Scandinavia and Central Europe, Baltic Bariatric hopes to tap into the global demand for obesity treatment by offering affordable gastric bypass surgery, the most radical solution available. Obesity is a worldwide epidemic and gastric bypass surgery ranks high on the list of most popular medical tourism procedures.
John Atkinson of Baltic Bariatric says, "There is an unmet demand at the lower price ranges. Patients who need care are being denied due to budget constraints and high prices. We have unique situation in Latvia – our doctors’ fees are still fairly reasonable while our hospitals have been modernized to Western standards. That means a great value proposition for the prospective patient." Procedures are performed at a private hospital located in Jurmala, a small resort town just outside Latvia’s capitol city, Riga.
The tiny country of Lithuania is close to the rest of Europe and the low cost of surgical and dental procedures in the private sector are due to the low cost of labour. With more dentists per capita than most countries, cosmetic dentistry tourism is increasing in popularity. Private clinics offer high standards.
As well as dentistry, spa treatment and health check-ups, Lithuania is also offering low-price cardiology, oncology, gynaecology, and other surgical treatment. Egle Poskiene, founder of medical tourism agency Your Health First, is seeing a growing interest from patients from the UK in Lithuania due to the increased number of cheap Ryanair flights to Kaunas from Stansted, Gatwick and Luton.

CroMedicor is a new network that connects hospitals, clinics, medical professionals and their specific health treatments to hotels and other aspects of Croatian tourism. CroMedicor promotes Croatia as a destination for health tourism.
In an attempt to help Romania’s economy back on its feet, the government has recently increased VAT from 19% to 24%. The good news is that medical services and supplies in Romania do not carry VAT .The even better news is that tourism VAT on hotel and transport remains at 9% which is a preferential rate the industry has enjoyed for several years. Romania’s position as a top medical tourism destination is improving both as the value of the Euro is rising against local currency, and prices for medical tourism are stable or decreasing as service providers for cosmetic dentistry, hip/ knee surgery or laser eye surgery cut prices.
Romania has emerged as one of the most popular destinations in Europe for dental treatment on account of unprecedented growth in its dental market over the recent years. It is anticipated that dental tourism numbers will rise at an annual rate of around 17% during 2010-2012 due to government support on promotional activities worldwide. As the country has one of the highest numbers of dental clinics of international standard, medical tourists from all over the world have started taking an interest in Romania for their dental treatment.

Wellness Tourism Worldwide (WTW) has issued the main findings from Phase 2 of the “4WR: Wellness for Whom, Where and What?” project. The full report will be available for purchase soon.
The objective of this research is to identify the main global and regional trends experts may envision in health-motivated travel by 2020. The findings are based on data collected from 140 individuals and organizations in over 50 countries-connected with wellness, tourism, spas and healthcare.
The report argues that in the future, the supply of wellness services will be quite different by 2020 than it is now. Lifestyle approaches such as yoga will dominate the supply of wellness services in North America and Northern Europe.
Wellness hotels and resorts are forecast to become the most popular wellness destinations in Africa, South America, Central America, Australia and New Zealand. In Central and Eastern Europe therapeutic services and treatment based on natural assets such as thermal spas will become the most important.
The downside is that as beauty treatment, day spas, massage and saunas become more widespread globally there may be less need for people to travel overseas.
The report looks at the possible changing popularity of saunas, psychological therapies, massage, beauty treatment, alternative therapies, natural products, ecospas, day spas, adventure spas, wellness and spa cruises, hot life retreats, mehotels, spa living environments, budget spas myspas, eco-fit resorts, dreamscapes, and well-working environments. Some of these may be unfamiliar and there are detailed explanations in the flyer.
Wellness tourism preferences are analysed for certain sectors- leisure and recreational spas, therapeutic services, medical services, wellness hotels/spa resorts, wellness/lifestyle services, holistic services, spiritual services, adventure spas, eco spas, and wellness/spa cruises.
Wellness tourism is one of the fastest growing forms of international and domestic tourism and is expected to continue for at least the next five years and probably for the next ten years. The globalization of standard and uniform products could pose a major risk.
The report provides predictions of -• Which wellness tourism products and services will become popular?• How the popularity will differ by continent.• Which wellness tourism products and services will decline?• How the decline will differ by continent.• Which lesser known products present an opportunity for market growth.• Strengths, weaknesses, opportunities and threats.• What are the market sectors by age and gender?• How it is and will it be funded.
A note of caution on the results is that with a smallish sample size of 140 respondents spread over 50 countries, the statistical accuracy is not robust. And with any report looking a decade into the future, the views will be strongly influenced by the current business of respondents. And as with any future predictions, a host of unknown elements can rapidly make nonsense of what seemed sensible at the time; two years ago could anyone have predicted the Arab Spring, earthquakes in New Zealand and Japan, the European ash clouds closing airports, or Qatar being awarded the World Cup?

After several years of steady growth, good marketing and success, Jordan’s medical tourism sector is witnessing a dramatic drop in revenue and patient numbers caused by the “Arab Spring”. The highest number reported was 240,000 patients from across the world, although this figure is reduced considerably when taking out people who are not medical tourists such as expatriates, embassy staff, holiday makers and business travellers.
According to Awni Bashir of the Private Hospitals Association (PHA), the number of patients seeking care in the Kingdom’s hospitals and accompanying visitors is expected to drop by 25 % by the end of this year. But other sources say that this puts a very optimistic slant on the expected drop in numbers which may be temporary but may also be permanent .The basic problem is that many of the countries who sent people to Jordan are in turmoil, or are a powder keg waiting to explode. Europeans and others seeing the destruction and 50,000 plus death toll in Libya on their screen, as well as regular reports of trouble in other countries- are taking a simplistic attitude. In the minds of most Western Europeans and Americans, they see North Africa, The Middle East and the Gulf States just as one area that is fill of violence, political turmoil, and other problems. Those from Eastern Europe and Asia have a more detailed understanding of the differences between the various locations. Jordan is not alone as other countries are also suffering declining numbers, but are not as open as Jordan about it. Jordan and others may try to market themselves as free from trouble, but the poor geographical grasp of the majority of the world’s population makes it hard to get people to understand that it is not just one problem area.
Traditionally, Jordan obtained the vast majority of its patients from Yemen and Libya. The business from Libya has dried up to zero. Yemen is down to a trickle. Jordan, which used to be a major regional medical tourism destination, has been severely affected by regional instability.
The PHA is trying to market Jordan to other nearby countries including Kazakhstan but success will take time and may have to wait until all the countries in the region are stable and quiet. Bashir admits that other traditional markets have problems too, with the number of patients from Iraq and Kurdistan not encouraging. The low number from Kurdistan and some other countries is because patients are finding it difficult to obtain visas to travel to Jordan.
Minister of health Abdul Latif Wreikat says the ministry has set up a medical tourism unit to help promote the business and identify areas that the government can change to make it easier for overseas medical tourists to go to Jordan. An office will be set up soon at the Queen Alia International Airport to assist those arriving to seek medical treatment in the country’s hospitals. The ministry is appointing health attaches at some of the Kingdom’s embassies overseas to help ease procedures for patients seeking treatment in Jordan.
Jordan is working hard, but the real problems are caused by events over which it could not predict and where it has no control.

Taiwan Land Development Corporation plans to build three healthcare villages in Hualien, Kiment and Hsinchu, capitalizing on the surging popularity of medical tourism. Industrial Technology Research Institute (ITRI) is a national research organization that serves to strengthen the technological competitiveness of Taiwan. ITRI suggests that the global medical tourism industry is worth US$40 billion in 2010, with up to 40 million people being medical travellers.
Taiwan Land Development Corporation believes that Taiwan offers excellent medical care, so can take advantage of business opportunities in medical tourism as it has gained a reputation in the world and is particularly respected by the Chinese. A recent economic cooperation framework agreement between China and Taiwan will encourage trade and tourism between the two countries.
Development of the village in the eastern county of Hualien is progressing well, and the company will apply to the Hualien county government in November to reserve 20 hectares of the village specifically for international travellers. The company will provide medical-related hardware and software and team up with hospitals to attract business from those seeking health checkups and cosmetic surgery in Taiwan. Many of the Chinese who will soon be permitted to travel to Taiwan individually are expected to seek cancer screenings and cosmetic surgery.
In 2008, about 5000 went to the island to undergo health checkups and cosmetic surgery. In 2009, that increased 40,000, mostly from China. More than 100,000 are predicted annually, as fast as Taiwan can build and staff hospitals. The market is set to expand when Taiwan opens to Chinese tourists on a foreign individual travel basis in early 2011. Taiwan’s hospital care is world-class. Despite a massive effort at upgrading its health care system, China’s is not.
Two years ago, Taiwan instituted an ambitious plan to make the country appealing to foreigners seeking healthcare by adding the check box "medical care" to visa application forms. Taiwan had a very hard time attracting Europeans and Americans not of Chinese origin. But the opening of Taiwan to Chinese tourists after 2008 has made a huge difference. Although for the time being mainlanders are allowed only group travel to the island, local hospital business has been flourishing from the influx of cross-strait patients. Taiwanese businessmen based in have China set up health and medical clubs with annual membership fees for Chinese members to be taken by the clubs on six-day trips to Taiwan that include physical check-up services.
Members of a 17-person tour group from Shinkong Medical Club of China’s Jiangsu province praised Taiwan’s medical advancements after a week-long sampling of Taiwan’s medical tourism. 12 had full-body non-invasive health checks at Taipei City’s Shin Kong Wu Ho-Su Memorial Hospital in Taipei as well as residing at a five-star natural hot spring resort in Taoyuan County and enjoying tailor-made nutritional meals throughout their stay. The entire package costs US$2000, about twice the price of a regular tour package.
Taiwan’s medical tourism will become one of the biggest attractions for mid-to high-income Chinese tourists. Although other countries, such as India, Thailand and Japan are all targeting Chinese for medical tourism, Taiwan is the best choice for Chinese tourists because there is no language barrier, the cost is reasonable and there is a sense of warmth and familiarity between Chinese and Taiwanese people.

GMC Hospital Ajman in the United Arab Emirates became the first hospital in the world to be accredited by the new international accreditor QHA Trent.
Regional healthcare player Thumbay Group has announced a Dh350 million expansion plan as well as a new brand identity for the Gulf Medical University and GMC Hospitals. The expansion plan in its first phase will cover several new projects, and the investment will be financed through Islamic banks.
"Learn from the World" will be the new brand statement for the Gulf Medical University. With over a decade of experience, the Gulf Medical University and GMC Hospitals have grown into international brands of repute and hence the need for a stronger brand value. The Gulf Medical University will be the first-of-its-kind full-fledged campus with a 300-bed specialty hospital, a mosque, a health club, an additional floor at the existing building, an expanded library, housing and hostel for faculty and staff, a convention center, an amphitheatre, and a restaurant. This will all be ready by 2012 as part of the first phase expansion.
GMC Hospitals is opening up new state-of-the-art hospitals in Dubai and Abu Dhabi, as well as a medical centre in Sharjah.Going global, the group plans to open a second unit of the GMC Hospital in Malawi, Africa, as well as spread its services to India. With the launch of the new brand identity, GMC Hospital promises several hi-tech services with focus on quality and patient safety. The QHA Trent, accreditation is seen as essential to encouraging medical tourism and the inflow of international patients to the GMC Hospital Ajman, located only 15 minutes from Dubai. Already receiving more than 100 patients a month from various countries.GMC’s Body & Soul fitness and leisure arm will soon be opening several outlets in Sharjah and Dubai.
QHA-Trent has been busy globally, to help tell people of the new organization. Professor Steve Green has visited St James Hospital in Malta, the flagship hospital of the leading private hospital group of that country, and was then part of a London health seminar where the UK and Chinese governments signed a memorandum of understanding to develop mutual collaboration on healthcare between the two countries. Meanwhile, Dr Alan Fletcher visited Cebu Doctors University Hospital, a leading hospital in the Philippines, and gave a series of lectures and seminars.

The Social Insurance Institution of Finland (Kela) reimburses treatment aborad in EU and EEA countries, and in Switzerland if the same medical procedures are not available in Finland within the treatment guarantee period. In 2009, hospitals in other countries invoiced Finland for just over EUR 12 million worth of medical treatments for Finnish tourists and expatriates. On top of this, Finland paid half a million euros for the medical care of Finnish patients living in Finland who opted for medical treatment abroad. The leading foreign country by far to have provided medical treatment for Finnish citizens was Spain.
All permanent residents of Finland are covered under the Finnish National Health Insurance scheme and are eligible for reimbursement of medical expenses under the Health Insurance Act. Reimbursable medical expenses include the cost of covered prescription medicines, the cost of obtaining treatment from private providers of outpatient medical services, and transportation costs related to treatment. Outpatient medical services include private doctors’, dentists’ and dental hygienists’ services, treatment prescribed by a doctor or dentist, and examination or treatment in a private institution.
In 2008 and 2009 Finnish patients have received treatment abroad based on decisions by hospital districts. This local jurisdiction was changes from May 2010 when Kela started reimbursing centrally for the treatment. The patient is not required to pay for the treatment. In addition to the cost of the treatment itself, Kela also covers the travel and accommodation costs for the patients and an escort if this necessary, plus the cost of medicine. Kela then invoices the patient’s hospital district for the expenses.
Where Finnish patients seek out treatment abroad on their own, Kela will cover the cost of treatment in the same fashion as it does when patients see private doctors in Finland. In practice, this translates to an average reimbursement of less than 20 per cent of the total cost. The numbers going overseas are increasing, but are still counted in dozens rather than hundreds. The main driver is specialised medical treatment abroad, such as for cancer, which they have not been able to get easily in Finland. According to law, patients are allowed to seek reimbursement for treatment performed in other EU and EEA countries, as well as in Switzerland.
The change from local to national jurisdiction has meant that, according to Kela, the majority of those who have applied for treatment abroad were rejected, although there are no statistics available on the matter. So the numbers going abroad are rising very slowly, but the number that the state is prepared to pay for, is falling. Finland has one of the most wide and varied state provisions of payment for health and social care in the world, but like all EU countries has to seek ways to control costs.
Dr. Reijo of Helsinki University Central Hospital (HUCH) accepts the modern reality of an international patient market, “We are in an increasingly globalised world and the standards are getting higher. In principle every option has to be open. Hospitals in different countries can also specialise in treatments of certain rare diseases. For example in cancer surgery practices there may be differences between different countries. Sending patients abroad to receive cancer treatment is always examined carefully and on a case-by-case basis.” The number of foreign patients treated in HUCH hospitals exceeds the number of Finnish HUCH patients that are sent abroad. The annual number of foreign operative unit patients is around 50.
Jussi Merikallio at the Association of Finnish Local and Regional Authorities adopts a realistic stance on paying for treatment at foreign hospitals. “If the treatment, safety, and price are in order, why not? If there is capacity in Sweden, a patient can travel there in a short time. But if the state is not prepared to pay for a type of treatment in Finland, overseas treatment should not be covered from public funds.”

325,581 guests visited Czech spas in the first half of 2010, which is a rise of 5 percent against 2009, according to CzechTourism. CzechTourism, a subsidised organisation of the Local Development Ministry, focuses on promoting the Czech Republic abroad. Czechs accounted for 175,000 visits and foreigners over 150,000-the exact split is not available.
Germans made 60 percent of the total number of foreign guests, with nearly 86,000 of them visiting Czech spas between January and June. Russians, Austrians and Ukrainians came next. Over 9,000 Asian clients visited Czech spas in the first six months of this year. The biggest increase in the number of foreign guests on the year was recorded for Israel, Austria, Slovakia, the USA and Russia. By contrast, CzechTourism registered the biggest decrease of visitors from Poland and Ukraine.
The average length of stay was 10.8 days. Czech guests spent an average of 11.8 days and foreign guests an average of 9.6 days in Czech spas. On average, Russian guests spent 13.7 days in Czech spas; Ukrainian guests 13.4 days and guests from Israel 10.4 days. By contrast, visitors from Poland spent 4.4 days on average and visitors from Slovakia 4.5 days on average. Spas in Karlovarsky region attracted 57 percent of all guests. Zlinsky region came second with nearly 10 percent of guests and Olomoucky region scored third with 7 percent of visitors.
One of the leading destinations for assisted reproductive technologies is the Czech Republic. Many European patients travel to other countries, both because they think that they will receive better quality care abroad and in order to undergo procedures that are banned in their home country. The Czech Republic is one of the popular destinations for the cross border reproductive care due to high standards of medical care in the country, a wide network of IVF centres, easy accessibility of the country by air (low cost airlines), road (motorway network linked to Western Europe) and rail, liberal legislation which enables to employ gametes and embryo donation programmes, genetic diagnostic testing and micromanipulations. Low prices are on offer so affordable treatment packages are another attraction for many couples.
IVF Europe unites 7 IVF clinics in various towns of the Czech Republic offering a full range of fertility services to clients worldwide. Partner centres are operated only by Czech proprietors. IVF Europe accounts for about one quarter of all IVF cycles in the country. All member clinics of the group are ready, with the assistance of multilingual coordinators, to tailor the treatment programme to individual requirements.

A Belgrade based Serbian Medical Tourism Cluster has been set up to involve all interested state and private organisations involved in providing medical and tourist services – spas, hospitals, clinics, institutes, hotels, tourist agencies, restaurants, and others who provide services connected to medical and wellness treatment. It currently has 19 members. The aim is to enhance the marketing position of the Republic of Serbia as a medical tourism destination and to offer highly professional services to all that are seeking medical treatment abroad. The 300 natural springs, 40 health resorts and 25 rehabilitation centres illustrates the tremendous potential in Serbia.
Cluster activities:

To improve and develop the medical tourism offer of Serbia.
To promote the harmonization with the EU standards in building up and developing institutions and legislature in the medical tourism field, and to analyze and plan medical tourism development in Serbia.
Preparation of brochures, guides, and online databases with medical tourism offers of the Republic of Serbia.
Organization of medical tourism conferences.
To promote domestic medical tourism at specialized fairs and conferences, to participate in international medical tourism associations.

Clusters represent geographic concentration of interconnected companies, related and different industries, specialized suppliers, service providers and associated supporting institutions (educational and scientific research institutions, agencies, etc.), competing, but also cooperating in a specific field. Clusters are established on the basis of common interest and needs in the sphere of procurement, sales, sectoral specialization, labour etc.
Dr. Marina Majki? from the Serbian Medical Tourism Cluster comments, “We have defined two fundamental problems. On the one hand is the infrastructure, which does not meet the desired criteria in some areas, and on the other, representatives of the medical profession and tourism industry will have to work together more closely."
The Ministry of Economy and Regional Development supports this and twenty other Serbian clusters. Cluster development promotion and institutional support within the regional, industrial and innovation policies, are part of the Lisbon Strategy objectives aimed at making the European Union the most dynamic and competitive economy in the world by 2010.
Zorica Maric of the Ministry of Economy and Regional Development comments, "The Serbian Medical Tourism Cluster is a completely private sector initiative which we helped fund in 2008."

General Electric is actively looking into enhancing its presence in Malaysia’s health travel industry. Stuart L. Dean of GE Asean says, "The local tourism-related healthcare sector is relatively small and there are lots of opportunities to tap the sector further. The sector can get a lot bigger. Continuous investment, cutting-edge technologies and a bit more marketing would certainly provide a vital platform for industry players to look into the sector. We have initiated the plan with the government and we hope to see serious kick-off early next year. The standard in the major cities is very good, but quality drops outside these cities.”
GE supplies private and public hospitals in Malaysia with the latest diagnostic imaging equipment and healthcare information systems. GE is developing new products to better serve Malaysia’s and the regional healthcare sector. Healthcare is one of the fastest growing businesses in Malaysia for GE.
Cheong Ah-Net Network, a Korean medical and dental supplement company based in Incheon Metro City, plans to set up in Malaysia as part of its expansion programme. Representatives of the company have been visiting several places in Malaysia searching for the right location for its venture. Kenneth Tak, the company’s local partner has suggested Kulim and Langkawi as Kulim is being developed as an industrial area while Langkawi is more a tourism location,” Both places have their advantages. Maybe in Langkawi, we can focus on dental surgery with tourists as our customers. They can come here for vacation and get our service."
Qi Group, the Hong Kong-based global e-commerce company headed by entrepreneur Vijay Eswaran, is eyeing strategically-located properties in Malaysia in the leisure, hospitality and health-related industries including setting up affordable specialist hospitals as part of a serious investment in Malaysia. The group is setting up five private specialist hospitals in the next three years providing affordable medical services as the hospitals will be outside urban centers .In Banting a four-storey hospital with 40-60 beds is expected to be fully operational is two years’ time. Other potential sites for such hospitals include Kluang and Kuantan. Vijay Eswaran says,” We are banking on the affordability of medical tourism in Malaysia, which is a powerful incentive to attract tourists, as Malaysia is a lot cheaper than Singapore. It fits into our tourism strategy."
Malaysia is an increasingly popular major medical tourism destination as if offers quality healthcare. Compared to many countries, costs are very competitive. An angioplasty which costs around US$57,000 in the US and US$13,000 in Thailand, is only about US$11,000 in Malaysia. A knee replacement procedure which costs around US$40,000 in the US and US$13,000 in Singapore, is only US$8,000 in Malaysia. Many hospitals have international accreditation and multi-lingual international patient centres.
Recently, the Malaysia Healthcare Travel Council (MHTC) was established under the Ministry of Health Malaysia (MOH) as the primary agency to develop and promote the healthcare travel industry and to position Malaysia as the healthcare destination of choice in the region. MHTC will also be a ’one-stop centre’ for all matters related to healthcare travel, to facilitate enquiries on policies and programmes on healthcare travel development and promotions.

Health care consumers, doctors, hospitals, care managers, insurance firms and medical tourism companies around the world will meet online at the first ever International Health Choices (IHC) Expo for three days – 4th to 6th February 2011.
Julie Munro, IHC co-founder says, “ Medical tourism is changing the face of health care for consumers and doctors, and IHC will show how good is the medical treatment abroad and how to get it.“ IHC co-founder Valerie Alphonso adds, “IHC takes medical tourism to the next level. It will change how people will view their health care choices in the future.”
Providers of global medicine, health care, and wellness solutions will be on display for three days on the internet at the IHC Expo, bringing together people who are looking for immediate, affordable, quality medical treatment with the doctors, hospitals, and clinics that can deliver it and the medical travel agents who can plan and manage the medical journey.
The IHC virtual exhibition will provide visitors and exhibitors with a multi-lingual state-of-the-art 3D virtual event platform. The virtual exhibition is a practical and direct way to gather together people located in widespread communities. Held online, it replicates an exhibition or conference experience including educational presentations and exhibition booths and offers advantages like instantaneous translation, and live video conferencing and product demonstrations. The exhibition is easily accessed via computers in homes. Attendance is free. The target is 10,000 health care customers and 150 hospitals, doctors, and travel companies from 30 countries.
The expo organizers explain why companies should be exhibitors:

Global coverage of target patient groups for any potential health care consumers as long as they have internet access.
Multiple languages so you can reach your target patient population in several major languages. The virtual expo will be available in English, Arabic, Chinese, Spanish, and Russian. Simultaneous translations in other languages will be available for selected meetings.
Cost-effective travel and meeting costs. A standard booth at the virtual expo costs about US$1,000. A similar booth at just one physical venue would cost about US$10,000 for hotel accommodations and flights for 2 staff people, booth, set up and materials.
At a virtual expo, doctors and managers can have conversations with patients that are one-to-one, direct and private. They can be by chat, by audio, or by video.
Everyone who visits your booth must provide a real email address. You can ask them to fill out a brief questionnaire regarding their interest. This will already be given to you as an electronic data file. You can do email follow up with each visitor.

Although medical travel conferences are springing up everywhere, an increasing number have been unsuccessful at attracting enough consumers, trade buyers or exhibitors to make them work. After one failed conference last year, speakers were asked by the hotel to pay not only for their accommodation and food, but a share of the conference costs, after the organizer apparently defaulted. Some conferences have been criticized as industry talking shops at which paying exhibitors do get not enough real leads and real business to justify the time and costs of attending. Is the virtual exhibition the answer? Only time will tell.

To meet the growing US and Canadian consumer demand for safe, quality and affordable healthcare abroad, the Mexican Health Travel Association has been formed. Carlos Arceo comments. “As US Insurers take notice of US consumer interest in having costly medical procedures performed abroad due to prohibitive costs and long waits, Mexico is an attractive alternative medical setting. The past three years are remarkable for Mexico as there are now 8 hospitals with JCI international accreditation and 71 private hospitals with national certification. Our association is a platform for the health travel industry for all of Mexico.”
Arceo has just promoted the Global Medical Tourism Congress and Expo in Mexico, focusing on Mexico as a medical destination, and adds, “We are implementing a wide-reaching education strategy to highlight Mexico’s health travel market, Mexico must plan and design strategies to promote medical, scientific, technological and tourist efforts to position itself at an international level as one of the top destinations in medical tourism. Mexico could become the favorite destination amongst United States citizens leaving their country and searching for medical attention in the next 3 years, due to its geographical vicinity and its costs, 50% cheaper.”
Mercury Healthcare, an international healthcare management company based in Denver, and Sekure Healthcare, a healthcare services firm based in San Diego, have been engaged to conduct monthly webinars over the next year that highlight capabilities and opportunities in the emerging Mexico health travel market. Maria K Todd of Mercury Healthcare applauds the formation of the Mexican Health Travel Association. “In today’s global environment, many organizations and US Insurers seek information on quality, affordable medical options.” Jim Arriola of Sekure Healthcare says, “When the first US insurers received regulatory approval to sell cross-border healthcare coverage in California 10 years ago, addressing quality assurance was arduous for insurers and state regulators. I expect more US insurers will extend benefit coverage into Mexico as accreditations and certifications demonstrate quality and minimize risk management concerns.”Those promoting Mexico argue that it is vital to add to individual marketing by agencies and hospitals, with a concerted effort to promote the benefits of Mexico and counter the bad image given by drug war violence. The average stay of a foreign patient is of 1 to 4 weeks for recovery, so hoteliers and developers, as well as tourist service providers must seize the opportunity offered.

Two new reports show that the recession has hit American healthcare spending hard. Many Americans are cutting back on medical treatment spending and use of medical spas. While the medical travel industry often argues that high costs of medical treatment in the US will mean more Americans travel abroad for treatment, the reports suggest that it is not a case of looking for cheaper treatment, but deciding not to have treatment at all or delaying treatment. Tourism figures also show that fewer Americans are travelling overseas for any reason.
Other figures for the first six months of 2010 confirm substantial drops in numbers visiting doctors or hospitals. The latest government statistics for July 2010, show that the unemployment rate remained steady at 9.5% in July. Unemployment stood at 14.6 million in July while the number of long-term unemployed was little changed at 6.6 million people. With consumer prices falling, unemployment remaining high and firms reluctant to start hiring again, people will continue to be wary over the coming months of any spending on non-essential medical treatment. All these factors make previous estimates of millions of of Americans travelling overseas for treatment in 2010 invalid and totally out of date.
With unemployment rates remaining at an all-time high, one in five Americans chose not to seek medical care for a recent illness or injury, with four out of 10 citing cost as the primary factor, according to a Deloitte Center for Health Solutions survey of more than 4,000 adults in the United States.Deloitte’s survey also shows a decline in the number of consumers visiting a doctor or health care professional in the past year; 79 % sought medical attention in 2010 compared to 85 % in 2009. Paul Keckley of Deloitte Center for Health Solutions says, "As the burden of care continues to be shifted to the individual, and more Americans lose their jobs and their health insurance, we expect this trend will continue. It will be interesting to see what happens in 2014 when the individual mandates requiring Americans to purchase health insurance kick in. Will we see a significant spike in visits to the doctor as more Americans join the ranks of the insured?" 1 in 5 consumers says they decided not to see a doctor or get health care services when they were sick or injured in 2010 compared to 1 in 4 in 2009.
Consumers are seeking alternative options to traditional care:

15 % reported visiting a retail clinic and 34 % said they would do so if it cost 50 %or less than the cost of a doctor’s appointment.
More consumers are seeking alternative or natural remedies before seeing a doctor (17 % in 2010 compared with 12 5in 2009).
More consumers are supplementing their current regimes with alternative remedies (20 % in 2010 compared to 16 % in 2009).

Consumers are also receptive to medical tourism, defined not as treatment abroad, but as treatment away from their home city or town. Only 7% sought health care services outside their local community in the last 12 months, unchanged from the 8% in 2009. Compared with 2009 (49%), slightly fewer (41%) would travel outside their local area to seek medical services. Older consumers are more likely to travel for treatment if a physician recommends it.
According to a new report on the US spa market by Irish researchers Diagonal Reports, the economic downturn hit spas, after years of incredible growth, very hard. Spas describe 2009 as a disaster as revenues fell 15% on the previous year. Such a drop shocked spas that had become accustomed to continuous expansion. A decade of double digit growth had led to oversupply of which has made the problem worse. Initially, spas delayed their response to falling revenues and did not react, by reducing prices, until late 2009.
There has been a shake out with some closures. Spas are concentrating on the opportunities. They can no longer be viewed as a license to print money but businesses that must control costs and offer services which clients want. Spas, once synonymous with luxury and pampering are no longer the preserve of a small and elite consumer segment. The technical revolution in spa equipment and facilities has brought wellbeing services (especially massages) to the masses. Spas have gone mainstream. The consumer switch from luxury to maintenance treatments benefits a leaner type of spa operators. Convenience is the key word. Compact services are now in demand and spas, which offer smaller price and smaller time, packages to their clients are now expanding in the US.
The key message coming from the USA is that fewer people can or are willing to afford to pay for health care. The hardest hit areas are not the essential treatments that are mostly covered by insurance, but cosmetic surgery and dentistry, and other non-essential health care. There is no evidence of millions of American medical tourists just waiting for the right country, hospital or agency with new offerings. There is potential in niche and specialist markets, but patients demand value for money and there are many rivals at home and abroad competing for the limited spend on healthcare.

Government proposals to lift a cap on the proportion of income NHS hospitals can earn from private work will mean several will seek to attract more paying patients from abroad. Health Secretary Andrew Lansley has set out the government’s ambitious plans to reform the NHS. Patients will get more choice and control, backed by an information revolution. The NHS White Paper, Equity and Excellence: Liberating the NHS sets out the Government’s long-term vision for the future of the NHS. The vision builds on the core values and principles of the NHS – a comprehensive service, available to all, free at the point of use, based on need, not ability to pay. Foundation Trusts (typically established as independent non-profit structures running large teaching hospitals) are to increasingly fall outside of state control. Legislation is anticipated that will remove borrowing limits; abolish the cap on the amount of income they can earn from other sources such as private patients to reinvest; and enable them to tailor their own governance arrangements. This relaxation of control is to be made so as to allow trust hospitals to be able to compete more freely with other healthcare providers. The 130 NHS foundation trust hospitals have had their private income capped for many years .The cap had meant most hospitals were unable to generate more than 2 % of their budgets from private income. To get foundation trust legislation through parliament in 2003, ministers agreed to a cap on private work to ensure the hospitals remained true to their NHS traditions. This has stopped some of the leading hospitals in the NHS competing with private firms for patients. Many had enough UK paying patients, meaning they had no incentive to seek overseas patients as their private counterparts do. But these restrictions are being removed as part of the NHS overhaul, which includes an order that all NHS trusts must become foundation trusts within three years. So eventually, all NHS hospitals will be free to seek private patients from at home or abroad. Sue Slipman of The Foundation Trust Network says, “It is exciting for foundation trusts. There are huge opportunities to innovate. One of the most obvious areas for expansion would be in fertility services where treatment on the NHS is severely restricted.”
Top NHS hospital trusts are already looking at building new wings and wards to cater for private patients set up hospitals abroad and offer airport-to-hospital services for medical tourists. Hospitals will be targeting rich potential patients from Russia and the Middle East; they do not plan to compete by cutting prices.
Manchester’s Christie Hospital plans to treble its private income from £10 million to £30 million within 10 years thanks to a deal with US-based private hospital group HCA which will see the company pay £14 million for a new private cancer centre. University College London Hospital has already gone down this route with a private US health firm, which has located a private unit on its site for cancer treatment. The firm leases the space as well as paying for the NHS services it uses, such as intensive care, radiology and cleaning and catering. Several British hospitals are already cashing in on their international reputations by marketing their services to overseas patients. The Royal Brompton and Harefield in London, the UK’s largest cardio-respiratory centre, devotes an entire section on its website to marketing its personalised, world-class service to overseas patients. It offers patients a city guide and even suggests trips to the high-end shopping facilities of nearby Sloane Street and Harrods. Moorfields, the eye hospital, has seen patient numbers jump five-fold to 9,700 after opening for business in Dubai; it is planning another hospital in Abu Dhabi. The Royal Marsden, a leading cancer hospital in London, already has substantial income from private patients, sees over 40,000 patients from the UK and abroad seen each year; and with its academic partner, The Institute of Cancer Research has discovered or developed more new anti-cancer drugs than the National Cancer Institute in the USA.Papworth Hospital in Cambridge, which carried out the first successful heart transplant in the UK, has made plans to expand to attract more private patients by building a new hospital and tripling private income.

Health and wellness tourism is now an international trend driven by health conscious consumers seeking to enhance their wellbeing through their travel experiences. Health tourism is travel undertaken by clients with medical conditions to enjoy a more salutary environment, to seek out alternative therapeutic treatments/therapies, or to visit a health spa. Wellness tourism is travel for the purpose of enhancing and engaging all aspects of a person’s physical, mental, spiritual, and social wellbeing, especially when maintained or achieved through healthy diet and regular exercise such as massage therapy, thalasso therapy or fitness training.
According to a Commonwealth Secretariat study, the worldwide health and wellness sector is a $ 40 billion market and is estimated to be growing at 30% per annum. Recognising that it is unlikely to ever be a serious medical tourism destination, but there are huge potential economic benefits in health and wellness tourism in the Caribbean, Caribbean Export Development Agency (Caribbean Export) has collaborated with the Caribbean Spa and Wellness Association (C-SWA) on a project to strategically assist the 15 CARIFORUM member countries; Grenada, Antigua and Barbuda, Barbados, Dominica, Belize, Dominica Republic, Guyana, Haiti, Jamaica, St. Kitts and Nevis, St.Lucia, St.Vincent & the Grenadines, Suriname, the Bahamas and Trinidad & Tobago, in developing and promoting health and wellness tourism. The project will begin later this year and will focus on;• Market research and strategy development• Marketing and promotion• Standards development The Grenada Industrial Development Corporation (GIDC) welcomes this initiative as it follows up on a study of Grenada’s health and wellness tourism sector undertaken in 2009, by GIDC in collaboration with La Luna and La Source, with assistance from the European Union through Caribbean Export Development Agency.
According to a new research report from Companiesandmarkets.com; The Caribbean experienced a mixed start to 2010, with sharp differences between countries in terms of tourist arrivals. In general, the picture was positive, with several countries posting increases in tourist arrivals, following a year of overall decline in 2009. St Lucia and the US Virgin Islands registered high levels of arrivals growth. Other countries including Aruba, Dominican Republic and Barbados experienced smaller levels of arrivals growth, while Bermuda had a quite dramatic drop in arrivals. These figures show that the local tourism market has not fully recovered, hence the increased interest in promoting spa and wellness tourism.

Costa Rican Medical Care (CRMC), a medical tourism agency specializing in medical and dental procedures performed exclusively in Costa Rica, has applied for membership with ProMED, the Council for the International Promotion of Costa Rica Medicine. ProMED, a private not-for-profit organization, coordinates the quality control and international promotion efforts of medical providers and the government. Its goal is to ensure the quality of services provided by the private health industry in Costa Rica when promoting medical tourism.
Tim Morales of CRMC says," Over the past two years, we have worked with minister of tourism Carlos Ricardo Benavides and ProMED’s Massimo Manzi to ensure our programme works according to the standards set by ProMED. We feel that by joining ProMED, we are supporting an organization that is looking out for the best interests of the patients who come to Costa Rica and ensuring that the providers we work with are up to the highest standards of accreditation set by the organization. We look forward to working to help Costa Rica continue to grow their medical tourism market in a safe and effective way. “
Tourists going to Costa Rica, attracted by the medical offers now have the ability to differentiate between the services offered. The new ProMED seal indicates the quality standards required in the United States, providing tourists with some reassurance in the services they are purchasing. Companies who want to obtain the label must comply with national and international legislation with a cost ranging from US$400 to US$7,000 annually.
So far only six companies have gained the seal of certification-• Clinica Biblica Hospital in San Jose is a general hospital offering a wide variety of procedures and surgery using cutting-edge technologies and techniques. It specialises in cardiology, cosmetic surgery, ophthalmology, orthopedics, and minimally invasive laparoscopic procedures.• Hospital CIMA San José is a general hospital• Hospital Hotel La Católica in San Jose is a hospital that uses the latest technology• Nova Dental is a full service dental clinic in San Jose that offers transport and booking for recovery facilities and/or hotels.• Universidad y Clínica UNIBE is a private clinic• Homewatch Caregivers Latin America is a provider of homecare services
There are three JCI-accredited private hospitals in Costa Rica, all ProMED members, and Costa Rica mainly targets American medical tourists with offerings at prices that claim to save up to 70% on most medical care procedures. One treatment that Costa Rica is promoting in the USA is Liberation treatment. Liberation treatment is a new procedure associated with chronic cerebrospinal venous insufficiency, which removes any blockages in a patient’s veins in a procedure similar to an angioplasty. This treatment for multiple sclerosis sufferers is still at the experimental stage and not authorized in the USA.

A survey published by medical tourism consultant Dr Prem Jagyasi suggests that people working in the medical tourism industry believe that their industry has yet to reach its full potential. The report also suggests that confusion, a lack of information and fear about complications following surgery are the main reasons for patient reluctance to cross international borders for health services.
The "statistical findings" are based on the views of 95 people in medical tourism. However, the small sample size and inherent sample bias makes it difficult to draw definitive conclusions from the report. The headline conclusion that “the medical tourism sector has yet to reach its full potential” is fairly predictable given that the respondents are those involved in promoting and running medical tourism businesses. Care must also be taken in considering the conclusions relating to the position of various countries within the marketplace. The nature of the respondent sample will have influenced the responses.
Taking these factors into consideration, the survey has to be seen as more of a “vox pop” of the industry rather than a research based statistical analysis. It’s a platform for generating discussion, rather than an analysis of the current climate. Here are the main points from the report:
• Medical tourism has not reached its full potential.Dr. Jagyasi, "There is an overwhelming perception among industry leaders that there is so much more that can be achieved." • 35 countries are important medical tourism destinations. India ranked as the number one popular destination, with Thailand and Singapore at second and third places. The United States had a surprise ranking at number four.Dr. Jagyasi, "The Asian and Far Eastern countries are well-established medical tourism destinations, so the top three placing were expected. The United States came in at number four, which indicates medical tourism is not all about low price affairs. Latin American and European countries were in the top ten, indicating that medical tourism is not dominated by one continent or geography – it is a truly global industry.”• Reluctance in some consumers to participate in healthcare tourism may be due to concerns about complications, confusion over aspects of available services, lack of information, and complicated offerings.Dr. Jagyasi. "Education is a vital component in allowing us to allow medical tourism to reach its greatest potential. If we can allay people’s fears about foreign treatments and guide potential health tourists with information on what to expect and important advice on visa and travel issues, then we will be providing a vital service." • The most popular reasons given for why patients travel abroad to receive medical treatment are affordability (costly in home country), accessibility (waiting period is high) better quality (care and support services are better quality than the home country) and availability (not available in home country).• The top challenges to the medical tourism industry are accessing reliable information; too many newcomers jumping on the medical tourism bandwagon, not experienced or understanding of the industry; lack of pre and post operative care arrangements, and complicated intra-country laws and legal procedures.• Essential components of a good medical tourism destination are quality standards of healthcare and wellness services, accessibility, and technology, facilities and specialisations available.Dr Jagyasi is also publishing a guidebook. He has high hopes that it will become a handy reference tool for those wanting to know more about the intricacies of travelling across borders for healthcare services.

Doctors Hospital has become the first hospital in the Caribbean to achieve international accreditation from Joint Commission International (JCI). This certifies that Doctors Hospital’s programmes meet international standards and follow the latest US guidelines on patient care and patient safety, and follows an ongoing program for continuous improvement.
News of the accreditation has already led to enquiries from agencies that see the Bahamas as a potential destination for American medical tourists due to the short air flight time and popularity with travellers. Charles Sealy of Doctors Hospital points out that the hospital already does handle a small amount of medical tourism business but that accreditation gives the hospital an opportunity to expand into more complex surgery rather than the existing outpatient surgical procedures. He believes it can offer those services at competitive rates with comparable accommodation, lower then US prices and in a more appealing location than most Central or South American competitors.
Future growth of medical tourism is very much dependent on planned expansion to increase the number of patient beds. Planned growth was put on hold as the hospital’s business decreased last year due to the local and international economy. The Nassau hospital continues to lobby the government to implement lower rates in the health care system of the Bahamas, to make medical tourism more competitive and to be able to offer attractive packages.
Minister of Health, Dr Hubert Minnis, says his ministry and the ministry of tourism want to encourage medical tourism, “"Medical tourism is a new frontier, and we think with the international accreditation it will be known worldwide that this institution delivers the safest quality care. They can offer care at standards that would be comparable to any institution in the USA." But apart from reflecting in the success of the hospital, the government continues to do nothing to promote medical tourism locally, despite being encouraged for several years to move beyond kind words.
Vance Jochim of American medical tourism agency Sunshine Medical Tourism, comments, “ If you want medical tourism to expand in the Bahamas, the hospitals must set up relationships with specialized medical tourism agencies and implement a process to ensure the same customer service and care as facilities in Costa Rica and Brazil. You also have to be price competitive with the other countries, but you have an advantage of the short travel distance from the US. “

Asian countries confident they are leading medical tourism destination should not get complacent. The darkest horse in medical tourism is not yet ready to take their place, but as manufacturing companies found, this country absorbs information on rivals and then offers a cheaper alternative.
Co-operation agreements with Taiwan, and encouraging Korean cosmetic surgeries, Indian and Singapore hospitals and other medical experts to set up in their country, are just the tip of the iceberg. Rivals may question the standard of healthcare in China, but although health provision in rural areas and for the poor is inadequate, the standard and price for the emerging middle class and new rich, is different.

Raffles Medical Group (RMG) has opened a new medical center in Shanghai. Raffles Medical – Shanghai is mainly targeting expatriates, corporate customers and high net worth mainland Chinese, for health screening, general medical and dental treatment. Yong Yih Ming of Raffles Medical – Shanghai, says,” China’s economic growth has cultivated a pool of Chinese who can afford high-quality medical care of international standards.” Dr. Ang Peng Tiam, of Parkway Cancer Centre (PCC) has obtained a practising license with Shanghai’s St Michael Hospital. PCC is setting up a satellite clinic within St Michael Hospital,

Boai Medical Group, China’s largest private medical organisation, has begun offering services to medical tourists in both modern medicine and traditional Chinese medicine. Dr. Carlos Che at Modern Hospital Guangzhou comments. " What we offer is a treatment programme that provides the best of both philosophies of care, as we have a wealth of clinical evidence that shows that TCM can enhance western medicine. We are very much looking forward to bringing the benefits of this approach to patients in the Gulf region." The hospital is only one of the group’s 56 hospitals and clinics in China. It has bilingual translators to help patients from different countries.
Boai Group has appointed medical tourism consultancy ExHealth, to assist it with improving international patient practices and to identify new opportunities, as well as providing support on ethical, cultural and legal issues. The group sees opportunities to attract Gulf residents, particularly from the UAE, and wants to take business away from Thailand and Malaysia, as treatment in China would cost a quarter of what it would cost in Dubai, or two-thirds of the cost in Thailand.
But China’s entry into medical tourism has another side. Despite official attempts to limit the organ transplant trade, Malaysians are still going to China for transplants. According to a report by the Malaysian Dialysis and Transplant Registry, some 60% of Malaysians have gone overseas for transplants in the past nine years (2000-2009), with 856 seeking treatment in China alone. World Health Organisation (WHO) adviser Dr Francis Delmonico, at a forum on organ trafficking and transplant tourism warned Malaysians not go to China, “"We do not know where they get the organs. But in most cases, the organs are taken from executed prisoners. People need to know that those who went abroad for organ transplants have become ill on returning home. Some Malaysians who went abroad for organ transplants returned home with diseases including TB, hepatitis and HIV.” The forum said that 60,000 transplants are taking place worldwide each year, and one in 10 are still done illegally-mainly in China, Pakistan, India, the Philippines and Egypt.

Jeju, South Korea’s biggest island, is transforming itself into a medical destination for foreign patients who are looking for treatment as well as tourism. Jeju Healthcare Town will begin construction later this year with the first part due to be completed early next year.

Jeju Healthcare Town will consist of three parks, one for wellness, one for medical treatment, and one for medical science and research. One of the main themes of Jeju Healthcare Town is medical treatment and research for a long life. Jeju seeks to attract foreign patients who want to have a check-up in the wellness park or medical treatment in the medical park. The main target will be Asian countries. The local government has provided a site of 1.48 million square meters in Seogwipo for the healthcare complex.
There are positive factors that can help Jeju Healthcare Town. Jeju Island is off the south coast of South Korea, between China and Japan. Eighteen cities with populations of more than 5 million are within 2 hours’ flight of Jeju Island. Jeju offers an unspoiled natural environment that other competitive medical destinations do not have. Jeju Island is traditionally well-known as a tourism destination. Korea offers state-of-the-art technology in medical treatment including surgery, diagnostics and cancer treatment.
According to the Korea Tourism Organization, the number of visitors to Korea for medical treatment has increased significantly. It aims to attract 850,000 overseas patients by 2015. Stackpole and Associates has created an innovative sweepstakes program to attract medical tourists to South Korea on behalf of its client, the Korean Health Industry Development Institute. The "Body and Seoul Sweepstakes" has launched with a three-week promotion of Asian hospitality and health care. The target is residents of the US who want to experience the travel and health benefits of medical tourism. It offers a package of health and wellness services for two as well as business class plane tickets and a five-night stay at the JW Marriott Seoul. A lucky winner and travel companion will be pampered with a VIP health check up, a dental exam and teeth whitening, traditional Korean medicine treatments, skincare services, and spa treatments as well as sightseeing in Seoul. The health and wellness services are offered by Seoul’s medical tourism destinations including East West Medical Center and the Aramdaun Spa. The sweepstakes runs from June 26th to July 19th.
The medical tourism market in South Korea is anticipated to grow at 30% a year during 2010-2012, says a new research report by RNCOS, “Emerging Medical Tourism in South Korea”. The growth in the South Korean medical tourism industry has been well supported by the government efforts and initiatives. In February 2009, the government reserved 5% of the total hospital beds for foreign patients. Most international patients come from China, Japan, the USA and the Southeast Asian countries, claims the report.

Jordan’s Ministry of Health is setting up a new directorate to monitor the Kingdom’s medical tourism sector. The directorate aims to address any complaints by Arab and foreign patients receiving treatment in the Kingdom and regulate the sector. The ministry is working with private hospitals to ensure that they abide by set treatment prices. One project aims to find ways of regulating and monitoring the quality of treatment provided to medical tourists to maintain the reputation of the country’s health sector.
As part of the new measures, the ministry will establish a liaison office at the airport to receive patients seeking treatment in the Kingdom’s hospitals and provide them with the information they need. It will also coordinate with embassies of countries that send patients seeking medical care in Jordan and follow up with the patients themselves from the moment they arrive and until they leave.
Considered one of the main contributors to the national economy, medical tourism brings in revenues of $1 billion annually. According to Private Hospitals Association figures, 220,000 patients from across the world received treatment in the Kingdom’s private hospitals last year, up from 200,000 in 2008 and 190,000 in 2007.
In cooperation with the Private Hospitals Association (PHA), USAID Jordan Economic Development Program (SABEQ) held a workshop for PHA member hospitals on guidelines for creating a customer service culture in hospitals. In line with its continued support for PHA member hospitals to become internationally accredited to promote medical tourism in Jordan, SABEQ Program’s support has been given to raise standards of members’ level of service through various training programs. SABEQ’s ultimate goal is to increase member hospitals’ revenues from medical tourism. Customer Service at hospitals is one of the pillars for medical tourism sector growth sustainability, as it reflects the standards of medical care in these hospitals and building a culture of customer service starts with top management leadership and direction. The workshop promoted the notion that each hospital employee, whether medical or non-medical, must offer excellent customer service.
Mark McCord of USAID SABEQ comments, “SABEQ had previously trained a group of employees at five PHA-member hospitals to become trainers in customer service. This workshop will enable hospitals to conduct continuous training for all their employees. To grow medical tourism in Jordan, hospitals must offer world-class customer service. The competition for foreign patients is significant, which makes excellence in customer services a prerequisite for success in medical tourism."

Kuwait’s Ministry of Health has announced plans to sign contracts with foreign medical experts to run medical facilities in the country. The move is part of a strategy to upgrade the quality of medical services on offer. The ministry is also adding new buildings at a number of general and specialist hospitals, to increase capacity from 1000 to 2000 beds.

The Taiwan cabinet has approved a proposal to establish a medical zone as part of its plan to turn Taiwan Taoyuan International Airport in Northern Taiwan into an “aerotropolis”, aiming to attract about 45,000 medical tourists annually in a new international medical district. The government will invest US$127.6 million over four years. The plan, set to be completed in 2020, will involve the expansion of existing airport terminals and the establishment of an aerospace industrial park and special zones for cargo, passengers and legislative services.
To develop the country’s medical tourism, Premier Wu Den-yih has also instructed the Department of Health to formulate plans to establish other medical zones targeting foreign tourists in central and southern Taiwan. His argument is that by offering international medical services, Taiwan can improve its global image and upgrade the country’s medical industry. The premier said similar international medical districts could be established near the international airports in central and southern Taiwan when conditions allow.
Plans for the development of the international medical district include the construction of several clinics geared toward providing high quality services, treatment and care for what is hoped to be increasing numbers of foreigners coming to Taiwan on medical tourism visits. It will also offer fast-track physical checkups and treatment, including various types of minor cosmetic surgery for passengers flying through the airport.
Taiwan’s first international medical district is planned to be developed in Taoyuan to take advantage of the main international gateway, Taiwan Taoyuan International Airport, the convenient transport network, a well-founded network for medical care, and booming business and industry with more than 10,000 factories, including some 40 in the biotech sector.
Cyrus C.Y. Chu of Taiwan research institute Academia Sinica is encouraging the government to promote medical tourism, "According to a 2000 survey, Taiwan’s health standard is second in the world. Taiwan ranks only behind Sweden, proving that the country has a strong foundation upon which to expand its health market. The revenue from foreign patients now accounts for less than 1 percent of total revenue at most hospitals in Taiwan. In comparison with Singapore and Thailand, progress is slow in Taiwan, mainly because hospital management does not treat medical tourism as an industry, but as a service. The government could divide the existing medical system into two parts in order to manage the local insurance medical service and the foreign medical industry. Other improvements, such as processing visas more efficiently for foreign patients, could also help the development of the industry. Developing medical tourism could attract foreign patients to Taiwan to accept treatment. Otherwise good doctors and hospitals will move to China, so, developing medical tourism is the better choice for Taiwan."

In an effort to promote medical tourism in Jordan and to position Jordan as the destination of choice for foreign patients, the USAID Jordan Economic Development Program (SABEQ) and the Private Hospitals Association (PHA) seek to increase the number of hospitals in Jordan with Joint Commission International (JCI) accreditation. They believe that JCI accreditation is critical in the promotion of medical tourism as it represents a standard of patient safety and trustworthiness. The PHA says that global outsourcing of medical care is becoming a vital and viable industry and that JCI accreditation will help Jordan open the door to additional markets.
Promoting medical tourism in Jordan heavily relies on conforming to a set of international standards to ensure Jordan’s positioning as an important medical services hub for both neighboring and distant patients. At present only six Jordanian hospitals have JCI accreditation. SABEQ is working with ten additional private hospitals that are working towards accreditation. SABEQ is sponsoring a targeted technical assistance program that will prepare these hospitals and others in Jordan for accreditation. USAID’s support through SABEQ for hospitals pursuing JCI accreditation focuses on activities that will lay the groundwork for success, such as conducting a gap analysis, providing technical assistance, and conducting mock accreditation surveys. Of the ten candidate hospitals, five were selected as potential JCI candidates in the short term, and thus SABEQ’s efforts will focus heavily on preparing them to meet JCI standards. Professor Assaf al Assaf says,” We believe the potential for Jordan’s medical sector will be greatly enhanced with adding more internationally accredited hospitals. Our goal is assist each candidate hospital in achieving a sustainable culture of exceptional quality and patient safety. With the help of Jordanian consultants and highly-skilled hospital staff and administrators, we are moving rapidly toward achieving this goal."
With the support of SABEQ, a PHA delegation went to Dubai to attend the Arab Healthcare Conference. The aim was to promote Jordan in Gulf countries as a medical tourism destination. Although Jordan’s healthcare services are gaining steady recognition, Gulf countries have not been previously approached. The PHA invited two UAE health officials to visit Jordan and evaluate medical services offered by private hospitals.
The USAID Jordan Economic Development Program (SABEQ) is a five-year economic development initiative implemented by Deloitte Consulting with international and Jordanian partner firms. The mission is to support sectors and activities for a knowledge-based economy, by making Jordanian enterprises into global value chains, promoting investment, and improving the environment to generate value added jobs, exports, foreign direct investment, and sector revenues as a powerful engine of economic growth.

Boomers Abroad, an online community popular with Americans and Canadians visiting, relocating and retiring to Latin America, has expanded its offering to include the Health Travel Guides network of premium medical and dental travel services. California based Health Travel Technologies (HTT) is a medical travel technology firm whose platform powers North American medical tourism agencies including Health Travel Guides and Dental Travel.HTT has signed an agreement with Boomers Abroad to provide a medical travel portal service for the popular Boomer’s Abroad website.
Health Travel Technologies is a business-to-business provider of medical tourism solutions and services that enable health care provider networks to cost-effectively market operate and manage international patient operations. Boomers Abroad, a niche portal, online community and social network, was launched in 2009 to provide information, education, and alternatives to the millions of Americans and Canadians now living in, visiting, or planning to relocate to Latin America.7 million Americans and Canadians currently live abroad and that amount is expected to double in the next 10 years. Many of those are retirees looking for warmer weather and a lower cost of living, something Latin America delivers with ease.
Luis Miranda of Boomers Abroad says, "Having the medical travel element as part of our site is important not only for retirees that need to figure out how to locate quality health care options while living in another country, but also for those Americans and Canadians who cannot afford or get the health care they need at home." Nishant Bagadia of HTT adds, "Boomers Abroad is a great new partner as it offers a very targeted community based website where people wanting to live, work and play in Mexico and beyond go for very specific needs. Healthcare is very high on that list. They provide us with a database of 18,000 people in need of medical travel services,and we can provide them with dozens of options for high quality healthcare in Latin America, comparable to what they experience at home, at prices up to 75% less than they are used to paying."
Luis Miranda comments, "There are many good sites for information, but we think that there is no substitute for the real testimonials of those already living life in another country. Our community consists of leading industry experts that share their personal experiences and knowledge in a great variety of areas, such as top destinations, community highlights, attractions, real estate, mortgages, tax, finance and lending, healthcare and insurance."

Jordan’s medical tourism sector witnessed a rise in patients last year, says the Private Hospitals Association (PHA). Private hospitals across the country witnessed a 10 per cent increase in foreign patients in 2009. 220,000 patients from across the world received treatment in the Kingdom’s private hospitals last year, up from 200,000 in 2008 and 190,000 in 2007. Initial figures for 2010 received from the 48 private hospitals affiliated with the association are promising and indicate that the number of medical tourists will continue to increase this year.
Iraqis represented the largest number of foreign patients seeking treatment in the Kingdom, accounting for 19 %, followed by Palestinians (16 %) and Saudi Arabians (15 %). Yemeni patients were fourth, constituting 14 % of the total, followed by Sudanese and Libyan patients at 13 % and 9 % respectively.
Although the exact percentages have changed, these results are very similar to the ones for 2008 and 2007. Attempts to widen the target market to include Europe, Asia and the Americas have not yet achieved much business, as the total for the over 40 countries outside the top six ones, is only 14% combined.
Fawzi Hammouri of PHA says, “The quality and competitiveness of healthcare in Jordan have made the country an attractive destination for foreigners seeking advanced treatments that are unavailable or unaffordable in their home countries.” The majority of foreign patients arriving in Jordan seek treatment for cosmetic surgery, cancer treatment, heart and brain diseases, kidney implantation, spinal and nervous system diseases. Medical tourism brings in revenues that reach $1 billion annually.

In a new research report “Poland Medical Tourism Market 2013 – An Untapped Opportunity”, Insight Market Research Solutions (IMRS) has identified Poland as one of the most promising destinations for medical tourism in Europe. In recent years patients from countries like the UK and Germany have visited hospitals and clinics in Poland for medical consultations and treatments. The huge differential in treatment cost has driven the inflow of patients from other countries to Poland. The entry of Poland into the European Union has also resulted in a positive thrust to medical tourism. The report gives a brief overview on the existing healthcare infrastructure in Poland in terms of number of public and private hospitals, medical personnel, and health resorts.
According to the report, the medical tourism industry in Poland has the potential to grow, driven by association and government support coupled with increasing number of private healthcare facilities. IMRS anticipates more than 15% annual growth for revenue in coming years due to increasing flow of medical tourists and rising per capita expenditure by medical tourist on treatments and surgery.
IMRS anticipates Poland will be able to overcome the challenge of India, Singapore and Thailand due to its proximity to European countries and presence of well-trained medical experts similar to western countries. Poland will continue to attract large number of medical tourists from other European countries due to less travel time and absence of visa requirement for travel within European Union borders, compared with travelling to Asia.
According to estimates from the Polish Association of Medical Tourism (PSTM), between 300,000 and 330,000 people visit Poland annually and spend an average of 1156 euro on voluntary medical and dental procedures such as porcelain crowns, breast augmentation, or dental implants. Artur Gosk of PSTM says. “If we can maintain a high level of service, these competitive prices will promote themselves.” PTSM reports that people are coming to Poland mainly from Germany, the United Kingdom and Scandinavian countries to seek cheaper medical treatment at Polish clinics.
PSTM has agreed to form a consortium together with the Polish Tourism Organization (POT) and representatives of the country’s health industry. POT is inviting the health ministry and local governments to cooperate to advertise medical tourism in Poland.

Cebu’s spa and medical-tourism players are hoping that medical tourists from Canada, where the health system has problems, will consider the island province as it seeks to promote itself as the wellness capital of Asia. The Cebu Health and Wellness Council (CHWC) is visiting Mabuhay Festival in Toronto and set to meet the Asian Canadian Business Association in Vancouver as well as meeting medical practitioners and business organizations. The aim is to get their help in promoting Cebu as a wellness destination. Cebu offers high-class spas, resorts and tourism destinations.
The objective is to promote health and wellness tourism, and to a lesser extent, medical tourism. Canada could be a lucrative market as there are many Filipinos living and working there. The Philippines tourism authorities say the country gets 100,000 medical tourists a year. Cebu gets more than 600,000 foreign tourists annually, or around 20 percent of the entire country.
A medical tourism facility is planned in Roxas City, Capiz, courtesy of local private investors with several doctors coming from the Philippine General Hospital (PGH).Capiz governor Victor Tanco who expressed optimism over the benefits that the P600-million project will be bringing to Capiznons.Tanco said the facility is similar to that of St. Luke’s Hospital where the patients will not feel that they are inside the hospital but instead experience the feeling of being inside a deluxe hotel. The facility will have a restaurant, sports facilities, and other wellness equipment.

Recent comments from within the medical tourism industry celebrating the opportunities opened up by healthcare reform have given the impression that reforms will be almost instant. That is far from the case. Most of the major reforms will not begin until 2014, some will not begin until 2016, and the consensus is that the full impact will not be felt until 2019.
There has been much information and misinformation on what happens. US consultancy, Deloitte, has been producing a weekly newsletter on healthcare reform. The timetable below shows edited highlights from a recent newsletter, supplemented by other independent sources adding extra detail:
2010• Catastrophic pools: Establishes temporary national high-risk pool for individuals with pre-existing medical conditions uninsured for at least six months. • All individual and group insurance plans must offer dependent coverage for children through age 26; insurers are prohibited from denying coverage to children because of pre existing health problems. • Insurance companies can no longer put lifetime dollar limits on coverage and cancel policies• Tax credits for small businesses that provide insurance.• New national strategy for health care quality improvement.
2011• Funding for community health centers increased to provide care for many low income and uninsured people.
2012• Hospitals, physicians, and payers encouraged to band together in accountable care organizations.
2013• Exchanges: creates consumer operated and oriented plan (CO-OP) program to operate non-profit, member-run health insurance companies in 50 states and District of Columbia offering a specified set of health insurance plans.
2014• Exchanges must accept and renew individuals and groups on insurance, with tightly controlled premium limits and no refusals.• Increased enrollment for Medicaid to cover low-income people – covers16 million.• Insurers banned from denying coverage to people with pre existing conditions, or charge higher rates to those with poor or chronic health conditions. • Insurers must cover maternity care as they do other medical procedures.• All legal residents must have health insurance, except in cases of financial hardship, or pay a per person fine to the taxman $695 (up to $2,085 per family).• Employers with more than 50 workers and no health insurance get very heavy tax penalty. • * Employers with 200+ employees to automatically enroll employees into health insurance plans offered by the employer. Employees may opt out of coverage. • Tax credits to small businesses that provide insurance—with 100% credits for businesses that employ 10 or fewer employees.• High-risk pools close.• Government to define minimum health insurance benefits by cover and amount on all health insurance plans offered through health exchanges and commercial plans targeting the individual and small group markets.
2016• Tax fines for having no health insurance increases to $750 per person and increases every future year with inflation.

Two medical tourism groups of business executives and their families from China will go to Taiwan in April and are expected to bring in substantial revenue. Walter Yeh of the Taiwan External Trade Development Council (TAITRA) says that with the average cost for a physical check-up ranging from US$1577 to US$4730) the 64 people from those groups are expected to spend a lot of money during their five- to seven-day visits.
The Guangzhou-based Xian Health and Medical Center, a new clinic funded by several Taiwanese businessmen operating in China, organize the medical tour groups. There is a membership fee for joining the centre, and every member is entitled to a six-day trip to Taiwan, including a one-day physical check-up. TAITRA advise that Southern China’s Guangdong province enjoys the highest GDP in the country, and it is targeting its capital city Guangzhou with a population of 20 million, to promote medical tourism to Taiwan.
With the assistance of the TAITRA, the centre, that already has over 1000 members, reached agreements with 18 medical centres and hospitals in Taiwan last year to organize the visits. As Taiwan has a good reputation for hip replacements and knee and heart surgery, the centre can also help introduce those services to potential Chinese clients.
The Zion Health Management Institute in China is building the first top-quality medical centre in the country, while strategically allying with 16 hospitals in Taiwan, including Shin Kong Wu Ho-Su Memorial Hospital, Cathay General Hospital, Changhua Christian Hospital, and Eonway Health Maintenance Center, as well as three hospitals in China, including Zhongshan Hospital. It will offer comprehensive physical checkups, treatment and upgraded services in dentistry, gynecology, psychiatry, Chinese medicine, anti-aging and chiropractic. It is linking with the World Society of Anti-aging Medicine (WOSAAM), an international non-profit organization based in Paris in that promotes anti-aging medicine through research.
A stem cell therapy centre built with donations from local business tycoon Terry Gou was inaugurated recently at the National Taiwan University Hospital. It has been named the Tai Cheng Stem Cell Therapy Center in memory of Gou Tai-cheng, the donor’s younger brother, who died of leukemia in Beijing in 2007. Gou wants to help others suffering from the same disease. The centre has 14 stem cell transplant wards and is only the first part of a US$472.56 million project financed with donations by Gou, that will include a 249-bed oncology center- as Gou’s wife died from cancer.

June and July 2010 will see thousands of soccer fans descend on South Africa for the World Cup tournament. Although fans will be from many places, the majority will be from the USA, England, Germany and Australia. At the World Cup there will be no British fans –only those supporting England, as Scotland, Wales and Northern Ireland did not qualify.
Several South African agencies and clinics optimistically hope that while they are in South Africa fans will also become medical tourists. Packages include cosmetic surgery, spa treatments, plus accommodation while they recover and guided tours.
Cape Town based Surgical Bliss has several World Cup packages on offer, breast augmentation, eye lift, tummy tuck and in vitro fertilization. Spa treatments, golf and shopping trips, and tours in and around the city can be added at extra cost. Particularly targeted are England and USA fans. Africare Health, a Sandton company mainly gets custom from African countries including Equatorial Guinea, Liberia, Nigeria and Kenya. The company’s World Cup package includes accommodation and local transport, with a choice of a safari, heritage or golf tour. Johannesburg based, Medi-Sculpt clinic has launched a World Cup face-lift and safari package that includes interaction with lion cubs and giraffes.
Another Johannesburg based agency, Serokolo Health Tourism is planning special health packages. Dr Tshepo Maaka of Serokolo Health Tourism says .We made our prime target sub-Saharan Africa, with long-haul destinations a secondary consideration. West Africa has become our biggest market but we are now receiving enquiries from the UK, Asia and Canada, which indicates the need to expand to include the overseas market. The World Cup soccer event may be their primary reason for coming here, but we have so much more to offer on the lighter side of medicine, from basic medical check-ups to spa treatments, eye checks, dental reviews, teeth whitening and so much more.”
Football fans traveling to South Africa will be mostly male, under 35 and with two pre-occupations – football and drinking! A few may even act as tourists, but with long distances between the various locations they are unlikely to have the time. Stadiums are spread far apart; the distance between Cape Town and Johannesburg is 880 miles. Much will depend on where, when and how the local police allow fans to travel; this will depend on how peaceful the fans are and whether historic rivalries such as Germany versus England flare up as they have at previous events. Most people who go to watch World Cup soccer support their own country and doing anything that is not football related is hard to plan. Fans will know where their country is playing in the first round, but which city they will be in depends on how far their country progresses in the competition. South Africa is mobilizing an extra 25,000 police for security, and the official police advice is for fans to stay in groups, and not to go anywhere individually.
The inclinations and young ages of the fans suggest that few will be interested in cosmetic surgery, fertility treatment or spas. But even if the agencies get very little actual business, it is probably a good advertising and marketing opportunity that raises the country’s profile.

Two hospitals, Salmaniya Medical Complex (SMC) and the Psychiatric Hospital, and all twenty-two primary healthcare clinics owned by the Bahrain government have received an Accreditation Canada international certification. The accreditation exercise is part of implementing and fulfilling Bahrain’s Vision 2030.
Vision 2030, the official plan for Bahrain’s economic future, demands that the government invests increasing amounts in healthcare to bring the kingdom up to international standards. Bahrain wants to become a regional centre for medical tourism. The country is looking to use its reputation as a Gulf leader in medical education to bolster its credentials as a medical tourism destination. The use of international accreditors is seen as part of the process of improving quality.
The Ithmaar Development Company is progressing a health and real estate development on reclaimed land dedicated exclusively to promoting and enhancing the kingdom’s health and well-being. The manmade island is Dilmunia at Bahrain. Reclamation work on the $1.6 billion island was completed last May, and a new island was added to the shores of Bahrain.
IDC’s Mohamed Khalil Alsayed explains, "Dilmunia at Bahrain is a development positioning itself as a global leader in the promotion and enhancement of health and well-being. It aims to enrich Bahrain’s tourism offerings. Dilmunia will be the destination for harried citizens of the Middle East and the world, in search of an environment that strives to prevent illness and only a few minutes away from Bahrain International Airport. It will promote healthy and active living through a combination of beautifully landscaped serene surroundings, health-oriented leisure amenities and world-class conventional, aesthetic and alternative medical facilities.
Inspired by ancient Dilmun, widely believed to be the Garden of Eden, the Dilmunia at Bahrain Island will be a lush green oasis. The island will include three five-star hotels offering alternative therapeutic services and a four-star hotel, in addition to the island’s anchor theme; the central health and wellness cluster in Dilmunia Health District. It will be a mix of residential, hospitality, leisure and commercial developments, surrounding a core of comprehensive health and wellness amenities, which will together offer an alternative balanced perspective towards life and living. IDC has signed agreements with a prestigious international hotel chain and is now finalising negotiations with a partner on the Dilmunia Health District that will include specialist clinics, hospitals, spas and other wellness facilities including treatment options through alternative medicine, physical therapy, as well as through diagnostic tests, dietary control and conditioning for the body, mind and soul.

Quality Council of India (QCI) ’s National Accreditation Board for Hospital and Healthcare Providers, (NABH), has launched a programme of accreditation of wellness centres like gyms, spas, cosmetic and skin treatment centres in the country.
Dr Bhawna Gulati of NABH says, “For the ordinary customer, this means that the gym or beauty centre that has gained such accreditation offers care and services of a required standard. People should be assured about getting what they are paid for. Accreditation means credibility. It makes all the difference between genuineness and quackery and that the massages offered are done by properly trained professionals.” The accreditation system identifies standards for wellness centres in a largely unregulated market that has seen huge growth. The accreditation programme is voluntary. Standards were fixed by a panel of experts. Aspects like customer rights and education, infection control, training of staff, infrastructure, processes and statutory and regulatory compliances were taken into consideration. The wellness accreditation is valid for three years.
The wellness & healthcare sector has so far been unregulated and subject to quackery by a handful of people who tarnish the Industry by making money using whatever means possible. The sector is looking at building up credibility for their services through a self-regulatory process of accreditation. Tthe Federation of Indian Chambers of Commerce and Industry (FICCI) worked jointly with NABH on the standards.
The Indian health and wellness market is estimated to be growing at 25% a year. The total number of spas in the country is 2,300. In the next four years, 700 new spas, both homegrown and international brands will open in India to meet the growing demand. Destination / hotel spas is another growing category where spas can contribute up to 15 per cent of a hotel’s revenue and in some cases is the second fastest income generator in the hotel after rooms. At present, India has around 20-25 major spa centers; most of them are spread in the southern states such as Kerala, Karnataka and Tamil Nadu.
There had been a significant rise in the health care facilities under AYUSH (Ayurveda Yoga Unani, Siddha Homeopathy). There are 3,400 AYUSH hospitals in the country. There are 12 Yoga hospitals as well. NABH is introducing Accreditation Standards for AYUSH Hospitals.
The accreditation programme for AYUSH Hospitals consists of two kinds of standards – accreditation and structural. Accreditation standards are based on three components- structure, process and outcome. These standards measure the quality and safety aspects of the care delivered to the patients. Structural standards that are basically deals with infrastructural requirements to help the organisations to deliver quality of care. For each speciality i.e. Ayurveda, Homeopathy, Unani, Siddha. Yoga and Naturopathy there are separate accreditation and structural standards as per their individual system of medicine and requirements.
A minimum bed number of 10 is essential for an AYUSH Hospital to be considered for the accreditation programme. The standards provide a framework for quality assurance and quality improvement for the AYUSH hospitals. The standards focus on all aspects of service delivery like customer rights and education, infection control practices, trained and experienced staff, infrastructure, environment safety, processes and controls among many others, statutory and regulatory compliances. The standards have been developed in association with the Department of AYUSH.

Jordan has recently become an attractive country for Yemeni patients seeking medical treatment. It has outmatched several countries that were popular with Yemeni patients including Egypt, Saudi Arabia and India. Yemeni patients are now the largest national group of medical tourists at the top ten private and public hospitals in Jordan. Yemeni patients enjoy preferential treatment, with a discount of 20 percent of medical bills, the same discount offered to Jordanians.
The Jordanian minister of health, Dr. Naïf Al-Faiz, emphasizes that the Jordanian government has placed medical tourism as a top priority, and has called upon the Hospital Directors’ Association to set specific mechanisms for the regulation of medical tourism under the ministry’s supervision and coordination. Jordan desires to provide fully integrated services, in terms of medical procedures, prices, and quality treatment. The country has succeeded in attracting patients from the USA, East Asia and Eastern Europe in the past few years. Jordanian medical treatment costs are not high if compared to the costs in other countries, such as Yemen, Sudan and Libya.Yemen will continue supporting medical tourism to Jordan. It will continue to send patients for treatment because of the high quality public and private medical services, said Yemeni deputy health minister Dr.Ghazi Ismail.
Promoting cohesion amongst different medical service providers and continuing in its efforts to promote medical tourism, the USAID Economic Development Program (Sabeq) invited Private Hospital Association (PHA) members and medical insurance companies to attend a focus group meeting at Sabeq premises, in a bid to protect patients’ rights in cases of malpractice.
Promoting medical tourism in Jordan means responding to requirements of certain markets that demand practices that guarantee the rights of patients. As Jordan has no medical malpractice laws or history, no patient can sue a Jordanian hospital or doctor for malpractice. This may be a problem if a business or insurance company pays for treatment, although outside the USA, whether or not a hospital can be sued, seems of little importance to medical tourists; in some countries the very principle of malpractice or negligence does not exist in law.
Discussion lead to the Sabeq programme being asked to provide technical assistance to create a new insurance product for hospitals and to ensure the correct application of international standards in Jordan, to cater for the interests of both hospitals and insurance companies Neither medical malpractice insurance nor complying with international standards, are relevant in local law if the law does not recognize the concept of malpractice. Whether a Jordanian hospital could be successfully sued in an overseas court for malpractice will remain a theoretical question until it happens. The suggestion is that a combination of legal expenses insurance and compliance with international standards could be an effective first line of defence, in covering the costs and countering allegations that they are not as good as American hospitals, against opportunistic US lawyers seeking large settlements for allegations that Jordanian hospitals were guilty of medical negligence when treating an American medical tourist.

The Department of Tourism (DOT), Department of Health (DOH) and Health and Wellness Alliance of the Philippines (HEAL Philippines) have denied reports in some newspapers that any of them recommend that international patients should go to faith healers or others who treat illnesses, that have no proper licenses to practice medicine or treat illnesses. The country has many faith healers, estimates varying from a few hundred, to American websites that suggest there are over ten thousand. A strong official statement followed reports in local newspapers and websites in early February, that have been noticed and repeated by a wide range of health and travel websites across the world
The relevant quotes from the Philippine Headline News Online are, “ Even as the Department of Tourism (DOT) continues to promote faith or spiritual healing as part of its medical tourism program, health secretary Esperanza Cabral said yesterday that these forms of healing are not recognized in the professional medical community.” and “Tourism Secretary Ace Durano announced that the DOT and the newly formed Health and Wellness Alliance of the Philippines are coming out with a new tourism package that will include faith healing services. Durano claimed that there are tour operators that specialize in faith healing but the DOH has not given them accreditation due to the absence of standards. Unlike natural health spas that provide the traditional hilots or massages, it is very difficult to set a standard for faith healers because they do not have establishments, he explained. But he admitted that faith healing has also enabled the country to lure many foreign tourists, particularly Russians. There is no scientific basis for faith healing, but we cannot just close our eyes because we know that there are people seeking for such service and it is available in our country, Durano pointed out. Faith healing and other forms of alternative treatments are very popular in the country, but the government had yet to promote this field of care to medical tourists until this time.”
The official response to this was a long damage limitation statement that includes, “This resulted from a misunderstanding of statements made by Joseph Ace Durano to a few of our friends and colleagues in the media. We are promoting overall holistic health, an approach to health that addresses the needs and wellbeing of body, mind and spirit. When he mentioned holistic medical tourism packages and spiritual healing to well-known and popular destinations in the Philippines, he never meant that foreign patients would be taken for treatments to so-called quack doctors, healers or other unlicensed and unqualified practitioners. Unfortunately, his words were taken out of context and a very different, very erroneous message was conveyed. Contrary to what people have been talking about, we do not encourage foreigners to visit the Philippines for them to be cured of their illnesses through these so-called faith healers. While we recognize that this is practiced in some parts of our country, it is crucial to emphasize that our medical and wellness tourism program includes only those that have undergone strict quality accreditation with the Department of Health.”
HEAL Philippines and the Department of Tourism also reiterate that kidney transplantation is not being promoted as part of medical tourism in the Philippines. This is in line with the official policy of the Department of Health.
From a war of words to real activity, the DOT is sponsoring the cost of surveyors from Accreditation Canada who will assess various healthcare organizations in the Philippines. They will be reviewing hospitals and clinics, as part of a drive to raise the quality of the healthcare system.

A recent case study by doctors at Mount Sinai Hospital in New York examined the ethical issues posed by transplant tourism. Full details of the study appear in the February issue of Liver Transplantation, a subscription journal published by Wiley-Blackwell on behalf of the American Association for the Study of Liver Diseases (AASLD). For copyright reasons we cannot publish the full text. But an official press release argues that US doctors are wary of transplant tourism because-
• Many American transplant professionals frown on the practice of transplant tourism where patients travel to countries such as China, India, and the Philippines for their transplantation.
• These transplant tourists may be subject to sub-standard surgical techniques, poor organ matching, unhealthy donors, and post transplant infections, prompting U.S. health care institutions to refuse treatment of these patients upon return to the U.S.
• Medical associations have responded with transplant tourism policies and guidelines to advise doctors on the ethics of caring for transplant tourists.
• Given the critical shortage of available organs in the U.S., transplant tourism has grown in popularity among patients awaiting transplantation. The United Network of Organ Sharing (UNOS) reports there are more than 105,000 Americans on the transplant candidate waiting list with more than 15,000 patients awaiting a liver transplant. UNOS data shows a decline in living and deceased donorship.
• A 46-year-old Chinese accountant was placed on the UNOS transplant and increasingly became more unwell. He then travelled to China and was transplanted two weeks after arrival. After transplantation, he returned to the Mount Sinai program requesting follow-up care, which was provided. He then developed biliary sepsis requiring hospitalization and re-transplantation seemed to be the only viable option.” While the patient was a medically suitable candidate, team members disagreed if it were morally right to provide him with a transplant," said Dr.Thomas Schiano, lead author of the study. The transplant team proceeded with a liver transplant and he is currently doing well.
• The study authors estimate that more than 400 patients received transplants abroad with 75% of those taking place between 2004 and 2006. Of those transplant tourists, 40% reside in New York and California, and the majority travelled to China, where organs from executed prisoners have been used in transplantations.
• Although transplant tourism is not held in high regard, the practice violates neither U.S. law nor the National Organ Transplant Act. UNOS policies allow a small percentage of each centre’s transplants to be allotted for foreign nationals, allowing transplant tourism within the U.S.
Medical associations have established transplant tourism policies to provide guidance to clinicians and uphold the principles of medical ethics. The American Association for the Study of Liver Diseases and International Liver Transplant Society have positions against the exploitation of donors, the recovery of organs from executed prisoners, and condemn the use of paid living donors. The American Society of Transplantation declares that optimal medical care should not be withheld from those recipients who have chosen to receive transplants as medical tourists from abroad.
Dr. Schiano comments, "Little guidance is provided to transplant centres and the professionals dealing with transplant tourists seeking care. Given the shortage of available organs, more patients may resort to transplant tourism as an option. Although we do not condone all of the practices associated with transplant tourism, it is our duty to provide all transplant patients with the same compassionate care and support, whether their transplantation was performed in the U.S. or abroad."
The article –
Article: "The Dilemma and Reality of Transplant Tourism: An Ethical Perspective for Liver Transplant Programs." Thomas D. Schiano, Rosamond Rhodes. Liver Transplantation; Published Online: January 26, 2010 (DOI: 10.1002/lt.21967); Print Issue Date: February 2010. http://production.interscience.wiley.com/journal/123262072/abstract
Wiley-Blackwell

http://www.wileyblackwell.com
http://www. interscience.wiley.com.

According to a specialist German medical tourism conference of doctors and academics, Germany attracted 70,000 patients from other countries for in-patient treatment in 2009.
A hundred doctors, academics and government advisors, met in Sankt Augustin to discuss ways to augment their country’s healthcare attractions for international patients, particularly from the Arab and Russian regions.
Jens Juszczak of the University of Applied Sciences Bonn-Rhein-Sieg introduced results from a new market study on international patients in German hospitals. This revealed that hospitals active in medical tourism have become more successful than they were two years previously. The reasons, he explained, are the systematic development of new markets, particularly Russia, as well as more professional and long-term marketing.
Leonore Boscher of the international department of University Medical Centre Hamburg, lectured on the importance of structured process flows and demonstrated where costs arise and how they can be controlled. The hospital is the largest among Hamburg’s hospitals with 1400 hospital beds. While the cost of a heart bypass operation in the U.S. depends on the reputation of the physician and ranges from $95,000 to $ 200,000, in Germany there is a fixed price, and that makes Germany an interesting destination. Swjatoslaw Aksamitowski of Knappschaftskrankenhäuser (Social Miners and Mine Employee’s Insurance Hospitals) outlined which offers or services are of interest to Russian patients and how hospitals can accommodate such requirements whilst also having to control the treatment process.
Professor Dr. Nicolas Abou Tara, adviser to Hamburg’s Ministry of Social and Family Affairs, Health and Consumer Protection regarding cooperation with Arabian countries, spoke of the type of treatments Arab patients tend to want, which regions and clinics they prefer and how hospitals can cooperate with clinics in the Arab states in the cross-border care of patients and via doctor exchanges. Hospitals in the Munich area are particularly preferred, he said. Inhabitants of the Gulf States see the city as international and attractive for tourism and quality shopping. Oriental patients, he said, tend to combine medical treatment with an extended holiday.
Although the contribution of foreign patients in relation to the total capacity of a hospital is comparatively small, their treatment should be viewed as a possible additional source of income, but this does come with a significant cost outlay. Key is a specialist international patient centre with multilingual staff; to arrange in-patient stays, arrange visas and aftercare. Another essential prerequisite is efficient and long term marketing.

Although Cuban-Americans can now visit Cuba, other Americans still have to get a visa and prove to the authorities that they have a good reason to visit. So far, President Obama has not delivered on his promise of free trade and free travel between the USA and Cuba.
A delegation from American trade organization World Trade Center Tampa Bay has just returned from a Cuba trip and issued a declaration aimed at promoting travel and business with the island. WTC intends to re-establish historic relationships between the Tampa Bay area and Cuba by encouraging travel of business and trade groups to Cuba. The organization believes that unrestricted and free travel for U.S. citizens to Cuba should be approved. An embargo currently prohibits most travel to the island and limits trade to food, agriculture and medical products. The organization has encouraged the University of South Florida to establish a medical school relationship with Cuban institutions and supports efforts to establish Tampa International Airport and the Port of Tampa as authorized gateways for travel and trade with Cuba.
Although Americans do travel for medical treatment to Cuba, they do so illegally. But Cuba is building on the medical tourism trade it gets from Canada, Latin America and Caribbean Islands. Cuba refuses to release statistics of how many medical tourists it gets and where they come from, as that could show how many Americans go there illegally. Cuba treatment costs are a third to a quarter of those in the United States, according to Latin American doctors and patients. For Cuba, health tourism is not only a source of income, it is a tool for promoting Cuba’s Communist system; and this explains the official American antagonism to the country.
Last year, the Dominican Republic and Cuba, which do not have diplomatic relations, agreed to allow weekly charter flights between the two countries, and since then at least 150 Dominicans have flown to Cuba for medical treatment, according to travel agents.
Cuba, which prides itself on its accomplishments in medicine, has made a business of inviting foreigners to its hospitals and clinics. It distributes a colour brochure titled, ’’Cuba, Health Tourism,’’ and a price list covering services from physical examinations to open heart surgery. It offers a basic package of seven nights and eight days in a hotel or a clinic, or longer stays depending on the seriousness of the problem. As well as in a network of clinics, foreigners are treated in special private rooms in state run hospitals. Medical tourists visiting the island report seeing Spanish, Italian, Chinese and even a few American patients.
Cuba attracts patients from throughout Latin America and the Caribbean, where advanced equipment and techniques are lacking and where there are often shortages of medicine and personnel. Cuban officials say more patients are now coming from the Dominican Republic than elsewhere in the Caribbean because of the direct flights and because the two countries share Spanish as their common language. Payment must be made in dollars, which Cuba needs to buy essential goods from Western countries.
One American excuse for not lifting the embargo is that Cuba is not prepared for a mass of US tourists. Cuba is aware of the value of tourism to its economy and what a change in US tourism policy would mean. This nation has rapidly developed hotels and resorts over the past two decades to cater to primarily Canadian and European travellers, 2.4 million tourists in 2009.
Cuba has been offering health tourism since 1989, for both medical treatment and health spas. All health tourism goes via Cubanacan Tourism and Health, a state owned company that uses a network of hospitals, private medical and dental clinics, opticians, drugstores and spas. It markets health tourism through travel agencies and private clinics. It runs the international clinics scattered all across the country, as well as medical outposts in hotels and resorts.

All major government hospitals will undergo rigorous checks to comply with international standards to improve services and reduce patient risk.
Dr Hanif Hassan Ali, Minister of Health, said, " While the medical institutions in the country are comparable to those in the developed world, accrediting them will not only raise the quality of health care but also attract international investors in the fast-growing sector.” Chicago-based The Mihalik Group (TMG), accreditation consultants, won the contract for the accreditation process. Gary Mihalik commented, “ It has been found that the accreditation process helps to reduce health care costs, improve efficiency of services and strengthen public confidence in the quality of health care.”
The five-year contract begins with an assessment of 14 hospitals, preventive medicine centers, primary health care centers, infectious disease clinics, nursing schools, pharmacies, dental clinics and a blood bank. Following the assessments, The Mihalik Group will work with the Ministry to bring the facilities into compliance with the equivalent of JCI standards.
A key reason for the accreditation is another attempt to stop locals going abroad for treatment. Limited access to quality health care and lack of confidence in the services available makes thousands of nationals and expatriates travel abroad for treatment, putting a huge burden on the government. In 2008, Dubai government paid Dh240 million to Emiratis for treatment abroad, in addition to an unknown amount of private spending by locals, and expatriates returning to home countries for elective procedures. In 2007, Dubai sent 946 Emirati patients abroad at a cost of Dh178 million. The current system loses business to other countries. Historical reasons why residents travel abroad for treatment are lack of trust, financial constraints or family pressure from back home.
Medical tourism is still an emerging concept in Dubai, although there are patients from other Gulf countries who fly in for treatment in select specialities at both government and private hospitals. The Total Joint Replacement Centre of Excellence (TJRCE) at the American Hospital is one such speciality that has made much progress towards this end. 40 per cent of the 4000 patients who have been operated upon by the centre come from other countries. Most came from Arab countries, particularly Kuwait. Patients that would have gone to London or Paris for knee replacements, now seek treatment locally.
The first Samsung Medical Center outside of South Korea will open in Dubai in March. Samsung Medical Center Dubai will provide advanced medical services for Emaratis and residents in Dubai, UAE, GGC countries, Middle East and North Africa. The centre will be in Dubai Health Care City.
The centrer will have highly specialized medical and nursing personnel in addition to the medical visits by consultants from Samsung Medical Centers and Hospitals in Korea. Samsung Medical Center was established in Korea in 1995 and includes 3 specialized hospitals in Seoul and other provinces.

Medical tourism has become a major international trend driven by health conscious consumers in the developed economies seeking the best way to their well being, through a travel and lower-cost healthcare experience.
One reason that prompts people to search for overseas solutions to their health problems is the possibility of saving money without sacrificing quality, and to see something new.
Latvia does not pretend to be a leader in medical treatment or diagnostics, but it is quietly becoming popular for health and wellness. Specialist centres and spas offer treatment courses for those recovering from chronic diseases with a variety of methods of treatment – gymnastics, massage, water procedures and diet that improve immunity and help to work all systems correctly.
Pine trees on sand dune beaches, a beautiful sea endlessly throwing foaming waves onto the flat sandy shore, that is a calling card from the Baltic resorts. Contemporary Baltic health resorts and spa complexes are replacing traditional sanatorium-type health resorts, coupled with contemporary treatment methods.
The Baltic has a tradition dating back to the 13th century of sanatoriums and health resorts. Europeans have long been flocking to Baltic countries to take advantage of its wealth of natural resources – its picturesque landscapes, excellent climatic conditions, mineral rich water and therapeutic mud deposits – in getting rid of different physical maladies and combating mental disquiet.
Operating all-year round, these rehabilitation centers and sanatoriums offer package treatments that include accommodation, meals, medical care, physiotherapy and recreation. Medical services include diagnosis and treatment with state-of-the-art medical and rehabilitation equipment.
A popular area in the coastal area of Jurmala. This resort city is near Riga airport and the capital of Latvia – Riga. One of the treatment centers is the national rehabilitation center Vaivari. It is near the summer aqua park complex Nemo. Mineral mud-based therapy helps to recover from vascular diseases, varicose, heart, lungs and digestive tract diseases. It specializes in post-operational recovery and orthopedic recovery from diseases and operations. Another famous resort rehabilitation center is Jaunkemeri, near Riga, that has special therapies with Kemeri mud and mineral water. It specializes in health problems like heart and vascular diseases, the central and peripheral nervous system, adiposity, backbone, digestive organs, metabolism problems, skin, gynecologic, urological, and children’s diseases.
Latvia is an example of a country benefiting from health tourism that is rarely noticed by the medical tourism self-promotion industry. It would do even better if it moved away from old Communist ties, by ceasing to call the locations “ sanatoriums ’ as the name reeks of institutionalized medicine where patients do as they are told or suffer the consequences.

There has been much news coverage in recent weeks about India and Mexico targeting Canadian patients. But some Canadian hospitals and a leading health investor believe Canada has potential as a medical tourism destination.
An international health care investor is the latest in a string of entrepreneurs calling for public hospitals to increase revenues by providing medical services to paying patients from outside Canada. Jack Shevel, founder of Global Healthcare Investments and Solutions (GHIS) of San Diego in California, USA, operates private hospitals in South Africa and the United Kingdom. In June, GHIS acquired 53 per cent of Toronto-based Centric Health, a diversified health care company whose holdings include Don Mills Surgical Unit, one of Ontario’s eight private hospitals. Sheval argues, “ Ontario hospitals could zero in on procedures such as hip and knee surgeries, that cost more outside Canada, for out-of-country patients. Health-delivery models are changing, creating opportunity for the private sector in Ontario. If there is a possibility for hospitals, if they have capacity, to augment their income, I think that should be encouraged.”
Shevel believes Canada’s health care will remain publicly funded, but the private sector will take on more of a role in delivering care. Centric lists medical tourism as a potential target. Centric Health’s vision is to be Canada’s premier healthcare company and is pursuing expansion opportunities. A subsidiary, Don Mills Surgical Unit, is a Toronto hospital caring for private local and international patients.
Canadian Medical Network (CMN) is a medical tourism agency that focuses on outbound medical tourism, but has been bringing small numbers of patients to Canada for 10 to 15 years. Several public hospitals in Ontario already welcome medical tourists. Toronto General Hospital will accept patients for treatment not provided in the patient’s home country (such as Caribbean patients who do not have access to complex medical procedures); a doctor must be willing to accept the patient before the patient arrives in Canada; and a bed must be available for the international patient without preventing access for any Ontario patient.
Ontario is sending an ever increasing number of patients to get care in the United States, but Health Ministry figures show about 34,000 patients from outside Canada receive treatment in Ontario hospitals a year, mostly as outpatients in emergency departments.
The concept of allowing patients from outside Canada to pay direct for medical care in public hospitals as well as private hospitals, is getting much less resistance than a few years ago. US government Medicare will pay Canadian hospitals that are on the US border if where patients live is closer to the Canadian hospital than the nearest U.S. hospital that is adequately equipped and available to treat the condition.
Canadian Healthcare International (CHI), a medical tourism agency, offers treatment at various unspecified Toronto hospitals and clinics, at prices lower than in the US, for American medical tourists.

An integrated medication tourism zone is planned in Nasugbu, Batangas, with completion due by November 2012. Local company Global Village Mobile Network Corp (GVMNC) has been approved by the Philippine Economic Zone Authority (PEZA) as a new ecozone medical tourism enterprise. GVMNC facilities will occupy a 24-hectare portion of the 52-hectare medical tourism park being developed by local group Camp David Investment and Holdings (CDIHI). PEZA has also approved CDIHI as a new medical tourism park developer subject to a presidential proclamation. CDIHI has allocated P318 million for the development of the park.
Facilities within the medical tourism park include a tertiary hospital that is designed to accommodate 100-bed in-patient suites, 8-bed intensive care units, 8-bed cardiac care units, 10-bed hemodialysis unit, 8-bed day care surgery unit, 3 fully functional operating rooms, a cardiac catheterization laboratory and a lithotripsy unit. A five-star hotel will accommodate visiting relatives and patients. The development also includes clustered home facilities for the elderly with long term medical care requirements. These are designed to provide programmed long-term care to 1152 residents, some locals but mainly Japanese retirees, with on-line telemedicine facilities. Other facilities in the park include healthcare, wellness and cosmetic surgery and spa; condominium administrative housing, country club complex, pavilion complex and satellite network hub facility.
The Cebu Health and Wellness Council (CHWC) is upbeat about Cebu’s potential in medical tourism. The group is seeing an increasing number of medical travelers in the province. It seeks to use the country’s growing expatriate Filipino workers, balikbayans, as envoys to promote medical tourism where they work.
CHWC is a private-public sector coalition developing and promoting the health and wellness industry in Cebu. It includes hospitals, doctors, dentists, spas, hotels, travel agents, tour operators and government departments.
The aim is to position Cebu as a premier health and wellness destination in Asia by attracting foreign patients through testimonies and first-hand experiences of balikbayans of local medical and wellness services. The Department of Tourism-Cebu wants to attract Filipinos around the world to come back home for health and wellness services and become ambassadors for the sector. So international Filipino communities with foreign friends would share by word-of-mouth their personal experiences of local health and wellness therapies. CHWC member-organizations are conducting talks with several Filipino communities abroad who could help bring in Filipino patients. Cebu also wants to attract Americans and Europeans seeking medical services and wellness vacation packages. The Philippines wants to catch up with rivals Thailand, India, Singapore and Malaysia.
This year’s Beauty, Health and Wellness Show will showcase the Cebu health and wellness industry. The BHW Show 2009 will take place on November 4-8, at the Ayala Center in Cebu. Organisers hope to better last year’s 47 exhibitors by targeting beauty salons, beauty clinics, hotel spas and day spas, fitness studios and gyms and health foods and restaurants. The show has changed from a trade show into a wellness event, and will feature dental and medical tourism forums.

While Poland has established itself as a leading European destination for patients from the UK and Ireland seeking dental treatment and elective procedures at an affordable price, it is also a popular destination for those eager for a wellness break.
Spa resorts can be found across Poland, from the Baltic coast in the north to the mountains in the south. Each spa resort offers a unique style and selection of spa treatments, as well as opportunities to rest and relax.
Warsaw-based medical agency StatMedica is helping people do just that, according to its managing partner Lukasz Liese. “While it is true that Poland is an attractive destination for patients seeking a high standard of dental treatment and surgery, it is also emerging as a popular destination for affordable spa treatments and relaxing breaks. We make it easy for patients and guests to consider their options.”
Local spa resorts are proving to be very popular with customers from the UK and Ireland, as the 500 weekly departure numbers show. In only one hour and 30 minutes, flights land on the Baltic coast.
Alison Hope of StatMedica in London, observed: “While guests can expect popular spa treatments such as saunas, steam rooms and massage, spa resorts in Poland also focus on the relationship between health and wellbeing, with many having a doctor, nutritionist and physiotherapist onsite. Guests can also expect some uniquely Polish spa treatments such as kryotherapy, salt-caves and thermal baths.”

SingaporeMedicine, the government-industry partnership to develop and promote Singapore as the region’s leading medical hub and international healthcare destination, makes medical tourism history by going on Facebook.
Its presence in one of the world’s most popular social networks provides opportunities to communicate and connect with prospective customers, as well as medical travellers who have gone home with successful stories. Dr Jason Yap, director of healthcare services at the Singapore Tourism Board, commented: “We are excited to explore this communication channel. The great thing about Facebook is that we will be able to reach out to people and foster our relationship with them.
“People will be able to share their experiences and insights with their friends and co-workers. Hopefully, they will help us spread the good word about the world-class healthcare services in Singapore.”
Facebook, the brainchild of Mark Zuckerberg, first saw the light in a US campus in February 2004. It spread to other campuses, bringing the total number of registered users by the end of that year to 1 million. By 2007, it had 30 million registered users. It now has over 100 million registered users globally.
Facebook is a free-to-use, privately owned free-to-access social networking site. It allows its registered users to find and exchange news, messages, photos and virtual gifts with established and new friends across a number of networks formed around location, workplace, university and so on. Several features within Facebook also allow individuals, businesses or organisations to create and administer interactive profiles for promoting products and brands through “word-of-mouth marketing”.
Launched in 2003, SingaporeMedicine is a multi-agency government-industry partnership committed to strengthening Singapore’s position as Asia’s leading medical hub and international healthcare destination. Led by the Ministry of Health of Singapore, it is supported by three government agencies: Economic Development Board, which develops industry capabilities; International Enterprise Singapore, which fosters regionalism by Singapore-based healthcare players; and Singapore Tourism Board, which markets Singapore as a healthcare destination to inbound international patients.

As part of its goal to boost medical tourism, the South Korean Cabinet has recently approved a set of bills to relax restrictions on marketing activities by local medical institutions targeting foreign patients. The bills now await parliamentary approval.
Lee Young-ho of the Korea Medicine Overseas Promotion Council reacted positively to the news, saying that deregulation will promote medical tourism.
“For the past few years, it is true that hospitals were unable to find patients, who, in turn, have difficulty in finding the right doctors for their treatment. Now, both sides will benefit from the system. The council will monitor whether agencies are taking excessive commissions.’’
Most medical tourists visiting South Korea come for dental care, plastic surgery and general checkups. According to the Korea Tourism Organization (KNTO), the first target are cosmetic-surgery patients from Singapore, China, Hong Kong and Japan. Next in line are dental patients from Russia and Mongolia. The last target are American patients who do not have private health insurance, Japanese patients seeking hemodialysis and other foreign national seeking specialised healthcare in the country.
The Ministry of Health, Welfare and Family Affairs as well as President Lee Myung-bak has designated medical tourism as one of the nation’s growth engines for the next five years. The country plans to attract 100,000 medical tourists by 2012.
However, there are still lingering obstacles to making Korea a medical tourism hub.
Won Young-sun of Wooridul Spine Hospital called for an expedited visa application process for medical travellers. “We have patients willing to come to Korea for treatment but who give up due to complicated visa procedures.’’ He added that the country also needs medical staff and coordinators able to speak foreign languages for the convenience of customers.
Meanwhile, the move to ease existing laws on medical advertising will also benefit local residents. Hospitals will be able to provide free transportation and offer discounts on medical treatment and accommodation to Koreans not covered by domestic health insurance. Under the current medical law legislated in 1951 and last revised in 1973, such incentives and activities are banned.

Local healthcare and tourism experts from the government and the private sector will gather in Manila this month in a summit to chart the direction of the Philippines’ medical travel industry.
Entitled “Embracing Health and Wellness in the Heart of Asia”, the summit organised by the Department of Tourism (DOT), is expected to lay down the groundwork to transform the country into a thriving health and wellness destination. The two-day gathering from October 22 to 25 at the Sofitel Philippine Plaza Hotel is expected to determine the country’s national branding and positioning in the global medical travel industry. Areas of discussion will include the establishment of a world-class health and wellness infrastructure and the identification of potential opportunities for the industry.
According to DOT Undersecretary Cynthia L Carrion, the Philippines should seize the opportunity to market itself as a health and wellness destination where the cost of treatment is just a third of that in the US or Europe.
She noted that the summit would address the first and greatest misconception that the Philippines has Third-World healthcare, a notion that conjures up images of decrepit medical facilities, insufficiently trained doctors, nurses and medical professionals, and an overall backward state of affairs. The summit is expected to hammer home the need for industry players to invest in upgrading and improving medical facilities in the country to keep an edge over competitors abroad.
In this regard, the Board of Investments (BOI) has granted incentives to the expansion of Makati Medical Center (MMC). Medical Doctors, Inc will build a 12-storey building for MMC that will contain new diagnostic and treatment centres, operating and delivery rooms.
The project will double MMC’s capacity from 500 to 945 beds, allowing the hospital to accommodate 4,500 more patients.
“The government deems it necessary to give its full support by way of tax incentives," said BOI said in a statement.
The MMC project is in line with the government’s medical tourism programme that markets the Philippines as an alternative health tourism destination. Other supported investment projects include the modernisation of The Medical City.
Meanwhile, the Department of Health (DOH) is also doing its share in promoting the country’s medical tourism industry.
In its 2009 budget for the Health Facilities Enhancement Program, the DOH is giving more money to medical facilities – such as the National Kidney and Transplant Institute and the Philippine Heart Center – that sign up for the government’s medical tourism programme.
Local doctors, however, are criticising the government for giving more money to hospitals promoting medical tourism than to ones treating local people.
They pointed out that more political pronouncements, an almost endless round of summits and conventions, and investment help are pointless until the infrastructure is improved and something isdone to stop doctors and nurses from emigrating abroad in large numbers.

The autonomous province of Jeju, which is approximately an hour’s flight from Seoul, is out to get a share of South Korea medical tourism traffic with plans to transform the island into a resort-style medical tourism centre.
The Jeju Free International City Development Center (JDC) has unveiled plans for "Healthcare Town" which has a price tag of approximately US$315 million. It is a joint project undertaken South Korean Government and the private sector. The government will provide and invest of US$99 million while the rest will be provided by the private sector.
JDC hopes to attract medical travellers by marrying Jeju island’s clean and green natural environment with cutting-edge healthcare. Overseas patients will be provided with a variety of health and treatment options, ranging from medical examinations, obesity treatments to wellness therapies.
The island is only a two-hour flight from five major cities in Asia, including Seoul, Beijing, Shanghai, Hong Kong and Tokyo.
Right now, JDC is making presentations about private investment in the Healthcare Town to Korean domestic enterprises and foreign investors from China, Japan, Malaysia and the US.
The Healthcare Town plans to open early in 2011.
The Wellness Park, which is one of Healthcare Town’s main features, has health as its core theme. Developing a medical and relaxation complex specialised in healthcare and recreation functions. It will include a medical examination centre, rehabilitation & alternative medicine centre, water park, riding park, and lodging facilities. Meanwhile, the Medical Park will be a medical complex that provides high-tech medical services, including a general hospital, specialised hospitals, and long-term care facilities.
Wooridul Healthcare one of the largest privately owned spine specialised hospital groups in Korea, plans to open a spine hospital on Jeju island by the end of 2010.

Swedish medical-travel agency, Salveo Travel, specialising in medical, cosmetic and dental treatment plus health and wellness tourism for the last two years, has launched a new specialist service called www.LasikAbroad.co.uk
The new site helps patients in the UK and elsewhere book laser eye surgery in Istanbul, Turkey. Turkey offers lower prices compared with eye clinics in Western Europe.
Salveo chose a surgery run by Dr Bas who has been working with laser-eye surgeries for 12 years. He was the first to use the wavefront technique in Turkey and is one of few that are certified for Intralase femtosecond laser in Turkey.
Dr Bas has written a book "LASIK", which is about refractive eye surgeries by the use of laser technology. The book is based on five years of research and the data that has been analysed is based on over 20,000 laser-eye surgeries that Bas and his colleagues have performed at the eye clinic. The book is used as a reference book at universities in Turkey.
Dr Bas has personally performed more than 50,000 laser-eye surgeries. His eye clinic is one of only three Turkish eye clinics that are allowed to use the Intralase femtosecond laser equipment. Dr Bas is a member of ASCRS (American Society of Cataract and Refractive Surgery) and ESCRS (European Society of Cataract and Refractive Surgery).
“Sometimes the cost of laser-eye surgery at home can be a deterrent to getting treatment,” says Habil Kantur, founder of LasikAbroad.co.uk.
“Getting eye surgery in Turkey is a solution for those who want the Lasik surgery, but who don’t want to pay the high prices associated with the procedure in the UK or elsewhere. The surgery costs much less in Istanbul.”
A standard Lasik Abroad travel package booked through LasikAbroad.co.uk costs £1,299 (US$2,399), and includes laser-eye surgery for both eyes, pre- and post-operative examinations of both eyes, post-op eye drops, a return ticket to Istanbul, a guided tour around historic Istanbul, a three-night stay at a four-star hotel near the hospital, transfers to and from the patient’s hotel, and free eye examinations for one year after the treatment. All standard packages also come with a money-back guarantee and five-year vision guarantee, and patients have the option to bring a friend or family member with them for just the cost of the hotel room and guided tour.

The number of foreigners coming to South Korea for medical care is still a fraction of those getting treatment in India, Thailand and Singapore. But hospitals, clinics and the South Korean government are trying hard to attract these tourists, who not only bring in money for cash-strapped hospitals but also help the economy by staying on to shop and sightsee after their procedure is over. Russians, Japanese, Chinese and Americans are the main target markets.
In South Korea, the government determines medical fees for the country’s residents, but hospitals can negotiate fees with foreign patients. In addition, the government hopes medical tourism will boost the economy by having patients stay for vacation in the country post-procedure. South Korea has revised its immigration policies to allow foreign patients and their families to obtain long-term medical visas and also has changed its laws to permit local hospitals to join in ventures with foreign hospitals.
Although no government records indicate how many medical tourists come to South Korea hospitals, a survey of 29 hospitals in the country found that 38,822 foreign patients were treated between January and August, compared with 15,680 in 2007, according to the Korea Health Industry Development Institute (KIHDI). The survey also found that 25 percent of the patients were from the US and 10 percent each came from China and Japan.
KHIDI has a European office in Glasgow, Scotland, and earlier this year opened three new international offices in Washington DC, Beijing and Singapore.
Wooridul Spine Hospital expects to attract 1,000 foreign patients and US$1 million in revenue from their treatments in 2008, its third year of wooing foreigners. Its patients come from 47 countries, with about a third from the United States.

Princess Beauty and Spa, a 20-year-old beauty-centre chain based in Thailand, seeks business opportunities overseas as it believes there is more room to grow this segment abroad than at home.
Spa tourism is one of the largest sectors of the whole medical, health and wellness spectrum, which some argue easily dwarfs surgical tourism in numbers, spend and profitability.
Company president Kanokporn Khematae-chit said recently that several European entrepreneurs have expressed interest in franchising arrangements that would take the spa’s services overseas. Talks are taking place, and she is very confident that several contracts will be concluded next year.
The company does not want to invest by itself, as it believes it can expand the number of its centres more rapidly by franchising. It has sold one overseas franchise to a business in Laos. Princess Beauty and Spa franchises will cover 150 square metres, smaller than the average size of between 400sqm and 500sqm for company-owned centres.
Another possible business model is the co-invested firm. Princess Beauty and Spa has already co-invested with the five-star hotel Westin in Bangladesh to operate a spa service. It has the opportunity to operate other spas in Westin hotels around the world. The company has also invested in the Princess Wellness Spa in a six-star hotel in the Ratchaprasong area of Bangkok, to open early next year.

Nip and Tuck Solutions, best known for offering medical tourists, cosmetic and other surgery in South America, has added Australia as a destination. The target market is Americans and Europeans.
Nip and Tuck Solutions is a trading name of Panama-based South Seas Pharmaceuticals and was one of the first to offer Panama as a destination. It has since added Costa Rica, Columbia, Peru, Ecuador, Bolivia, Venezuela and Argentina to the list of destinations.
Nip and Tuck Solutions Australia has been launched in Brisbane to offer medical tourists, the services of Australian surgeons and specialists. Coinciding with the weakening Australian dollar, prices for cosmetic procedures and other common operations have been slashed to rates comparable with India and Thailand.
Nip and Tuck Solutions argues that clients from the US should choose Australia over such destinations as India and Singapore, as the exchange rate on the Australian dollar is almost 40 percent lower than the US dollar and the comfort level of being treated in an English-speaking country that shares much in common culturally with the US. It also points to costs more comparable to Asia than the US.
Although hospitals are not keen on medical travel, smaller specialist clinics are. The Cairns Fertility Centre in Queensland has recently combined its clinic with a five-star luxury resort, complete with masseurs and a spa. The clinic specializes in assisted reproduction and in vitro fertilization (IVF) procedures, and plans to take in patients early next year. The facility hopes to attract 50 percent of its patients from around the world and 50 percent from within Australia.

Because of long queues for surgery and expensive private health care at home, an increasing number of Finns are going to private hospitals in Estonia.
The affordable rates at Estonian dental clinics have long attracted Finns. Now more Finns are also going there for outpatient surgery at Estonian private hospitals. The reason is that the local healthcare system is less efficient than it was, and queues for surgery are growing. There is little competition in the Finnish private healthcare system, and this means high prices.
One Estonian healthcare business is Medimatkat, which offers operations for varicose veins, gall bladders and knee joint keyhole surgery. Medimatkat, has worked in Finland, and says that patients here suffer from an inefficient health care system and surgery queues. It has a Finnish partner, Medifi Healthcare Travels, which believes that health care travel to Estonia will increase in the future. Medifi is a medical tourism agency specializing in sending Finns to Estonia, Sweden, Germany and India.
In 2012 Finnish social insurance fund Kela paid over 350,000 euros in health insurance compensations for services bought in Estonia. An operation carried out in Estonia may only cost a third of the Finnish price — and patients can often get Kela to pay for part of the cost, under the new EU cross-border healthcare rules. Kela opened a cross-border healthcare information unit in January, after a new act was passed to comply with the latest directive.

The Israel Tax Authority has opened an investigation into suspicions that senior doctors have taking under-the-table payments from medical tourists. The State Prosecutor’s Office has opened a criminal investigation. The hospital has suspended the surgeons pending a full internal investigation.
These moves came in response to a report aired by a Channel 2 television investigative programme. The report suggested that three senior surgeons at Tel Aviv’s Ichilov Hospital – Professor Shlomo Constantini, Professor Zvi Ram and Dr. Yossi Paz – demanded large sums of money from a journalist posing as an agent for medical tourists. The report claimed that doctors regularly take cash payments for neurosurgery and cardiac surgery on medical tourists.
The Health Ministry legal team explained, “The television report does not leave much room for doubt regarding the nature of the transactions. The responses that were quoted, including those of the doctors themselves, do not alter the picture or remove the burdensome impression that emerges from the investigative report, and the filmed evidence supports this impression. We are determined to do everything necessary to put an end to any black-market medicine in government hospitals.”
Health Minister Yael German added, “ Medical tourism must be dealt with and regulated, and guidelines to ensure public welfare must be set. This is being done by a public committee that has been considering the problem and studying the issue seriously for several months already. Shocking as the investigative report was, we must ascertain the facts before making decisions.”
Critics point out that the ministry has been dithering on medical tourism for years. The Ometz organization, which promotes good governance, has asked the state comptroller to investigate medical tourism, “ It takes up a significant slice of Israel’s public hospitals, and the ones hurt by this are Israeli patients. Despite the Health Ministry’s promises to deal with the issue, the situation has got worse. The number of operations and medical procedures for medical tourists has risen significantly, due to a lack of close supervision by the Health Ministry. Since this is an important source of revenue for the hospitals, their appetite and covetousness have grown upon identifying the potential of medical tourists.”
The health and finance ministries and hospitals are blaming each other for the failure to regulate medical tourism. The health ministry claims that it has published guidelines on medical tourism but hospitals and the finance ministry took no notice, but they both reply that the health ministry has published reports with suggestions, but not issued any guidelines or regulations. The health ministry responds that it has been trying to find out how big medical tourism is in Israel, but many hospital groups refused to co-operate with parliamentary investigations.
Recent events have also triggered a debate between those who argue that medical tourism gives doctors more experience and hospitals much needed revenue, and those that argue that medical tourism denies beds and treatment to locals.
The only common ground is that both sides agree that the health ministry has not issued clear guidelines on what is and is not permitted for doctors who treat foreign patients.
The health ministry admits that with tight restrictions on local prices, that a surgeon who treats a medical tourist can get three or four times what he gets for operating on an Israeli patient. The ministry plans to urgently publish instructions to hospitals that they must not pay those who operate on foreign tourists any more than they get for operating on local residents and that doctors must not charge medical tourists more than locals. But this could still allow hospitals to charge medical tourists more than locals.
This hasty decision triggered another round of arguments. A furious Leon Eidelman of the Israel Medical Association said: “They have killed medical tourism in all public hospitals. Medical tourists will all go for surgery to private hospitals.”
Hospitals have tried to keep a low profile in the various debates, as they are limited to what they can get from the government and health funds for treating locals, and do not want to lose the medical tourism income that keeps some of them financially secure.
Hospitals want detailed regulation on medical tourism to know where they stand, and what they can and cannot legally do. Most argue that this would control those hospitals and doctors who are over charging medical tourists. Politicians have dithered for years as they see that medical tourism brings in revenue, but fear that regulation could reduce the money that hospitals make, which in turn would force them to pay hospitals a fairer price for treating locals, and in turn would mean Israelis paying more for their health funds.
Medical tourism companies, hospitals and doctors have set up the Israeli Medical Tourism Association to formalize and foster the business, amid the public debate over the controversial practice. The organization seeks to put more pressure on the German Committee, which is reviewing Israel’s healthcare, including medical tourism and private healthcare. The committee favours formalizing medical tourism with few restrictions, and has put pressure on ministers that have continually blocked proposals by stating, "The basis and foundations are that no Israeli patient should be harmed, but medical tourism is positive, enriching the experience and the coffers of public hospitals." The ministry has not replied publicly but healthcare officials have leaked their views to the local press; that this is an empty slogan, because so long as the occupancy rate of wards is 98%, compared with the OECD average of 77%, every medical tourist who is hospitalized for even a couple of days is at the expense of an Israeli patient.

Although waiting times and other problems of the Canadian health system became worse in 2013, the number of outbound medical tourists has probably seen a slight decline. The numbers are calculated in such a way that they are rather conservative, and actual numbers going to the US or elsewhere could be higher.
The Fraser Institute’s annual waiting list survey asks doctors in 12 major medical specialties what percentage of their patients received non-emergency medical treatment outside Canada in the past year. In 2013, averaged across all medical specialties, almost 1% of patients in Canada were estimated to have done so, the same as in 2012.
Putting these numbers together with data on the number of procedures performed in Canada from the Canadian Institute for Health Information reveals that a conservatively estimated 41,838 Canadians received treatment outside the country in 2013.This is a slight decrease from the 2012 estimate of 42,173. At the same time, the wait time from specialist consultation to treatment in Canada increased from 9.3 weeks in 2012 to 9.6 weeks in 2013.
Faced with waiting for treatment for months, many Canadians choose to be medical tourists. Canada’s monopolistic health-care system means that getting private treatment in Canada is not easy, but the rules do vary by province.
Among the provinces, the estimated number of patients going outside Canada –

Province

2013

2012

Alberta

5,527
6,661

British Columbia

8146
8,132

Manitoba

1636
1,435

New Brunswick

372
997

Newfoundland

486

649

Nova Scotia

927
858

Ontario

19,118
15,725

Prince Edward Island

8
28

Quebec

4,904
6,308

Saskatchewan

714
1,380

For the 12 medical specialties, the largest numbers of patients receiving care outside Canada were urology (6,635), general surgery (5,537), and ophthalmology (3,083). Smallest numbers were cardiovascular surgeries (114), radiation treatment for cancer (127), and chemotherapy for cancer (249)
Even allowing that these are estimates, the number of Canadians with and health care demands that could not be met in Canada is large. How many of these would stay in Canada and in their home province if there was a free private healthcare market and plenty of private options, is not known. And how many more would have liked to join them, but could not afford the travel and private care?
Some Canadians were sent abroad by the public health care system because of a lack of available resources or that some procedures or equipment are not provided in their home province. Others may have concerns about local quality, seeking out more advanced health care facilities, higher tech medicine, or better outcomes. Others may have gone overseas as their condition was getting worse, and they either could not wait, or worried that local care was not as good as top US standards. Some may have gone abroad to avoid delay and to make a quicker return to work.
That a considerable number of Canadians travelled and paid to escape the failings of the Canadian health care system is true, but the reasons are far more complicated than the usual answer of long waiting times.

Addis Ababa in Ethiopia is the centre of local outbound medical tourism. Due to poor local healthcare, an increasing number of Ethiopians are seeking healthcare in other countries.
The problem is that most of them cannot even afford the cheapest Indian treatment. So as well as seeking gifts and loans from friends and relatives, many advertise to ask people to help with hospital costs.
The number of foreign hospital representatives in Addis Ababa is increasing significantly to address a growing demand of medical travel in the country. Five years ago, there were three foreign hospital representative offices, but there are now over a dozen. Thailand based Bumrungrad International Hospital was among the pioneers in opening a representative office six years ago. During the first three years the office sent only 60 people in a year on for treatment but in the last two years the office has sent over 1000 people to Thailand.
Opened two years ago for the same purpose, the representative office for the Dubai based Rak Hospital, is dealing with people, often referred from local hospitals for services not available in Ethiopia such as orthopedics, joint replacement, neurosurgery, spine treatment, interventional cardiology, cardiac surgery, laparoscopic treatment and bariatric surgery Rak Hospital gets 240 people traveling from Ethiopia to Dubai every year.
There are also representative offices of Indian, Turkish, Saudi Arabian and South African hospitals in the capital.
It is not just treatment, many just want to travel for a medical checkup as they are not happy with the quality of the local health services and prefer to get checked abroad.
Ethiopians spent over 30 million dollars in medical treatment expenditure abroad, in 2012, according to estimates by the Ministry of Health.
Ethiopia has 130 public and 70 private hospitals, and better local care may reduce outbound numbers. The Myungsung Medical Center (MCM), a Korean-run health centre in Addis Ababa, has a $ 9 million expansion project to encourage Ethiopians to stay in the country for medical treatment.
Exactly how many Ethiopians travel for health reasons is not known, but local estimates put it at over 10,000.

Taiwan has opened five international health liaison centres, including four at airports, with the aim of boosting medical tourism. Run by the Ministry of Health and Welfare, the aim is to provide health consultations to visitors.
They are at Taipei (Songshan) International Airport, Taiwan Taoyuan International Airport, Taichung International Airport and Kaohsiung International Airport, with an additional one in Taoyuan county
With good quality healthcare and inexpensive prices, Taiwan has great potential for developing medical tourism. The country has seen a. growing number of foreign visitors getting medical treatment or health checkups in the country. It had 170,000 in 2012 and predicts final figures for 2013 will be 200,000.Taiwan has seen tourism numbers rise from 7.3 million in 2012 to 8 million in 2013.
The establishment of the five health centres is part of a free economic pilot zone project, which opens free trade districts at ports and international airports to foreign investment (including those from China. Aiming to join regional economic blocs such as the Trans-Pacific Partnership and the Regional Comprehensive Economic Partnership, the government seeks to make Taiwan a free economic. zone
The Ministry of Health has said it has selected 45 hospitals and clinics to provide quality services to meet the needs of foreign visitors, and the centres will give advice to help match visitors with the most suitable place. A total of 25 staff speaking Mandarin and English will work at the liaison centers, seven days a week, to help travelers- although critics point out that medical tourists will have worked out what hospital they plan to go to and why, long before arriving at the airport.
The Taiwan External Trade Development Council (TAITRA) is participating in shows and fairs worldwide to promote Taiwan’s medical tourism industry; the country’s main trade promotion body will also provide guidance and introduction to Taiwan’s services at its 60 offices around the world.
Local hospitals want the government to run advertisements in in-flight magazines and promotional banners at local and foreign airports.
Treatment for medical tourists will not impact on resources for treating Taiwanese nationals, said the Ministry of Health, seeking to reassure public concerns over plans to promote Taiwan as a medical tourism destination. It says that most medical tourists go to clinics or to hospitals as outpatients, with only around 3% becoming inpatients with overnight stays. It added that even on current numbers, the total numbers of medical tourists is way less than 1% of all patients. Most medical tourists go to Taiwan for checkups and cosmetic surgery.

The new Cayman Islands medical tourism venture, Health City is nearly complete. The $80 million hospital has an official opening scheduled for February 25th, and the first patients are expected to arrive about a week later. Construction work on the hotel, the next phase of the project, is set to begin in March.
The 140-bed hospital in Grand Cayman will initially offer cardiac surgery, cardiology and orthopedics. It has begun a marketing campaign to attract patients, initially from the Caribbean region. It will not target the US market until it has achieved JCI accreditation, a process that will take at least another six months.
Key medical positions have been filled with doctors from India, and the majority of the nursing staff is expected to come from the USA and Canada, as there are few trained staff locally. Caymanians will be mostly in administrative roles.
For the Cayman Islands, the hospital is much more than just another business venture. So much time and effort has the country invested in the project that it sees medical tourism as the potential third biggest economic activity after tourism and offshore finance.
The hospital seeks to price services, at around 50% of US prices; this may or may not be a low enough price to tempt Caribbean patients away from competing countries.
Local co-owner Gene Thompson says that is has always been the plan to start slowly with Caribbean patients first and then seek to market the hospital to insurance companies, private individuals and employers in the US and elsewhere in the region. Sceptics argue that attracting Caribbean patients in sufficient numbers to pay for such a huge investment will not be easy, nor getting US patients; while the chances of insurers and employers taking up the offer are slim.
Getting to the hospital is not straightforward; for many in the region, it involves a round-trip via Miami. The hospital owners are in talks with Cayman Airways and other local operators, including Blue Sky airlines, a new venture planned by a group of Cayman-based businessmen. To enable patients to get there easily and cheaply, they will need new scheduled and charter flights throughout the Caribbean and Central America, and not having to go via the Miami hub.
The long-term plan is to build a medical training facility on site and work with the Department of Education and the University College of the Cayman Islands to recruit and train Caymanians for the health-care industry. Even if this happens, it is many years in the future.

The medical tourism research group at Simon Fraser University in Canada has reported why Mongolians travel for treatment in ’Outbound Medical Tourism from Mongolia’
Some doctors and health care administrators think that developing a more patient centred approach in Mongolia’s public health care system will lessen the number of Mongolian patients who go to other countries for treatment.
One of the main reasons that Mongolian patients go abroad is because they are dissatisfied with how they are treated in the public health care system. If these issues are addressed through system reforms that focus on improving provider-patient relations, patients may be more willing to access medical care domestically.
The Mongolian health care system is perceived by some to be highly political. Personal connections with health care administrators, doctors, and political figures may be used by some patients to gain access to better or faster medical care locally. The outflow of Mongolian patients through medical tourism may act as an impetus for health system reforms, ultimately reducing the influence of personal connections on access to health care as the government seeks to retain patients.
The Mongolian health care system has a poor reputation in some domestic circles, being perceived as ineffective, inefficient, and/or of low quality. While this view is certainly not held by all Mongolians, this perception motivates some patients to pursue medical care in other countries. If this perception can be changed by improving the reputation of the Mongolian health system domestically, fewer Mongolians will travel abroad for care.
Creating new types of private medical care in Mongolia (private hospitals) is seen to be one way of retaining local patients who would otherwise travel abroad for medical care.

The Council for Health Service Accreditation of Southern Africa (COHSASA) has introduced a new four-year award to give appropriate recognition to healthcare facilities in its quality improvement and accreditation programme that show consistently high standards over a period of time.
Up to now facilities that meet standards required by the COHSASA programme have been awarded two-year and three-year accreditation awards.
A hospital that earns accreditation for the first time receives a two-year accreditation and this can be extended to three years if a validation visit conducted by COHSASA 15 to 18 months after accreditation shows that standards are being maintained and that the quality improvement programme is not only being sustained but also improved. To reward those that have maintained excellent standards and accreditation over a number of years, with no outstanding areas of non-compliance, will be awarded accreditation for four years. A condition of the award is that hospitals will be required to undergo a mandatory interim survey after two years. In addition, any hospital receiving the new award will be subject to review if there is any substantiated complaint or allegation that it is not maintaining the accreditation standards.
COHSASA has implemented the first phase of the Malawi quality improvement and accreditation programme and the pilot programme for three hospitals and three primary health care clinics has begun. The aim is to develop Malawi standards, a system-strengthening process for hospitals and clinics, and piloting of accreditation in both public and non-state facilities.
COHSASA is helping the Botswana Ministry of Health to develop standards and guidelines for hospitals and primary healthcare clinics.

There are signs that inbound medical tourism to the USA is on the rise and that employers are looking at whether domestic medical tourism can save them more money for less hassle than overseas medical tourism.
Andrew Jacono of the New York Center for Facial Plastic and Laser Surgery says there has been a recent upswing in patients from around the world traveling to New York City for cosmetic surgery, fueled by the seemingly flawless features of US film stars. "In one recent month alone I had patients from Romania, Turkey, Singapore, France, Italy and Russia in my practice."
Rhinoplasty, facelifts and eyelid lifts are among the most popular requests, with the overall trend leaning toward achieving a more youthful appearance while preserving natural ethnic characteristics.
Even with the higher cost of cosmetic procedures in the USA compared to Thailand, Singapore, Mexico and India, the USA remains a cosmetic surgery draw for those who seek the highest quality. Luxury accommodation is a key reason why cosmetic surgery tourists go to New York City as packages can include top hotels, world-renowned restaurants, limousine transport, and entertainment options.
While there is much talk about US employers saving money by overseas medical tourism or domestic medical tourism, there is very little action and a concern from insurers and employers that any money saved is more than offset by hassles of administration and having to sell the idea to employees who are only used to very local treatment.
One agency that claims it has a solution is EmployerDirect. It argues that the answer is bringing medical tourism back to the United States with quality surgeons and bundled case rates for orthopedic, spine, cardiac, and many general surgeries.
EmployerDirect has launched SurgeryPlus, a supplemental medical benefit that reduces the costs of planned surgery by bundling case rates at high-quality providers with sites of excellence regionally dispersed throughout the USA. All costs are negotiated before surgery using top surgeons by specialty. It can be bolted on to any existing self-funded medical plan with bundled case rates already in place for procedures such as: orthopedic, spine, cardiovascular, bariatric, general surgery, carpel tunnel surgeries, and other minor outpatient procedures including colonoscopy, endoscopy, arthroscopy. Each procedure is implemented by a care coordinator, who acts as a personal assistant for each member from the time of their provider consultation, all the way through post-operative follow-up. Care coordinators help select a SurgeryPlus provider, schedule appointments, aid in transferring medical records, manage travel logistics for patients when necessary, and supervise a member satisfaction survey.
Thomas Johnston of EmployerDirect says, "We are bringing medical tourism back to the United States by offering patients access to high quality surgeons potentially within 30 to 60 miles from their home. We can also offer 30 to 50 % savings to their medical plans when compared to traditional insurance. SurgeryPlus is an especially powerful solution for self-funded employers introducing consumer-driven health plans to their employees. It provides them with a clear choice for quality surgeons close to home, at a lower cost."
The problem for the company and other promoters of domestic medical tourism is that after years of hype about how much money they could save on overseas medical tourism, employers and insurers are justifiably nervous about the cost saving and quality of medical tourism services. Almost all companies who attempted to sell overseas medical tourism found resistance from employees, managers and in-house human resources and insurance teams; so are nervous about whether the hassle of selling a non-local concept internally is worth saving a few dollars.

Switzerland puzzles many in medical tourism as it keeps increasing medical tourism numbers despite having some of the highest prices in the world.
Lianne van den Bos of Euromonitor International explains, “The continued high prices in Switzerland, when compared to neighbouring European countries, is offputting especially for European tourists who see Switzerland as a high price country.
But tourists coming from China, Asia and Middle East are far more concerned about quality. Medical tourism in Switzerland is seeing increased business from Brazil, Russia, India and China and Middle Eastern countries. Health and wellness tourism was one of the most profitable and growing tourism segments in Switzerland in 2012 despite high prices and competition from other European countries having similar natural landscapes such as Austria or Germany. Medical tourism represents the fastest-growing health and wellness category in Switzerland over the past five years with around 5 % growth in 2012.”
Being significantly higher priced than other medical tourism destinations such as Hungary or Germany, Switzerland attracts affluent medical tourists from all over the world. Private hospitals in Lausanne, Berne and Geneva are where medical tourists seek popular procedures, including medical spa treatments, cosmetic surgery, IVF treatment, neurosurgery, obesity surgery, and orthopaedic surgery.
Swiss hospitals also offer many other procedures including dentistry, laser eye surgery and laser hair removal.
Swiss health and wellness tourism is worth over CHF3 billion. It was one of the most growing sectors in 2012 together with being the second-largest market in Europe in the health and wellness tourism segment. Medical tourism accounts for 30% and spas for the remaining 70%, reports Euromonitor.
Sowmya Rajagopalan of Frost and Sullivan adds, “Tourism is a key sector for Switzerland’s economy. 6% of Switzerland’s export revenues come from tourism and around 17-20% of this revenue is contributed by health, wellness and medical tourism. It is mostly the affluent population from Russia, China and Gulf countries that look at Switzerland as the destination for medical and wellness tourism.”
The Swiss Hospital Association represents 300 hospitals and estimates that between 1 and 2% of all patients come from abroad, although it could be much higher. Switzerland’s main markets are the Gulf States, Russia, China, and former Soviet countries. Switzerland’s largest private health-care group, Hirslanden, has 14 hospitals and is seeking annual growth of 10% in foreign patients within the next five years. It gets many patients from Saudi Arabia and the UAE.”
While medical treatment in Switzerland costs an average of CHF20,000, studies show that additional spending including shopping, hotel stay and entertainment means the real income from medical tourism is five to ten times higher – a substantial amount in this high priced country, and an explanation of why the Swiss are very keen on attracting health, wellness and medical tourism-particularly from high spenders from China, Russia and Gulf states.

BMI Healthcare has reported new figures which illustrate a sustained growth in their operations to attract international patients to the UK. BMI has seen a 48% surge in international patients within its hospitals in the past year.
Scott Feldman, who joined BMI Healthcare as International Director in 2013, has overseen the continued development of BMI’s international arm, and comments:
“The international market in the UK has traditionally been focused within the London market place…in the next year we expect to further expand and enhance our offering to continue the growth of international patients looking to make informed decisions on their health.”
The majority of international patients treated within BMI Healthcare’s facilities are from the Gulf regions of the Middle East. BMI has invested in multi-faith prayer rooms, transport for patients’ families, appropriate food, media and entertainment as well as onsite Arabic speaking liaison representatives to cater to this particular market.
Meanwhile they continue to advance their international offering with new appointments in London for an International Assistant and International Liaison Officer to enhance the translation skills within hospitals in the capital.

Most medical associations and professional bodies react angrily to medical tourism, with lurid tales of damage to patients and how quality overseas can never be as good as at home; facts and evidence are not required for these ever available opinions in the global and national media. A US cosmetic surgeon has looked at cosmetic surgery tourism in another way- how it makes local markets work harder to get and retain customers.
Many Americans travel to Brazil or Mexico for a less-expensive rhinoplasty or breast augmentation procedure and the trend is having an impact on the market in the USA for cosmetic surgery, according to an article in Plastic and Reconstructive Surgery – Global Open, the official open-access medical journal of the American Society of Plastic Surgeons (ASPS).
The paper, by ASPS member surgeon Dr. Kevin Chung and Lauren Franzblau of the University of Michigan, discusses the rise and transformation of the medical tourism industry, foreign and domestic forces that influence cosmetic surgical tourism, and the pros and cons for all involved parties.Chung and Franzblau argue that- "The rapid globalization of the industry marks a fundamental shift in the world’s perception of elective procedures: patients are becoming consumers and these medical services are being viewed as commodities."
Prices for cosmetic surgery in many countries are typically much lower than in the USA – even after factoring in travel and accommodation costs, having an operation overseas can be much less expensive.
In many countries, governments are working actively to foster their cosmetic surgery tourism industry. Some destinations market procedures performed in resort-like settings, encouraging patients to combine a vacation with cosmetic surgery. Traveling abroad also lets patients recuperate privately, without anyone at home knowing that they have had surgery – when they return they claim they were simply on holiday.
The growth of medical tourism may have a significant impact on the cosmetic surgery market in the U.S., but also raises concerns over physical safety and legal protection. Although destination countries promote the quality and safety of their procedures and facilities, there is often little evidence to support these claims- but on the other hand there is little evidence to support claims that US treatment is always safer or better.
Chung argues that it is pointless for US cosmetic surgeons to rail against cosmetic surgery tourism, as it does not appear to be going away in the foreseeable future.
Instead, the surgeon argues that US surgeons and clinics just have to learn to live with being part of an international market, and work out how to compete in it.
Chung and Franzblauwrite suggests that as US surgeons may find it hard to compete on price, effective strategies may include emphasizing superior quality and safety of care, or developing niche markets of procedures that can be profitably performed at home.
The authors emphasize that medical tourism is not purely good or bad — either for patients or the countries involved. Patients maybe drawn by lower costs, but must consider the potential risks of undergoing surgery in a foreign country, as well as travelling after surgery- including risks and follow-up care.
For the USA and other developed countries, medical tourism means fewer patients and less revenue — but may also bring increased opportunities for collaboration with rapidly modernizing countries in other parts of the world. Chung and Franzblau conclude,” To retain patients and be competitive in a global market, US cosmetic surgery must be vigilant of the changes in medical tourism and must adapt to these changes."

The Association for Medical Tourism of Guanacaste has been launched. A group of more than 30 representatives of companies in the medical and tourism sector in Guanacaste formally joined as a group to promote medical tourism in the region.
Guanacaste is a province of Costa Rica in the northwestern part of the country, along the coast of the Pacific Ocean. It borders Nicaragua to the north and is the most sparsely populated of all the provinces of Costa Rica.
The constitution process involves three months of work and planning to organize a comprehensive platform that may cover the entire chain of medical and tourism services required by foreign patients traveling to the province for treatment.
The group resulted from the evaluation of the province and its ability to differentiate itself as a destination in terms of quality, medical care, infrastructure, and natural wealth.
President Ronald Guerrero, of San Rafael Arcángel Hospital explains, “Through the brand Guanacaste Health & Travel, we plan to promote partnerships and boost the traffic of national and international patients in the area. Doctors and companies in this group must meet certain requirements to ensure quality and safety of tourists and patients.”
For 2014, the goal is for the province is 5,000 health tourists, with average spending of $7,000. This project aims to inject $35 million during 2014, with the possibility of a strong and sustained growth over the next 10 years.
Companies that are part of the initiative and are working to develop a joint proposal include: American Airlines, Delta Airlines, Swiss Travel , CALITUR , Caturgua , Hilton Hotels , National Rent a Car, Arias & Muñoz Law Firm , AAAHC Certification , Costa Rican Board of Tourism, San Rafael Arcángel Hospital, Banco Nacional, Sansa, UCIMED, United Airlines, Relaxury Premier Service, Procomer, Huli Health , Hermosa Health Promotions, Enjoy Group and Ecodesarrollo Papagayo, and IMAGO advertising agency.
Guanacaste intends to position itself as the new destination with a comprehensive offer of services including: cosmetic surgery, orthopedics, general surgery, gynaecology, ophthalmology, and dental treatment. It also plans to offer medical check-ups to holiday and business travellers.

As the Japanese medical tourism industry grows, clinics and travel agencies are beginning to work together.
A number of hospitals and travel agencies in Japan have started promoting medical tourism to cater to a growing demand overseas for thorough physical examinations and advanced medical treatment.
After recent setbacks, the government has an ambitious target of more than tripling the annual number of foreign visitors to Japan by 2030, partly by encouraging new types of tourism. Agencies, clinics and hospitals hope they can piggyback on any national tourism campaigns.
A key target market is China. Although Chinese and local Japanese patients will pay the same fee for treatment, it will cost the Chinese more. Apart from travel and accommodation, the poor standard of foreign language by Japanese medical and ancillary staff will mean that most people will have to pay for a medical translator. And many will have to pay an agent to co-ordinate care and travel, as few Japanese hospitals offer packages or international patient services.
Nishidai Clinic, a pioneer in PET scans, began accepting customers from abroad in December 2009; but after two years has only helped 210 foreigners, most of whom are wealthy Chinese. With an aging society, Japanese hospitals have become experts at medical check ups, particularly for older patients.
For Japanese hospitals, accepting visitors from abroad is a plus because it helps the hospital make better use of its expensive medical equipment, such as the PET scan machines.
To promote medical tourism, the Japan Tourism Agency began holding workshops with people involved in the medical and tourism industries in July 2009. In January 2011, the government introduced a medical visa that allows foreigners to stay in Japan for up to six months for medical treatment. The number of tourists entering Japan on medical visas was 450 for the first nine months of 2013.
The government’s goal of raising foreign tourism from just under 8.4 million in 2012 to 10 million in 2013, and over 30 million in 2030, is part of a new economic strategy, and travel agencies are taking advantage of the trend.
Nippon Travel Agency began arranging medical tours for foreign visitors in April 2009. Business has been slow with 100 customers from China in 2012, compared with 40 between April and December 2009. The rate slowed after diplomatic tensions rose with China over the Senkaku Islands dispute and the March 2011 earthquake and tsunami ravaged the Tohoku region and set off the Fukushima nuclear crisis.
Agencies and hospitals are now targeting Russia, Vietnam and the Philippines for checkups, treatment for cancer, leukemia care and fertility treatment.
In 2009, JTB formed an alliance with hospitals to offer interpretation and other services to help foreigners get treatment in Japan. That alliance now involves around 130 hospitals.
The problem is that few Japanese hospitals are prepared for foreign patients. The biggest drawback for medical tourism is language. But there is also a culture of Japanese doctors expecting patients to bow to their expertise, and while the Chinese may be used to such treatment at home, those from other countries will expect doctors to work for them and have elements of customer care that are unknown in most Japanese medical institutions.

Hospitals close to borders now have to deal with more cross-border healthcare and a new study offers practical help.
’Seven case studies on cross-border collaboration and health system interactions’ is a new 179 page report edited by Irene Glinos and Matthias Wismar for WHO’s European Observatory on Health Systems and Policies.
The European Union Directive on the application of patients’ rights in cross-border health care explicitly calls for member states to cooperate in cross-border health care provision in border regions. Given that most such collaboration in the health care field involves secondary care, the new legal requirement means that hospitals that are close to national frontiers will be the focus of significant attention.
But how do hospitals interact with each other and with other health care actors across borders? Why does cross-border collaboration take place? Who actually benefits from it? And when does it work? These are the questions at the heart of the book.
Seven case studies examine the circumstances under which cross-border collaboration is likely to work, the motivations and incentives of healthcare organisations and the role played by health systems, individuals and the EU in shaping cross-border collaboration.
The study is original in offering qualitative and analytical scientific evidence on aspects of cross-border collaboration involving hospitals in 11 EU and non-EU countries (Austria, Belgium, Bulgaria, Denmark, Finland, France, Germany, the Netherlands, Norway, Romania and Spain).
This book is of interest to decision-makers and hospitals engaged in or considering cross-border collaboration. Questions on feasibility, desirability and implementation are at the core of the analysis. The book puts forward policy conclusions directly linked to the EU Directive on patients’ rights and proposes a toolbox of prerequisites for starting or maintaining cross-border collaboration in health care.
In addition to its deliberate policy perspective, it also focuses on the intersection between the EU and domestic health systems known as cross-border health care.

The two essential factors that will determine the development possibilities of health tourism services in the Caribbean are global competitiveness and sustainability, say the people behind the planned Negril International Hospital in Jamaica.
It may be two or three years before it can open but the aim is to build a financially viable business that is sustainable and which provides access to affordable and quality healthcare in a private facility. The target is to bring quality medical wellness services to the world and to the Jamaican populace.
The proposal is unusual in that the aim is to have doctors as equity investors in the hospital; plus Jamaicans and foreign professional investors and maybe private-equity firms and individuals.
The hospital project managers say that global competitiveness will be determined by:
•The cost competitiveness of the services.
•Patient/customer satisfaction.
•Quality of patient/customer care.
•Easy accessibility and efficient cross border payment reconciliation.
•High-level integrity for patient data storage, confidentiality, security and clinical reconciliation.
•*Efficient telemedicine enabled cross border services, with portability of patient records and information on mobile media.
Sustainability will be determined by:
•A health tourism model developed to reflect the unique Caribbean competitive brand
•Adaptation of health tourism model to Caribbean health care and tourism high quality services, culture and clinical standards
•Professional excellence, easily integrated into global health tourism value chain
•Unique Caribbean health tourism brand
•Automatic health system of constant product review and modernization / upgrading of services to keep ahead of global trends
•*State of the art diagnostic, ICT and extraordinarily efficient and caring patient / customer relationships and services
•Close links to the local economy.
The logic is that any medical tourism hospital in the region has to care for locals too. The hospital argues that you cannot just take a hospital model from the USA or Asia and just place it on a Caribbean island, as several projects plan, as it will not have the local culture.

The medical tourism research group at Simon Fraser University in Canada has been busy studying elements of why Canadians pay to go overseas for treatment that they could get at home for free; ’Canadian patients’ perspectives regarding the use of medical tourism for hip and knee surgery’
Due to Canada’s aging population, rates of arthritis and the demand for hip and knee replacement surgery have increased. System capacity has not always been able to meet this demand, in some cases resulting in lengthy wait times for these surgeries. While wait times are an important driver of medical tourism for hip and knee surgeries, they are not the only reason individuals seek treatment abroad. Candidates for hip or knee surgery commonly decide to go abroad for three main reasons: discontent with the Canadian healthcare system, preference to avoid real or perceived wait times for care, and/or the desire to get the best possible care, including procedures not available in Canada.
Interviews with former Canadian medical tourists who chose to undergo hip and knee surgery internationally suggest three common characteristics among this group.Compared to those who access hip or knee surgery at home, medical tourists are less likely to believe that osteoarthritis is a normal part of aging. These people are heavily motivated by a desire to maintain or resume active lives without immobility, including continued employment, volunteer activities, and physical hobbies. They are commonly convinced of the need for prompt surgery in order to decrease pain and restore quality of life. Going overseas is viewed as a method to speed up this process.
These individuals justify their decision to go abroad by identifying limitations in the Canadian health care system, including real or perceived barriers to accessing timely surgery. Lack of domestic access to hip resurfacing, which is less invasive than hip replacement, is also often cited as an issue.
Medical tourists seeking osteoarthritic surgery tend to be comfortable making healthcare decisions without physician input. They seek out information independently, consider the reputation and credentials of surgeons abroad, and value personal testimonies from former medical tourists. Previous international travel is another key factor in their decision to go abroad.
Given that these individuals may not consult with their doctors before or after going abroad for care, Canadian doctors should be proactive in identifying patients that require education on the risks and benefits of medical tourism for these procedures. The group has also created an information sheet for patients considering traveling to other countries for health care .The researchers earlier found that while Canadians opt for medical tourism for a variety of reasons, there is a range of ethical concerns related to health and safety risks that are not typically top-of-mind, and few resources to find answers.
The one-page information sheet outlines for prospective medical tourists several key points to consider, from unforeseen costs and procedure risks to contracting diseases and patient rights .It also points to the potentially negative impacts medical tourism could have on local communities.
Those considering medical tourism should weigh the pros and cons and become better informed on the potential consequences of the option for themselves and other before making a decision.

New research from price comparison site Confused.com reveals how the British are embracing cosmetic surgery tourism. The research claims that 30% of people who have had cosmetic procedures went abroad.The research states that cosmetic surgery tourists are most likely to travel within Europe for their procedures, with Switzerland the top destination for face-lifts (29%), botox (28%) and liposuction (14%). The Czech Republic is the country of choice for boob jobs (19%), lip fillers (18%) and nose jobs (17%).
Some people are opting to travel even further afield to get cosmetic surgery, with Thailand a cosmetic surgery hotspot. More than a quarter of those seeking teeth-whitening procedures abroad (28%) opted to visit Thailand to get this done.
This boom in cosmetic surgery tourism can largely be attributed to people looking to save money, with cosmetic surgery tourists citing cost as the main reason (25%) for going abroad, claiming that they cannot afford to have the procedure done in the UK. Others claim that they opted for surgery abroad so that they could also enjoy a holiday at the same time (20%).
People are travelling abroad for surgery based on recommendations from friends and family (11%), or because they had heard a celebrity had been to the same foreign clinic or surgeon (10%).
Of those who travelled abroad for a cosmetic procedure, only 46% were pleased with the results, and just 15% would recommend it to others. 19% who opted for a foreign cosmetic procedure have had to have further treatment to correct a problem, compared to just 6% of people who stayed in the UK.
A concerning number of people travelling abroad for cosmetic procedures caught an infection (33%) following their surgery or treatment, while only 9% say that this has happened when having a procedure in the UK.
The research findings reveal that only 14% notified their doctor before travelling to a different country for a cosmetic procedure.
For those travelling abroad for surgery or medical treatment, ensuring they are adequately protected should the worst happen is also highly important, which includes taking out the right travel insurance. Yet of those who went abroad to have some form of cosmetic procedure, only 33% took out travel insurance, with even fewer notifying their existing insurer (29%) of their plans.
Mhairi Edwards of Confused.com says:” Our research suggests that cosmetic surgery tourism is now a popular trend amongst Brits, with potential patients going overseas where prices are lower and procedures are more readily accessible. However, it is clear that there are increased risks associated with travelling abroad for cosmetic procedures. People considering surgery or procedures abroad should ensure they are fully protected, because they could be left in the lurch if things go wrong. Notifying your doctor and ensuring you have adequate travel insurance are a must. Travellers should also beware that normal travel insurance might not cover them for all procedures abroad, so they need to be thorough when choosing the right policy for them. If consumers are tempted by the prospects of a nip and tuck or a brighter smile at a smaller cost, we urge them to do their homework so that their bargain treatment does not prove to be a costly mistake.”

The Philippines needs to focus on niche treatment and on expanding its markets to capture a greater share of the medical tourism market, a new report from think tank, Philippine Institute for Development Studies (PIDS), says.
According to “Health-enhancing holidays: challenges in expanding medical tourism in the Philippines’ the country is cheaper than many Asian competitors in surgical procedures but it continues to get a small share of the market.
The study used 30 key findings from medical-tourism benchmarking research gathered by Mercury Advisory Group to assess the domestic industry relative to its counterparts in leading countries. It found that although the Philippines meets most of the competitive yardsticks, the country’s market niching is weak. The Philippines appears to have cast its net as widely as possible. The country has too wide a definition of target market niches of elective surgery, stem-cell therapy, cosmetic surgery, and dental care and wellness treatment.
The country should break into untapped markets, particularly the large non-balikbayan market in the United States and Europe. Balikbayan refers to any overseas Filipino returning to the Philippines.
Service providers have been dulled by the captive market of overseas Filipino workers and balikbayan, resulting in less attention to other untapped markets.
The country’s cover all the bases approach to medical and wellness tourism needs to be narrowed more strategically, with a clearer message, and based on the country’s natural endowments and cost advantage.
There is a need for the Philippines to strengthen its marketing campaigns, whether national, joint or corporate. The lack of a sustained Philippine marketing campaign abroad has been pointed as a major shortcoming of medical tourism in the country.
Service quality and care needs to be improved, -there are few internationally accredited health facilities although their number is increasing.
The report suggests commissioning an international consulting firm, with local counterparts, to conduct a comprehensive study on the medical-tourism industry covering its global competitive advantage and market niches, the binding constraints, its future prospects and needed policy thrusts.

The government of Trinidad and Tobago has identified the health tourism sector as a niche for potential growth and is implementing strategies for promoting and developing products and services. To capitalise on the potential, a plan is being made to develop to expand the existing market and promote medical tourism. Although it gets some regional and diaspora medical tourists from neighbouring Caribbean territories and the USA, medical tourism is limited and underdeveloped.
The government’s plan is to make the country a prime destination for medical tourists and investors. It is just a three-hour flight from Miami and a 4 1/2-hour flight from New York.

CTA Economic & Export Analysts has prepared a draft strategy for medical tourism funded by the Commonwealth Secretariat on behalf of the T&T Coalition of Services Industries (TTCSI). According to the draft strategy, there are numerous opportunities for growing this unique segment of the services sector.
There is excess capacity in the health system. The country’s ten private hospitals have 39,000 beds, with 31,000 being used per year. The overall objective of the strategy is to increase the number of medical tourists visiting by 5.500 within three years and then grow at a rate of 20% a year. The Trinidad diaspora is 1.3 million; mostly living in the USA, Canada, and UK.The 5,500 target includes 4,000 from the diaspora; 2,000 from USA, 1,500 from Canada and 500 from UK. It is the commercial centre of the Caribbean and has earned a reputation as an excellent investment site for international businesses. The country has a stable economy and boasts modern infrastructure and qualified people.?
To build momentum for foreign direct investment in health care several new developments and facilities upgrades are under way. Investors are now being sought for leisure attractions on Trinidad’s northwest coast with the Chaguaramas Development Authority (CDA) working to turn more than 14,000 acres into one of the most inviting tourist destinations in the region. The CDA is inviting investors to design, build, finance and operate these recreational facilities. Under construction is a new national oncology centre, which will be a model for health tourism in the Caribbean and serve as the main treatment centre for cancer in the country. It will open in November 2014 and will offer cancer treatment and diagnostic technologies such as the CyberKnife, PET/CT and nuclear imaging .The country wants to promote itself for medical treatment and for wellness holidays.
Cooperation, coordination and awareness raising within the country and development of a national brand and identity as a medical tourism destination are essential to realizing the potential of the sector.
The first key role is to ensure that the sector works together to promote their collective interests both within Trinidad and Tobago and globally. This is a necessary condition to future plans and any hope of achieving set targets.
The success of the strategy depends very much on the various local government bodies, private health care, airlines, travel agents and local hotels working together and the government committing funds to promote medical tourism. Previous attempts at turning a desire to increase medical tourism into action have failed due to the inability of the various parties to work together, and the government failing to provide adequate funding; perhaps this time it will be different.

A new report by SRI International on the global impact of wellness tourism says that wellness tourism is a US$438.6 billion global market. Wellness tourism accounts for 14% of all domestic and international tourism expenditures.
In ’The Global Wellness Tourism Economy report by Ophelia Yeung, and Katherine Johnston, wellness tourism is defined as travel associated with the pursuit of maintaining or enhancing one’s personal wellbeing.
Domestic wellness tourism is much larger than international, representing 84% of wellness tourism trips and 68% of expenditures. Wellness tourism is projected to grow by more than 9% per year through 2017, nearly 50% faster than overall global tourism.
Wellness tourists are high-yield tourists, spending 130% more than the average tourist. More than one half of the projected growth in wellness tourism trips through 2017 will take place in Asia, Latin America and Middle East/North Africa. India will have the highest increase in wellness tourism and is expected to grow at a rate of 20% a year through 2017.
Ophelia Yeung comments,” This new research clearly reveals that more people are now choosing destinations that help them keep or get healthy while traveling, while a smaller and also growing segment are also now taking trips with the specific, sole purpose of improving their personal well-being.”
The wellness tourism economy includes all expenditures made by tourists on these types of leisure and business trips, including lodging, food and beverage, activities/excursions, shopping and transport.An international wellness tourist spends 65 % more per trip than the average international tourist; the domestic wellness tourist spends about 150 % more than the average domestic tourist.SRI makes a distinction between primary and secondary wellness tourists: the former defined as those taking a trip entirely for wellness purposes, the latter engaging in wellness-related activities as part of a trip. Secondary-purpose wellness tourists constitute the majority (87 %) of total wellness tourism trips and expenditures (86 %). And while wellness tourists spend dramatically more than the average international or domestic tourist across the board, a secondary-purpose wellness traveler spends less than a primary.While tourism authorities tend to focus on inbound, international travelers, domestic wellness tourism is actually significantly larger than its international equivalent—representing 84 % of wellness tourism trips and 68 % of expenditures. International inbound wellness tourism represents a $139 billion market (32 % of total).While over 50 % of the projected growth in wellness tourism through 2017 will come from Asia, Latin America, and the Middle East/North Africa, the SRI study found that today’s typical wellness traveler is well-educated, well-off, middle-aged and hails from Western and industrialized nations. Europe and North America drive the outbound international wellness tourism segment, with five countries—the U.S., Germany, Japan, France and Austria—currently representing 63 % of the global market. France, Austria, Germany, Switzerland and the USA drive the most inbound, international wellness tourism arrivals. Countries that attract the most domestic wellness tourism trips: USA. Germany, Japan, China and France.Spa tourism is a core component of wellness tourism (41 % of market), but non spa-related wellness tourism (whether healthy hotels and cruises; baths/springs; fitness, yoga or lifestyle retreats; travel to nature parks/preserves; organic/natural restaurant expenditures; and other healthy lodging and retail) represent 59 % of the market.Jean-Claude Baumgarten of the World Travel & Tourism Council comments “ Wellness tourism is poised to reshape tourism as we know it. So many 21st century forces are fueling it, including the rise of chronic diseases and the unprecedented stress of modern life. What people want to achieve during their ever diminished time off is undergoing a sea change, with millions more every year demanding destinations that deliver physical, emotional, spiritual and environmental health—along with enjoyment.”

Income from medical tourism increased sharply in 2011 and 2012 to reach $140 million in 2012, according to data collected by the Health Ministry and the non-government organization Hatzlaha. The Israeli government is exploring whether to curb or regulate medical tourism; despite the revenue it brings in-with worries that locals could suffer. The ministry has a dilemma that many hospitals have cited commercial issues for refusing to co-operate with official enquiries on how many medical tourists they actually get, as nobody has been able to find out the real numbers.
The public hospitals took in NIS 291 million from medical tourism in 2012. Health maintenance organization Clalit reported that its 10 hospitals had revenues of NIS 70 million from medical tourism in 2012. Hadassah University Hospital in Jerusalem had revenues totaling NIS 108 million.Private hospitals, including Assuta in north Tel Aviv, also had sizeable revenue from medical tourism but refused to provide numbers. One estimate indicates that Israel’s hospitals had revenues of more than half a billion shekels from medical tourism.
The public hospital with the highest medical tourism revenues was Sheba Medical Center, Tel Hashomer, with NIS 130 million a year – up nearly 70% since 2010. It was followed by Ichilov Hospital, Tel Aviv, which had revenues of NIS 99 million (up 44% since 2010), and Beilinson Hospital, Petah Tikva, at NIS 39 million – a 490% increase over the figure from 2010.Other public hospitals with medical tourism revenue were Rambam in Haifa, with NIS 36.4 million in revenues; Assaf Harofeh Hospital, Tzrifin, at NIS 15.9 million; and Schneider Children’s Medical Center, with NIS 13.6 million.
A subcommittee within the health ministry has been set up in an attempt to regulate medical tourism, which has no government oversight or standards. Many attempts have been made to set standards and regulations for medical tourism- all have failed to happen. In May 2013 the committee said that medical tourism should account for no more than 10% of a hospital’s revenues from operations. But it has yet to submit its recommendations, so this limit is not official, and it may be impossible to enforce.
Medical tourism is a very sensitive issue for Israel’s health system. Every medical tourist admitted raises the question of whether that person is taking the place of an Israeli patient, particularly given that the hospitals are very overcrowded and the wait for treatment is long.
Medical tourists come primarily from the former Soviet Union and from Mediterranean nations. They visit for a fixed duration, and may receive treatment ahead of Israelis.
For hospitals, medical tourists are very attractive and lucrative patients. Hospitals charge them much more than they receive from Israeli patients, and one of the reasons some hospitals refuse to co-operate with the ministry is a suspicion that they greatly increase the prices for medical tourists- so increased revenue may not equate with increases numbers- but be due to severe price increases and a concentration on more expensive surgery. Unlike insurers, the medical tourists pay the hospitals immediately, and in cash. The money goes into the hospitals’ parallel business operations, as opposed to the budget subject to government oversight, which means the hospital directors have more control over the money.
No authority in Israel has full data on medical tourism. The Health Ministry has only partial data that includes the state hospitals’ revenue. It does not know how many patients are treated, or in which departments. Many public and private hospitals have refused to provide any revenue figures or numbers.

A new report on modern travellers suggests that medical tourism may have to rethink some fundamental issues.
Within medical tourism are two competing views- one that says the industry should promote medical travel as a stand alone .The other older view says that medical travel should be promoted as medical tourism with medical care and tourism combined. Neither suggests medical travel should be combined with business travel.
A major new report shows that many younger travellers now mix business and tourist travel – by adding personal time to business trips or just combining the two. This will cause problems in national and international travel statistics that tend to separate business and holiday travel numbers. It will also mean that medical tourism may need to rethink how it markets to younger professional people-particularly when promoting the softer health and wellness end of the market. The industry may also have to move to selling mainly via mobile devices.
In the 1990s, Expedia turned the travel industry on its head by unlocking travel agent information and bringing it to the mass market. Expedia has turned its attention how to meet the needs of future travelers who increasingly book leisure and business travel by social media and combine the two types of travel.
A new report from Expedia ’Future of Travel’ sees the traveller of tomorrow operating in an ever more fluid space, a world of blurred boundaries. They expect to move seamlessly from device-to-device; from online to offline and back again; from business to leisure and vice versa. Mobile is their personal assistant helping them to plan and book travel; change plans, especially in business travel; connect with friends and colleagues. Their office may be on the plane, at the airport or in a hotel room, and Wi-Fi is more important than extra legroom or upgrades.
Their priority is to cut through the clutter, preferring brands and services, which save them time, and ones that make life and life on the road easier and more enjoyable.
Whether hailing from developed or emerging markets, Millennials – those currently under 30– have grown up in the world of mobile devices, the internet and social media. They have higher trust in the internet but also higher expectations about how sites and apps will deliver great personal experiences using that information and the speed at which that should happen. The Millennial generation expects to be in control and make their own decisions. For this generation, technology, particularly mobile is their personal assistant. Expedia research shows that Millennials are planning and booking travel using their smartphones more than any other group.
Travel providers – and medical tourism providers – will have to be fully enabled through any platform, knowing that buyers interface, interact and navigate through different devices in very different ways. For independent or smaller businesses this represents a significant technological challenge and investment.
Millennials have grown up in a world of working from remote locations and on the move so when it comes to business travel they are equally comfortable with blurred boundaries.
54% of employees have extended a business trip into a holiday. Millennials are more likely to extend their work trips to turn them into personal trips – and are twice as likely to do so when travelling alone than their counterparts over 45.
Expedia sees a new a wave of travellers where the future of travel is to delight all customers as they plan their next vacation or business trip-which is personal and collaborative, fluid and flexible, and of course mobile.

Research by CroMedicor, a Croatian medical tourism portal, compared prices in Croatia to other European countries. The study compared prices in Croatia to those in the UK, Germany, Slovenia and Italy.
The results of the study were based on a selection of specific dental treatments, including dental implants, crowns, dental veneers, tooth whitening and dentures.
The UK was identified as the most expensive, followed by Italy, Slovenia and Germany; prices were lowest in Croatia. In some cases, fees were up to 70 % higher in the UK than Croatia.
In the UK, the price of a single dental implant was 1,800 Euros, compared to 1,300 Euros in Italy and Slovenia, 1,000 Euros in Germany and 800 Euros in Croatia.
The cost of treatment is the most significant factor in the growth of dental tourism, as many patients from the UK and other Western European countries are looking to save money on their dental treatment.
While other types of medical tourism factor in quality and comfort, with price being only one factor; on cosmetic and dental surgery, non-invasive treatments are often similar in quality of service and product, so price becomes more important.
Dental tourism also reflects the changes in the way Europeans access dentistry with simple treatment and repair now being far less important than dental implants and cosmetic dentistry.
With regular, affordable flights to Eastern Europe available from a number of airports, having dental treatment abroad has never been easier and people are more aware of the price differences thanks to adverts and articles about dental tourism. Dental tourism does offer people the chance to save money on dental treatment, but patients still need to check out the quality of what is on offer.
The CroMedicor health platform connects dentists and doctors in Croatia to locals and overseas medical tourists in Europe, China and the Middle East.

Leading Australian health insurer NIB is planning to sell offshore surgical packages to Australians from 2014.
The health fund will launch NIB Options on cosmetic surgery and major dental work. It is talking to clinics and specialists in Indonesia, Malaysia and Thailand.
Mark Fitzgibbon of NIB explains; “People are increasingly travelling across international borders for healthcare. We are building a medical travel business here. Tourism has the wrong connotations. We will provide customers with the opportunity to relax and recuperate in a nice resort, maybe, but it is not a holiday.”
Growing its Australian residents health insurance is still the top priority for the insurer but the company has to pursue new sources of earnings as regulatory constraints on pricing make it hard to lift margins in Australia, where market competition has intensified. Unless it is able to grow and make money, it will be taken over as rivals already have it in their sights.
The medical insurer says it will guarantee the safety and quality of these services, although Australian associations of doctors and dentists are challenging this claim, saying that Australian doctors and dentists must meet higher standards of care and qualifications and that these are not matched overseas; but they have always been against the principle of medical travel and have been unable to back up their dislike with any proof that overseas care is of poorer quality.
NIB Options will launch in January 2014 and initially focus on cosmetic surgery. It is not part of the insurance business but functions as a portal, and offers both local and international options for cosmetic surgery. Overseas options involve the bundling of transport, medical and accommodation services.
The incentives for customers to take up the plans will centre around trustworthiness, safety and choice. Customers will pay to cover the overseas procedure and any follow-up procedure that might be needed when they return to Australia. NIB has already made arrangements with local cosmetic surgeons in Australia for aftercare.
NIB used the testing of its electronic voting system to conduct a straw poll at a recent shareholders meeting on the question of whether they would consider travelling overseas for medical tourism. 60 % of shareholders would consider overseas treatment.

With one of the world’s strongest tourist industries, Thailand is now working to build on its international reputation, developing high-earning segments and broadening its market reach.
The country is aiming to generate a record $63.9billion in revenue from foreign and domestic tourists in 2014, says the Tourism Authority of Thailand (TAT). The government has set a target of attracting more than 28 million foreign visitors in 2014, up 7% on the projection for 2013.
TAT has launched a new marketing strategy for the country, focused on driving the tourism sector up the value chain and boosting revenues as much as attracting greater volumes of visitors. There will be a renewed emphasis on Thai culture and selling the country as a quality destination. The core theme of the 2014 strategy has been dubbed “Higher Revenue through Thainess”.
Priorities include greater diversification of source markets; broadening the range of destinations within the country to promote regional development and reduce congestion at popular sites; better regional connectivity; bringing in more visitors during the low season; and a focus on niches such as medical tourism to mitigate the impact of higher numbers of arrivals.
TAT is aiming to increase the proportion of visitors in the $20,000-to-$60,000 income range from 30% to 40% in 2014. To this end, it is developing more luxury tourism products and working to bring in more middle-to-high income visitors from growing markets such as Turkey, Eastern Europe, Africa and the Gulf, as well as building on core markets in Western Europe.
The fastest-growing tourism markets for Thailand in 2014 will be China and Russia, with substantial populations that are increasingly keen to travel abroad. Most visitors from these countries tend to be in the low-to-medium-income tourism segments, and that to boost arrival numbers and earnings; Thailand needs to start attracting more well off tourists from top emerging markets.
To boost the Chinese market, TAT will open its fifth office in China in Guangzhou (Canton) by the end of the year, to cover South China. The first four offices are in Beijing, Kunming, Shanghai and Chengdu. TAT expects the number of Chinese tourist arrivals to Thailand to reach 5.4million in 2014, compared to the projected 4million for 2013.China is now the world’s largest outbound tourism market, and Chinese citizens take more than 83 million overseas trips a year, according to the Beijing-based China Tourism Academy.
The number of Chinese visitors to Thailand soared by a remarkable 93% to 1.12 million in the first quarter of 2013.Thailand’s relatively low prices appeal to Chinese and Russian visitors. TAT expects 1.9 miliion Russian visitors in 2014 and is aiming to attract more Russian medical travellers.
Thailand is in the fortunate position of already having a large and flourishing tourism industry and a strong profile in many important markets. But achieving the ambitious targets for 2014 involves not just clever marketing, but real investment in tourism infrastructure, from hotels to airports, to ensure that the country’s projected image as a quality destination is matched by reality.
Tourism Authority of Thailand (TAT) has launched a series of videos, digital brochures, and PowerPoint presentations to promote medical tourism; including:•Global accreditation ensures quality healthcare in Thailand•Holistic anti-aging treatments abound in Thailand•Rejuvenate in style at a Thai destination spa•Thailand crowned leader of global dental tourism•Treat yourself and your skin to a holiday in Thailand•Wellness spa seekers find natural home in Thailand•Nine reasons to make Thailand your medical tourism destination•Treat yourself to fabulous health in Thailand

International patients coming to the UK for private medical treatment are a lucrative source of income for the NHS, but more UK residents travel abroad for treatment than international patients travel to the UK for private or NHS treatment.
This is according to a new study,’Medical tourism: a cost or benefit to the NHS? ’ published in PLOS ONE, by researchers at the London School of Hygiene & Tropical Medicine and the University of York. Lead author is Johanna Hanefeld. The research is funded by the National Institute for Health Research Health Services and Delivery Research Programme.
The new study is the most extensive analysis yet of UK medical tourism and looks at its impact on the NHS economy. As part of the study the researchers analysed the International Passenger Survey, conducted interviews with returning UK medical tourists, policymakers and NHS managers, and reviewed published literature.
They also made 28 freedom of information requests to NHS foundation trust hospitals in the UK to obtain figures on foreign private patients; 18 of these hospitals provided useable data. The researchers found that, despite the small numbers of international private patients being treated – 7% across this sample – these patients were responsible for almost a quarter of total private income in these trusts. This represents an income of £42 million across the 18 hospital trusts during 2010-2011.
13 of the hospitals that provided data were in London, and the largest numbers of foreign patients were at hospitals internationally known for their specialism.
Johanna Hanefeld comments, "Our analysis shows that private foreign patients may be more lucrative than UK patients treated privately within the NHS. This could be a strategic area for growth for NHS Trusts wishing to expand private patient activities and increase income, especially following the NHS reforms that removed the cap on income generated from private patients. We can also see from our research that – contrary to some popular media reports – the UK is a net exporter of patients. In 2010 an estimated 63,000 UK residents travelled abroad for treatment, while around 52,000 patients came for treatment in the UK. The level of patients travelling to the UK has remained relatively stable over the last decade, while there has been a substantial increase in the number of UK residents travelling abroad for medical treatment." It should be noted that these figures are 2010, and may not reflect what is happening in 2013; while there are problems on IPS figures that make converting them to national figures a chancy affair. IPS figures do not cover car travel between Ireland and Northern Ireland –while the biggest problem for inbound and outbound numbers is that people have to choose a reason for travel – so a medical tourist who combines treatment and leisure/recuperation will always answer ’holiday’, so is not picked up in medical travel which is a part of ’other reasons’. Neil Lunt concludes, "Where many NHS Trusts are trying to increase efficiency, medical tourism is a way for them to increase income from non NHS sources."
According to the IPS data, UK residents most commonly travel for medical treatment to North, West, and Southern Europe with France being the most visited country over the decade. Central and Eastern Europe are second most popular, while Poland and Hungary are increasingly popular. Dental patients increasingly travel to Hungary and Poland. Fertility tourists often travel to countries in Eastern Europe, Cyprus and Spain.
Major source countries for patients coming into the UK include Spain, Greece, Cyprus and the Middle East; the latter being mostly Kuwait and Dubai/UAE.

Governments and healthcare decision makers across the globe should be wary of the myths and hype surrounding medical tourism, warns a team of British researchers, led by the University of York and funded by the National Institute for Health Research (NIHR).
In an article, to be published in the journal Policy & Politics by Policy Press, the researchers challenge the idea that ever greater numbers of patients are prepared to travel across national borders to receive medical treatment.
The authors, who include academics from the London School of Hygiene & Tropical Medicine, Royal Holloway University, and the University of Birmingham, looked beyond the NHS and the UK to address the wider international issues of medical tourism, examining how other countries are addressing this global phenomenon.
They describe three myths of medical tourism: the rise and rise of medical tourism; enormous global market opportunities; and that national governments have a role to play in stimulating the medical tourism sector through high-tech investment.
The researchers say these three widely held assumptions cannot be backed up with hard evidence but are encouraged by interested parties such as associations, healthcare providers, and intermediaries between providers and patients.
Neil Lunt from the University of York explains, "In the past decade the global health policy literature and consultancy reports have been awash with speculations about patient mobility, with an emphasis on how ever greater numbers of patients are travelling across national jurisdictions to receive medical treatments. Yet authoritative data on numbers and flows of medical tourists between nations and continents is tremendously difficult to identify. What data does exist is generally provided by stakeholders with a vested interest rather than by independent research institutions. There exists no credible authoritative data at the global level, which is why we are urging caution to governments and other decision-makers who see medical tourism as a lucrative source of additional revenue. Our message is to be wary of being dazzled by the lure of global health markets, and of chasing markets that do not exist."
The paper was informed by a research project funded by the National Institute for Health Research Health Services and Delivery Research Programme. It uses the findings from a two-year study into the impact of medical tourism on the UK’s health system to make broader observations that the researchers believe apply to medical tourism globally.
The report authors argue that in terms of medical tourism, a level playing field does not necessarily exist and they challenge the view of open and global markets. Networks, history and relationships, they say, may explain a great deal about the success of particular destinations.
Daniel Horsfall from The University of York carried out the statistical analysis for the study, "We found that historical flows between different countries and cultural relations account for a great deal of the trade. The destinations of medical tourists are typically based on geo-political factors, such as colonialism and existing trade patterns. For example, you find that medical tourists from the Middle East typically go to Germany and the UK due to existing ties, while Hungary attracts medical tourists from Western Europe owing to its proximity."
The team of researchers has already published an Organisation for Economic Co-operation and Development (OECD) report on their findings, while Dr Lunt has delivered the message of caution to the World Health Organisation and the Portuguese and Ukraine Governments.
Author of ’Medical Tourism Facts and Figures 2014’ Ian Youngman comments; “This timely research is a counterpoint to those who would have you believe that the market is growing very fast everywhere. My latest research suggests that there is growth, but some countries are increasing business, others are static and others are seeing less business. It is very much a regional business, and there is a huge move away from price competition to competition on quality, specialisms and even luxury. Where I take issue with the research is that Malaysia, Thailand and South Korea are examples where government support has proved successful in increasing business year on year, while destinations such as India or Spain where governments have done little or are even against the concept have seen numbers fall. Governments who just invest in conferences or spend money marketing without establishing a proper medical tourism strategy and infrastructure may as well just burn piles of dollar bills.”

The article ’Market size, market share and market strategy: Three myths of medical tourism’ will be published by Policy Press at the University of Bristol in the journal Policy & Politics in 2014. It is currently available on fast-track to subscribers: www.ingentaconnect.com/content/tpp/pap/pre-prints/content-PP_PP_010

Thailand is possibly the largest medical tourism destination by revenue and by numbers, but the latest medical tourism numbers add to the confusion.
Two local bodies publish figures:• The Ministry of Health works with Kasicom Research Centre. For 2012, the organisation reports 2.53 million medical tourists to Thailand.• The Tourism Authority of Thailand (TAT) works with the Department of International Trade Promotion. For 2012, this organisation reports 858,000 or 700,000 medical tourists to Thailand.
Both sets of figures are often published and used by others as “medical tourism statistics” but this is incorrect.
In 2010, the Ministry of Health explained that their figures included:• 70% medical tourists• 25% resident expatriates• 5% business travelers and tourists.A further twist came in 2012 when an official admitted that this was not correct; Somchai Pinyopornpanich said the three main groups of foreigners seeking medical treatment were:• 26.6% medical tourists• 41.4% resident expatriates• 26.65% travellers
In 2013, TAT explained that while one figure was medical tourists, the higher figure came from research that included wellness and spa tourists. Whatever the explanations, the discrepancies are substantial.
Looking at the latest figures from the Ministry of Health and Kasicom Research Centre, the total figures are:- 2010 1,980,000- 2011 2,240,000- 2012 2,530,000 It then goes on to say where they came from. Although often used, as medical tourism numbers both the total and source figures are actually international (non-Thai) patients, whether or not resident in Thailand, so include expatriates, business travellers, holidaymakers and others who are not actually medical tourists. The additional problem with the data is that it records facility visits, not the number of unique patients/customers. So, if one person makes multiple separate visits to the hospital during a stay or generates multiple billing instances on the hospital billing system (e.g. for pharmacy, radiology, physiotherapy etc), they are recorded as multiple patients. So, the figures may be “inflated by five fold or more. The good news for Thailand is that the figures do show a rising trend.
The latest figures on where patients come from are also confusing. But 2013 figures from the Ministry of Health and Kasicom Research Centre say:• In 2010, 2011 and 2012 Japan was the biggest source of medical tourists by nationality.• In 2010 and 2011 the second biggest source was ASEAN countries (Brunei, Cambodia, Indonesia, Laos, Malaysia, Myanmar, Philippines, Singapore, South Korea, and Vietnam) • By 2012 the USA had overtaken the total of ASEAN countries as number two. • Figures for 2010, 2011 and 2012 list the third, fourth and fifth biggest source, but as the ten ASEAN countries are counted here as one source, this is misleading and we are really talking about 12th, 13th and 14th places by countries. • In 2010 and 2011, the next largest group after Japan and ASEAN countries were from the Middle East, USA and UK; and for 2012 this was the same but Middle East renamed as Gulf states and US and UK numbers larger than Gulf totals, with Australia showing as next highest. Gulf/Middle East includes half a dozen countries and Thailand has successfully targeted and attracted medical tourists from these states.
Another problem with these figures is that they use nationality, not residence, so the US and UK numbers may result from the many thousands of expatriates from those countries resident in Thailand or other Asian countries who may be counted wrongly as medical tourists.
Are you confused? Additional information from TAT may clarify or confuse you more.
In mid-2013, TAT carried out a study based on 30,000 interviews and questionnaires for a period of one year between April 2012 and March 2013. The study showed that health and wellness tourism generated 858,340 trips to Thailand and produced estimated earnings of 31.12 billion Baht (USD 997 million) for the Thai economy. The figures include medical tourism within health and wellness, but TAT are unable to say how many are medical tourism and how many are health and wellness tourists, or even if a spa holiday is counted in either.
For 2012 if we go back to TAT medical tourist figures of around 700,000 and Kasicom’s figure of 2.53 million, there is a rather large discrepancy.
TAT figures are medical tourists while Kasicom’s are international patient numbers.
Taking the Ministry of Health’s admission that only 26% are medical tourists, this brings the figures down to around 630,000. On this basis it suggests that the TAT figure of just under 700,000 may make sense; and still keep the country as number one destination; no claims for or by a country of “a million plus medical tourists” has ever been proven, or indeed is likely.
But we are left with making many assumptions on how many of TAT’s health and wellness tourists, and how many of Kasicom’s international patients are medical tourists.
It would be a positive move for the two groups to talk to each other and produce some joint figures that clarify the matter.
If nothing else, the Thailand medical tourism numbers shows us the dangers of relying on “internet fact” where estimates become reality and international patients are miraculously transformed into medical tourists.

In July 2013, the European Commission published a proposal to modernise EU rules on package travel. The proposed changes may mean that new laws will equally apply to medical tourism agents and intermediaries.
The Package Travel Directive (90/314/EEC) protects European consumers going on holiday and covers pre-arranged package holidays combining at least two of the following: (1) transport, (2) accommodation (3) other tourist services such as sightseeing tours (sold at an inclusive price and when the service covers more than 24 hours or includes an overnight stay).
The Directive delivers consumer protection and covers: information requirements, liabilities for services (e.g. sub-standard hotels) and protection (reimbursement of sums paid or repatriation) in the case of a tour operator or airline going bust.
The aim of the revised Directive is to extend the current protection for traditional, pre-arranged packages to new combinations of travel services. If those new combinations of travel services feature the characteristics associated with packages, the consumer is protected under the new rules.
For example, a combination that includes all services in one contract or where all services are sold at an inclusive price will be considered a customised package, irrespective of whether this combination of travel services is sold online or off-line. Such customised packages will be protected in the same way as traditional, pre-arranged packages.
The basis is the EU Directive from 1990 on package travel. The reform responds to a fundamental transformation of the travel market: People are increasingly taking a more active role in tailoring their holidays to their specific requirements, notably by using the internet to combine travel arrangements rather than choosing from ready-made packages out of a brochure.
Whilst package holidays remain popular, new markets in terms of both products and how they are sold have emerged, mainly due to the internet. This has enabled airlines, hotels, tour operators and other travel organisations to promote and sell their products directly to consumers in different ways and often avoiding intermediaries.
Dynamic packages/customized holidays have also become an attractive option for consumers since they allow them to tailor their holiday to suit their individual tastes and requirements and to purchase holidays and short breaks in their component parts. Sometimes the components are from the same provider but equally they may be from different ones. These holidays do not fall within the traditional definition of a package and this inevitably causes uncertainty when considering the application of the current regulations.
So the proposed update of the 1990 rules is essential to bring the Package Travel Directive into the digital age. This means: protection for an extra 120 million of package travellers.
This update will bring for buyers of traditional and customised packages:
•Clear information: Consumers will be told exactly what kind of product they are buying and what kind of protection is included in their travel arrangement.
•Stricter controls on price surcharges: Changes to the final price after consumers have signed a contract should be the exception. But if they occur, they need to be predictable and fair.
•Better termination rights: Unplanned events can and do occur before departure. The new rules aim to reflect this reality, to give package travellers the possibility to terminate the contract before they leave on holiday against a fair amount of compensation to cover the organiser’s costs. Consumers will also be able to cancel the contract, free of charge, before departure in the event of natural disasters, civil unrest, or similar serious situations at the destination that would affect the holiday, for example when national authorities advise against travelling to a specific destination.
•A single contact point if something goes wrong: Consumers will be able to address complaints or claims directly to the retailer (the travel agent) from whom they bought their holiday.
For buyers of other customised travel arrangements:•A right to get their money back and be repatriated, if needed, in case the seller, the carrier or any other relevant service provider goes bankrupt.•Better information about who is liable for the performance of each service.•For businesses it will cut red tape and compliance costs by:o Creating a level playing field between different operators,o Scrapping outdated information requirements. So operators will no longer have to reprint brochures every time a detail changes. o Excluding managed business travel,
EU-wide rules will make cross-border trade easier, with common rules on information requirements, liability and other obligations towards travellers.
Intermediaries will be made explicitly liable for booking errors in relation to packages and other customised travel arrangements.
It is anticipated that this will be followed by a couple of years debate and then the member states will have another two years to implement the new legislation into its own law. The changes are therefore unlikely to come into effect until 2016.
For now, travel companies and consumer organisations continue to lobby the EU to influence the final outcome.
There has been discussion as to whether or not medical travel packages – often sold as a combination of medical travel and a holiday, do or do not have to comply. If the new rules include, as expected, packages where the various aspects are from different providers but sold to the customer via a retail agency, then where an agency sells medical care, travel, and accommodation to the same customer in one transaction, then even though they may not think of themselves as being a travel agent or tour operator, it will be almost impossible for them to claim that the Europe wide rules do not apply to them .It would be totally logical that if the medical part of the package is sold to a consumer in Europe ( even if treatment is in Asia) and the contract is between the patient and the hospital, that the agency as travel retailer could become equally liable for poor service, unexpected costs and other problems; and it could even stretch to include medical negligence.
All agencies need to keep an eye on developments as it is normal for countries when passing laws on new EC directives, to do an EC plus law, adding extra rules and penalties wider than the basic directive requirement.

Argentina’s tourism organization INPROTUR is promoting niche areas of the country’s tourism under the banner of ’Argentina Authentic”. The twelve selected niches are polo, Jewish experience, educational, patrimony of mankind, rural, urban, cultural and cruises- plus health, wellness, spa and thermal.
In all these sectors, and in a separate campaign on luxury tourism, Argentina is promoting quality, comfort and care; having moved away from price competition.
Health tourism is promoting medical tourism by emphasizing the quality, professionalism and high-tech services of hospitals and clinics-plus personal attention, comfort and specialist services.
Wellness tourism is promoting cosmetic surgery, beauty treatment, anti-stress and weight loss services in clinics, and promoting the range of beauty, therapy and relaxation services in thermal spas and health centres.
Thermal spa tourism is promoting the 40 thermal spas with water that has volcanic, magmatic or telluric origins. They offer treatment illness of the skin, bones, digestive, breathing, and circulative systems, as well as relaxation and beauty treatments. In the North, there are 17 thermal spas. In the province of Entre Ríos, ten thermal centres promote themselves as thermal parks that can be visited by the whole family all year round.
Spa tourism is promoted as offering relaxation for local and international tourists, with health and beauty treatments, within natural landscapes and many outdoor activities. – all with specialist staff and a medical director to assure the quality of treatment and care.
8 new spas are opening by 2014, while most of the existing spas are new or have been recently upgraded.
INPROTUR also says that spa and health tourism grew 38% in the 5 years between 2008 and 2012, and is predicted to grow faster than medical tourism in the next few years.
Argentina sees huge potential in luxury travel, one of the fastest growing global tourism segments. This niche aims at those who can afford to stay in a 5 star’ hotel and want tailor made services, not package travel. Several spas and hotel spas promote themselves to this profitable market.
Luxury travel hotels with wellness offerings include-• Iguazú Grand Resort Spa & Casino• Las Balsas Gourmet Hotel & Spa • Llao Llao Hotel & Resort, Golf-Spa• Los Cauquenes Resort & Spa – Ushuaia
Las Balsas Spa offers an exclusive service for guests, inviting them to relax by Nahuel Huapi Lake with physical exercise routines, massages and face and body treatments. The spa offers a gym; an in/out heated pool, Jacuzzi, sauna, Scottish shower and relax room- with a Pilates bed.
Luxury spa travel is becoming an important area within luxury travel, and also meets the growing demand for wellness travel. The spa experience is becoming a necessity for both male and female luxury travellers. Spas are increasingly driving factors in a destination choice so the luxury hotel industry and the spa and wellness sectors are working together to maximise inbound luxury tourism opportunities.
Argentina is one of the first countries to concentrate health and wellness tourism promotion, not just on the care and quality of the offering, but emphasizing its appeal at the top-end, and the most profitable niche of luxury travel. Spas and hotels are investing in new build and upgrades to target this sector, while most competing countries still focus on price.

Indian hospitals saw 18,000 Nigerians on medical visas in 2012, a trebling in numbers in the last three years. With Nigerian politicians more determined than ever to stop this loss of foreign exchange, Indian hospital groups looking long term see the future as building hospitals in Nigeria.
47% of Nigerians visiting India in the year 2012 did so to get medical attention, according to figures from the Indian High Commission. These 18,000 medical tourists spent $260 million in scarce foreign exchange in the process. (Around $15,000 per medical tourist).
This trend results from the inequality in access to healthcare and dearth of medical facilities, which have remained major, upsets to Nigeria’s healthcare.
The trend of referring patients from health institutions in Nigeria to similar institutions in India is a common practice. This development has made many Nigerians lose confidence in the ability of the nation’s healthcare institutions to deliver quality healthcare.
Mike Chukwu of Assetswise Capital has identified low standards of patient care, an absence of world-class hospitals and diagnostic centres and the stunted growth of the healthcare system in the country, as responsible for this massive medical tourism to India; “A poor pipeline for high skills, poor health value chain, as well as low health insurance cover, have led to weak effective demand for healthcare services, resulting in poor economics of scale for hospital services in the country. Medical equipment in some hospitals is bedeviled with irregular maintenance and upgrades, and diagnostic services not readily within reach, raising questions of quality control, availability, timeliness and reliability. Ambulatory services are often not available or affordable. There is an absence of internationally recognised certifications, a weak regulatory and supervisory framework, and weak framework for legal indemnities. There is poor management, plus poor staffing in terms of number and specialties of doctors and other healthcare providers. These have resulted in the low standard of care in the country.”
Chukwu advised that the approach to reversing the medical tourism problem in Nigeria must be to develop private sector healthcare- “There is need to improve access to capital, develop and enforce quality standards, mobilise public and donor money to the private sector, modify local policies and regulations to foster the role of the private sector and foster health insurance.”
Health minister Muhammad Ali Pate says that it is essential to unlock the market potential for health services in the country by creating an enabling environment for the private sector to grow.
The Federal Ministry of Health will look at regulations to discourage growth of medical tourism and review fiscal policies (economic incentives, tax, foreign exchange, import tariffs) that affect healthcare, to create more favourable economic incentives for doing business in the healthcare sector.
Another top Indian hospital has sealed a deal to set up collaborative medical services in Port Harcourt, Rivers State, at the First Rivers Hospital. Medical cases can be properly examined and successfully managed in Nigeria without the extra burden of overseas travels while only complicated surgeries will be directed to Ruby Hall Clinics in Pune for specialist care. The investment means an upgrade for facilities and healthcare services at First Rivers Hospital, as well as providing online/real time and direct access to specialist consultants’ expertise at Ruby Hall Clinic.

Demand for international tourism remained strong throughout the first eight months of 2013,and this is good news for medical and health tourism.
According to the latest UNWTO World Tourism Barometer. Between January and August 2013, the number of international tourists worldwide grew by 5%, driven by strong results in Europe, Asia and the Pacific and the Middle East. Prospects for the last four months of 2013 remain upbeat. In the first eight months of the year, international tourist arrivals grew by 5% to reach a record 747 million worldwide, some 38 million more than in the same period of 2012. After a solid start of the year, demand for international tourism maintained strength throughout the Northern Hemisphere peak season. The months of June to August have shown sound results – in absolute numbers, international arrivals topped 125 million in both July and August, while in June the 100 million arrivals mark was exceeded for the first time. Europe (+5%) benefited the most from the growth of tourism in the first eight months of 2013, with an estimated 20 million more arrivals in the region. Given that Europe is the world’s largest tourism region with many mature destinations, a 5% growth rate is very positive. Central and Eastern Europe (+7%) and Southern and Mediterranean Europe (+6%) performed particularly well. Asia and the Pacific (+6%) continued to show robust growth bolstered by South-East Asia (+12%) adding some ten million arrivals. The Americas (+3%), which gained four million additional arrivals in the first eight months of the year, reported comparatively weaker results, with North America (+4%) in the lead. Africa (+5%) where growth was by led by the recovery of North Africa (+6%), received two million extra arrivals, while in the Middle East arrivals rebounded by 7% after two years of decline. With very few exceptions, the positive results in arrivals are also reflected in the international tourism receipts reported for the first six to eight months of the year. Among the 25 largest international tourism earners, receipts grew by double-digits in Thailand (+27%), Hong Kong (China) (+25%), Turkey (+22%), Japan (+19%), the United Kingdom (+18%), Greece (+15%), India (+14%), Malaysia (+12%) and the United States (+11%). Emerging economies continue to lead international tourism expenditure, with all BRIC countries except India, reporting double-digit growth. China posted an extraordinary 31% increase in spending, while the Russian Federation (+28%) and Brazil (+15%) likewise saw a sound increase during the period. Tourism spending was slower in the advanced economy source markets of Canada (+4%), the United Kingdom (+2%), France (+2%), the United States (+1%) and Germany (0%), while Japan, Australia and Italy saw declines in expenditure.

DNV has received accreditation from the International Society for Quality in Healthcare (ISQua) for its International Hospital standard. DNV is now poised for international accreditation expansion.
Karen Timmons of DNV says, “Receiving ISQua accreditation demonstrates to ministries of health, hospitals, funders and key stakeholder groups that organisations receiving DNV’s international accreditation meet the highest international benchmarks for standards and are focused on continuous improvement,”
DNV’s International Hospital standard integrates a quality management system based on ISO 9001 principles, along with proven proactive risk management principles and specific clinical and physical environment requirements to enhance safety and quality. Upon accreditation to the standard, the hospitals have a solid framework for identifying goals and implementing improvements at every level of their organisation. The accreditation provides assurance to patients, the public and stakeholders of the high standard of safety and quality of service provided by the hospitals.
The requirements of DNV International Healthcare Accreditation are based upon those in DNV’s USA standards that have been approved by the US Government’s Centers for Medicare and Medicaid (CMS). The international requirements have been adapted so as to have applicability internationally, with sensitivity to local laws and practices.
ISQua, the International Society for Quality in Health Care, is a non-profit, independent organization with members in over 70 countries. Its mission is to drive continual improvement in the quality and safety of health care worldwide through education, research, collaboration, and the dissemination of evidence-based knowledge.
DNV and GL have merged to form DNV GL. Driven by its purpose of safeguarding life, property and the environment; DNV GL enables organizations to advance the safety and sustainability of their business. DNV GL is a leading provider of classification, certification, verification and training services. Its origins go back to 1864, and today DNV GL operates globally in more than 100.In business assurance, DNV GL is one of the world’s leading certification bodies.

DNV Healthcare is the leading accreditor of US hospitals integrating ISO 9001 quality compliance with the Medicare Conditions of Participation. All by itself ISO is a framework perfectly suited to the complex, variable world of healthcare delivery. But when it is fully integrated with the Medicare Conditions of Participation, and proven effective by hospitals nationwide, it is something truly unique in the world of accreditation.
DNV Healthcare with offices in Cincinnati and Houston in the USA is a division of DNV Business Assurance, based in Italy.
DNV is rapidly expanding its hospital accreditation services. Over 300 hospitals in the US have switched to the NIAHO accreditation delivered by DNV. This standards platform, which is also the basis of DNV International Accreditation, is changing the perception of what accreditation is and how it can be used by hospitals to achieve optimum performance.
DNV Business Assurance rates public healthcare trusts in England on behalf of NHS Litigation Authority, is recognised by the Ministry of Health in Slovenia to meet its local requirements for quality and reimbursement, and has established a partnership with the China National Health Research & Development Centre in risk management for Chinese healthcare reform. Building on its extensive experience in biorisk and infection control, DNV Business Assurance has recently developed the first international infection risk management standard for hospitals.

With a dozen or more Caribbean countries targeting medical tourism, a specialist Canadian academic suggests that the Cayman Islands has a slim change of succeeding.
The Health City Cayman Islands project represents a new phase in the Caribbean’s medical tourism ambitions. While other countries in the region are happy with 50 to 100 bed hospitals, this 2,000-bed hospital project and supporting development in the district of East End in Grand Cayman is bigger than all schemes elsewhere in the region added together.
The medical tourism project, locally known as the Shetty hospital, has caught the attention of international researchers interested in the feasibility of large-scale medical tourism in the Caribbean and the potential effects of such a large development on a small territory like Cayman. The university’s medical tourism research group has studied the sector in Barbados, Canada, India, Jamaica and Mongolia.

Simon Fraser University Professor, Jeremy Snyder told local media, “One of the big key differences for the Health City development in Cayman is the scope of it. If they really spool it up to the size they are talking about, they will be a massive player globally. It will certainly be the largest such development in the Caribbean targeting international patients.”
Health City is a joint venture between Dr. Devi Shetty’s Narayana Hrudalaya group and Ascension Health Alliance, which runs the largest Catholic and nonprofit health system in the United States.
Another distinguishing characteristic of Cayman’s project is its reliance on foreign-trained medical professionals who will live on the island full-time.
Snyder argues that it is totally unrealistic to expect Canadian patients to fly to Asia, which is why the Indian group began the project in a country that is much nearer to Canadian and American patients
Snyder suggests that it is very difficult to predict if particular projects will work out or what their precise impacts – positive and negative – might be; “There is a lot of speculation out there, and not a lot of good empirical research.“
He argues that the good signs are that Health City is backed by Dr. Shetty’s group and Ascension Health, building has begun, and capital backing seems solid.
Existing medical tourism projects in the Caribbean are relatively small. Existing medical tourism in Caribbean countries tends to involve elective procedures such as fertility treatment or cosmetic surgery, or else offer services not available in the patient’s home country, such as stem cell therapy or prostate cancer treatment. But few Canadians or Americans travel far for heart surgery, the basis of the project.
Health City’s initial 140-bed hospital will focus on cardiac, cardiologic and orthopedic services, with costs at 40 to 50% of US rates. If all phases of the US$2 billion development get completed, all specialties will be available, in sixteen years time. Health City expects to get the first patients in early 2014.
In Cayman, Dr. Shetty is gambling that Health City will be attractive to doctors from different countries, particularly the USA and India, looking to settle locally, although living costs are not cheap.
Snyder worries that the magnitude of Health City raises some concerns, such as if there will be enough housing to accommodate large numbers of health care workers. Another human resources-related concern is if the medical tourism hospital will soak up technicians, nurses and orderlies from the public system. Other concerns about any major development, including Health City, are their possible negative impacts on the natural environment. Health City developers have repeatedly attested to the sustainable features built into the project.
Snyder concludes, “On the one hand, there is a lot of upside. There are many talented Indian doctors. Shetty, as a big player, may be able to pull it off. There are a lot of risks involved. It is an unproven concept in the Caribbean.”

When medical tourism speaks of accreditation, JCI and other multinational agencies are usually mentioned. But many small centres across the globe are turning to smaller and cheaper alternatives.
The vast majority of ambulatory surgery facilities in the world are unaccredited, operating independent of any peer review and inspection process. AAAASFI and AAAHC are now filling that gap.
The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) is the largest not-for-profit accrediting organization in the United States. More than 2000 ambulatory surgery facilities are accredited by AAAASF. AAAASF conducts an accreditation program that certifies that an accredited facility meets nationally recognized standards.
Until 2009, AAAASF limited itself to the USA. It expanded into countries where the majority of medical tourists are Americans requiring outpatient treatment. This may be very attractive to small hospitals and clinics for which international accreditation by JCI or others is not cost-effective compared to the volume of Americans treated.
American Association for Accreditation for Ambulatory Surgery Facilities International (AAAASFI) has developed a global programme to inspect and accredit surgery and dental clinics that exceed superior standards. All accredited clinics must pass inspection of all practice standards in the following categories: general environment and safety, operating room environment, policies and procedures, recovery room environment, blood and medications, medical records, quality assessment, personnel and anesthesia.
Fees are based on how many specialists work in the surgical facility. Facilities must be in 100% compliance with all standards and practices during and after the accreditation process. Once paperwork is complete and floor plan approved, AAAASFI can usually secure an inspector to evaluate a facility within 30 days.
AAAASFI now has members in Australia, Belgium, Brazil, Canada, Columbia, Costa Rica, El Salvador, Finland, Greece, Guatemala, Lebanon, Mexico, Serbia, South Africa, Switzerland and the West Indies.
The Accreditation Association for Ambulatory Health Care, accredits 5000 US organizations in a wide variety of ambulatory health care settings, including ambulatory and office based surgery centers, managed care organizations, as well as Indian and student health centers. The accreditation process involves self-assessment by the organization, as well as a thorough review by expert surveyors.
AAAHC began expanding internationally with Costa Rica, and last year expanded into Peru. AAAHC plans to expand to other countries in South and Central America have been slower than expected, with resources concentrated on the USA; but it expects to speed up the international side soon.

Ever since IMTJ began, there has been a discussion on whether or not EU rules on cross-border healthcare would have a major or minor effect on medical tourism.
When the cross-border healthcare directive was originally agreed, most of Europe seemed prosperous, but since then we have seen economic bailouts for Cyprus, Greece, Ireland, Portugal, Spain and others. We have seen political turmoil in several countries, with dramatic cuts to public healthcare spending in several. The European Union has expanded to 28 countries.
28 countries are full members — Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden and the UK.
Potential candidates for EU membership are Albania, Bosnia and Herzegovina, Iceland, Kosovo, Macedonia, Montenegro, Serbia and Turkey.
Over the last decade, the EU Court of Justice has issued rulings confirming the right for patients to be treated outside their home country and reimbursed under certain conditions, but the applicable rules were still not entirely clear.
Directive 2011/24/EU on patients’ rights in cross-border healthcare clarifies these rules.
In addition:•It creates a network of national contact points to provide clear, accurate information on cross-border healthcare.•It helps EU countries share experiences on how to provide patients with the best possible care, for example using new health technologies.
Directive 2011/24/EU on patients’ rights in cross-border healthcare clarifies the rules on access to healthcare in another EU country, including reimbursement. All the new rules and laws refer to planned treatment only; separate arrangements exist to deal with emergency and unplanned accidents and illnesses.
Under EU law, any EU resident can seek medical treatment in another EU country if:•The specific treatment they need is not available in their home country, but is covered by statutory health insurance/ free national health system.•Or the medical circumstances of their case mean they might not receive the treatment in time. Medical circumstances include degree of pain, the nature of any disability (which might for example make it impossible or extremely difficult to work), the probable course of the disease, and medical history.•If people want their home health insurer to cover the cost of hospital treatment abroad, they must ask for prior authorisation.•Once authorised to seek medical treatment in another EU country, they should be treated there on the same terms – and charged the same costs – as a person insured in that country.
EU countries have until 25 October 2013 to pass their own laws implementing the Directive.
Even countries supportive of the changes such as the UK, Netherlands and Germany have been very late in bringing in regulation, a supporting network and new rules for their citizens on when and how they can get planned healthcare in other countries.
Those strongly opposing the directive have delayed and dithered so much that several could take years to implement legislation. The country leading the opposition to the whole concept was Spain, and in recent months it has shown that it has little interest in complying, with flagrant disregard for existing regulations on unplanned and emergency healthcare for foreign nationals. Many reports have said that the European Commission is taking legal action against Spain, but these are not correct. At present all the European Commission can do is investigate problems; trying to prosecute a country that no longer has enough money to provide healthcare for its own people would be a long, tedious and probably pointless exercise.
The vast majority of countries seem to be in agreement with the principle of the new laws, but are not hurrying to do much about it. A few small countries that see great potential to send citizens overseas are changing their laws. One problem is that there is no central database recording where each member country is with legislation and setting up systems.
Meanwhile, the current and expected effect on medical tourism in Europe seems negligible.

The new Belize Medical Tourism Association seeks to promote medical tourism to Belize and eventually end the practice of Belizeans going abroad for medical care.
The association has members from the medical and tourism sector. It sees medical tourism as an opportunity for medical practitioners and wants more members of the Belize Medical and Dental Association to join. Foreigners have been accessing medical services in Belize for years but in an ad hoc manner. Now, Belize will be marketed internationally as a destination for medical tourism. Patients will be offered packages that include medical services, hotel accommodation and tours.
Belize is a tiny country with only 318,000 residents. The former British colony is very close to the United States, and as a tourism driven economy gets 918,000 tourists a year, two thirds of them from the USA.
At present it gets a few American medical tourists a year, mostly for dental work. To expand medical tourism it will need outside investors to partner the few local private hospitals by expanding, updating and improving their facilities. The limited state system will not get involved in medical tourism.
Belizean doctors generally come from abroad, some as volunteers to help the locals, and the vast majority work in publicly funded clinics or hospitals with very little time and resources for special care. However there are a few doctors that run their own private medical and dental practices, with some even advertising to foreigners.
The Belize government wants to develop medical tourism but Belize has a problem with violent crime, much of it drug-related, and the trafficking of narcotics to the US. Belize is on a US blacklist of countries considered to be major producers or transit routes for illegal drugs.
The government sees the only way of making medical tourism work is to encourage overseas investors to set up in the country, preferably as partners to locals. But talks so far have failed as the investors want to have total control, and to fly in US doctors as needed, which most local medical professionals oppose.
Most available medical procedures are cheaper in Belize than in the USA, but many locals head north into Mexico for treatment, where costs are even lower, facilities are better and more procedures are available. Facilities, equipment and doctors in Belize are in extremely short supply, so the range of available treatments is limited at best. No local hospitals have international accreditation.
The Belize Trade and Investment Development Service (BELTRAIDE) has weighed the pros and cons of medical tourism to provide input before developing an effective national policy.
Despite all the problems Dr. Marcelo Coyi of the Belize Medical Tourism Association is positive; “Medical tourism will vastly improve the healthcare service of Belize. It will create jobs and strengthen the economy. A foreign investor in medical tourism is likely to partner with a local hospital. Money will be spent to improve the hospital’s facilities. That investor will then promote the benefits of receiving care at the hospital to their clients. Another investor in medical tourism may prefer to partner with a local doctor to provide care for their patients. A cardiologist in the United States would partner with a cardiologist in Belize to offer heart surgery to their patients in Belize at a cost more than ten times cheaper. Our local doctors will improve with more medical practice; they will be making more money, and the foreign partner will make a hefty profit as well. Medical tourism also makes the country more likely to keep talented Belizean doctors at home.”

Wellness tourism is growing rapidly, but a survey shows that travel agents, particularly in the USA, do not fully understand the market.
The surging interest in healthy lifestyles, coupled with the desire for unusual travel, is contributing to the growth of the wellness tourism market. Consumers are using vacations to jump-start a health regimen, detox from a digital word, and learn healthier behaviors. While wellness-focused vacations are one of the hottest trends, US travel agents, suppliers and destinations report they need more information in order to successfully sell wellness travel.
According to a series of surveys aimed at travel sellers and travel suppliers conducted by Wellness Tourism Worldwide between 2012 and 2013, respondents identified the following needs for better understanding of:•Wellness travel products and services.•Wellness travel motivations•Wellness consumer demographics•Consumer health issues
With epidemic levels of stress contributing to chronic disease, it is no surprise consumers want vacations designed to benefit mind, body and spirit.
Camille Hoheb of Wellness Tourism Worldwide comments, ”Health opens the door to a whole new world – as does travel. Wellness travel presents an amazing opportunity for both the travel industry and the clients it serves. It is both personally and professionally rewarding; everyone wants to be vibrant and well. Over the last couple of years I have enjoyed meeting hundreds of travel sellers who are excited about wellness travel. Yet, they told me they do not know where to start. So we wrote a how-to guide with the input from hundreds of travel professionals and consumers.”
’The Guide to Selling Wellness Travel’ is written specifically for travel agents, but is a useful resource for anyone interested in selling wellness travel. Cost $39.

By the end of 2015, all residents and expatriates in Qatar will be covered by a national health insurance scheme that will lock out other health insurers but with a window for them to offer treatment abroad.
The standard of health care in this very rich country is good, but can be expensive. Qatar has implemented national healthcare reform intended to alleviate the state of the burden of healthcare costs within the local Qatari population. Only one in ten Qataris has private heath insurance.
By 2015, all individuals living within the country will have a private health insurance policy. In the case of local Qataris this will be funded by the government, however for expatriates employers will be responsible for the provision of appropriate cover, and in the few cases where there is no employer the expatriate themselves will have to buy cover. The fees will be paid annually along with the renewal of residence permit. Cover for locals will be wider than for expatriates.
Qatar’s universal health care coverage program is in five stages and is expected to be fully operational for Qatari citizens and expatriates by the end of 2015.
The pilot phase of the NSHI was launched in July 2013 with Qatari women being provided coverage for maternity, obstetrics, gynaecology and other related issues at Hamad Medical Corporation (HMC) and a selected few private hospitals.
The second stage to be launched in the first quarter of 2014 includes all Qataris, offering them all basic health services at HMC and other private health services providers.
The third stage, scheduled for the third quarter of 2014, will target Qataris and with the coverage expanded to 23 primary health care centres. White collar expatriates and visitors are to be covered by the NSHI’s fourth stage in the first quarter of 2015 and blue collar expatriates in the fifth stage by the end of 2015 at three specialised labourers’ hospitals.
85% of the working population is expatriate; some professionals but mostly low paid domestic and manual workers. Expatriate workers outnumber Qataris by six to one.
New state company National Health Insurance Company (NHIC) runs the country’s new health care insurance system- National Social Health Insurance (NSHI). Qatari insurance company Al Khaleej Takaful has been appointed as the third party administrator for NHIC to handle essential administrative processes.
NHIC will make annual contracts with healthcare providers, based on a unified schedule of fees and charges. NHIC will cover a basic bundle of health services. Other operators could also cover additional and optional services, which give room for partnership with different entities. Though insurance companies will not be able to cover basic health services for the next 10 years, they can cover additional and special services not covered by the main scheme such as cosmetic procedures and treatment abroad. All the public and private health care providers in the country will be included in the NSHI scheme within 10 years; it is up to each entity to attract customers by providing good services at competitive prices.
The local government is authoritarian, and as it owns the national insurance company and many of the hospitals, it now seems that competing insurers will be locked out from providing cover for locals or expatriates, except for supplementary cover above that provided by NHIC.
Local and international insurers had hoped they would be able to compete with the national scheme, but a meeting clarified the position.
Dr Faleh Mohamed Hussein of the Supreme Council of Health explained.”All the public and private health care providers in the country will be included in the NSHI scheme within 10 years. Our target is to provide all the inhabitants of Qatar, even visitors, with the best basic health services, and it is not about profit or loss. Most countries are now opting for NSHI as the only system that services the interests of both nationals and expatriates. Some GCC countries are now trying to benefit from Qatar’s experience. NSHI will cover a basic bundle of health services. Other operators could also cover additional and optional services, which give room for partnership with different entities. We have started with a limited number of hospitals in the pilot phase. Insurance companies will not be able to cover basic health services for the next 10 years but could still cover additional and special services not covered by the main scheme such as cosmetic procedures and treatments abroad. Local insurers may lose health business when NSHI is fully implemented, but the impact will be very limited as they have other areas they can expand other fields to make up for this.” Private health insurance in the region is still new so it will be unlikely that local health insurers will offer cover for cosmetic surgery or treatment overseas.
The new insurance may put an end to the 1,000 or so Qataris that the government pays to go overseas for treatment. But it is unlikely to stop the increasing numbers of well-off locals who pay to go to Europe and Asia for medical treatment.

Much has been written about how uninsured Americans are a key medical tourism target. Most of this is now out of date as this October sees the first national move to get more Americans buying their own health insurance to cover treatment at home.
The key changes of the new healthcare law is that from January 2014, all individuals must either have health insurance via their employer, or buy their own cover.
• Those without insurance will receive a tax penalty• Anyone earning less than $45,960 will be eligible for tax credits to help reduce insurance costs. • Health insurance exchanges offer new Bronze, Silver, Gold, and Platinum plans from a range of insurers.• Increased Medicare benefits means very few people have no health insurance.
The number of people unable to buy cover will shrink drastically as:• It is now illegal for health insurance policies to put limits on how much they pay people for medical bills.• Insurers can no longer charge people more if they have a pre-existing condition, no matter how severe; and cannot turn away new customers.• Those who earn less than $45,960 as an individual (or $94,200 for a family of 4) will receive a tax credit to help pay for some or all of the insurance premium. There is a large portion of the American population who currently have no health insurance. That is fine if their health remains good. But all it takes is getting sick for a few days or getting injured, and they can be saddled with medical bills they are unable to pay. The situation has deteriorated in recent years with more and more Americans facing bankruptcy due to medical bills.
As of 2014, all Americans will be required to carry health insurance. Any American who has not purchased a health insurance policy by April will be subjected to tax penalties. Suggestions that people will choose to opt out totally underestimate the reach, aggressiveness and power of the US tax authorities.
In the past, parents could no longer carry health insurance for older children after their 18th birthdays unless they were full-time students. Now parents will be allowed to carry a health insurance policy on for their child until that child has passed their 26th birthday.
Insurers could turn away people with pre-existing conditions, especially conditions like diabetes and cancer, as uninsurable. The new laws mean it is virtually impossible for the insurance company to deny anyone at all.
The new law has created a few different standards of health insurance. The gold and platinum policies will be more than most people can afford, but the lower two standards, bronze and silver have been designed to be affordable. Anyone who purchases either of these policies will only have to pay a nominal monthly premium.
Forcing the health insurance companies to cover the cost of free preventative medical procedures is another innovation. The free screenings include: mammograms, colonoscopies, depression, obesity, and blood pressure. And there is a wide range of free counselling including on stopping smoking and domestic violence.
The impact of “Obamacare” calls into question the strategy of targeting uninsured or underinsured Americans with medical tourism services.
To help Americans find affordable health insurance, a new network of private, state and national health insurance exchanges has been set up. Each state will have its own online marketplace, or exchange, and offer in-person help. Some states, including Maryland, will run their own marketplaces. The federal government will run others, including Virginia. A federal site, The Health Insurance Marketplace, will direct people to the right marketplace.
The marketplaces will tell people if they are eligible for Medicaid, which many states are expanding, or if they should sign up for private plans. Small businesses will also be able to sign up their employees for policies on the marketplaces in many states. People with employer-arranged cover will not buy on the exchanges, nor will those on Medicare, Tricare or Veterans healthcare plans.
Medicaid provides health coverage for some low-income people, families and children, pregnant women, the elderly, and people with disabilities. Medicaid programs must follow federal guidelines, but they vary somewhat from state to state. Medicare benefits have expanded under the health care law–things like free preventive benefits, cancer screenings, and an annual wellness visit.
As insurance sold via exchanges is regulated in what it can cover, there is no scope for the many millions of policies sold via exchanges to include any element of medical tourism cover; so those targeting Americans for medical tourism will have to concentrate on mostly uninsured areas including dental treatment, cosmetic surgery, obesity treatment and fertility treatment.
27 million Americans are expected to buy health insurance through exchanges. 19 million could qualify for a subsidy to pay all or part of the costs of health insurance.

A recent decision of the Indian government is to allow its senior officials to have medical treatment outside the country and be reimbursed for the best possible medical care abroad, with the costs borne by the taxpayer.
84,000 top civil servants of the IAS and IPS are now entitled to reimbursement for medical treatment abroad; including airfare and the expenses of an attendant. Reimbursement for treatment abroad was earlier restricted to MPs and IFS officers working abroad. The new notification modifies rules that have been in force for 30 years. There are checks —treatment abroad must only be for complex procedures cleared by a medical panel — but the principle has upset hospitals promoting India as a location where all types of treatment are available.
According to health minister Ghulam Nabi Azad, the latest medical tourism figures are for 2011, but all indications suggest that 2012 and 2013 could even be lower ”The has been a decrease in the number of foreigners visiting India for medical treatment in 2011, compared to 2010. Of the total 63 million foreign tourists in 2011, 138,803 came seeking medical treatment. In 2010, of the total 57.8 million foreign visitors, 155,944 came for medical treatment.”
In view of the falling rupee against foreign currencies, the number of medical tourists to India has jumped by 40 % in the past six months, according to the Associated Chambers of Commerce and Industry of India (ASSOCHAM). DS Rawat of ASSOCHAM claims, "The fall of the rupee versus the dollar has proved to be advantageous to patients from Middle East, Africa and SAARC countries to the extent of 35 to 45 % saving on complex surgeries. So the inflow of patients has also gone up by 40 % during the last six months.” The ASSOCHAM figures have to be used with caution as over recent years they have regularly claimed millions of medical tourists when official figures put numbers in the region of 250,000.The recent ASSOCHAM announcement claims that Indian gets 2.5 million medical tourists and that this will increase to 4.5 million by 2015; both figures are a tenfold multiplication of government estimates.
ASSOCHAM claims Indian medical tourism has an annual growth rate of 25 %. Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, Maharashtra and New Delhi are fast emerging as the states where hospitals and clinics have the most benefit from medical tourism.
That the Indian government has no joined up policy on medical tourism is shown by the independent actions of various departments all pulling in different directions.

The Tourism Ministry has extended a financial support scheme to include medical tourism. The ministry organises road shows in overseas markets, participates in travel marts, creates brochures, CDs, films and other publicity materials for promotion of medical tourism.

A partnership between Courtyard by Marriott in Bali and its neighbour in Nusa Dua, the new Bali International Medical Centre, is expected to see a sharp rise in medical tourists from the region and beyond.
The 250 room Courtyard by Marriott – the brand’s 900th hotel worldwide – links a popular hotel brand in the four-star segment with the most up-to-date medical facility in Bali to produce what Marriott says is "the first medical tourism hotel in Indonesia".
At BIMC, services offered include emergency and in-patient care, dialysis treatment, cosmetic procedures and dental treatment.
WiFi and TV connections along with services such as reflexology, manicures, pedicures and facials are available to in-patients to help recovery from treatment.
BIMC is planning other health and medical facilities that include retirement villages with integrated medical care along with further clinics and hospitals in Bali and throughout the Indonesian archipelago.
With 900 locations in 36 countries, Courtyard is Marriott’s largest brand. All Courtyard by Marriott hotels participate in the Marriott Rewards frequent travel programme that allows members to earn hotel points or airline miles for every dollar spent during each stay.
BIMC Hospital Nusa Dua is the group’s second hospital to open in Bali. It was opened in May 2012 in the centre of the Bali Tourism Development Corporation complex. A key target market is medical tourism to Indonesia, so it has foreign technical staff and an international multilingual team.

Ramsay Sime Darby Health Care, a joint venture between Sime Darby’s health unit and Ramsay Health Care, expects to expand its hospital network to at least 12 in the next three to five years.
Tan Sri Mohd Bakke Salleh of Ramsay Sime Darby Health Care explains. “ The expansion plans go beyond Malaysia and Indonesia. It is all dependent on the commercial benefits. We are looking at potential in Indonesia and Malaysia, as well as other parts of South-East Asia. Two key potential countries are Vietnam and China. It will take three to five years to generate positive cash flow, as we seek expansion with both greenfield and brownfield hospitals around Asia.”
The company says that three to five years is the normal gestation period for such investments but a typical payback period for hospitals is about nine years. On average, a new hospital would cost the company RM200mil to RM300mil while existing hospitals will depend on the market value.
Expansion into China is slow, as although it has identified certain locations and met up with operators, it cannot proceed without local partners.
The company will continue to source for locations where there is a catchment of middle-class people. In Malaysia and most markets, prime hospitals are always in developed areas.
International patients make up of 6% of total patients in the Malaysian operations at the moment; these are expatriates, travellers and a few medical tourists. The group hopes to increase the international patient numbers to 10% in the Malaysian hospitals within two to three years.
At the moment, the group has three Malaysian hospital assets from Sime Darby Healthcare and three in Indonesia from Ramsay.
Healthcare service providers should tap into the growing health tourism sector in an effort to turn the nation into a regional healthcare hub, argues Malaysian prime minister Seri Najib Tun Razak; “This can be achieved by healthcare service providers entering into cross-border collaborations with their international counterparts. Efforts to develop health tourism sector via national key economic areas and the Malaysia Healthcare Travel Council have shown positive results. Over the past three years, Malaysia has seen more than 20% growth in health tourism, and generated almost RM600mil in revenue last year. The positive growth is due to MHTC’s role in providing the technological platform for web-based medical and health-related information to a global audience. Among the countries fast becoming interested in Malaysia’s medical tourism industry is Japan, which has registered 20% growth. Many Japanese are those under the Malaysia My Second Home programme or via word of mouth from friends and relatives.”

The Malaysia Healthcare Travel Council (MHTC) predicts 700,000 medical tourists to the country in 2013. Dr Mary Wong of MHTC says, ”Malaysia received 392,000 medical tourist arrivals in 2010 which increased to 583,000 in 2011 and 671,000 in 2012. We aim to increase the numbers by up to 15 % per year.”

A new paper argues that local claims of the potential for medical tourism in Jamaica and other Caribbean islands are unrealistic due to the limited health resources and skills available.
Professor John Connell of the University of Sydney, Australia, has written a paper ’Medical Tourism in the Caribbean Islands: A Cure for Economies in Crisis? ’, published by The University of Prince Edward Island.
Abstract”Small island states have increasingly sought new means of economic diversification. Several Caribbean states have begun to develop medical tourism, partly building on existing tourist-oriented economies. Medical tourism has boomed in this century in several states in Asia and in Central America. The Bahamas, Barbados and the Cayman Islands exemplify different strategies for medical tourism, in order to generate foreign exchange and new employment, and reduce costs from overseas referrals. Most medical tourism projects have been developed by overseas corporations and are oriented to a US market. Business principles rather than healthcare dominate development strategies, notably of emerging transnational medical corporations, and raise ethical issues. Success will be difficult to achieve in a crowded and competitive market.”
Connell is critical of the strategies of Caribbean countries. He suggests that some can develop a limited medical tourism industry if they focus on nationals who have gone to live overseas and/or offer limited niche offerings for overseas Jamaicans when they visit; only if they can attract skilled doctors and nurses back from overseas.
Most Caribbean islands have some potential for medical tourism as:• They are familiar to tourists from North America and Latin America.• They are easily accessible by the target Americas markets.• They have tourism oriented economies and infrastructure.• English is the main language and Spanish is spoken too.• Most island states have modern healthcare systems.• Diasporic tourism (locals and their descendents who live abroad) is significant.
But they all have common problems-• Healthcare systems are adequate but not as complete or up to date as many of the countries they are targeting.• There are concerns over quality of care and aftercare.• Where quality of care is essential, it is hard for small states to market or prove this.• They face strong regional competition from Mexico, Cuba, Panama, Costa Rica and others where travel costs and care costs are lower.
The number of island states seeking to develop medical tourism continues to grow, despite the problems, and the challenges of breaking into an overcrowded and competitive global market where price matters and experience is critical. Some are being misled by outside consultants who make implausible claims and promises.
Success is possible for some, but others have little hope of breaking in. Offering specialisms that are not readily available in the US, Canada or local countries is the most likely route to limited success; but numbers will always be small compared to elsewhere.
Potential winners include-• Antigua addiction therapy• Barbados fertility tourism• Bahamas prostrate cancer and spinal surgery
The small-scale success of the Barbados fertility centre contrasts with the huge projected numbers in the Cayman Islands. A new 140-bed Barbados hospital would need 10,000 patients a year to give investors any profit. A 2000 bed Cayman hospital would need 150,000 clients a year to make money. Most medical tourists go with a companion or family, placing enormous pressure on local resources. Estimates of potential numbers are probably inflated. Not all new projects will succeed, or even launch, as there are suggestions that some potential investors in announced proposed ventures are having second thoughts as to whether they would ever get their money back.
Those countries who could have some success are where the country and healthcare offerings are sophisticated. But the region suffers from relatively high costs compared to established regional competitors. Developing sophisticated and expensive facilities with no guarantee of success in a sensitive industry with boom and bust cycles is risky at best. There is a lack of skilled health workers. The new US insurance regimes exclude medical tourism outside the USA.Medical tourists tend to go offshore for simpler low risk procedures rather than complex surgery or long-term cancer treatment.

As part of efforts to save the country an estimated $200 million in foreign exchange that it loses annually from medical tourism to India and other countries, the governor of Lagos state Babatunde Raji Fashola, and minister of health, Professor Onyebuchi Chukwu, have inaugurated a new Indo-Nigerian multi specialty clinic, Vedic Lifecare Nigeria.

Vedic Lifecare Clinic was set up by Indo-Nigerian businessmen with clinical, technological and management support from Manipal Hospitals of India. Manipal Hospitals is one of the most patronised hospitals by Nigerians on medical tourism to India.
The Nigerian local government says that with state population of 21 million, it is very difficult to meet the health needs of all Nigerians. So as well as existing state run hospitals, it seeks outside investors to help build new hospitals. It has nominated Lekki to be home to a medical village where investors who want to partner with the state can help to provide local healthcare services in a small-scale medical city.
The government says – “With Vedic Lifecare Clinic there will be no need for anybody to travel to India for medical treatment. We appreciate the partnership they have brought to us. We can now save our airfare, accommodation, the trouble of procuring visa and other expenses in India. We promise a good return on their investment.”
On a national basis the government is determined to curb outbound medical tourism. It hopes that perhaps within the next five years they will see people going to Nigeria for medical treatment. But small hospitals like this new family oriented healthcare facility will work for local care, rather than high-class medical tourism.
Much of the government’s health strategy depends on the upgrade of federal hospitals to deliver better health services, training of health personnel and the involvement of the private sector.
Rajen Padulone of Manipal Health Enterprise commented, “A social seed sown more than five decades ago is today the country’s third largest healthcare group with a network of 15 hospitals and three primary clinics providing comprehensive care that is both curative and preventive in nature for a wide variety of patients not just from India but also from across the globe. Our focus is to develop an affordable tertiary care multispecialty healthcare framework and further extend it to homecare. With this new Nigerian venture we seek to take an international standard of medical service to Nigeria- which has been suffering from serious disease outbreaks.”
Vedic Lifecare Nigeria is planning a bigger hospital next to the new one, which they hope will be commissioned within five years. It also plans to take the concept to Abuja, Port Harcourt and Warri.The company aims to provide healthcare for the local population at affordable prices through the Manipal Hospital Network. It will offer the same range of multi-disciplinary specialist to the people of Nigeria as obtainable in India.
Nigeria’s plan to have at least one world-class private hospital and diagnostic centre in each of the six geo-political zones of the country by May 2015 is nearing fulfilment. A national health committee has analysed the low private sector involvement in the country’s medical businesses and drawn up strategies for improvement of private health entrepreneurship. It is on the verge of developing a business model for the sector to encourage private sector collaboration in the nation’s healthcare business. The committee claims that an average Nigerian medical tourist spends between $20,000 and $40,000 on a trip.
The Federal Ministry of Health is also working on a National Health Insurance Scheme, and legislation for this is underway.

As part of its international "Find Your Fabulous" wellness and medical tourism campaign, the Tourism Authority of Thailand (TAT) has a friendly global competition intended to salute ladies who are still fit and fabulous after their 40th birthdays.
The Fabulous 40+ Photo Contest invites women from around the world to submit images showing off their fabulous form, and the contestant showing the most youthful, age-defying appearance will be rewarded with an exclusive 3-day Find Your Fabulous trip to Bangkok.
On Facebook, candidates become fans of ThailandMedTourism and the Find Your Fabulous campaign; then, they submit their most fabulous photos – with their name, age range (40+, 45+, 50+), current location, and a photo description. Submissions should show the fresh face and figure, confidence, poise, and charisma that define the modern woman today in her 40s, 50s, and 60s and beyond.
The winners of the Fabulous 40+ Photo Contest will be determined by the number of votes. The one with the most votes will be the winner, followed by the first and second runners-up respectively. The winner will receive a 3-day/2-night exclusive health and beauty package for herself and one friend.
In addition to a full medical checkup, dermatology treatments, and a spa package, the grand prize also includes two roundtrip air tickets and a deluxe 2-night stay at the stylish 5-star Sofitel So Bangkok, with daily breakfast. The first runner-up will receive the health & wellness packages for two as well as accommodation, while the second runner-up will receive the health and wellness packages for herself and a friend. All the awards – 3 awards for 2 persons each – bring the total value of the prizes to over USD $30,000.
The contest runs until the 30th of September 2013, with the winners’ announcement via Facebook scheduled for the 3rd of October. Awards are redeemable between the 15th of October and the 15th of December, 2013.
TAT hopes that the Fabulous 40+ Photo Contest will promote Thailand’s thriving medical and wellness industry. Thailand has become a leading wellness spa destination, providing many therapies, earning itself the unofficial title of Spa Capital of Asia. Bangkok, Chiang Mai, Hua Hin, Koh Samui, and Phuket – major destinations for both health and leisure tourism – are all home to many wellness spas catering to Thais and travelers.

Taiwan is succeeding in attracting well-off Chinese tourists from the mainland with health examinations packages.
Ever since Taiwan authorities launched a 15-day health/medical tourism permit for mainlanders last year, more than 30,000 people have traveled under the initiative, mainly for high-end physical checkups, cosmetic surgery or anti-aging therapies, according to the Taiwan External Trade Development Council.
The new policy aimed to broaden the island’s health tourism market by attracting more customers from the mainland. Residents of 26 major cities on the mainland can travel to the island on an individual basis, while medical tourists in groups on package tours can be from anywhere in China.
Only 39 hospitals and clinics are authorized to treat Chinese medical tourists. One of these, Shin Kong Medical Club of Taiwan has had 3000 since the new rule was implemented. Hung Tzu-Jen of Shin Kong Medical Club explained, “Most are rich male entrepreneurs between 45 and 55 from Jiangsu, Hebei and Fujian provinces.” The hospital focuses on health screenings for cancer and cardiovascular diseases, which have become top killers across China. Each customer spends $1,230 on average for a package. These customers make up 5% of the total at the clinic.
Taiwan strikes a good balance between quality and affordability. But as more countries target Chinese medical tourists, faces stiffer competition. The very well off Chinese from Beijing and Shanghai are increasingly looking to Europe, UK and the USA, as they do not need to save money and see these areas as offering extra.
Wang Chen-fu of the Bureau of Foreign Trade commented, "Regulatory liberalization on both sides of the Taiwan Strait has created the perfect conditions for developing cross-strait medical tourism. In June 2011, Taiwan opened its door to independent travelers from mainland China, and from September the number of mainland Chinese cities from which independent travelers can embark on visits to Taiwan has increased to 26.The recently signed Cross-Strait Trade in Services Agreement will expand two-way interchange of medical services. Under the agreement, Taiwan healthcare services firms are able to operate independently invested institutions in all 22 mainland Chinese provincial capital cities, as well as in four special municipalities. This is up from four provinces and one major city before negotiation of the treaty.”
The Ministry of Health and Welfare reports that international medical care centres are to be established in Taiwan’s free economic pilot zones. They will provide referral services to medical tourists from abroad.

The city of Ruzhou in Henan province is seeking to build a medical tourism resort. The Boyi Group from Taiwan plans a cross-straits Ruzhou hot spring medical tourism resort that will be the first of its kind in the world. By combining the advanced medical services system in Taiwan with the natural and cultural resources in Ruzhou, the resort aims to attract visitors who want to restore their health.
Phase one construction covers an area of 133 hectares, with an investment of $860 million. It will provide four kinds of themed packages: hot spring recreation, health checks and cosmetic surgery, 9D cinema experiences and Chinese culture seminars. The 400-hectare resort is expected to be completed within three years.
The Boao Lecheng International Medical Travel Zone, a special zone for overseas medical institutions in Hainan, will begin construction within 3 months after preliminary plans have been completed. Upon completion the health centre in Lecheng will be equipped with high-end medical equipment, providing the most advanced cancer treatment and anti-aging services. The project, which covers a land area of 20.14 square kilometers, is expected to be completed and put into use within 2 years. Project developers Hainan Boao Lecheng Development Holdings has established a long-term cooperative relationship with the London Zero Carbon Pavilion, Tsinghua University, and Tongji University.
Qixiangling Rain Forest Hot Spring Resort plans to work with local hotels, golf clubs and tourism enterprises to build a local tourism brand. With abundant rainforest resources, fresh air and clear water, Qixiangling plans to build itself into a brand health care tourism destination.
As the first international brand hotel in Qixiangling, the Hilton Hotel Qixiangling has plans to transform the hotel into a healthcare resort, which is expected to open for business by the end of the year.
The establishment of the alliance of local resorts means that advertisements will be displayed at airports and bus stations to boost the brand image of Qixiangling healthcare tourism.
The medium- and long-term plans for Qixiangliing health care tourism are also to be decided in the near future.
Many medical professionals believe that China can be competitive globally, given its low healthcare prices. Shanghai was among the first places in China to get serious about medical tourism. In June 2010, the Shanghai Medical Tourism Products and Promotion Platform was established with the support of local government agencies including health and tourism bureaus. The platform was soon able to bring together over 20 participating hospitals in the metropolis, handling patient inquiries online, helping contact hospitals that can offer the right treatment, and even arranging the entire trip. The company that runs the site says it gets 100 inquiries a month, but is much vaguer on numbers who actually go to China for treatment.

Shanghai East Hospital treats 50,000 foreign patients a year, but most of these are expatriates working in the city or travellers, so this doesn’t give an accurate idea of how many people have travelled to China for treatment.
Hainan Province plans to build a special zone for medical tourism, the first in the country. Sanya Hospital in Sanya, Hainan Province, has been promoting Chinese therapies such as acupuncture, massage and cupping therapy to attract tourists. The hospital gets around 2000 overseas customers year, mainly from Russia and Central Asia, and it now has a travel agency to help expand its medical tourism business.
Chinese hospitals may be cheap, but apart from a few targeted at international patients, most struggle badly on aspects such as international patient communication and management, patient safety and security, partnerships and value of service. China is undergoing healthcare reform and one of its primary goals is to strengthen the non-profit status of public hospitals. The local debate is whether or not medical tourism, as a relatively high-end form of healthcare, might take away resources needed for the basic healthcare of the Chinese population.
Government regulations now allow public hospitals to set aside 10 % of their medical resources to VIP services for local and international patients, which could be used to develop medical tourism.
Another uncertainty is the Chinese government’s commitment to developing medical tourism, as building the industry to be truly internationally competitive would involve cooperation between a number of government agencies including health, tourism and immigration. There are no signs that this is going to happen in the immediate future.

Since a national insurance system was launched in Rwanda, citizens regularly cross the Burundi border to get better, cheaper care.
Rwanda is a poor rural country with and although it has a national insurance system, local hospitals are every strict on not offering free treatment even if just one family member at an address is not recorded as having paid for their health insurance card. Records are poorly kept and hospitals use any excuse.
Across the border in neighboring Burundi, doctors and nurses are less strict; the National Health Service is also much less expensive, and available both for Burundians and Rwandese. The Burundian health service is fast and efficient and often treats Rwandese patients first due to the distance they travel.
Another advantage for patients crossing the border is that several Burundian hospitals are close to the border with Rwanda. Going there costs less than being transferred to more distant Rwandese hospitals. The subscription to a private insurance is optional in Burundi, as opposed to Rwanda where it is a compulsory national insurance scheme run by private insurers.
The currency exchange rate also affects the medical exodus to Burundi. One Rwanda franc is worth more than two Burundi francs. So care is cheaper in Burundi.
The migration of Rwandese patients started as soon as the nation’s compulsory private health insurance policy was launched in 2009. The authorities did not understand why a large number of people living near the border had still not subscribed to this new universal access to health care. Very poor people from the overpopulated region of the North, who came East searching for arable lands, were the first to go to the Burundian health services.
It has become normal for Rwandese people who live near the Burundian border to go over the border just for minor treatment.
Burundi, one of the world’s poorest nations, is struggling to emerge from a 12-year, ethnic-based civil war. Half the population lives below the poverty line.

Cyprus is aiming to attract more medical tourists through the use of "imported" doctors. The Ministry of Health has granted temporary licenses to doctors from non-EU countries that are interested in providing treatment and performing operations on foreign patients in Cyprus, provided that the medical treatment is not practiced by Cypriot doctors.
The Ministry of Health and Cyprus Medical Association are co-operating so that Cypriot doctors can benefit from this plan, through their further training in operations and medical practices, which are not provided in Cyprus. The Cyprus Tourism Organization and Cyprus Medical Association are working together to promote the island as a medical tourist destination. The Cyprus Health Services Promotion Board is also focused on the development and promotion of Cyprus as a Medical Centre and the provision of health services in general. The Board was founded in November 2006 after an initiative taken by the Cyprus Chamber of Commerce and Industry (CCCI), and brings together healthcare providers across Cyprus who deliver services to residents, holidaymakers, visitors and travelling patients.
Local newspaper Cyprus Mail was not impressed by the plan to "import" doctors and commented, “Could anyone seriously believe that granting temporary licences to foreign surgeons to perform a few dozen operations a year in Cyprus would promote medical tourism? Even most of the money that would be paid for these operations would be taken out of the country by the foreign surgeons; hence the economic benefits would be minimal. To attract medical tourism a country needs not only several well-equipped hospitals, but also many specialist doctors. Cyprus has neither because the small population cannot justify the creation of big general hospitals or allow the development of the level of specialisation that would attract patients from abroad. If the government were serious about developing medical tourism it would first have had to carry out an in-depth study of how this could be achieved. We suspect that as soon as it saw the level of investment required, in equipment, facilities and human resources to turn Cyprus into a regional medical centre it would immediately abandon the plan.” There is room to improve the promotion of Cyprus tourist destinations online, according to a recent study by the University of Nicosia and PricewaterhouseCoopers. It looked into Cypriot tourism to record opinions, views and messages from the two main factors that shape the tourist scene – the tourists and the local professionals.
The food, accommodation and hospitality were listed as the island’s strong points where tourists seem to be especially satisfied. On the other hand, tourism-related websites are not frequently visited.
PwC Cyprus examined and evaluated specific forms of tourism, conducting targeted interviews with selected people from the tourist activity in Cyprus. They concluded that health and wellness tourism was popular as one in three tourists visit Cyprus for health and wellness reasons, recording a significant increase in comparison to previous years.
The main advantages of health and wellness tourism include the quality of services and facilities as well as the quality of added services. Despite the fact that tourists were generally satisfied with the tourism infrastructure in Cyprus, only a small percentage of all tourists (6.3%) said that they got their money’s worth in Cyprus.

The UK’s second biggest cosmetic surgery provider, The Hospital Group has acquired a controlling share in Mills and Mills, a medical tourism company in Spain.
Mills & Mills was founded in Marbella 4 years ago by British husband and wife team David and Debbie Mills. Having over 35 years cosmetic surgery experience between them they recognized a gap in the market and have since become one of the leaders of medical tourism in Spain. Despite the recession, cost of air travel and overseas accommodation, record numbers of British patients are choosing to undertake treatment with Mills & Mills in Spain for cosmetic, dental and weight loss treatments. With investment from The Hospital Group they can now implement their plans for expansion.
The Hospital Group continues its international expansion and this deal follows a recent acquisition of four clinics in Ireland. It offers patients a safe option should they prefer to have their surgery abroad. For Mills & Mills it means that their patients can continue to benefit from pre and post surgical consultations at The Hospital Group’s UK and Ireland based clinics. Both companies are looking to expand worldwide. The companies have plans to employ top surgeons from around the world and they have recently appointed top cosmetic surgeon Dr Mario Russo as clinical director.
David Mills of Mills & Mills says” We are very excited to be working alongside The Hospital Group. Director David Ross and I have know each other a long time and we both have the same high Ideals when it comes to patient care. We want to give people more choices and more affordable surgery; this merger will make that happen. We want Mills & Mills to be viewed as more European. We are currently opening clinics all over mainland Spain, the Canaries and the Balearic islands. Since the launch of our new Spanish brand and Spanish language website we have literally seen hundreds of new customer enquiries.”
The Hospital Group is investing in new computer systems to integrate Mills & Mills and the Spanish operation into the group along with investment into Mills & Mills marketing particularly on the internet. Mills & Mills is based in Southern Spain as it offers affordable prices, the confidence of being within the EU, a short-haul flight from the UK, as well as high levels of medical care within a multi-lingual private hospital.
The Hospital Group has a network of 15 clinics around the UK and four in Ireland. A private hospital near Birmingham is the world’s biggest specialist plastic surgery facility. The group is the UK’s number one in weight-loss surgery and hair transplantation and also expert in non-surgical treatments and cosmetic dentistry.

Baltic countries Estonia, Latvia and Lithuania have got together with GUAM countries: Georgia, Ukraine, Azerbaijan and Moldova to see how they can co-operate on health tourism.
All are latecomers to the scene and have more to offer on health, wellness and spa tourism than on medical tourism. But they are also countries where overheads are low, so keeping prices affordable for people who may not be able to afford Western European prices.
Their locations and historic links also mean they have better access to the booming medical tourism markets of China and Russia, with most having the huge advantage of having many Russian speakers.
Jurgita Kazlauskiene of the Lithuanian Resorts Association sees that to develop health tourism in the Baltic states, the role of spas is vital, “Key to success will be how to run and promote joint projects between Baltic and GUAM countries and their customers. Also important is how to ensure sustainable development of tourism and how to increase the role of tourism of the economies of the regions.”
As well as local Baltic/GUAM cross border co-operation, the region has to consider if there is any potential or impact in European Council rules on the application of patients’ rights in cross-border healthcare. When looking at cooperation in health care and health tourism, regional cooperation is vital for small EU countries.
Local health resorts help cut costs in the health system. Each euro spent on medical rehabilitation saves three Euros that would otherwise have to be spent on conventional medicine such as pharmaceuticals. After staying in a health resort, patients take less medicine, visit the doctor less often, and are less absent from work.
Cooperation between the Baltic states on health tourism is important due to geographic location, a mild climate, and that there are no cultural or language barriers. This cooperation has been successful for many years by carrying out a number of regional projects, but all the counties are looking at promoting a Baltic wellness concept.
The countries have an unofficial Baltic medical tourism cluster. Acknowledging that the internal market of each country is small and internal consumption is low, there is mutual understanding that it is necessary to specialize in certain areas and services, and that there is a need to develop new products that could be marketed together in larger markets, such as Germany, Norway and the UK. Specialization or offering of tailor-made products is one of the key factors to stay unique and maintain the quality of services.
National rehabilitation centre Vaivari in Latvia has signed a medical export cooperation agreement with the Ministry of Health of Azerbaijan.Vaivari has already received the first 30 patients from Azerbaijan, with the launch of a new rehabilitation programme. Every year Vaivari gets 3500 patients for rehabilitation and health treatment, one third of these patients are children. The target for 2013 is to provide health rehabilitation for 4000 patients within the same financial funding.

Despite being a pioneer in medical tourism, India’s central government failure to promote the sector, and the complex medical visa system that puts off medical tourists, is pushing the country into becoming an also-ran in medical tourism.
Whilst the governments of competing destinations spend time and money in promoting medical tourism, official apathy and bureaucracy in India threaten to reduce rather than increase numbers.
Doctor Prathap C. Reddy, the cardiologist who built the Apollo hospital chain in India is seeking overseas growth as the nation’s visa policies drive medical tourists to rivals. Reddy has told several Indian newspapers, “Growth in the number of visitors seeking treatment for heart ailments, cancer and orthopedic surgery is falling short of estimates as India’s special visa for patients forces them to visit an immigration office. India is losing clients to Singapore and Thailand as visa rules and greater awareness of drug-resistant germs that spread from the South Asian nation scare away patients. Government has not just neglected medical tourism, it has done everything to ruin our prospects of becoming a tourism center. I once said India should become the global health-care destination – now I am swallowing those words. It could grow ten-fold in the next five years, if only the government would facilitate it, the way other counties have.”
In theory, anyone who wants to go to India for treatment must apply for a special medical visa. In practice, many just use normal visas, but then run the risk of not being allowed re-entry if they need more treatment. Anyone going to India for medical care has not only to get one in advance, through the labyrinth of the Indian civil service, but in India, before treatment, the patient has to personally attend a local police/ administration office which can be many miles from the hospital and may have erratic opening hours. The visa is not available to people from many African countries.
Finding that the numbers and profit from inbound medical tourists are offering lower returns than overseas investment means that Apollo Hospitals is considering building or investing in hospitals in Indonesia, Cambodia and Tanzania. Apollo forecasts the number of overseas patients seeking treatment at its hospitals in India will increase from 65,000 in 2013 to 80,000 by 2014, which is still only a small percentage of total patient numbers. Fortis Healthcare also supports medical tourism, but is another group seeing more potential and profit in hospitals outside of India. Vishal Bali of Fortis Healthcare says, “Medical tourism to India will increase if the nation allows faster clearance for patients through immigration points, and guarantees the processing of medical visas within 24 hours.” Fortis attrcats 1,000 international patients a year.
Although it is often claimed that India attracts millions of medical tourists, various sources suggest that the real figure is now between 250,000 and 350,000.
After Dr.Reddy’s comments became public, local commentators supported his view:• “There continues to be little growth of professionalism among medical tourism companies and the hospitals that treat medical tourists.”• “Many individuals and businesses with little understanding or appreciation of the complexity of the medical tourism industry solicit customers from abroad.”• 2Understanding of marketing principles that apply to medical tourism is limited. False advertising, lack of patient privacy, and ignorance of safety of medical tourists are widespread.”• “Care management of medical tourists that protects their safety and good treatment outcomes is virtually non-existent.”• “The fledgling Indian Medical Travel Association never got off the ground as a force as information on its website has not been updated since 2009 and appears dormant; and no other organization has emerged to take its place.”• “Individual medical tourists, or medical tourists sent by medical travel companies from abroad, are vulnerable to local doctors, clinics, hospitals and medical travel companies that often take advantage of them.”• “There is no quality assessment for medical tourism through third party certification of these hospitals, clinics, doctors and medical travel agents.”• “Hospitals may be moving to health certification, but that does not mean they can deal with medical tourists properly as they may lack translators, customer care and facilities that are acceptable in India but not in other countries.”• “Medical tourists to India are at risk because there is a general lack of knowledge, experience or understanding among those who treat and care for them about the quality and safety issues to which medical tourists are vulnerable.”

International tourist arrivals grew by 5% during the first half of 2013 compared to the same period of 2012, reaching almost 500 million, according to data by UNWTO.
Growth was above the projection made at the beginning of the year (+3% to +4%) and is also exceeding the trend of the UNWTO long-term outlook Tourism Towards 2030 (+3.8% a year).
Destinations around the world welcomed 494 million overnight visitors in the first six months of 2013, according to the UNWTO World Tourism Barometer. This represents an increase of 5% or an additional 25 million international tourists compared to the same period of 2012. Growth was stronger in emerging economy destinations (+6%) than in advanced economies (+4%), a trend which has marked the sector for many years now.
Taleb Rifai of UNWTO explains, “That international tourism grew above expectations confirms that travelling is now part of consumer patterns for an increasing number of people in both emerging and advanced economies. This underlines the need to rightly place tourism as one of the key pillars of socio-economic development, being a leading contributor to economic growth, exports and jobs.”
In a still uneven global economic environment, results were positive in all regions and subregions, though the overall picture was mixed. Europe (+5%) performed surprisingly stronger than expected, driven by Central and Eastern Europe (+10%) and Southern and Mediterranean Europe (+6%). Asia and the Pacific (+6%) also exceeded expectations, boosted by South-East Asia (+12%) and South Asia (+7%). On the other hand, results were weaker than anticipated in the Americas (+2%), as South America and the Caribbean lagged behind.
The first half or the year normally accounts for 45% of the total arrivals count of the year (the Northern hemisphere high season months of July and August fall into the second half). Growth is expected to continue in the second half of 2013 but at a gradually slower pace. UNWTO forecasts 2013 to end at 4% or slightly above, thus exceeding the initial estimate for the year.
Asia and the Pacific (+6%) saw robust growth boosted by the increase in arrivals to South-East Asia (+12%), a subregion that is maintaining the extraordinary momentum of recent years, and South Asia (+7%).
In Europe, international tourist arrivals were up 5% despite the lingering economic difficulties. Growth was led by Central and Eastern Europe (+10%) and Southern and Mediterranean Europe (+6%).
The Americas (+2%) reported a rather weaker first half of 2013 compared to the strong growth of previous years. Central America (+4%) performed above the region’s average, while arrival numbers were flat in the Caribbean and in South America.
In Africa (+4%), the growth of recent years was sustained during the first half of 2013 due to the continued recovery of North Africa (+4%) and the positive results of Sub-Saharan destinations (+4%).
The Middle East rebounded after two years of negative growth with an estimated increase in international arrivals of 13%. Yet, results should be taken with caution as growth is rather uneven across destinations and the many uncertainties in the region could drastically change the picture.
Emerging economy outbound markets continue to drive growth both to emerging and advanced economy destinations.
China (+31%) and Russia (+22%) led the growth in expenditure on travel abroad among the top ten most important source markets in the world during the first half of 2013. Outside the top ten, Brazil is back with a 15% increase after a more moderate 2012.
Expenditure from traditional markets, on the other hand, was more modest. Canada (+3%) and France (+2%) led the group, followed by the flat results of the United States, Germany and the United Kingdom, and negative figures from Japan, Australia and Italy.
There are no specific results for medical tourism, but the above figures suggest that Chinese and Russian markets have good potential; although as this is now common knowledge, competition for people from these 2 countries is going to get extremely fierce.

Plans by Chinese investors CSST International to contribute up to 44 million Euros to the development of a health village in Flúðir, South Iceland, have fallen through. Financing projects in health tourism in Iceland has been difficult with two other projects failing to launch.
The Flúðir project was launched in 2008, assuming a village of 200 apartments, service buildings, pools and a rehabilitation centre where more than 100 people were to be employed. The plans were downscaled after the Icelandic banks collapsed. The project’s leader Árni Gunnarsson is still hopeful and seeking other investors, but funding is hard to find. PrimaCare’s private hospital in Mosfellsbær and Nordic Health Pro’s private hospital in Reykjanesbær, are both still seeking funding.
PrimaCare hoped for a hospital in Mosfellsbær where medical travellers could have joint replacements. Nordic Health Pro was planning a private hospital in Reykjanesbær, hoping to fly in patients from abroad, but both projects have been stalled for several years and may never happen.

PrimaCare was founded in June 2008 to develop, build, operate, and market a state-of-the-art medical resort destination in Iceland. The hospital model integrates a surgical specialty hospital with an elegant boutique-style hotel and after-care facility. Located just outside of Reykjavik, Mosfellsbaer is 45-minutes from the international airport, and is a green and health-focused community.
The Chinese contractor for Flúðir Spa, Smart Cities International is a specialist in environmentally sustainable projects. The company works in close cooperation with the Chinese government and employs 8000 people. The idea was for the health village to be marketed in China. The number of Chinese tourists visiting Iceland has increased but it is still only 7000 a year.
The planned hospitals in Reykjanesbaer and Mosfellsbaer both plan specialized surgery and treatment, joint replacement, and other specialist services.
Patients are flown in from Greenland and Faroe Islands to the Landspítali national hospital in Reykjavík in accordance with agreements with the authorities in those countries. But attracting private patients from abroad is not easy.
One completed project, the dental implant clinic Nordic Smile in a glass tower by the Reykjavík seaside, used local and Swedish dentists. Attempts to contact the clinic failed, with website suggestions that it has closed down.

The Association for Health Tourism in Iceland still feels that in the longer term, there are opportunities for private hospitals.Iceland has a reputation for outdoor bathing, exercising, rehabilitation and a healthy lifestyle, but translating that to health-related tourism is proving difficult.

Individual health plans that include a health optimisation service and an insurance programme that means patients can be jetted to the best clinic in the world for their specific condition if necessary, has been launched in the UK after being first offered in the USA.

One Hundred Years has been set up by a group of US healthcare veterans who wanted to call on the best doctors in the UK to form part of a global network that promises to members consultation, health planning and treatment from the best doctors anywhere in the world. Everything about a member’s health is managed by One Hundred Years, so customers are not liaising with their GP one minute and an insurer the next.
One Hundred Years provides global, best-in-class private health management services. The service identifies individual client health and lifestyle goals and delivers those outcomes via personalised health programmes managed by private health advisors, doctors and scientists.
The idea is to build individual health programmes that are personalised, proactive, and built around medical centres of excellence. This is not cheap.
The company’s health management services can be fully integrated with health insurance to provide global cover to each individual client.
Virgil Bretz of One Hundred Years explains,” Our health management model is analogous to the best examples in wealth management. Wealth managers have long understood that no two clients are alike. Our clients greatly value health. Personalised, strategic, and coordinated expert advice is as important in planning a long life of great health as it is a portfolio of wealth.”
Costs are dependent on clients’ life circumstances and the depth of service they opt for. These range from Health Service 001 – providing health advisory and optimisation – to Health Plan 001, which includes full health insurance.
Clients are able to access their private health advisory team in person, by direct phone, online and via a dedicated smartphone app. Global medical records can be curated. All personal medical data is maintained in a fully secured environment.
Budget annual memberships are £5,000 but the top tier service, including global 24/7 access, can cost up to £100,000.
One Hundred years also operates in the US, but is a Dutch company based in Amsterdam. It is available to individuals and to companies wanting to cover several top executives.
Highly personal healthcare advice, navigation and management are at the cornerstone of the private health management services. It offers optimized health and fitness; best in class medical expertise and outcomes; VIP treatment and total convenience; appointment scheduling, second opinions, physician communication, coordination of care and all interactions surrounding the payment of provider and hospital bills.
The health advisory team will arrange priority access to top doctors and hospitals worldwide; coordinate travel, overseas logistics, and emergency situation management when needed.
It guarantees that if a customer suffers a health problem anywhere in the world it will get them to a top doctor within hours. And if there is nobody immediately available because they are in a particularly remote spot, it will fly them to a country where they can gain expert attention.

The good news for medical and health tourists to Thailand is the establishment of an official medical mediator; but the bad news is that it looks increasingly likely that all tourists will have to have travel insurance.
The Ministry of Public Health is setting up a medical mediator group to handle disputes over bill payments for treatment involving foreigners and hospitals in Thailand. The mediator group will comprise 18 members, from both public and private medical organisations and representatives from the Foreign Affairs Ministry, Thai Life Assurance Association and Healthcare Accreditation Institute. Sub-committees on finance and technical issues will be appointed to consider disputes. Outside experts will be invited to take part if needed, on a case-by-case basis.
The mediator group will act as negotiators and review opinions based on international medical practice and appropriate financial responses. The ministry aims to upgrade the medical dispute settlement mechanism to international standard, as part of the policy to make Thailand a medical hub.
If the two parties involved agree to enter the system, the case must be concluded within 90 days. It is intended initially to serve the needs of foreigners who find they must meet medical expenses because they have no health insurance coverage. This group makes up about 80% of foreigners seeking medical treatment in Thailand. The ministry’s statistics show that 40% of complaints lodged with the government in 2012 related to the services of healthcare institutions, followed by treatment method (15%), expensive treatment bill (9%), behaviour of medical professionals (9%), and illegal clinics and illegal doctors (8%).
The Ministry of Tourism would like to make it compulsory for all foreign tourists to have travel insurance before entering the country because unpaid bills are putting a huge strain on cash-strapped public hospitals in major destinations, particularly Phuket.Tourism business operators warn that this measure may keep away travellers as well as tarnish the country’s image.
The ministry is concerned about foreign tourists’ unpaid medical bills that cost the country more than 200 million baht annually. Based on the tourism ministry’s data, up to 6.19 million tourists, or about 28 per cent of the total 22.35 visitors, came to Thailand as part of a tour package last year. Thailand earned 984 billion baht in revenue from tourist spending in 2012, and expects to earn as much as 2.2 trillion baht from visitors in 2015. Phuket has had to shoulder 5mn baht a year in medical costs for foreigners who don’t have insurance or are unable to pay for the services, says the Phuket provincial public health office. Whether they can pay or not, hospitals have an obligation to treat foreign patients. Many are motorcycle-related accidents. Those who have health insurance are able to receive emergency treatment at private hospitals, while those who do not, need to be referred to public hospitals.
The ministry’s plan is that all foreign tourists should buy an insurance package, which would cost about 500 baht ($15). This would first be applied to tourists who apply for visa at Thai diplomatic missions overseas. The ministry has yet to decide whether this would apply to those who do not need a visa to enter the country. Curiously, the proposal is backed by some foreign embassies, including Germany, the logic being: ’If they can afford to travel, they can afford to buy travel insurance’.
According to the Association of Domestic Travel, tourists going toThailand on tour packages are already required to buy travel insurance, which allows them to claim 1 million baht for death and up to 500,000 baht for injuries.
For travellers from Europe, America or other countries with an established insurance market, buying travel insurance does not seem to be a problem, but even getting travel insurance from poorer Asian countries may be impossible.
For regular Western tourists, travel insurance is easy to get, but even in this sector, a substantial number will have health problems that make it harder to get affordable cover.
Where a serious problem could arise and could backfire on Thailand, is that normal travel insurance does not cover people going overseas for medical care; and the specialist medical travel market is very new, quite expensive, and not available in many countries.
Much depends on whether the ministry plans just to seek proof of cover, or follow the example of other countries where they arrange a travel insurance scheme that has to be bought in advance or at the arrival airport, and seems to also make money for the countries that do this.

Sweden is decentralizing the operation of cross-border healthcare to the regions.
It often tops the world rankings for the best healthcare. The Swedish healthcare system is universal and free for all. It is government funded and decentralised. The problems are few, but for some operations in some regions there are queues for treatment and the relatively high cost of private Swedish healthcare means that patients can choose many EU countries where they could get quicker treatment at prices that would be lower than the local costs; although they would still have to pay for accommodation and healthcare so numbers taking advantage are not expected to be high.
While Swedish counties normally pick up the tab for health care, the central state has administered and paid for health care purchased in other EU countries. But that system is set to change on October 1st, although the state has promised to earmark funds in the autumn budget for the counties to dip into to ease the transition.
Sweden is divided into 290 municipalities and 20 county councils, which include the regions of Gotland, Halland, Västra Götaland and Skåne.There is no hierarchical relation between municipalities, county councils and regions, since all have their own self-governing local authorities with responsibility for different activities. The only exception is Gotland, an island in the Baltic Sea, where the municipality also has the responsibilities and tasks normally associated with a county council.
In theory, patients will get more choice on what treatment to seek abroad, but nobody is sure what the result of transferring the decision-making process to the regional level will be. The regions could be very strict, or if there are local queues, could pay for treatment and other costs too. The decision of who gets what from whom will transfer over to the counties, which will confer in reviewing patient applications with the National Insurance Agency.
Hasse Knutsson of the Swedish Association of Local Authorities and Regions (SALAR) says that while patients can apply retroactively to have their treatment or operation paid for by Swedish authorities, there is never a guarantee that the full cost will be reimbursed, "If replacing a hip costs 55,000 kronor in Sweden, but you get it done in Germany where the price is 70,000, you would only get back 55000.”
In 2012, 3,000 Swedes got money back for health care obtained abroad, but 400 people who applied for coverage were rejected. Swedish patients most commonly seek help with skin conditions and eye problems, but there are signs that ailments that Swedish health care has little capacity to treat are pushing patients over the borders.
Hasse Knutsson of SALAR admits, "It is difficult to speculate about what effects this reform will have, both in terms of the number of people leaving for treatment and people coming here. There may be more patients coming here."

The number of Dutch patients who travel to Belgium for medical treatment is increasing. Particularly for orthopaedic treatment of hips or knees; and also for heart surgery, caesarean sections and hysterectomies. The Dutch have been going to Belgium for medical care since the 1970s. In the Netherlands there is a six months wait for a hip replacement, but no delay in Belgium.
Belgium also gets signicant numbers of hospital patients from Germany, France, UK, Italy and Luxembourg; with much smaller numbers from Spain, Poland, Romania and the USA. The total number has risen 18 % from 2007 to 2010. 2012 and 2013 figures will not be available until 2014 and 2015 respectively. These are not all medical tourists.
The 2012 report from the “Observatoire de la mobilité des patients” covers the years 2007 to 2010. In 2010 Belgium welcomed more than 46,000 patients from neighbouring countries, and these figures do not include the thousands who go to Belgium for dental treatment or cosmetic surgery. 30,000 of the hospital patients in 2010 were from the Netherlands, compared to 26,000 in 2007.
The reason the Dutch cross the border is to avoid the long waiting lists typical of their country. The number is expected to rise due to the new EU rules on cross-border healthcare that Belgium and The Netherlands are both expected to implement this year, and the increasing number of Dutch insurers doing cross-border deals with Belgian hospitals on volume of patients for low prices; health insurance is compulsory for all residents in the Netherlands and people choose from a range of insurers who compete on service but not on price or cover.
The Observatory on Patient Mobility was set up by Inami and the FPS in 2011 to measure the impact of overseas patients on local hospitals and to ensure that the waiting lists for Belgian patients do not increase with the arrival of foreign patients. So far, locals have not faced delays while the arrival of foreign patients “provides hospitals with money and as most patients come for complex operations it keeps surgeons busy and up to date."
Care has to be taken with the figures, as they are not just medical tourists. The figures embrace all ’non-residents’ so include temporary expatriates, holidaymakers, and business travellers.
To confuse matters more, the figures above are only hospital inpatient figures, and do not include day-cases. For 2010, the total number of non-residents was 28,690 inpatients plus 158,762 days for day-cases (days, not patient numbers). Most patients go to Antwerp, Brussels, Ghent, Bruges or Hasselt, all of which are also major tourist destinations.
In percentage terms, 60% come from the Netherlands, 20% from France, 4.5% from Luxembourg, 2% to 3 % each from the UK, Italy and Germany, 1% from Spain and less than 0.5% from Romania, Poland and the USA. When delving into the detail of the report the latter low numbers are almost all travellers and short-stay expatriates, while many of those from the Netherlands, France and Luxembourg are medical tourists. The Poles and Romanians are temporary migrants.

Malaysia expects record medical tourism revenue, Cambodia targets Australian dental tourists, Sri Lanka considers specialist medical tourism and South Korea plans a medical tourism zone.
The Malaysia Healthcare Travel Council (MHTC) expects the medical tourism industry to record RM630 million revenue this year, up from RM584 million last year.
Dr Mary Wong Lai Lin of MHTC explains, “The number of foreign patients has increased year by year, and last year we had 671,000 patients, an increase from the 583,000 patients recorded in 2011.We believe this year, the medical tourism industry will continue to grow and we expect some 700,000 foreign patients. Foreign patients continue to choose Malaysia for medical treatment as the government regulates the country’s medical tourism industry and the hospitals are well equipped with the latest technology and facilities. Patients are from Indonesia, India, Japan, China, UK, US, Australia, Bangladesh, Libya and Nepal.”
Australia has some of the most expensive dental treatment in the world and for years many Australians have gone to Thailand looking for high quality dental work at a fraction of the costs. Now Cambodia is joining in. An Australia resident in the city has formed a company specializing in taking Australians to the city for dental work. Michael Howard has set up an agency called Kingdom and Crowns.
A root canal and a crown at Roomchang Hospital in Phnom Penh will cost around $700 whereas the same work in Australia would be up to $3,000. The first Australians are due to start arriving in the city this winter. This is potentially an enormous market for Cambodia as Cambodian prices are slightly cheaper than Thailand and of good quality. Roomchang Hospital has a foreign patient ratio of 40%. 10% of their patients have traveled to Cambodia specifically for medical care. It is expected that that number will increase significantly. The dental clinic was the first in the country to achieve ISO 9001-2008 certification.
Although the government of Sri Lanka has made it clear that they do not want to encourage medical tourism as there is no spare capacity, but will promote local specialities in alternative therapies, natural and wellness offerings. A local doctor is keen to get them to agree to specialist ear transplant surgery.
Dr. Devanand Jha of Lanka Hospitals explains, “Sri Lanka bears a potential in becoming a hub for medical tourism, particularly in the area of cochlear implants. 96 cochlear implants have been done in the hospital. The cost of surgery in Sri Lanka is attractive, with ample resources and technology available in the country.” Post therapy is a key requirement in the procedure, where speech and language therapists use auditory verbal therapy. This vital need for post-operative therapy would limit the potential to places where such therapy is available locally, as it would not be practical to fly to Sri Lanka.
Seoul City, the capital of South Korea, plans to establish a special medical zone where tourists can enjoy specialized and concentrated medical services. Seoul’s Jung-gu District Office has filed a formal request to designate a downtown area of 560,000 square meters as a medical tourism zone.
From September South Korea is relaxing visa restrictions for travelers from China and Southeast Asian countries. The issuance of multiple visas for Chinese nationals will be increased, and one-year visas will be available for Southeast Asian travelers who have visited South Korea at least once — with three- and five-year visa options possible for those with multiple past visits. Currently, only three one-year visas have been given to Southeast Asian tourists visiting the country multiple times in the past two years.
The South Korean ministry also plans to expand the amount of visas available for foreign patients visiting government-approved hospitals.

The Australasian Medical and Dental Tourism Association is a new medical tourism association for Australia and New Zealand. It is the first and only organisation in Australia to standardize the quality of medical tourism delivered by professional agencies. More details of how it wants to make local agencies more professional, and a website are coming soon.
Australia and New Zealand face the usual problem of whether or not a medical tourism agent is a travel agent or tour operator for purposes of the local law. There are plans to deregulate travel agencies and tour operators in Australia. Local legal cases differentiate between travel agencies and tour operators, and between inbound and outbound travel.
A recent decision of the Federal Court of Australia ATS Pacific Pty Ltd v Commissioner of Taxation [2013] FCA 341 (15 April 2013) raises significant issues for sellers of packaged tours. The court found that a term could be implied into the contract between the entity selling the package and the travel agent purchasing it and that this in turn means that the agent passed on that promise to the customer, so could not argue that all it provided was booking and arranging services.
Taking this logic further, it means that any agent could be held responsible for non-performance by the end service provider such as a hotelier or hospital. What is not clear is if the logic applies as much to travellers going from Australia as to travellers going to Australia.
Greg Morling of the Australasian Medical and Dental Tourism Association explains, “In Australasia the preferred destination for medical procedures is Thailand. The medical tourism sector here has been an area of controversy for several years with little benchmarking, standards or regulation. This has now changed and we have set ethical standards and standards of practice for the industry here. There are cowboys who have given agencies with integrity a bad name. Some of these are travel agents making a quick buck by tacking on some surgery as part of their client’s travel arrangements. Medical tourism agencies should be treated as specialised tour operators, not travel agents.”
While most Australasian medical tourism is outbound, there is a small amount of inbound. In New Zealand’s Queenstown, a stem cell centre for locals and medical tourists aims to be operating by the start of 2014.The target market is sportsmen and osteoarthritis suffers, with a view to later treating multiple sclerosis and diabetes. It will be an extension of Queenstown Regenerative Medicine; a specialist plasma treatment centre; -and collaboration between Marcelle Noble and Dr Peter Britton, Dr John Flynn of the Gold Coast in Australia and Professor Richard Boyd, director of immunology and stem cell laboratories at Monash University in Melbourne.
Marcelle Noble is the owner of Queenstown Regenerative Medicine and says that the purpose-built centre is dependent on funding by private investors. Queenstown would be the only centre in New Zealand to offer both plasma and stem cell therapy.

NHS England has published an update on changes to the administration of European Cross-border healthcare.
From April, NHS England was made responsible for the administration process for patients seeking funding for treatment in the EEA and Switzerland. Previously primary care trusts administered this process individually.
NHS England has set up a European team to administer the two routes whereby patients can apply for funding.
These are:• The S2 route – a direct arrangement between the NHS and the state healthcare provider in the other European country.• The EU directive route where patients pay the costs of treatment abroad and then claim reimbursement from the NHS when they return.
The European team does not deal with cross-border healthcare issues within the UK or outside the EEA and Switzerland.
The S2 route is funded by agreements between states. Under the EU directive route, the local clinical commissioning group identified as the responsible commissioner for the patient will be invoiced by NHS England for any costs the European team has agreed to reimburse. Reimbursement costs will be the lower of the actual cost of treatment or the equivalent cost to the NHS of the providing the same treatment.
Clinical commissioning groups are a core part of the government’s reforms to the health and social care system. In April 2013, they replaced primary care trusts as the commissioners of most services funded by the NHS in England. They now control around two-thirds of the NHS budget and have a legal duty to support quality improvement in general practice.
More changes are on the horizon in October 2013 when new regulations will be published as part of the UK’s obligations to implement the EU Directive on Cross Border healthcare. Under these new regulations care commissioning groups will be required to publish information to inform patients what their entitlements are in respect of cross-border healthcare with the EEA and Switzerland and information on any access criteria or thresholds that apply.
NHS England will update this information in October and the Department of Health will also issue directions to accompany the regulations when they become law.
Wales, Scotland and Northern Ireland will provide information individually on how their country deals with cross-border healthcare both with each other and England as well as with Europe.
NHS patients in England have to seek prior approval before they seek to get treatment outside of England. They have to decide where they want to go and what treatment will be and apply directly to the European team of NHS England either beforehand or after treatment. The NHS does not arrange any overseas treatment or travel; it only pays for all, part or none of it. The team decides if the patient is eligible for the selected treatment. If the answer is yes, then the patient is reimbursed and the NHS recovers the money from the patient’s local care commissioning group. Both figures are limited to the lower of either what the treatment actually cost, or what it would have cost the NHS.
NHS England is the national contact point for treatment under the EU cross-border healthcare directive, both for English patients going overseas and European patients seeking treatment in England. It will soon publish detailed information in easily accessible electronic form for both incoming and outgoing patients. The information must include details of treatment and service and what this means for patients’ entitlement.
For some treatment, English patients can arrange treatment and then seek to get the NHS to refund all or part of the cost, except for any travel or accommodation costs. For specialized treatment, the exact nature of which is still being defined, the patient must seek prior authorization, and to not do so means that the NHS does not have to refund anything to the patient for overseas treatment.
The European team has another role that will be replicated in every participating country – to provide the European Commission with detailed data on inbound and outbound cross-border healthcare activity, whether funding was approved or not.
The cross-border deal applies anywhere within The European Economic Area (EEA) – a free trade zone between countries of the European Union (EU), Iceland, Norway and Liechtenstein; plus Switzerland.
The right to seek NHS-funded medical care does not extend beyond Europe, although if there is treatment available in the USA or Canada that is not available in the EEC, then the NHS can consider paying for that treatment.
One potential problem flagged up by the NHS is that while other countries may have agreed to cross-border healthcare at a political level, whether doctors or hospitals at local level have been informed of, or choose to pretend ignorance of, the deal is another matter; so far practice and theory are far apart.

Best known for medical tourism, Thailand is now promoting all types of health and wellness tourism. Tourism Authority of Thailand (TAT) has a new marketing strategy for 2014. Having recently conducted a survey on tourism, TAT says that health and wellness will become a niche market to receive special focus in its marketing efforts during the next few years.
Pongsathorn Kessasamli of TAT explains, “Future marketing will concentrate on certain niche markets, which is a significant change in focus for Thailand’s tourism industry. The country had 22 million visitors in 2012, and there are 24 million visitors projected for 2013. Consequently, it is not necessary to simply encourage more tourism; instead, efforts will be directed to promoting the popular attractions that Thailand has to offer.”
TAT has joined with Thai Airways International, Asia Web Direct, and more than 30 leading providers of health, beauty, and spa treatments to launch a digital marketing initiative promoting the country’s thriving health and wellness industry. The campaign takes aim at women in the Asia-Pacific market, including Thailand, who are looking for ways to rediscover themselves. The offer is for a wide selection of exclusive deals on wellness and beauty treatments, spa packages, and hotel stays in Thailand.
The ’Find Your Fabulous’ digital marketing campaign promotes the health and beauty segment of Thailand’s tourism industry. Over 30 leading providers of wellness-related services including clinics, spas, and health centres have signed up to offer over 150 packages of exclusive health, beauty, and hotel deals that allow tourists from all over the world to book online and receive special pricing.
There have been many claims on the number of medical tourists, with figures based on hospital numbers. Problems with these figures include over–inflation due to counting hospital visits not unique patients, inclusion of people buying medicines, and the inclusion of expatriates and business and vacation travelers who fall ill. Various attempts to improve figures have failed as hospitals have a marketing incentive to over claim, Last year the Department of Health broke down the figures and showed that only 26% of the claimed numbers were actually medical tourists; the rest were foreign residents, business travelers and holidaymakers.
So TAT has approached the problem from a totally new direction. To reach a solid understanding of what encourages tourists to visit this country, TAT carried out a study based on 30,000 interviews and questionnaires for a period of one year between April 2012 and March 2013. The study showed that health and wellness tourism generated 858,340 trips to Thailand and produced estimated earnings of 31.12 billion Baht for the Thai economy. These figures include medical tourists, health tourists, wellness tourists and spa tourists. The figures are not broken down by type, but as Thailand is the spa capital of Asia, many will be spa and wellness travellers rather than medical tourists.
Thailand has invested heavily in its health-care services to meet the rising demand for accredited medical care with modern, first-class facilities. Thailand has also done much to develop and improve its spa services. The spa industry’s desire to achieve and maintain high standards amongst spa professionals has led to the creation of the Thai Spa Association. This not-for-profit organisation seeks to promote the industry and to establish high standards in staff training, spa management, and the production and supply of equipment. These standards have had a positive impact on the development of the industry and its reputation for excellent customer service.
There are two common approaches to link hotels and spa/wellness offerings. One is to combine the two in wellness hotels; the other to is to link existing spas with existing hotels and other accommodation. Krabi Riviera is a leading provider of luxury holiday villas in Southern Thailand, and people wishing to stay in one of Krabi Riviera’s luxurious villas can also enjoy a range of spa services. Guests can choose from a wide selection of spa providers in the nearby town of Ao Nang, together with having the option of using Krabi Riviera’s own in villa massage programmes.
The spa/wellness sector is targeting four groups that have been shown to spend more money than average, and to be increasing in numbers: higher-end travelers from Russia, China, Germany and India. A huge increase in the number of tourists from China, Russia and India in the first quarter 2013 has benefited spas, says the Thai Federation of Thai Spa (TFTS). The main destinations are Bangkok and resort destinations such as Chiang Mai, Phuket, and Pattaya. Potential is seen in promoting Thailand to South Koreans and to older Japanese travellers.

Stenden Rangsit University is undertaking customer research for the Thai Spa Association and TAT. The spa research includes both an extensive investigation of spa consumers as well as spa operators. The main goal of the research is to respond to a lack of quality academic research that currently exists in the spa industry and deliver research results in the form of specific industry recommendations. The overall objective of the spa consumer research is to have a better understanding of consumer behaviour and perception, including current trends of treatments and therapies, buying behavior and the decision making process.

The increasing closeness and international activism of leading Central and South American countries is behind the revival of Cuban medical tourism. Cuba had considered targeting US customers, but the numerous broken promises of US politicians that economic sanctions on Cuba would be lifted mean that it limits local targeting to Canadians.
Venezuela, Argentinia, Ecuador and Cuba are together leading the region in supporting development of local economies, globalisation, political influence and resisting US attempts to influence economic and political change. One way this is happening is through sharing expertise on healthcare.
Cuba has survived more than 40 years of US sanctions intended to topple the government of Fidel Castro. It also defied predictions that it would not survive the collapse of its one-time supporter, the Soviet Union.
Cuba’s main source of foreign income is the sale of medical services to other countries – state employed doctors and nurses travel abroad to work in 15 countries contracted to Cuba for medical services; including Algeria, China, Portugal, Jamaica, Qatar, Surinam and Ukraine.
Cuba is one of the unsung heroes of medical tourism, as it has been quietly attracting people from overseas for decades as Cuba has high quality doctors and healthcare. The government controls access to all local hospitals for overseas patients. The government pay for care deals and inbound medical tourism are both controlled by government agency Empresa Comercializadora de Servicios Médicos de Cuba S.A., known as Servimed.Servimed, a government-owned for-profit medical services company that caters to foreigners, has website pages in Spanish, French and English, the last two aimed mostly at Canadians, or Americans pretending to be Canadians.
Tourism to Cuba is growing and 2012 saw record 2.8 million tourists, but there are no figures on how many of those were medical tourists. Specialist expertise is on offer for rehabilitation, eyecare and cosmetic surgery- all at very competitive prices. Havana’s Cira Garcia Clinic specializes in cosmetic surgery and only deals with foreigners; most come from Latin America, but there are also patients from Angola, Canada, Spain, and Cuban-Americans from the USA. Other Havana hospitals, Hermanos Ameijeiras and Gonzalez Coro, have opened international rooms for medical tourists. An increasing number of hotels are targeting medical tourists.
Argentinean football legend Diego Maradona went to Cuba for drug addiction treatment and has been followed by thousands of people from his own and nearby countries. The late president of Venezuela, Hugo Chavez was treated for cancer, and thousands of Venezuelans have followed him. Over 40 clinics now offer treatment to people from this country. African and Latin American leaders have also sought medical attention in Cuba, including Ecuador’s Rafael Correa, and their countrymen follow.
Many foreigners pay in much-needed hard currency, but thousands of Venezuelans travel to Cuba each year for free medical treatment, benefiting from an agreement that Hugo Chavez signed with Fidel Castro in 2000. Cuba has dispatched some 30,000 doctors over the past decade to work in the poorest regions of Venezuela, and in exchange Venezuela provides Cuba with oil at a discount.
The communist government of Raul Castro seeks to revive the island’s economy, by generating revenue from medical tourism. Due to economic sanctions Cuba is a poor country, but it spends heavily on education and health services. Medical supplies are expensive as US trade sanctions prevent Cuba buying from nearby USA.
Relations with the US showed signs of a thaw following the election of President Barack Obama, who in April 2009 said he wanted a new beginning with Cuba. But the ban on US travel to Cuba is still there 4 years later as Obama is angry that Cuba has publicly allied itself with the anti-US policies of Venezuela, Ecuador and Argentina.
Canadians are a target market for eye surgery, dentistry, cosmetic surgery, medical check-ups and orthopedics. Servimed even has a special website for Canadians. It promotes the low price and high standards; many Cuban hospitals are certified ISO 14,001 (Hygiene, work-place security, environment) and ISO 9001 (general quality control)-These are internationally certified standards of quality and many hospitals in developed countries do not meet these standards.

Several accreditors have been very active recently, proving that there is more to international accreditation than JCI.

DNV Healthcare and the Accreditation Commission for Health Care (ACHC) have created an alliance to provide single-source accreditation services to large hospitals and health systems. DNV is the only accrediting body for US hospitals to combine the Medicare conditions of participation with the ISO 9001 Quality Management System into a unified accreditation programme. The collaboration between DNV and ACHC is non-exclusive and does not alter the standards or processes each uses to deliver its accreditation services. ACHC is an independent not-for-profit organization providing healthcare accreditation since 1986
QHA Trent is offering Accreditation Plus to hospitals or clinics that have already gone through a basic holistic accreditation from QHA or one of the other recognised accreditation schemes. It enables enhanced, more detailed accreditation for particular services a hospital or clinic may be offering.
QHA Trent also offers a special standard for assisted conception/IVF that affords clinics and hospitals offering these services the opportunity to ensure that what they do is as safe, risk-free, ethical and effective for patients and staff as it can possibly be.

Temos International has launched a medical tourism friendly hotel programme that defines the special criteria for hotels involved in medical tourism; it is audited and certified by TÜV Rheinland.
Another certification to be launched soon by Temos is a standard for international reproductive care; based on the existing internationally agreed guidelines and combined with the Temos quality criteria and a quality management programme that includes the preparation and post discharge processes of the patient in the home country and the onsite procedures in the destination country.

Accreditation Canada International has a new contract with Ecuador’s Ministry of Health to implement standards of quality and patient safety in its 44 hospitals. The five-year project addresses several areas that will assist hospitals in their efforts to meet international standards of quality and patient safety. According to the Ministry of Health, ACI was chosen because the Canadian model of health was determined to be the best fit because of its focus on public and primary care organizations.
ACI is now the largest provider of international accreditation services in Slovenia. The Association GIZ Specialisti (GIZ), a group of 16 specialized ambulatory centres, is an association of ambulatory care organizations across Slovenia. ACI will accredit a range of services for GIZ and is expected to announce similar deals with other ambulatory care organizations and hospitals in Slovenia and Croatia soon.

In medical tourism, Southeast Asia is a key and fast advancing market. Cambodia and Vietnam now want a share of the action that Singapore, Thailand and Malaysia have.
The two newcomers Cambodia and Vietnam aim to become legitimate medical tourism destinations, too. Cambodia believes it can succeed as an inbound medical travel destination. Like neighboring Thailand, it believes that all the pieces are in place to attract high-end wellness tourists focused on holistic health experiences. As a subset of medical travel, high-end wellness tourists like luxury spa treatments, and Cambodia has this. A 6-star health & wellness retreat is set to open in 2014.
Dentistry in Cambodia is set to offer cut-price dental tourism as modern clinics in Phnom Penh, Siem Reap, and Sihanoukville are providing good care, with English-speaking staff, and Western-trained dentists, for prices even cheaper than countries in the region such as Thailand.
As for Vietnam, hospitals and clinics are investing in high-tech equipment and services such as refractive laser surgery. Several eye hospitals in Ho Chi Minh City now seek medical tourists. Organ transplants, laparoscopic surgeries, cardiovascular care, and advanced obstetrics are additional areas seeing increasing numbers of patients from abroad. And Vietnamese cosmetic surgeons have embarked on a joint venture with their colleagues in Busan, South Korea to develop medical tourism.
Taiwan will try to establish a stronger presence in the growing cosmetic surgery market in Vietnam, a country with a thriving economy and great business potential. The time is right for Taiwan to get a foot in the door as Vietnam’s cosmetic surgery market is still in the nascent stage, said Hubert Chih, a researcher at Taiwan’s Industrial Economics and Knowledge Center, “Women in Vietnam do not have much confidence in cosmetic surgery, as the clinics there are usually small ones that seem to lack professionalism. There are many beauty salons on the streets of Vietnam.Non-surgical treatments such as skin whitening, laser toning and wrinkle smoothing are very popular, Women are concerned about the safety of cosmetic surgery procedures. For investors interested in getting into the cosmetic surgery business in Vietnam, big chain clinics would be a good option.”
Vietnam is keen to learn from other countries. National Taiwan University Hospital and Vietnam’s Huu Nghi Viet Duc Hospital have signed an agreement on a medical care exchange programme.

Around the world hospitals have been disappointed at the slow adoptions of medical tourism by US insurers and employers. One key reason is that their time and energy is taken up by the still evolving and major changes to US insured healthcare.
The federal government is building health insurance Marketplaces (also called Exchanges) in 34 states, and insurers have to decide in which states they want to offer special products via these marketplaces. Under the Affordable Care Act, on Oct. 1, 2013, people and small businesses will be able to purchase insurance through a marketplace. Officials hope it will be as easy to operate as web-based travel shopping sites like Travelocity. People can look for different insurance options and decide the type of plan they would like to buy. They will also learn if they qualify for tax credits to help pay for insurance or for Medicaid, the health insurance program for people with low incomes. Insurance coverage is set to begin in 2014.
A new report from Deloitte University Press explains how big the change is.
“The US health insurance industry plays a ubiquitous role in the nation’s economy. Major changes are afoot—from employer activism, to increased participation in government-sponsored health insurance plans, to the state-by-state implementation of the Affordable Care Act of 2010. The implications for products and services, costs, and the role of trust in the system are worth a closer look.”
A few highlights on insurance:
• 56 % of employers purchase health insurance coverage for their employees.• 17 million individuals buy their own health insurance.• 400 insurers, including 154 with more than 100,000 enrollees.• The Congressional Budget Office says up to 27 million could be newly insured, and over the decade only 4 million may lose coverage as a result of employers paying a penalty and walking away.• Enrolment in federal and state insurance programs is over 100 million including Medicare, Medicaid, Federal Employee Health Plan, Children’s Health Insurance Plan, State & Local Government Employee Health Plans, and Military Health Plans (Veterans Health/TRICARE).
And on the changes:
• Driving fundamental change in the US health insurance industry was the passage of the Affordable Care Act (ACA) in March 2010. Prior to the ACA, there was no law that required employers to provide health insurance coverage to employees and no law that required individuals to buy it for themselves. Both have changed. The law requires employers with more than 50 full-time employees to provide affordable insurance or pay a penalty — $2,000 per employee per year.• From 2014, US citizens not eligible for Medicaid or other public programs must purchase health insurance or pay a penalty that is the greater of $95 or 1 percent of the difference between the household’s taxable income and tax threshold, increasing annually for three years. • New regulatory constraints on how health insurance plans operate, with new rules at the federal level and vesting responsibility in states to implement a number of major structural changes including Medicaid expansion and creation of health insurance exchanges. So while the industry is likely to see increased coverage as a direct result of the ACA, it also faces additional compliance and oversight from state and federal regulators.
How the Affordable Care Act provisions directly impact the commercial health insurance industry:• Prohibits lifetime limits• Restricts annual limits• Requires coverage for preventive services with no cost-sharing• Extends dependent coverage to age 26• Requires uniform explanation of plan benefits• Prohibits discrimination based on employee compensation• Requires quality of care reporting• Requires reporting of medical loss ratio and provision of rebates• Annual rate review• Imposes guaranteed renewability requirements• Prohibits discrimination based on health factors• Prohibits discrimination against medical providers• Requires coverage for essential health benefits• Limits out-of-pocket spending• Limits cost-sharing• Prohibits excessive waiting periods
Deloitte predictions:
• Enrolment in insurance plans sold by private insurance companies may increase dramatically in coming years. Employers that provide coverage may offer high deductible plans that transfer risk to employees while protecting them against catastrophic costs. Individuals lacking access to insurance through an employer and the self-employed may purchase individual plans through private insurers• The insurance industry will consolidate with fewer US health insurers, but their enrollment and scope of operations may be broader.• The health insurance industry is in the enviable position to take advantage of these major drivers of innovation: Consumerism: Integrated health: Big data.• Ultimately, the health insurance industry’s value proposition boils down to managing health costs without compromising safety and outcomes.• Bets on the demise of the health insurance industry are ill advised.
Another Deloitte report “Power to the People? How health care reform could result in the disruption of the group health insurance industry.” explains how, through a mechanism of change known as disruptive innovation upstarts and new entrants may assume marketplace leadership at the expense of group health insurance incumbents.
The bottom line for anyone wanting to target US insurers and employers with overseas medical tourism is that even if they can spare you the time, any proposition has to comply with state and national rules on product design plus cost and quality rules; the days of bolting on a medical tourism offering to existing insurance are well and truly over. Those who have little understanding of the US healthcare changes will quickly be shown the door.

The International Society for Stem Cell Research (ISSCR) is urging Italian lawmakers to heed concerns of scientists around the world about the premature practice of offering unproven stem cell treatments and to recognize the importance of regulatory oversight and patient protection when developing new stem cell medicines.
Stem cells hold great promise for the treatment of a wide range of diseases and injuries; however, years of laboratory research followed by rigorous clinical trials are required to deliver safe and effective therapies to patients. Currently, the range of diseases for which stem cell treatments have been demonstrated to be safe and beneficial remains limited. ISSCR believes that ongoing research will eventually lead to new clinically proven therapies but until the research has been completed we cannot be sure which diseases can be treated effectively with stem cells, or how the stem cells should be used to ensure safety and effectiveness.
The excitement about the promise of stem cells has resulted in confusion for patients struggling to cope with incurable diseases. The ISSCR is concerned that inadequately tested stem cell treatments are being marketed around the world to patients and their families without the necessary safeguards in place to ensure safety and efficacy.
Shinya Yamanaka of ISSCR explains, “Stem cells have the potential to improve the treatment of many serious diseases but cell-based therapies present new challenges. In our enthusiasm to advance cures, we must not ignore the laws and regulations that exist to protect patients and ensure that medicines are manufactured under rigorous conditions and then proven safe and effective before being marketed by companies. Patients have been harmed when treatments circumvent the medical regulatory process.”
ISSCR’s guidelines for the clinical translation of stem cells emphasize that processing and manufacture of any cell product should be conducted under expert, independent review and oversight, to ensure as much as possible the quality and safety of the cells. The guidelines recommend adherence to strict procedures for extensively manipulated stem cells intended for clinical application. In the United States and Europe, cellular products that are highly manipulated outside of the body before being administered to patients are considered medicines and are subject to regulatory review and oversight by the US Food and Drug Administration and European Medicines Agency, respectively.
The ISSCR reiterates the value of a strong biological rationale for clinical interventions with stem cell-based products, based on rigorous evidence from pre-clinical studies and a plausible hypothesis for how cells are expected to improve a disease process.
Concerns have been raised about certain stem-cell-therapy treatments. These sorts of new techniques potentially offer exciting possibilities to patients for the treatment of a range of difficult or previously untreatable conditions. Like all treatments, these techniques also come with benefits and risks. Specific rules were introduced in the European Union (EU) in 2007 (Regulation (EC) No 1394/) to ensure that medicines involving cell therapy are subject to appropriate authorisation, supervision and controls in order to reduce and manage those risks.
The European Medicines Agency stresses that the protection of patients is at the core of those rules. In addition to applying the same safety and efficacy rules as for all medicinal products, the quality and manufacturing of these products is set out in good-manufacturing-practice requirements. These are globally recognised standards for quality assurance in the production and control of medicines.
Security and control of medicines derived from stem cell manipulation is tightly controlled by the EU advanced-therapy legislation. Cell therapies are defined as medicinal products when there is more than minimal manipulation of any cell type destined for clinical application or where the intended use of the cells is different to their normal function in the body. Any use of such cell-based medicines is subject to authorisation and controls, including their manufacture.
The recent decision announced by Italy’s health minister, authorizing the administration of cells that have been described as mesenchymal stem cells to patients with neurological disorders, has raised concern in the international research community. Shinya Yamanaka of ISSCR comments, “We sympathize with patients with incurable diseases. However, there is little objective reason to believe that these patients have the possibility of benefiting from a mesenchymal stem cell therapy and treatment decisions should not be made outside of a controlled clinical trial without data on safety and efficacy.”
The ISSCR believes that innovative and compassionate care is important, but untested therapies should only be offered outside of clinical trials in limited circumstances where there is sound theoretical reason to believe the patient could benefit. This exception does not justify commercializing unproven therapies.

5,000 Nigerians go to another country for treatment each month, claims Dr. Adeyeye Arigbabuwa of the Association of General and Private Medical Practitioners of Nigeria. The figures are said by him to come from several sources, but it is not clear on what those figures are based, so may be no more than a guess.
He explains, ”Why do people go for medical tourism? They go because they are looking for value; they are looking for quality and also affordability. While Nigeria has enormous potential in the medical field, the facilities needed to get value, quality and affordability are not available. We have the medical expertise but not hospitals that the average Nigerian can afford.’
The doctor suggests that the Nigeria Tourism Development Corporation claims that about 60,000 Nigerians each year go to Europe, Asia, America and other parts of the world, and that in 2012, Nigeria spent $260 million in India for medical care. However, neither of these figures can be traced to a reliable source; they have become ’facts’ by endless repetition.
One politician has threatened to privatise key hospitals to check health tourism. The logic is that by doing so they can improve facilities and stop Nigerians going abroad for treatment. Federal Minister of Health, Professor Onyebuchi Chukwu says that the federal government is also setting up six tertiary facilities by 2015 and that the nation should attain universal health insurance coverage before embarking on privatising the hospitals to ensure that the cost of accessing healthcare would not be beyond the reach of most Nigerians, "If we make everything private, people cannot afford it; so, we need to be careful. I rather feel that we first get universal coverage, and then begin to privatise. By then, I am sure everybody can afford it. But then, this is my own personal opinion, not that of the ministry yet."
It is not yet clear if the proposed privatization would apply to new private hospitals that had recently opened, after encouragement by a government unable to afford to build its own hospitals, and been funded by overseas investors or overseas hospital groups.
Chukwu disclosed that some federal hospitals already operated on a public/private partnership basis would not be affected. This includes the ultra-modern cardiac centre at University College Hospital, Ibadan, and Lagos State University Teaching Hospital (LASUTH).
Nigeria is not the only country impacted by outbound medical tourism, as the trend is a challenge to the entire sub-region and needs to be tackled through appropriate human resource, the West African College of Surgeons (WACS) has said. WACS president Professor Herve Yangni-Angate explains, “Integration of medical communities in West Africa is a big challenge which needs to be confronted.” What he suggests is that rather than each country working to solve medical availability problems, the 18 West African countries should work together to seek to divert money that goes to overseas hospitals, to building local hospitals and sharing specialist expertise and facilities between them.

Low prices, highly skilled staff and state-of-the-art equipment are attracting medical and health tourists to Polish clinics and spas.
In 2011, foreigners spent z?.800 million in medical facilities in Poland, according to Medi-Tour, a travel agency specializing in medical tourism. Analysts estimate that the sector is expanding at a double-digit growth rate each year.
While prices are much lower than in Western Europe it is the quality of medical treatment and local expertise that is more important for longer-term success. The drain of qualified doctors and dentists to other EU countries has now slowed to a trickle.
In Poland there are a large number of private clinics that are attracting dental and cosmetic surgery tourists. There are over 40 health resorts in Poland, mostly in the Beskidy and Sudety mountain regions, as well as over 200 wellness and spa centres. They all use state-of-the-art equipment and modern therapy methods, while making use of rich natural resources. Polish spas and wellness centers attract mostly tourists from the former Eastern bloc countries, but also Scandinavians and Germans.
To encourage potential clients, clinics, spas and travel agencies are joining forces to offer foreign patients medical packages that include medical treatment, spa stays and trips to cultural and historical sites.
A study for the Polish Tourism Organization outlined potential countries where Poland could target medical tourists. The report highlighted the United Kingdom, Russia, Germany, Scandinavia and the USA as having the best potential.
A major obstacle is that local tourist agencies are rarely involved. So patients have to do their own research when seeking for Polish health facilities. Specialist medical tourism agencies are active. Wroclaw-based Euromedica is targeting UK residents as potential clients for cosmetic procedures.
There are regional initiatives. One is in the Warmi?sko-Mazurskie region, focusing marketing activity on patients from Russia’s Kaliningrad Oblast, who are already frequent clients in medical facilities there. In a single hospital in Olsztyn, Russian patients spent z?.126,000 in 2012.Another is Bydgoszcz, trying to attract Irish clients by going to Irish trade shows.
In 2012 the government introduced a programme, co-financed by the EU, aimed at promoting medical tourism to Poland throughout the world, for the 2013-2015 period.

The various claims of how many medical tourists a country attracts are notoriously unreliable, even where there are monitoring systems in place. A new academic study suggests one simple reason for this; even major international hospitals are pretty poor at keeping simple records of how many medical tourists they have. And it is not just the usual problem of counting in expatriates, travellers and non-resident nationals who are in the country for reasons other than being a medical tourist. It may be the result of poor recording by hospitals; whether or not a patient is a medical tourist is not at all important, to staff already busy with other duties.
A new academic study ’Medical Tourism in India – Economic Development and the Global Healthcare Industry’, by Kristen Smith from the Centre for Health and Society, University of Melbourne, has been published on Academia.edu, a platform for academics to share research papers.
The research explored how medical tourism as both an industry and a practice fits within the world system. Using multi-sited ethnography. it investigated five large private hospitals in Mumbai in affiliation with the Tata Institute of Social Science. Observations were conducted in hospital waiting rooms, board meetings, administrative meetings, hospital wards, waiting rooms and consultancy rooms. There were 15 semi-structured, in-depth interviews.
The paper says that levels of international medical tourism are largely unknown due to inconsistent and irregular data at national and global level. Even at a micro level, few hospitals keep correct records.
Researcher: “Medical tourism, how many cases do you get a month?” Hospital administrator: “ Oh, not just this thing but also walk ins, okay and..from the other people too…so around ten patients a month…, so we don’t know this exactly. “
Examination of a wide range of data shows increasing international patient mobility, but different patterns are emerging geographically and socially.
The five hospitals were one corporate and four trust hospitals. The four trust hospitals differed in their age, reputation, management (two were corporate outsourced) and size (bed capacity). Two of the hospitals were built in the last five to seven years. One hospital was in the midst of extensive renovations. One had a multi-tower building being built behind it to increase capacity from 400 to 700 beds. One was acquiring more land for further building.
None were specialist medical tourism hospitals. Three hospitals had official tie-ups with different consulates including: Oman, Japan, Saudi Arabia, Kuwait and the UAE. One or more consultant surgeons with rooms at each of the hospitals have their own websites marketing to international patients. They all left the marketing of medical tourism to their consultants and to medical tourism agents. Each hospital paid two or more agencies for referrals.
Of the five hospitals, only three had websites selling medical tourism on the expectation that people would somehow find their website. These rather basic websites employ different tools to advertise their services, such as: patient testimonials, video footage of the hospital and staff or virtual tours; photo galleries; details of packages and pricing; doctor profiles and publications. Three of the hospitals in the study had special international package deals for a range of treatments, but only one had significantly different pricing scales for international patients compared to local patients.
The paper looks at three ’facts’ on Indian medical tourism:• Medical tourism is a revenue driving industry, as it will increase export earnings through attracting foreign exchange into the country, lowering fiscal deficit and assisting the economic development.
The paper argues that medical tourism is just part of a boom in the Indian healthcare industry. The government is spending lots of money on the infrastructure in a hope that it will increase medical tourism.
• Medical tourism will improve local health systems. The economic growth medical tourism generates results in an overall increase of national income, thus creating equity in access through allowing more of the population access to private care and allow funds to go back into the health system.
The paper argues that the logic employs the widely critiqued notion of the trickle-down concept, but is thinly veiled. With no mechanisms in place to ensure any profits of medical tourism are directed towards public benefit, there is no validity to this claim.
• Medical tourism will improve health care standards. The promotion of medical tourism will raise the standards of health care across the country through competitive market practices, which will translate to an increase of the standards in the public sector.
The paper argues that while this may be the case, it is difficult to separate the varying results from medical tourism, the rise in private health insurance, a move to international accreditations and national accreditation. The key concern is that a move to international standards is likely to increase costs for local patients, as the infrastructure costs are higher. Although medical tourism is not the only impetus for increase of standards and prices, it certainly is one key driver both directly and indirectly.

Romania is well known for health and spa tourism, and while dental tourism numbers are on the rise, the country wants to offer a wider range of services.
Thousands of people travel to Romania to treat their dental conditions, and that can be an opportunity for health tourism, says Vasile Cepoi, state adviser to the Prime Minister, “Thousands of people are treated in dental clinics here, which they promote by themselves. The foreign patients pay a quarter of what they would pay for these services in their country. There is an opportunity for wider Romanian medical tourism. On spa and health tourism there is still a significant potential for growth. Medical tourism has the opportunity to grow in terms of ophthalmology, cosmetic surgery, cardiac surgery, intervention cardiology, cardiac and orthopedic prosthesis and in-vitro fertilization. We have resources, we are motivated and we want to develop this activity to the benefit of the patients from Romania, from Europe and from anywhere in the world.”
Cepoi highlighted that the concept of health tourism is not sufficiently defined in the country. This makes finding out how many go to Romania much harder, and why quoted figures vary wildly. He also pointed out that the state had done little or nothing to promote health tourism, and that there is mistrust in the quality of services offered.
The government’s answers to the latter problem are an internationally recognized quality management system for those services and a new liability insurance system for those providing the related services. Vasile Cepoi explains, “The medical tourist must know how possible damage can be covered and who to contact if there is a problem.”
For the former problem, the government is setting up an inter-ministerial working group to draw up a national health tourism strategy.
In Romania, the government certifies five spa resorts and ten other resorts will be soon, according to the Ministry of Regional Development and Tourism. Romania has over 120 spa resorts with natural resources having therapeutic properties, of which 40 are tourist resorts of national interest and 80 of local interest.

Nicaragua seeks to position itself as a medical tourism destination, states a report commissioned by a local government agency.
Nicaraguan based Calvet & Associates specialize in promoting inbound investment into the country and other Central American states. So, they have an incentive to paint a rosy picture; 90% of the major investment projects in Nicaragua go through them.
The investment consultants claim that nearby Costa Rica attracts 100,000 medical tourists and US$300 million in revenue each year. This contrasts sharply with figures of 50,000 or less from within Costa Rica; even these figures are guestimates rather than actual numbers.
There is no denying that more people are going to Central America, partly due to the now very large numbers of Hispanics in the USA.
Raul F. Calvet of Calvet & Associates claims that Nicaragua could receive US$27.2 million in 2020 from medical tourism and US$105.2 million by 2025.
The study says that medical tourists spend more and stay longer than normal tourists, with 80% of patients traveling with a family member or a friend.
However, to have any chance of achieving these figures, the country would need substantial inbound investment to build hospitals, clinics and hotels. The agency has a portfolio of potential project ideas seeking investors, including hotels and other developments
Nicaragua has only one hospital certified by Joint Commission International. Medical costs are low and there are direct flights to several cities in the United States, where millions of Central Americans reside, representing a high potential of tourists. For Central America, the largest market for medical tourism is the United States due to its proximity and cultural links.

PRONicaragua is the Nicaraguan Investment and Export Promotion Agency, whose mission is to generate economic growth and job creation in Nicaragua by attracting high-quality foreign direct investment. It sees potential in medical tourism.
In 2011 Nicaragua enjoyed the highest rate of economic growth in Central America. Tourism is also prospering. International arrivals passed the 1 million mark for the first time in 2011. According to the Nicaraguan Tourism Board (INTUR) in 2012, Nicaragua received 1,179,581 tourist arrivals and US$422 million in revenues, a growth of 11.3 percent and 11.5 percent, respectively. A new tourism incentive law that brought in 400 inward investment projects in tourism is a key reason for the increase.
According to 2012 statistics from INTUR, the main source markets for tourism in terms of region were Central America (65 %), North America (24 % and Europe (7 %t). In terms of countries, the main source markets were Honduras (21 %), U.S.A. (20 %), Costa Rica (14 %), El Salvador (13 %) and Guatemala (8 %). The hotel industry has been developing mainly in the capital Managua, which holds 46.7 % of the hotel rooms of the country.
Medical tourism is currently very limited : less than 1,000 a year, mainly from Managua and Granada, with a few from the USA, mostly Nicaraguans resident in the USA. Intur is trying to set up a national medical tourism body.
There is long-term potential to tap into the US market but the country will need hospitals and clinics for people to go to, plus doctors and nurses.
Nicaragua is striving to overcome the after effects of dictatorship, civil war and natural calamities, which made it one of the poorest countries in the Western Hemisphere. It has very little infrastructure but in recent years has seen hundreds of inward investment projects.
Some of the factors that make Nicaragua an attractive investment destination for tourism projects include its cultural richness, natural beauty, competitive property costs, skilled labour force, generous tax incentives, the country’s strategic location and easy access from international markets.
The Tourism Incentive Law provides the investor with a diverse and generous tax incentive framework, considered among the best in the region. The law provides incentives and benefits for investments in lodging, tour operators, transportation of tourists, airlines, and others.
The incentives include:• Exemption from 80 to 90 % Income Tax for 10 years• Exemption from property tax for 10 years.• Exemption of import duties and VAT on the purchase of equipment and fixtures of the building for 10 years.
Nicaragua last year set a new personal best for foreign-direct investment after a monstrous 91% jump in foreign-direct investment in 2011. In real terms, foreign investment levels have more than doubled over the past two years. Last year’s record growth numbers were the result of 349 investment projects from 37 foreign countries, with Venezuela leading the charge, representing 16% of the total investment. Panama and the United States were second and third, respectively, representing 15% of the total foreign investment in the economy.

You wait ages for a decent and serious book on medical tourism that is not a sales promoting tourist guidebook, and all of a sudden along come two.
Pramod Goel, founder of PlacidWay, a health tourism resource based in Denver, Colorado, has written a new book, ’Evolution of Medical Tourism: From Cottage Industry to Corporate World.’
The book addresses topics such as the future of 21st century global healthcare and the medical tourism industry as a whole. Available in Spanish and English from Amazon, it focuses on challenging issues such as dealing with supply and demand, developing adequate marketing channels, the importance of patient nurturing and patient centred care. It offers guidance and information to entrepreneurs as well as established providers in the medical tourism industry.
Goel believes that the importance of customer satisfaction and infrastructure requirements are vital in the growing and extremely competitive industry of health travel. He strives to provide a user-friendly analysis of the history, present and future status of the medical tourism industry that will serve entrepreneurs and medical providers.
IMTJ has not seen a copy of the Goel book, but has read and can recommend the other much heavier read by a collection of medical and tourism academics. Published by Palgrave Macmillan, ’Medical Tourism and Transnational Tourism’, is edited by David Botterill, Guido Pennings and Tomas Mainil. Some of the chapters have already been published in academic publications, but making them more accessible here is a very good idea.
The editors explain, “Medicine and tourism have become separated in contemporary popular consciousness. The former implies anything but a pleasurable experience and the latter presumes a healthy disposition for participation. We argue that this popular conception of the separation of tourism and medicine ignores an historical continuity of lineage from the 18th century pursuit of a cure at resorts and spas, to 20th century notions of holidays as worker welfare through to global patient mobility in the quest for cutting-edge medical interventions in so-called untreatable conditions. Disciplinary divisions within the academy have reinforced the separation between medicine and tourism in popular culture, but there is now an emergent challenge to re-think the medicine/tourism nexus. Under the influence of transnational health care consumption, two very contrasting traditions of Western thought are now confronting one another. This book provides a comprehensive landscape of diverse research communities attempts to capture its implications for existing bodies of knowledge in selected aspects of medicine, medical ethics, health policy and management, and tourism studies.”
As it is written from people not active in the business, it does have a wider perspective and more depth than much of what is produced about the industry. It is far from a cheerleader for the business as it asks questions on topics that many in medical tourism prefer to avoid. The tables and long source lists can be tiresome, but the copy itself is interesting, and most chapters would provoke an interesting debate.
Introduction; David Botterill, Tomas Mainil and Guido Pennings1. Sickness, Health, Tourism and the Ever Present Threat of Death: Nineteenth Century Spa and Seasonal Travel; David M. Bruce2. A Way through the Maze: Exploring Differences and Overlaps between Wellness and Medical Tourism Providers; Cornelia Voigt and Jennifer H. Laing3. Caring For Non-Residents in Barbados: Examining the Implications of Inbound Transnational Medical Care for Public and Private Health Care; Jeremy Snyder, Valorie A. Crooks, Leigh Turner, Rory Johnston, Henry Fraser, Laura Kadowaki, Mary Choi and Krystyna Adams4. Tourists with Severe Disability; Angie Luther5. Beauty and the Beach: Mapping Cosmetic Surgery Tourism; Ruth Holliday, Kate Hardy, David Bell, Emily Hunter, Meredith Jones, Elpseth Probyn and Jacqueline Sanchez Taylor6. Cross-Border Reproductive Care around the World: Recent Controversies; Wannes Van Hoof and Guido Pennings7. Transplant Tourism; Thomas D. Schiano and Rosamond Rhodes8. The European Cross-Border Patient as both Citizen and Consumer: Public Health and Health System Implications; Tomas Mainil, Matt Commers and Kai Michelsen9. Canadian Medical Travel Companies and the Globalization of Healthcare; Leigh Turner10. The Ethical Management of Medical Tourism; Guido Pennings11. Habermas, Transnational Health Care and Cross-Culturalism; Tomas Mainil, Vincent Platenkamp and Herman Meulemans12. The Impact of Medical Tourism in Low- And Middle-Income Countries; Melisa Martínez Álvarez, Richard D. Smith and Rupa Chanda13. The Impact of the Internet on Medical Tourism; Daniel Horsfall, Neil Lunt, Hannah King, Johanna Hanefeld and Richard D. Smith14. Towards a Model of Sustainable Health Destination Management Based On Health Regions; Tomas Mainil, Keith Dinnie, David Botterill, Vincent Platenkamp, Francis van Loon and Herman Meulemans

Thanks to its geographical position, the conditions in neighbouring countries, economically reasonable prices and advanced medical facilities, Iran is gradually becoming a destination for Islamic and regional medical tourists.
Hospitals in Iranian cities offer medical and health care services for foreign medical tourists, and for the Iranians who go to large cities from those parts of the country that lack such services.
Geographical closeness and cultural and religious similarities have turned Iran into one of the best and most economically reasonable destinations for the Islamic world and regional countries for health tourism.
Local market leader Jordan is struggling to cope with the healthcare needs of over a million Syrian refugees, and war casualties, plus a negative image from the arrival of US troops and cross –border problems with Syria. If it can avoid being dragged by other countries into war, then Iran has a very high potential for expansion and further development of this type of health tourism.
The depiction of Iran as a backward nation in other countries is very misleading as it has a highly educated workforce and is a local leader in scientific and health development. Iran is one of the top five countries in the world in biotech and nine out of 15 high usage biotech molecules are produced in Iran.
So Iran has a great opportunity to attract medical tourists of Islamic and regional countries. The existence of mineral fountains in many parts of the country, targets one market. Other markets include fertility treatment, stem cell treatment, dialysis, heart surgery, cosmetic surgery, and eye surgery. It also produces unique medicines such as the anti-AIDS drug IMOD, and other high-tech drugs.
The foreign medical tourists can be sub-divided in two groups. The first group is those who travel from advanced countries to other parts of the world seeking high-level medical service at considerably lower prices.
The other type of medical tourists are those who come from less advanced and less developed countries, such as Afghanistan and Pakistan where the medical services are not satisfactory and Iran can offer them greater health services at very reasonable prices.
30,000 medical tourists enter Iran annually, and economic surveys show that each medical tourist brings three times as much hard currency to the country than regular tourists. There are also some 200,000 health, wellness and spa tourists.
Dr. Hassan Rushki of the Iranian Health Ministry’s Health Tourism Committee explains, “Each foreign medical tourist brings to our country an average 4 to 6 thousand US dollars. If the infrastructure for health tourism were improved, we would gain a substantial amount of hard currency from this industry, which is why we need to develop medical tourism. Unfortunately, despite the high profitability and the huge potential of Iran for attracting health tourists, health tourism has still not been recognized as a national industry in our country. Medical services in Iran are comparable with those offered in advanced countries. We must develop and make further investments in our tourism industry.”
The Health Tourism Committee sees the neighboring countries of Afghanistan, Pakistan, and Iraq – all with poor healthcare services – as achievable target markets. People from Pakistan are often not prepared to go to historic archrival India. People from Afghanistan or Iraq are increasingly reluctant to go to places with strong US connections such as Jordan, Saudi Arabia and Dubai.
Dr. Hassan Rushki adds, “China highlights their acupuncture medical treatment and Thailand highlights its massage therapy sessions – each attracting a huge number of tourists to their countries. Iran has unused capacities in similar fields, and rare medicines rarely found elsewhere, which should be taken full advantage of.”
The country accepts that in order to expand their health tourism industry- renovation of hospitals, standardized health services and improving the quality of health are services are essential and urgent.
Iran has already produced rules and regulations for tourist health care service centres so that hospitals and clinics that want to offer health tourism services to foreign citizens need to acquire licenses from both the Ministry of Health and Iranian Tourism Organization.
Offering health service training to employees of tourism agencies and opening international patients’ wards at the hospitals are among the other already adopted measures by the Health, Remedy and Medical Training Ministry.

A plan in Finland to establish a new-generation hospital as a joint venture between the public and private sectors is taking shape in Lappeenranta.
The South Karelia Social and Health Care District (Eksote), Nordic Clinic and Holiday Club Resorts have joined forces and launched a project that will ultimately result in the establishment of a new hospital. The operational models for the new hospital will further increase the efficiency of organising health care services. The hospital will provide services to Finnish and international private patients.
Pentti Itkonen of Eksote explains,” This project holds great interest for us. Encouraging tourists to use health care services available in our district has been one of the goals of South Karelia for quite some time. A jointly run hospital will help us develop our activities in a very tangible manner. The project will increase our income. An arrangement like this will allow us to separate public and private health care. The locals can rest assured that the establishment of a jointly run hospital will not lead to longer waiting times or adversely affect the availability of care for people living in the area. The new hospital will also attract new doctors to the area. This is excellent news as we have had trouble recruiting doctors. The hospital represents an entirely new kind of close collaboration between the public and private sectors. It will also help us prepare for the inevitable changes brought about by the EU Directive on patients’ rights, which enters into force in 2014. Our goal is to allow the private and the public sector to use their special expertise and resources to the best effect, producing the best possible health care services in a cost-effective manner.”
Project developer Wirma Lappeenranta is a business development company in Lappeenranta that provides services to entrepreneurs, companies and tourists. It aims to develop the operational environment and competitiveness of the region. Establishing a centre for health and wellness tourism is one of the key goals of their business strategy. Markku Mäki-Hokkonen of Wirma Lappeenranta comments,” Health and wellness services are an excellent example of valuable services that will attract skilled professionals to the region and create more jobs. Holiday Club has been a trendsetter for the business sector in the area. Health tourism also benefits other service providers in the region, such as companies providing rehabilitation and travel services.”
Holiday Club Resorts is a leading European timeshare and tourism company owned by a consortium of the management, Varma, Suomen Teollisuussijoitus, Ilmarinen, Fennia Group and a group of Finnish private investors. Holiday Club Resorts has 32 resorts and 1500 holiday homes, mostly in Finland. Seven of the resorts feature not only holiday homes but also a spa hotel. Nine resorts are located outside Finland: in Sweden, on the Costa del Sol in Spain and in the Canary Islands.
Nordic Clinic is a Finnish medical tourism agency specialising in Finland and the Nordic countries. It only works with carefully selected leading service suppliers in the private and public sectors. Nordic Clinic’s service range includes specialised medical care, care on the ward, consultations, health care hotel and travel agent services, which are offered through its network of quality certified partners.
Nordic Clinic will provide the new enterprise with a brand, a system for managing integrated care pathways in the field of specialised medical care, a sales and administrative organisation and the opportunity to use its existing customer relationships with Finnish and international insurance companies. Holiday Club Resorts will provide accommodation services and be actively involved in sales and marketing activities. All the operators believe that South Karelia has major potential for health tourism.
In the new hospital, an individual treatment pathway will be created for each patient, and the patient’s need for treatment will be determined early on and in as much detail as possible. The goal is to refer the patient to treatment as quickly as possible, which helps cut down waiting times and costs. If everything goes according to plan, the hospital will open by late 2014 or early 2015.

Jamaican health tourism is needs to place greater focus on attracting overseas based Jamaicans and their families. The Jamaican Diaspora Canada Foundation says 300,000 Jamaicans live in Canada, and there are four and a half million around the world.
Phillip Mascoll of the Jamaican Diaspora Canada Foundation argues, “Health tourism is a market we seriously need to tap into. I do not want to spend my twilight years in the cold. I would much prefer to spend it in Negril or Ocho Rios, but there are things you need to put in place. The fundamental right of every Jamaican is personal security, which is a problem in this country. Old people are afraid. When you reach 75 you want somewhere to come and retire that is sunny, where you can see a doctor and there is a clinic. We have the capacity to put those things in place. And there are also people in the diaspora who will come here and build those places, once the crime has been dealt with. Jamaicans will come any time, no matter what, but foreigners will not do that."
The Jamaican Diaspora Canada Foundation argues that expatriates are willing to work closely with the Jamaican government to improve healthcare and develop health tourism. But they need the government to “ walk the walk, not just talk the talk”. It argues that there is no better place to recuperate from anything than Jamaica. But warns that local politics and bureaucracy can and often do get in the way.
A Jamaican doctor is behind the consortium of 50 doctors from North Carolina in the USA, which will be building Jamaica’s five-star medical 200-room hospital in Rose Hall, Montego Bay. American Global MD (AGMD) is developing the country’s first five-star medical tourism facility. AGMD is a consortium of American-trained physicians and investors, all of whom have strong Jamaican links as a result of having previously studied or practiced in the country. Under the MOU, AGMD will build a fully amenitized 200-bed hospital and medical facility that will target the North American and Caribbean markets. It will deliver services ranging from elective surgeries, rehabilitation and naturopathy.Under the first phase of the project, a 50 to 75 bed patient facility will be constructed to offer cosmetic surgery, bariatric services and dental care.

JAMPRO, the Jamaican government’s tourism and investment promotion agency reveals that members of the diaspora are now also organising to invest US$200 million to build a health facility in Negril.It is working hard to bring other investors on board to develop health tourism.
JAMPRO says that many people from abroad, including the Caribbean are currently utilizing health facilities in Jamaica. Innsurance companies in Caribbean countries encourage people to travel overseas for medical procedures, as local facilities are often not available.
Jamaica has often promoted health and medical tourism, but has failed to attract American and Canadian business.The idea of concentrating on Jamaicans living in those countries is being explored as opposed to general marketing to people who have never been to Jamaica and may find the culture off putting.
The closeness and ease of travel to Jamaica for North Americans, along with Jamaica’s traditional reputation as a strong tourism destination with relatively low labor costs mean that the medical tourism sector has significant potential for the island. By air, Jamaica is one to three hours away from the United States and is in the Eastern Standard Time zone, making it convenient to do business with the USA, Latin America and the Caribbean.

After falling sharply in 2010, health spending remained flat across OECD countries in 2011 as the economic crisis continued to have an impact, particularly in those European countries hardest hit by the crisis, according to OECD Health Data 2013.
While health spending grew on average by close to 5% year-on-year from 2000 to 2009, this has since been followed by a sluggish growth of around 0.5% in 2010 and 2011. Current expenditure on health (excluding capital expenditure) grew by 0.7% in both years. Preliminary figures for some countries suggest a continuation of this trend in 2012.
The drop has been primarily driven by a collapse in the growth of government health spending since 2009 – recording close to zero growth in both years on average. Private health spending also slowed down in many countries in 2010 and 2011, as household incomes remained flat or decreased, although the reduction was more limited.
In Greece, overall health spending dropped by 11% both in 2010 and 2011 after a yearly growth rate of more than 5% on average between 2000 and 2009. These reductions were mainly driven by deep cuts in government spending. Ireland, Iceland and Spain also experienced two consecutive years of negative growth in health spending. Some countries, such as Estonia and the Czech Republic, saw severe falls in spending in 2010 followed by a modest rebound in 2011. Other countries, including Portugal and Italy, may have delayed cuts in 2010, but then reduced public health spending in 2011. In Portugal, public spending dropped by 8% in 2011 after remaining stable between 2009 and 2010. Only two OECD countries – Israel and Japan – have seen acceleration in health spending since 2009 compared with the period before.
Away from Europe, health spending growth also slowed in 2010 and 2011, notably in Canada (3.0 % in 2010 and 0.8% in 2011 in real terms) and the United States (2.5 % in 2010 and 1.8% in 2011, also in real terms). In the United States, the share of health spending to GDP has remained at 17.7 percent between 2009 and 2011, after years of steady increases. It is not clear yet whether the recent slowdown reflects mainly cyclical factors and may therefore not have lasting effect when economy growth picks up, or whether it reflects more structural changes such as a slower diffusion of new technologies and pharmaceuticals, and changes in provider payments resulting in greater efficiency.
Reductions in public spending on health in many OECD countries have typically been made across the board. Pharmaceutical spending has been a prime target, with spending falling slightly in 2010 followed by deeper cuts in 2011. Many countries have increased cost-sharing for pharmaceuticals, reduced prices and coverage, and promoted the use of generics. In 2011, Portugal, Greece and Spain reduced spending on prescription pharmaceuticals by 20%, 13% and 8% respectively. In Spain, the share of generic drugs (in the total volume of consumption) more than doubled between 2006 and 2011.
In many countries, governments have also decided to cut their spending on prevention and public health, although these typically represent only a small share of their overall health budgets. More than three-quarters of OECD countries reporting expenditure on prevention and public health for 2011 showed a real-term cut in spending.
Many governments have also tried to contain the growth in hospital spending – one of the biggest ticket items in most countries by cutting wages, reducing hospital staff and beds, and increasing co-payments for patients.
As a result of the minimal growth in health spending across OECD countries in 2010 and 2011, the percentage of GDP devoted to health declined slightly in most countries. Health spending accounted for 9.3% of GDP on average across OECD countries in 2011, compared with 9.5% in 2010. Excluding capital spending, current expenditure on health as a share of GDP dropped from 9.1% on average in 2010 to 9.0% in 2011.
These are some of the short- and long-term trends shown in OECD Health Data 2013, the most comprehensive source of comparable statistics on health and health systems across the 34 OECD countries. Covering the period 1960 to 2012, this interactive database can be used for comparative analyses on health status, risk factors to health, health care resources and utilisation, and health expenditure and financing.
OECD Health Data 2013 is available in OECD.Stat, the statistics portal for all OECD databases. Individual data on each of the 36 countries is available.
While demand and need for healthcare is growing in every one of these 36 countries, the amount that the state can provide is diminishing every year. In many countries, the gap will be filled by local private healthcare. Identifying and filling the gaps by nation will be what drives future medical tourism.

A study of the experiences of cosmetic surgery tourists, led by the University of Leeds, challenges widely held perceptions about the safety and motives of people travelling overseas for treatment.
The two-year study, ’Sun, Sea, Sand and Silicone’, is the first to use in-depth interviews, video and photo diaries and questionnaires to analyse cosmetic surgery tourism from the perspective of the patient’s experience. The study was funded by the Economic & Social Research Council.
Findings are based on the accounts of more than 100 patients from the UK, Australia and China, as well as 100 people involved in the industry.
While bad experiences have typically grabbed headlines, the researchers found that 98% of the patients would repeat the procedure in the same country and medical facility. Many patients also praised the clinics for diagnosing and treating underlying health problems during pre-surgery tests.
The profiles of the patients also challenge the stereotype of a cosmetic surgery tourist as being a wealthy, glamorous and globe trotting Westerner who is exploiting low-wage economies.
According to Professor Ruth Holliday from the University of Leeds, “The patients we interviewed were ordinary people on modest incomes – administrators, nurses, shop workers – who travelled abroad because they could not afford to have the surgery at home. Some patients from the UK commented that private surgeons at home viewed them as walking cheque books, whereas surgeons abroad saw them as a whole person.”
Investing in their physical appearance was only one of four motivating factors for opting for cosmetic surgery. Other reasons given by patients were correction, such as ear pinning and nose reshaping; repair, such as post-pregnancy breast uplift or tummy tuck; and anti-aging, such as a face-lift or hair transplant.
The findings also show that the quality of the surgeon, rather than the desirability of the destination, was the key deciding factor in choosing the location. Many patients reported that they enjoyed some sightseeing during their trip, but the emphasis was on travelling for affordable surgery and then returning home as quickly as possible.
When asked how they had selected a surgeon, the researchers found that people preferred reading reviews from other patients, while the advice provided by surgeons, clinics or cosmetic surgery tourism agents was often seen as being tainted by profit motives.

In Nicaragua, tourism is prospering. International arrivals passed the 1 million mark for the first time in 2011, according to the Nicaragua Tourism Board (INTUR). Some local hospitals now see medical tourism as the next opportunity
Nicaragua enjoys one of the highest rates of economic growth in Central America. Tourism is growing as the country shakes off the now way outdated image of a country riven by civil war, gangsters and drug lords.
A year ago Managua’s Hospital Metropolitano Vivian Pellas began promoting simple surgery to Americans. It now gets 10 patients a month from the USA and Canada. Arlen Perez of Hospital Metropolitano Vivian Pellas explains, “It is hard getting Americans to come here to Nicaragua’s capital, if they have no local family connections. Our target is 50 patients a month for the next 2 years two years at least.”
The hospital is targeting Latinos in the USA with adverts that suggest a hip or knee replacement, or gastric surgery, can be less than half the cost of in the USA.
While other Latin American countries Mexico and Costa Rica are popular medical tourism destinations, Nicaragua has been forgotten. But it is lucrative for the tourist trade as patients and people who come with them tend to stay longer in than tourists. Some hotels are partnering with hospitals to attract patients.
Nicaragua badly needs better roads, better education, and better hotels. Few hospitals are up to the standards expected by American medical tourists. Foreign investment in Nicaragua has been growing for the last 5 years, but most investment is from local businesses. Nelson Estrada is developing a $16 million spa hotel near the sea that would also offer cosmetic surgery and other wellness services to wealthy foreigners.
Nicaragua’s economic expansion is projected to decelerate slightly over the next three years yet maintain a steady rate of around 4.5%—according to the Nicaraguan Foundation of Economic and Social Development (FUNIDES).
Dr. Carlos Muñiz of FUNIDES explains, “The keys to success are consolidating macroeconomic stability, diversifying our sources of foreign aid, increasing productivity, improving infrastructure, health and education, and strengthening our institutional democracy and governability.”
As the country increasingly weans itself off dependency, and considerable political interference, on loans from the USA and Venezuela- to where overseas money is for investment, medical tourism can play a small part in increasing tourism.

Thailand must not overlook unexplored medical tourism potential in Eastern Europe, Central Asia and the Middle East, says the Tourism Authority of Thailand (TAT). Besides Russia, whose citizens have become big travellers to Thailand, Ukraine, Kazakhstan and Uzbekistan are the three rising stars listed by TAT. These countries could help to offset declining tourism from Europeans states beset by slowing economies. Medical and wellness tourism is mirroring mainstream tourism in where customers come from.
Thailand has been successful in attracting tourists from Russia in recent years, with the number of tourist arrivals from that country rising by 24% to 1.31 million in 2012.
In the Middle East, TAT is looking for new markets in Gulf countries as traditional channels such as Dubai and the wider UAE have become saturated. TAT sees potential in Oman, Qatar, Saudi Arabia and Jordan. TAT also plans to boost the number of visitors from Lebanon and Egypt, where Thailand’s tourism image is positive.
Thai medical tourism is largely ignored by tour operators, leaving hospitals to sell their products direct to consumers or use non-travel related representatives to drum up business. That is the conclusion of Naowarat Namitan from Bangkok International Hospital, who says that the hospital wants to tap business from Myanmar, Vietnam, and Cambodia, but travel agents are slow off the mark, ”Although we sell our medical services in neighbouring countries tour operators in those countries are not really interested, or lack the knowledge to create packages involving medical visits. The Middle East and Australia are the strongest markets for our medical tourism.”
Thailand’s medical, health and wellness tourism industry expects a further boost of business as the Asean Economic Community rules begin in 2015, but expects stiff competition from Malaysia, Singapore and Indonesia, especially for Muslim tourists.
Nithiwat Gijsriurai of Bangkok Hospital says they are aiming for more patients from Asean countries in two years’ time, "Last year, we treated 812,447 patients of which 130,335 come from overseas, including Gulf states Qatar, United Arab Emirates, Kuwait, Oman, Saudi Arabia and Bahrain. We have Thai doctors who can speak Arabic as well as Arabic translators and an Arabic wing in the hospital. Malaysia is also a choice destination for overseas Muslims. "
To ensure they continue to be a leading destination, Thailand has increased the length of automatic visa extensions from 30 to 90 days for all Gulf state nationals- and this will be extended to all Asean members by 2014.Thailand intends to enlarge its customer pool by training or recruiting Arabic-speaking doctors, nurses and translators.
The Asean Economic Community (AEC) will create a single market for Southeast Asia with 600 million people, working on a similar basis to the European Union.
The ASEAN member states are;• Brunei Darussalam• Cambodia• Indonesia• Lao • Malaysia• Myanmar• Philippines• Singapore• Thailand• Viet Nam
The Thai government has a strategy for now until 2016 to promote medical tourism by emphasising the nation’s excellent service in general medical treatment, health promotion, traditional Thai medicine and alternative medicine. Bangkok is promoted as the spa capital of Asia, and efforts are being made to make other major tourism destinations recognised on the same level, including Chiang Mai, Phuket and Samui.
A recent survey of 22 medical travel agents from the United States, Australia, the Middle East and Europe found that foreigners have a positive impression of Thailand’s medical tourism industry.
According to Tourism Authority of Thailand (TAT) and the Ministry of Public Health, Thailand’s medical tourism statistics show that in 2012 foreign visitors sought Thai medical services on more than two million trips. But this does not mean 2 million medical tourists as it counts each visit to a hospital as a trip.
Official estimates recorded 58 billion baht revenue for Thailand in 2009, 65 billion baht in 2010, 97.8 billion in 2011 and 121.6 billion in 2012.

The Airports Authority of India (AAI) has issued a tender for opening a medical tourism centre – a first of its kind for India, although not globally at the Sardar Vallabhbhai Patel International Airport to help international medical tourists coming to the city of Ahmedabad.
Airport director R K Singh explains, ”The aim is to improve facilities for passengers and not just to earn money." AAI will provide 10 square meters of space at the arrival area of the international terminal to the highest bidder. The space will be provided at a lower price than what AAI charges for other counters like food and hotels. The aim is to provide necessary information on procedures, monetary transaction and international code of treatment.
On being asked why patients would go to a medical tourism centre at the airport when they have flown in for pre-arranged appointments at a specific hospital, Singh’s reply was, "People always seek better facilities. The centre will help them find the best option available for them. If you go to a hospital, you will have to wait for your turn for long. The plan aims to do away with this waiting time. AAI has consulted with Apollo Hospitals, Shalby Hospitals and Vasan eye care for the medical tourism centre."
It may simply be that there is a misunderstanding on the use of the centre. International patients – who may have had to list hospital and doctor details to get a medical visa – are unlikely to change their mind on where they will be treated. It would make more sense for local hospitals to combine to offer a reception centre and taxi/bus service for booked in patients and any family with them.
Ahmedabad is a fast growing city that wants to be a key destination for medical tourists in India. The state the city is in claims that there has been annual growth of 33% in business compared to an average of around 20% in the country; although there is no data to back up either statistic.

Receipts from international tourism in destinations around the world grew by four per cent in 2012, reaching US$1,075 billion, figures from UNWTO reveal. This suggests that health; wellness and medical tourism could also be slowly growing globally.
Travel business growth is equal to the 4% increase in international tourist arrivals, which reached US$1,035 million in 2012. An additional US$219 billion was recorded in receipts from international passenger transport, bringing total exports generated by international tourism in 2012 to US$1.3 trillion in the latest UNWTO World Tourism Barometer.
Taleb Rifai of UNWTO comments “It is encouraging to see that the growth in international tourist arrivals was equalled by a comparable increase in spending in spite of continued economic challenges. Considering that tourism is a key export for many economies around the world, this result is good news as it provides foreign reserves to destinations, and contributes to job creation in tourism as well as in related economic sectors.”
By regions, the Americas (+7%) recorded the largest increase in receipts, followed by Asia and the Pacific (+6%), Africa (+5%) and Europe (2%). Receipts in the Middle East were still down (-2%); yet report a steady improvement compared to the decline recorded in 2011.
In absolute values, Europe saw US$ 457 billion in tourism earnings- equivalent to 43% of the world’s total tourism receipts, the largest share by region. Destinations in Asia and the Pacific (US$ 323 billion) account for 30% of international tourism receipts and the Americas (US$ 215 billion) for 20%. In the Middle East (4% share) total tourism receipts reached US$ 47 billion and in Africa (3% share) US$ 34 billion.
The top 10 ranking of destinations by receipts remained virtually unchanged in 2012, with the United States, Spain, France, China and Italy leading, followed by Macau (China), Germany, United Kingdom, Hong Kong (China) and Australia.
A number of the more mature destinations among the world’s top 10 earners showed remarkable results: the United States (+11%), France (+7%), Germany (+6%), the United Kingdom (+5%) and Hong Kong (China) (+14%). Other advanced economy destinations with growth rates of 10% or above include Sweden (+17%), Japan (+33%), the Republic of Korea (+14%) and Finland (+16%).
Among the emerging economy destinations highest receipts growth was reported by Thailand (+25%), India (+22%), Poland (+13%), South Africa (+18%), Egypt (+14%), Vietnam (+18%) and Ukraine (+13%).
There are no separate figures for health or medical tourism, but medical tourism trends often closely follow mainstream trends. With much focus on other regions, this report suggests that many may undervalue the importance of health, wellness and medical tourism in Europe, as it is less high profile than other areas.

The UK health secretary, Jeremy Hunt, has blamed problems in the Accident and Emergency units in NHS hospitals on ’health tourists’ from Africa and Europe. He has stated the cost to the NHS at £200 million a year.
The actual reported figure from the NHS for 2012 has been previously published as £11 million pa, up from £2 million pa in 2002. This is the total figure for all non-resident foreigners who have received free treatment in NHS hospitals to which they are not entitled. The NHS further admitted that very few of these non-resident foreigners flew to the UK for treatment. Most were already in the UK on holiday, on business or to study. Many are legal immigrants from other EU countries
Earlier this year, Prime Minister David Cameron promised tighter controls to limit immigrants’ access to the NHS, saying, “What we have is a free National Health Service not a free International Health Service”. Since then Cameron has been forced into a u-turn after being informed that it is impractical and possibly illegal to get harassed and overbusy A and E staff to check paperwork, by declaring “ There were no plans to change the universal right to treatment in casualty.” Trying to restrict treatment for citizens of any other EU country would also be a breach of EU rules.
The figures released by health minister Anna Soubry provide a breakdown of the cost over the past decade. Under current rules, non-resident foreigners can use the NHS and their governments are supposed to pay back the cost of care. Poor enforcement and poor record keeping by hospitals means that many governments are not chased for bills, or when chased, they simply ignore the request, and no legal action is taken to recover the money. The number of cases where the bills are due to an individual not paying, are relatively few.
These and other reports also show that many of the ’health tourists’, are actually people from overseas flying in and paying for care in private beds at NHS hospitals.
The £11.5 million figure may be on the low side due to under-recording. This emphasizes that the NHS has to be much better at identifying who is entitled to free care and who is expected to pay. But establishing practical, effective ways to make sure that patients who are not eligible pay their way, is easier for politicians to demand than for hospitals to do; bearing in mind that the first priority of any doctor is to treat anyone who is ill or injured; a failure to treat simply because they may be unable to pay a bill, could be a serious disciplinary breach.
Some EU migrants do not use the NHS. For example, low cost health and dental clinics have opened in the UK to cater for Poles who may be happy speaking English for food shopping, but prefer to speak Polish and approach health in a Polish way, when discussing health problems.
The British Dental Association and the Royal College of GPs have expressed concern about the government’s proposed immigration reforms and a new law that would limit the free access of recently arrived migrants to the NHS. The law would require doctors and dentists to check that patients are eligible for free health care before treating them. The law would also require visitors to the UK to pay a contribution towards any NHS treatment. The Royal College of General Practitioners, a professional organisation for doctors said that the proposals would turn them into border guards and they had no role in policing access to the NHS. Dr Judith Husband of the British Dental Association adds, “Any decisions must be underpinned by the principle that doctors and dentists primary obligation is to treat patients requiring urgent care, policing who can or cannot pay for it is not part of their role.” If any law gets passed, it will not be in place until mid 2014 at the earliest; and it has many legal and practical problems to overcome.
Among a total NHS budget of £104 billion, £11.5 million is fairly insignificant. The NHS pays £1 billion a year to other countries for the treatment of UK citizens abroad, as it always pays the bills. But many countries that should pay for treatment of their citizens in the UK either never pay the bills or only pay some, or only pay if chased through the courts; these unpaid bills are within the £11.5 million. Also within this figure is a substantial amount for unpaid bills for treatment of staff of overseas embassies in the UK; embassies owe various government bodies for healthcare, parking fines, and road taxes, and they cannot be prosecuted or taken to civil court for non-payment.
The negative publicity from the political grandstanding to view all ’health tourism’ as a ’bad thing’, both in the UK and overseas has inevitably caused damage to the real paying inbound and outbound medical tourism business in the UK.

After years of talking and several failed attempts, the Maltese government has established a way for the disparate health and medical tourism providers on the island to work better together.
The ministry for health has set up a business friendly section for private healthcare providers to promote contacts with the business community for ventures within the health sector and to help health tourism.
All private sector health services will be able to use this new project from self-employed health operators to private clinics and hospitals. It will offer advice on the development of partnerships between the public and the private health services.
Health minister Godfrey Farrugia explains," It will serve as a contact point, and work with private health sector stakeholders to develop public and private health services for a sustainable health system on a national level."
This section works with the ministry for tourism and ministry for enterprise to promote health and medical tourism, by acting as a catalyst for private health care providers who seek opportunities in health tourism.
Traditionally Malta has relied on tourism for a living, with most tourists coming from Italy and the UK, but with both countries having economic problems, this traditional market is struggling .Two other important markets, Libya and Egypt, also have problems; while attempts to attract Americans have not done well. The island has pinned much faith on attracting Russian tourists.
The government’s u-turn to support health and medical tourism, even in a very limited way, is probably as much to do with the struggles of the local tourism trade as any sudden interest in promoting medical tourism.

Thailand is still the leading global medical tourism destination by numbers but the travel trade is concerned that low prices and high numbers may not be the most profitable path.
They are concerned that hospitals and agents are in danger of becoming complacent and not thinking ahead on how to keep attracting high numbers in the future without seeing profit margins gradually eroding to keep and gain business.
The medical travel trade is calling on Thailand to improve its medical tourism by adding new services and maintaining its high treatment standards.
A recent Tourism Authority of Thailand (TAT) survey researched the views of 22 medical travel agents from the US, Australia, the Middle East and Europe. The agents said people are still looking for experienced doctors, advanced technologies and high-quality facilities and staff when they go to Thailand.
Medical tourism is a revenue generator for the travel trade and local hospitals. According to the Tourism Authority of Thailand, in 2012, 2.4 million foreign visitors went to Thailand for health services, generating revenue of 14 billion baht. TAT expects that number to rise to 3 million over the next three years, resulting in doubled revenue growth.
TAT plans to promote new advances in cosmetic surgery, fertility, anti-ageing and cell therapy. Markets such as Australia, the Middle East, Russia and the US are targets.
According to TAT, 600,000 high-income Chinese travelled to Switzerland and Singapore last year for anti-ageing and cell treatments. Where those figures come from is unclear as they are much higher than any other known figures for outbound Chinese medical tourism.
But the logic of TAT is correct in that Chinese customers are one of the biggest and highest spending markets this year, so TAT and some local medical travel agents are focusing on that market.

Researchers at Simon Fraser University’s medical tourism research group have come up with some simple medical tourism guidelines for Canadians.
A one-page information sheet for prospective Canadian medical tourists outlines several key points to consider, from unforeseen costs and procedure risks to contracting diseases and patient rights. A Canadian Institute of Health Research grant supported the work.
Professor Jeremy Snyder and his colleagues have spent two years talking to those in the industry around the globe, doctors and former patients to examine the pros and cons.
Professor Snyder explains, “It can be hard to gauge what the quality of care abroad is like, in some cases fantastic care, but the regulatory systems might be different or they just might have trouble telling. It can be difficult to make sure you have continuity of care. So, if you are getting dental implants in Mexico, there might be linguistic barriers, when you are bringing medical records back home or your local dentist might not be able to get access to those records.”
The group also points out that there can be consequences for people living in the destination country. Professor Snyder explains, “Canadians are not aware of the potential for negative impacts for the people in the countries that are welcoming medical tourists. Medical resources are going into private care for foreigners. Potentially it is a good thing because it brings in revenue. Medical tourism might direct resources away from low-income settings or redirect health personnel into the private system and away from the public system”
Snyder warns of the risks of infectious disease or unforeseen costs, but also beleives that most Canadians return healthy after experiencing treatment that is a lot faster and less expensive than at home, “We have talked to many Canadians who have gone abroad for care for a variety of reasons and most people are happy with how things turned out. But some return home requiring expensive on-going treatment that burdens people in Canada waiting in queue. We want to educate people about these concerns.”
For Canadians going overseas the most popular procedures include hip, cosmetic, reproductive and dental surgery, as well as experimental treatments for multiple sclerosis and cancer. Many travel to Mexico, the Caribbean and Europe each year and the researchers expect numbers to increase.
Snyder and colleagues undertook a study published earlier this year looking at the legal implications of the risks of medical tourism for patients, which pointed to concerns over unintended and undesired effects on patients’ home healthcare systems. In 2011 a focus group found concerns ranged from surgery and treatment complications to uninformed decision-making.

Sheikh Mohammad Bin Rashid Al Maktoum, Prime Minister of UAE, and the constitutional monarch of Dubai will take direct control of the Dubai medical tourism initiative and intends to build more hospitals and continue the high profile at medical tourism conferences and exhibitions.
The Dubai plan for 2013 to 2025 must meet the challenge of high prices, rotating doctors, concerns of locals on quality of care, and concerns of overseas medical tourists about political instability in the region.
Eisa Al Maidour of the Dubai Health Authority (DHA) reports that the authority is identifying gaps in services, building capacity and increasing investment: “We expect a steady increase in healthcare requirements. Within the DHA network of health centres and hospitals, we have increased capacity by 12%”.
Health authorities in Dubai will spend $820m on rebuilding Rashid Hospital, as well as opening three new hospitals and 40 health centres.
One practical aspect of the new strategy is meeting the need to serve people accompanying patients. The authority has plans to build two five-star hotels for this purpose.
Dubai’s ruler has long sought to promote Dubai as a favoured destination for health tourism in the Middle East, and the latest initiative began in 2012. Since then, several measures have been taken to unify the medical tourism strategy of many official Dubai organizations. Sheikh Mohammed is determined to promote Dubai as a favoured destination for health tourism in the Gulf and Middle East, however much it costs.
DHA strategy 2013-2025 seeks to deliver five goals: prevention and awareness; easy access to health services; quality, and investment and competitiveness, through 43 initiatives backed by a control plan and key performance indicators.
The DHA has a three-phase plan to find urgent solutions to pressing challenges dealing with customer service in the short term, administrative and technical affairs in the medium term and strategic issues in the long term.
Hospitals in Dubai benefit from being very new, in a tax free set-up, with 100% foreign ownership allowed, international accreditation and no restrictions on investment.
Despite the advantages, massive investment and heavy government support Dubai’s main customers are still locals, expatriates and travellers. Getting people to travel from other Gulf countries who are also investing in healthcare facilities has proved difficult; while Europeans and Americans are reluctant to visit due to the relatively high prices, long travel times and concerns of political unrest in the Middle East.

For many years, Cambodia has been a source of patients and health tourists for nearby countries. That is about to change.
Although many Cambodians will still go overseas for medical treatment, the country will soon see the first step in inbound health tourism.

AHMS Collection, a hotel development firm from Thailand, will expand its health and wellness operations into Cambodia in 2014 with the opening of a luxury private island resort targeting the high-end medical, beauty and wellness-focused tourism sectors. The resort is being built at a cost of US$21 million.
Anchalika Kijkanakorn, owner of Akaryn Hospitality Management Services (AHMS), explains, “Unlike many other resorts we will not be just selling the accommodation; as it is about the whole holistic experience, the seclusion, the villas, the technology of the spa treatments, and the ambiance. We are targeting guests who want to stay for seven to 14 days. Part of that is due to the location, which is quite out of the way, but mostly it will be down to the experience they can have there.”
AHMS will work with travel consultants specialising in medical, meditation and anti-ageing tourism to tap established and emerging markets. Anchalika Kijkanakorn adds, “The world has become so small that I cannot say we will be focusing on the European markets as there is so much opportunity from emerging markets in Asia. The UAE will also be one of our key targets as Arabs are very big on health tourism these days.”
The new Akaryan Retreat at Koh Krabeay will be a destination wellness and spa retreat on the private island of Koh Krabey, Cambodia. This 6 star private island resort is a 20-minute boat transfer south of Sihanoukville and welcomes its very first guests in 2014. With only 35 private pool villas, guests are invited to experience the rare luxuries of space, security and seclusion within a tropical island setting. The spa will blend modern technology with natural science wisdom. State of the art facilities will include a medication cave and water therapy suites with full holistic, fitness, medical and spa facilities available for guests. Each villa has a private infinity pool, a large terrace – with day bed and private ocean view garden.
Koh Rong is Cambodia’s second largest island, off the coast of Sihanoukville. There were ambitious plans for two spa resorts, 160 villas, a beach club, a lagoon and a private airfield. But all that has been built is a handful of wooden beachfront bungalows.

58 million tourists went to Spain in 2012, but as many come from within Europe, the country worries that economic woes could slow increases in numbers and profitability. So after being lukewarm on health tourism and sometimes aggressively against medical tourism, Spain now sees health tourism as a potential money-spinner that could rescue some troubled holiday areas.
Health tourism has become more important in Spain in recent years, attracting more than 20,000 international tourists in 2012, according to Secretary of State for Tourism, Isabel Borrego. At a recent tourism conference, Borrego noted that increasing numbers of domestic and international tourists are visiting Spanish spas or taking part in health-related travel.
In 2012 21,868 international visitors went to Spain to for various health treatments, spending in total EUR 12.1 million, according to data provided by Turespana.
The government’s tourism department sees health tourism as strategically important as the average spend of a medical tourist is significantly more than that of a conventional tourist and the time spent in the country is generally longer.
Turespana claims that 9 million Europeans are health tourists each year and by 2020 this could double. What has to be watched here is the rather loose interpretation that mixes spa and health and medical tourism all within the same definition. Both Turespana and Spanish politicians use health and medical tourism as interchangeable terms.
One attraction to Spain of health and medical tourism is that while much conventional tourism is seasonal, these are much less so, although health tourism tends to be more seasonal than medical tourism. Borrego sees both as, “An important unseasonal factor that is a golden opportunity for tourism, that will also improve the quality and diversify Spanish thermal spa offerings. Health tourism is the niche of the future with great capacity for growth will benefit from Europe’s increasingly older population with greater life expectancy. The two key markets for Spain are Germany and Britain.”
Spain’s tourism industry sees innovation, technology, product differentiation and public-private collaboration as key elements to attract between 75 and 80 million tourists in 2015. These are some of the points raised in the report ’Hot Topics of Tourism in 2013’ presented in Madrid and prepared by PwC Consulting based on the opinion of the representatives of the sector in Spain.
Alvaro Klecker of PwC commented, “Although in recent years there has been growth in this sector, it is insufficient and there have been declines in the profitability of all business areas. Although the number of foreign visitors continues to increase, with 58 million international tourists in 2012, domestic tourism suffers greatly. Spain must offer improved services and make better use of technology if wants increased tourism numbers. There must be better communication of the offer to tourists, and a need to understand what people want. It must link tourism to the entertainment industry and promote non-seasonal tourism with a target of 20% additional income outside the high season. Profit margins have reduced, and there is a need for changes in the Spanish tourist business model by focusing on attracting more visitors, improving efficiency and restructuring travel agencies."

Many countries welcome expansion in medical tourism, but the boom in Israel’s medical tourism has been attacked by a government official, the State Comptroller, in his annual report on healthcare; Joseph Shapira told Parliament, ”The booming industry luring foreigners to Israel for medical procedures infringes on the principle of equality in the provision of health services”.
According to the Health Ministry, revenue from medical tourism in state hospitals was NIS 54 million in 2009. But by 2011, it was 2.2 times higher, at NIS 119 million.
Medical tourism to Israel is also growing for private hospitals and is expected to increase more in the future. Future tourism and medical tourism will be easier after Israel’s government approved an "Open Skies" deal to allow more EU flights, lower air travel prices and increase competition after April 2014.Tourism is a major industry in Israel, bringing in more than 3.5 million visitors a year.
The Health Ministry both owns and runs state hospitals, as well as supervising healthcare nationwide. There is an increase in private healthcare in public hospitals; while the ministry is helping private interests build and run a public hospital with private medical care in Ashdod. There is also an increase in private healthcare, with politicians and economists divided as to whether or not an increase in privatisation of state healthcare is good or bad for the public.
In the 2012 annual report, the comptroller notes that the ministry has very little data on what and how many services – mostly elective surgery – are provided by the 11 private hospitals around the country,” The rate of activity of the private system cannot be compared with the public system. Going to a private hospital for surgery enables patients to choose their own surgeon – usually doctors who work mornings in the public hospitals and moonlight in the afternoons and evenings. There was a 22% rise in private hospital activity between 2005 and 2010 compared to only 14% growth in public hospitals during that period. The time may have come to prohibit patients in private hospitals from being able to choose their surgeon or consultant.”
Medical tourism and whether treating foreigners in public and private hospitals comes at the expense of Israelis is a vital issue raised in the report. The shifting of dwindling numbers of medical personnel to the care of outsiders may also harm the Israeli public, but the ministry has not examined the problem and set down rules. The ministry says that it is now doing so.
The government has often said it will regulate medical tourism, but the latest report and replies in Parliament suggest that new rules and regulations will be devised, but it could take a few years.

At the Asian travel association PATA’s annual conference, medical tourism to and within Asia was discussed as an important sector of Asian tourism. While getting medical tourists from other regions is important, the consensus was that the real future growth will come from within the region; so needs to be better developed.
Kenneth Mays of Bumrungrad International Hospital in Thailand said: “The US and Obamacare do not generate big opportunities for Asian hospitals. Real growth is not coming from the US but from the region within a seven-hour flight radius like Myanmar, Cambodia, Vietnam and Indonesia.”
Zadok Lempert of Thailand-based Panorama-Medica Group, added: “Asia has been the preferred destination over the last decade due to high-quality, less expensive medical treatments. It is a niche market that is becoming mainstream.”
And Ralf Krewer of Bangkok Hospital explained, “The distinction between medical tourists and leisure travellers is becoming blurred, leading to a new global patient. Patients are behaving like travellers, seeking higher service levels and evaluating the total package and not just medical expertise.”
PATA and the Hong Kong Polytechnic University’s School of Hotel and Tourism Management (SHTM) have released ’Asia Pacific Visitor Forecasts 2013-2017’ to help tourism practitioners anticipate future trends. Published annually with a quarterly breakdown, it offers information on visitor arrivals from key source markets to 41 destinations in Asia-Pacific, as well as visitor expenditures and departures of PATA member economies. This will help destination countries predict arrivals, tourism receipts and departures according to country/region of origins.
The latest data says that visitor arrivals to Asia-Pacific will continue to grow with an average annual growth rate of 4.1 % from 2013-2017 and reach 581 million by 2017. China is predicted to remain the top inbound destination in Asia-Pacific, peaking at 147.4 million visitors in 2017, while its outbound traffic to the region will exceed 100 million by 2015. Hong Kong will be the second largest inbound destination in Asia Pacific in 2015. Cambodia, the Maldives, Chinese Taipei, Bhutan and Mongolia are the top five fastest growing destinations for visitor arrivals over the period 2013-2017.

A new survey shows why it can be very misleading for agencies and hospitals in other countries to quote against US prices. A typical and common advert may read,” The cost of heart surgery costs about $40,000 in X versus the $150,000 in the United States.” In reality, the price of heart surgery in the US is rarely anywhere near $150,000 and in some rural US hospitals may be below $40,000. Across the EU, publishing misleading price comparisons within or targeting EU customers is illegal under advertising laws, and while advertising standards in the US are less strict, blatant misleading adverts can be illegal; it varies state by state and some states take a tougher stance than in the EU. If you use price comparisons, you must be able to back them up with a real source. Taking general prices from the Internet is not sufficient.
A federal government survey found huge disparities in hospital charges depending on where people live. Centers for Medicare & Medicaid Services (CMS) is a US federal agency that administers Medicare, Medicaid, and the State Children’s Health Insurance Program. As part of the Obama administration’s work to make the healthcare system more affordable and accountable, CMS data has been released that shows significant variation across the country and within communities in what hospitals charge for common inpatient services.
The data includes hospital-specific charges for the more than 3,000 U.S. hospitals that receive Medicare Inpatient Prospective Payment System (IPPS) payments for the top 100 most frequently billed charges. Hospitals determine what they will charge for items and services provided to patients and these charges are the amount the hospital bills for an item or service.
Average charges and average Medicare payments are calculated at the individual hospital level. Consumer can access the data to make comparisons between the amount charged by individual hospitals within local markets, and nationwide, for services that might be furnished in connection with a particular inpatient stay.
Health Secretary Kathleen Sebelius announced a three-part initiative that for the first time gives consumers information on what hospitals charge. $87 million is available to states to enhance their rate review programs and further health care pricing transparency. Kathleen Sebelius commented, " Consumers do not know what a hospital is charging them or their insurance company for a given procedure, like a knee replacement, or how much of a price difference there is at different hospitals, even within the same city. This data and new data centers will help fill that gap.
Hospitals will now be required to tell patients how much they charge for procedures, a move that should spark competition and lower costs; as well as giving a huge boost to domestic US medical tourism.
The report shows significant variations in prices from region to region, or even in hospitals within the same region. The report shows a joint replacement in Ada, Oklahoma could cost $5,300 compared with $223,000 in Monterey Park, California, a suburb of Los Angeles. Have a heart attack in Ogdensburg, New York, and it will cost $15,087. But at Valley Regional Medical Center in Brownsville, Texas, the bill will be $66,000. In South Carolina, Trident Regional Medical Center in North Charleston charges $59,000 to treat a heart attack, but nearby Aiken Regional Medical Center charges $37,000.
Because insurers often pick up the bill directly, consumers have not had to shop for better prices. However, as more employers have moved to low premium, high-deductible plans, which leave consumers paying more out-of-pocket costs, they must pay attention to how much a procedure costs. Employers have asked for procedure costs so they can limit hospitals within employee networks to those with the highest quality at the lowest cost. Insurers do deals with hospitals to pay prices that are often much lower than what hospitals charge the uninsured.
The CMS data is good, but not easy for consumers to use or understand. So the nonprofit Robert Wood Johnson Foundation (RWJF) plans to publish a user-friendly interactive map based on the data, so people can choose where to be treated. Dr. Risa Lavizzo-Mourey of RWJF explains,” Transformation of the health care delivery system cannot occur without greater price transparency. While more work lies ahead, the release of these hospital price data will allow us to shine a light on the often vast variations in hospital charges."

The majority of Arab women who want cosmetic surgery have one destination in mind; London, England. Leading cosmetic surgeon Professor Laurence Kirwan says that 90% of Arab women who leave the Middle East to have cosmetic surgery performed go to Europe. And over half of them from Saudi Arabia, The United Arab Emirates, Qatar and other countries in the region choose London for their treatment.
Professor Kirwan says,” London is famous for a lot of things and now you can count top-notch cosmetic surgery among those things. These women come from very wealthy backgrounds and they can afford to go anywhere in the world to have their cosmetic surgery done so naturally they choose the place with the best reputation."
According to Kirwan, 20% of wealthy Arabs who have cosmetic surgery would now choose to come to Europe – with 10% of those coming to London.
But even with an influx of potential new patients, Kirwan is now going to take his services to them. He will now be consulting in Abu Dhabi once a month.” The Arab market continues to grow as Arab and Middle Eastern women continue to become more open to the idea of cosmetic surgery. It just makes sense to go to where the market is growing."
Kirwan already has an international presence with clinics in Harley Street in London and in New York and Connecticut in the USA. He has long been sought out by wealthy clients from the Arab world and expects his consultancy will be in high demand in Abu Dhabi.
Arab women, like their Western counterparts, are influenced by what they see in the media and want to feel good and look beautiful. Despite the fact that cosmetic surgery is outlawed in some Arab states and that many Arab women remain covered around all but their husbands and family, they still want to look the best that they possibly can.

Although medical tourism in the Caribbean consists more of outbound trips to the USA than inbound business, several countries are seeking to develop local business.
In the Bahamas, American World Clinics (AWC) are still to decide which island is the best first one for new hospitals for medical tourists, expatriates and local patients seeking a US standard of medicine and medical care. AWC already operates in Barbados, and is looking at the Canary Islands and Uruguay. The company works closely with local governments in developing their hospitals on a public-private partnership model.
The Bermuda Hospitals Board (BHB) has been actively exploring medical tourism. It is offering a new prostate treatment in Bermuda that is not yet available in the USA. An increase in medical tourism has been good for local hotels, with 1,000 hotel bookings a direct result of the new prostate treatment. Bermuda is upgrading its hospitals to make them more modern and more appealing to tourists. They are looking to add dental and cosmetic surgery.
Jamaica has approved a new hospital built by local doctors in a public-private partnership in St. James, as the government looks to encourage medical tourism industry.
The first total hip replacement procedure performed in the Turks and Caicos Islands was a success and establishes the country as a medical tourism destination. A team of overseas doctors from Global MedChoices (GMC) performed the first total hip replacement at the Cheshire Hall Medical Facility on Providenciales. In all, five patients were brought to the island by GMC. InterHealth Canada contracted the surgeon through Global MedChoices, a US based medical tourism agency. The plan now is to fly in more patients from the USA and Canada, to be treated by flown in Canadian and US doctors. InterHealth Canada runs two hospitals on the islands.
The government of the Cayman Islands spends a fifth of its annual budget on healthcare. Dr. Devi Shetty’s new Health City Cayman Islands, currently being built in East End, will reduce the amount of overseas travel for medical procedures. The need to travel overseas for healthcare has been a drain on both the government and private individuals’ purses for many years. For the year ending June 2011, the cost of overseas healthcare claims incurred under the official insurance programmes for treatment off-island for civil servants, veterans and seamen, indigents and other residents covered by the government’s insurance company was almost $30 million, almost all in Florida hospitals.
Health City Cayman Islands is ahead of schedule and the site is on track for its expected completion in February 2014. The construction of the first phase, which consists of four linked buildings that make up a single complex, is being done on 14 acres of the site, which could eventually cover 200 acres. The first patients are expected to be admitted to the 140-bed hospital in March 2014.It will specialize in cardiac surgery, cardiology and orthopedics. Indian hospital group Narayana Hrudayalaya is partnered by Ascension Health Alliance, the largest private not for profit health network in the United States.
While many of these new hospitals and clinics claim to be aimed at medical tourists, the first effect is likely to be a reduction in the number travelling to hospitals in the USA and elsewhere. So whether the number of new inbound medical tourists will be higher than the reduction in outbound medical tourists across the Caribbean is an interesting question. Overseas investors may well make a long-term profit from developing hospitals, if they can get the locals and expatriates to use them. Getting profit just from increased inbound medical tourism is a major challenge.

Christina deMoraes founded the International Medical Tourism Chamber of Commerce (IMTCC) in 2012. It is based in California in the USA. It is still small with only six listed members, all in the USA; plus MedNetBrazil, a company owned by deMoraes.
The IMTCC was founded so that medical tourism consumers, healthcare providers and medical tourism service providers have an unbiased source to guide them on matters of competence and trust in this growing industry. The logic is that global healthcare should be based on patient centred care, with transparent pricing, plus aftercare and support- all in an ethical way.
Christine deMoraes comments, “I am the founder and we are gathering members. I started more than ten years ago while I was living in Brazil. I was a patient myself and then started helping others like myself. I handheld 300 patients through their medical tourism experience in the first few years. What was essential for me was to provide my patients with advocacy, aftercare and accountability. I am inclined to trust that the majority of medical tourism agencies would prefer to do an excellent job if they were given the tools, workflows, protocols and mentoring they need. I also believe that patients would be more trusting and recognize the value we add, the savings we assure and the stress we relieve if they had a source to go to for credible information and education. Aftercare is an essential part of the puzzle that is often missing. Without adequate aftercare, patients suffer, doctors’ results are less than optimal and our industry’s reputation is negatively affected.”
The IMTCC is about connecting people; building relationships in integrity and providing standards of performance as solutions to the issues of the medical tourism healthcare experience.

With significant government backing, Turkey is rapidly expanding in medical tourism and has set itself some ambitious goals.
The Ministry of Health aims to make $7 billion in revenue from 500,000 foreign patients in 2015, while it has set its sights on reaching $20 billion in 2023 from 2 million foreign patients.
Within the health ministry is the Department of Health Tourism, which aims to promote medical tourism and co-ordinate other government and private sector activity. It is also responsible for providing emergency health services to Turkey’s 34 million tourists.
By health tourism, Turkey means medical tourism, thermal/spa tourism, elderly tourism and disabled tourism. The department operates a free 24/7 helpline plus free interpretation service in English, Arabic, Russian and German; getting 700 calls a month. In 2013 it will handle 2,000 calls a month and will expand the service to include Persian and French. It has a website in four languages.
Foreign patients treated in public or private or university hospitals have to be registered with the health ministry. In 2012 Turkey had 210,000 medical tourists compared to 156,176 in 2011, 109,678 in 2010, 91,961 in 2009 and 74,093 in 2008. The Department of Health Tourism analyzes these figures by province, hospital, and county of origin. It expects 2013 to produce at least 250,000 medical tourists.
Medical tourists mainly seek eye treatment, hair transplants, dentistry, and cosmetic surgery; plus orthopedic treatment, cervical herniated discs and slipped disk treatment, gynecological and urological operations, plus treatment at ear, nose and throat clinics. 91 % use private hospitals and the remaining 9 % use public hospitals.
Germany, Russia, Azerbaijan, the Netherlands, Iraq and France top the list of the countries whose citizens visit Turkey for health tourism. In addition, a significant number of visitors come from Ukraine, Belgium, Kazakhstan, Romania, Libya, Georgia and the UK. Turkey attracts the largest health tourists from Germany, the Netherlands and France, as the population of people with Turkish roots is high.
The health ministry plans new medical tourism regulation this year; including regulation of medical tourism agencies, medical spa rules, rehabilitation service laws, plus general health tourism regulation. The ministry also expects that the share of public hospitals in attracting foreign patients will increase to 10 % in the years to come.
The top five destinations for foreign patients are Istanbul, Kocaeli, Ankara, Antalya and Mu?la.
During 2013 the health ministry and other government departments plan new laws on health free-zones that could contain- hospitals, clinics, rehabilitation centres, thermal tourism, elderly living resorts, and wider tourism offerings. 85% of customers are expected to be from overseas, as are 60% of doctors. There will be tax, investment and planning advantages.
The government plans a host of other promotional activities and legal reforms to make Turkey an attractive and safe place for medical tourists.

The Health Consumer Powerhouse (HCP) monitors and compares healthcare systems among 35 countries, including all EU member states as well as Canada. Using more than 20 different health consumer indexes this Swedish organisation provides guidance to patients and information to governments. In 2005 HCP launched its first Euro Health Consumer Index.
Johan Hjertqvist, founder of HCP offers an outsider’s view of medical tourism:
“Medical travelling, health tourism, cross-border care – when there is hype the labels tend to grow in numbers. Every week I get invitations to medical tourism fairs and exhibitions, activities perhaps more frequent and economically important than the travelling and treatments as such. Not least Europe east of the EU seems to catch up, with numerous conferences and exhibitions in Russia, Belorussia and Ukraine.”
“Today probably not too many people would think of going to Kiev or Minsk to have a hip replacement but things might change. Belarus even claims to have a "medical tourism city". In Russia the target group seems to be wealthy residents interested to go abroad to avoid the many downsides of Russian healthcare. Going West is expensive for Russians but the steady flow of medical tourists already flying from Moscow to London, Zurich or the US suggests that they can afford it.”
“As the inter-EU exchange of cross-border patients becomes more organised, with the cross-border directive implemented into national law, you can expect two major routes of patients to emerge: one for publicly funded treatments, according to the directive, and one for out of pocket paid services. The private one is already rich of cosmetic and life-style surgery but probably as well, complicated, resource demanding and sometimes acute specialist procedures not available in the country of the patient. The public version will deal with treatments suffering from long waiting lists, lack of quality or unavailability at home.”
“The public road may not prove broader than the private one as many governments want to restrict travelling for care. In the private lane there is a tradition of simplifying access, picking up the visitor at the airport and providing a smooth procedure.”
“As decided by the European parliament in 2011, by October 2013 every citizen of the EU will have the opportunity to go abroad to have a medical treatment. The patient will have the right to the same public funding that otherwise would be available for a treatment in their own member state.”
“Governments will be obliged to provide foreign visitors with information about their legal rights, what to do in case of poor treatment and also about treatment options, access, quality of care, patient safety etcetera.”
“But while a few EU member states will allow citizens to make their own judgment to travel to another country, the vast majority of member states will be using roadblocks with many conditions before allowing treatment abroad, or not.”
“You can expect some governments to be at the front, welcoming mobility and transparency, while many others will lag behind, offering a minimum of information and with little co-ordination work.”
Recent HCP reports include ’ Impatient for change’, an overview of European health systems and the political context within which they exist; and ’Social media – nothing for Swedish healthcare’, an intriguing analysis of why with a very high IT-penetration and many users of social media, Swedish healthcare is reluctant to open up for such communication with patients. But there are a few limited efforts, mainly in the big cities, including Stockholm that has put a healthcare guide system on Facebook.

A travel agent specialist course on medical and wellness travel is under development by The Travel Institute and Well-Being Travel.

Well-Being Travel, an agent for medical and wellness tourism, is providing guidance and resources for the course, including creating key learning objectives. It arranges medical tourism trips at medical destinations organized by medical partner Companion Global Healthcare.

The Travel Institute is a nonprofit organization that educates and certifies travel professionals, is responsible for writing and administering the course, creating an online test and certifying successful candidates.
The online course will be offered in a series of modules, some of them focused on travel for medical procedures, including the legalities and risks. Modules will also cover the wellness/health vacation market, including resort, spa and cruise wellness vacations. Travel to medical spas or for holistic health reasons will also be addressed. The course will include interactive exercises, images, audio, graphics and testing.
The time is right for a course that enables travel sellers to take an advantage of a lucrative niche, says Anne Marie Moebes of Well-Being Travel, “Health and wellness tourism is a multibillion-dollar industry that continues to grow.”
The partnership between Well-Being Travel and The Travel Institute brings together the required elements for furthering US travel agent education on wellness travel. Well-Being Travel provides the necessary resources for travel agents to be successful in this market; The Travel Institute has the expertise to launch an educational programme.
The Travel Institute makes its money from educational courses, while Well-Being Travel partners with travel agents to promote domestic and international medical and health tourism; the travel agent arranges the airline and hotel, while Well-Being Travel arranges the medical and health aspects via Companion Global Healthcare.
While travel agents actively promote spa, health and wellness tourism-many are worried that they do not have the medical knowledge to arrange medical tourism trips and could be held liable if something goes wrong with the operation.
So far, globally, attempts by travel agents to sell medical tourism have not been very successful, with some travel groups setting up medical tourism subsidiaries and soon closing them as costs exceeded income.

Despite local doctors mounting an aggressive ’medical tourism is dangerous’; campaign to protect their income, an increasing number of Australians are going to Asia for lower priced cosmetic surgery and cosmetic dentistry.
Australians are travelling to countries including Thailand, India, South Korea, Turkey and Malaysia, for a range of medical and dental work.
Meredith Jones from Sydney’s University of Technology is researching one aspect of medical tourism – cosmetic surgery – and says price is no longer the only motivator. “Now more people say things to me like I would prefer to have it overseas because I can recover away from family and friends, or they say I think I will get better care overseas. So there is also this perception that you do actually get better care for far less money."
Meredith Jones estimates that cosmetic surgery tourism by Australians is a 300 million dollar a year industry. She says about 15,000 Australians travel overseas each year to undergo cosmetic procedures.
And her research shows a growing number of people are going in groups, “Most of those people are women in their late teens or early 20s. They travel in groups and they mostly have breast augmentation surgeries. And there are also people who say my friends were doing it so I decided to do it as well.” Dr Jones says costs vary a lot overseas but cosmetic surgery is generally half price or less than in Australia.
Geoff Dobb of the Australian Medical Association says Australians should avoid undergoing medical procedures overseas as medical tourists run the risk of a less-skilled surgeon, less sterilised conditions and a higher risk of infection from multi-resistant bugs, “If they come back to Australia with complications, these can be extremely difficult to retrieve. And of course there can be, in many occasions, very little redress against the places where the surgery has been performed. People come back and can be seriously disfigured by the surgery that they have been subjected to elsewhere. People need to be aware that the standards of medical facilities are often significantly less than they would be in Australia and without carefully inspecting all of the procedures they have in those hospitals they may not be aware of the risks that they are exposing themselves to."
There is no evidence to support Dobb’s claim that Asian cosmetic surgery is of a lower standard than in Australia. Dr Jones says according to her research, the Australians who get cosmetic surgery done overseas are generally happy with the result, and that there is no more risk of complications or bad practices overseas than in Australia.
The most popular procedures overseas are cosmetic surgery: breast augmentations, facelifts, and tummy-tucks. But local medical tourism agencies report that there is an increasing interest spinal surgery, neck surgery, hip replacement, knee replacement, shoulder reconstruction, and fertility treatment.
The AMA has been a long-time critic of medical tourism, and suggestions from customers and medical travel agencies that an increasing number of Asian cosmetic surgeons and dentists are using more up to date techniques than their Australian rivals fuels the flames. The AMA is quite measured in its criticism. In contrast, some Australian surgeons are strongly opposed to it, believing that overseas cosmetic surgery has serious shortcomings.

The Greek government is finally looking at developing medical tourism, but is it too late?
A bill for the development of medical tourism in Greece is currently being prepared by the Greek Ministries of Health and Tourism and will soon be released for public consultation, says health minister Andreas Lykourentzos.
The bill will aim to establish an institutional framework for the development of the necessary infrastructure and provision of advanced services in the health tourism sector.
Lykourentzos notes that public and private sector collaboration is essential and state hospitals could also be included in the planning once they were certified. Health units could provide high quality health services.
According to the study “Development of Medical Tourism in Greece,” conducted by the Institute of Social and Preventive Medicine on behalf of the Hellenic Chamber of Hotels, a very high and perhaps overambitious target for Greece is the annual arrival of 100,000 medical tourists that would each spend an average of 4,000 euros (3,000 euros for medical expenses and 1000 euros for accommodation and other expenses) in the country.
The Hellenic Chamber of Hotels suggests that pilot programmes should be launched in Lasithi, Rhodes, Santorini, Athens, Thessaloniki and Thessaly for the development and promotion of an integrated network of medical services for foreign visitors at a local level. The pilots would include travel packages and a marketing strategy. They would be implemented through local hospital units with the participation of primary clinics, hoteliers, travel agents, local government and transport services. The aim is to evaluate the feasibility of the research project based on the capabilities of local providers and agencies.
The study suggests that Greece could provide rehabilitation travel packages (through the collaboration of rehabilitation centres with hotels); fertility treatments-in vitro fertilization and assisted reproduction (through the collaboration of medical centres with hotels); facilities for dialysis patients (hotels and rooms-to-let associated with dialysis centers); spas and rehabilitation centers (equipped with necessary infrastructure for individuals with musculoskeletal disorders, neurological disorders, the elderly); plus packages for ophthalmology and cosmetic surgery.
Greece’s desperate economic plight means that the government is looking at finding ways to help the economic mainstay of tourism, and helping the struggling healthcare system. In the past government and hospitals were both dismissive of promoting medical tourism and even if the concept gets the go-ahead, getting instant results with high numbers is rather unlikely.

The NHS for England is consulting on the UK government’s suggestions for implementing a directive that concerns patients’ rights to cross-border healthcare in other member states of the European Economic Area.
It applies to England only as Wales, Scotland, and Northern Ireland operate the NHS each in their own way.
’Cross border healthcare and patient mobility: consultation on the UK implementation of Directive 2011/24 EU (on the application of patients’ rights in cross-border healthcare)’ is seeking views and the consultation closes on 24th May 2013.
The EU Cross Border Healthcare Team of the NHS in England is seeking views on:• Centralising cross-border administration at the NHS Commissioning Board in England from 1 April 2013• Setting up a cross-border healthcare National Contact Point for England (within the NHS Commissioning Board) by October 2013• Improving information on patients’ rights and entitlements.• Provisions for dealing with patients from other countries who want to use NHS facilities under the terms of the directive.• How the processes of prior authorisation and patient reimbursement should work.
The centralization is a done deal as the various local trusts have been replaced by the national NHS Commissioning Board. From April 2013, the NHS commissioning system – of primary care trusts and specialised commissioning groups changed substantially so that most of the NHS commissioning budget is now managed by 211 clinical commissioning groups. These are groups of general practices that come together over a defined geography to take on responsibility for commissioning the best services for their patients and population. Nationally, the NHS Commissioning Board commissions specialised services and primary care.
The Department for Health and Social Services of the Welsh Government has issued an almost identical protocol for cross-border healthcare services.
The situation between England and Scotland also needs to be resolved but the possibility that Scotland will become independent in the future complicates predictions.
Health boards in Scotland can at present arrange travel to specialist transplant centres such as Freeman Hospital in Newcastle or Papworth Hospital in Cambridge and there are few, if any, costs for patients. However, if Scotland votes to leave the UK in the 2014 referendum, patients seeking treatment in England, Wales or Northern Ireland would have to use one of two complex routes agreed between EU member states.
Margaret Watt of the Scotland Patients Association says, “Whatever the outcome of the referendum, there is already pressure on patients when it comes to travelling for medical treatment and the system for treatment south of the border is complicated enough. We do not want to see patients placed with any additional burdens.”

The Taiwan government wants to open up more of its health care sector to foreigners and encourage overseas medical investment.
The government set up special economic zones to attract big foreign companies, including three major industrial parks in Hsinchu, Taichung and Kaohsiung where local and foreign companies can enjoy logistical, economic and tax advantages that create jobs for the local population. The island’s Council for Economic Planning and Development proposes to give foreign tourists full access to medical facilities located in these zones.
Taiwan’s tourism industry relies heavily on the huge influx of tourists from China. The quality of medical treatment in Taiwan is the main reason for the arrival of tourists from the mainland. Now tourists from Mainland China can travel on their own. Until a year ago, they had to be part of organised groups.
Between the start of 2011 and the end of 2012, medical tourist spending rose fourfold to US$ 135 million. Not surprisingly, the Taiwanese government wants to increase the number of patients receiving health care treatment in Taiwan.
Most come to the country for medical check-ups and cosmetic surgery; and the latest official plan is to offer them access to the whole range of medical and hospital services.
In addition, the new plan seeks to attract medical organisations from other countries into the special economic zones to serve foreign and Taiwanese patients, and further improving the island’s high quality health care system.

Manouchehr Jahanian of the Cultural Heritage, Handicrafts and Tourism Organization has stated that Iran hosted 200,000 health tourists in 2012, earning $1.5 billion, a figure more than double 2011.
Last year, more than 4.5 million foreign tourists spent $9 billion in Iran and created jobs for 2.5 million people directly or indirectly. Tourism is up by a million people on 2011; people being attracted by diversified climates as well as numerous tourist and historical attractions.
Most health tourists were from Azerbaijan, Turkmenistan, Iraq, Turkey, Kuwait, Oman, India and Pakistan. These include medical tourists as well as health and spa tourists.
The number of Omani nationals visiting Iran for medical tourism is on the rise with around 5,000 Omanis seeking treatment in the country every year, according to the Iranian Embassy.
Medical tourists from neighbouring states mostly come for transplants, ophthalmology, orthopedics and dentistry.
Iran’s Cultural Heritage, Handicrafts and Tourism Organization (ICHHTO), has conducted studies that suggest the best targets are Iraq, Afghanistan, Persian Gulf states, Central Asian nations and Iranians residing abroad.
In 2012 Iran launched new plans to expand medical tourism in the region. The Health Tourism Committee has been formed in collaboration with representatives of Foreign Ministry, Iran Medical Organization, Iran’s Cultural Heritage, Handicrafts and Tourism Organization, and the Commercial Chamber of Health Ministry.
The government is planning a new health tourism law that will regulate who can offer medical tourism-60 hospitals have indicated interest.
Pressure continues to mount on Iran over its nuclear programme; and the presence of US and EU warships off the coast, is hardly conducive to attracting American or European medical tourists.

Americans going overseas for medical treatment will find it long and difficult, if not impossible, to sue for medical negligence either in the US or the country they were treated in, said Nathan Cortez, Associate Professor of Law, Southern Methodist University Dedman School of Law, in a recent presentation at North Carolina Journal of International Law and Commercial Regulation Symposium.
Professor Cortez says that American patients opting to leave the United States to have procedures done overseas may not realize that they may be forgoing the legal protections of American courts. Patients are bearing the brunt of legal risks because it can be very difficult to successfully sue in the US or overseas.
In the USA, jurisdictional issues and deciding under which theory of liability to sue are difficult obstacles to overcome when dealing with a foreign doctor and foreign hospital. Professor Cortez focused on the legal system in India to showcase the challenges patients face even if they are willing to sue overseas. Typical delays in India’s civil courts can go on for fifteen to twenty years, and while patients can elect to pursue claims through consumer forums known as Consumer Dispute Redressal Agencies, there can still be delays averaging two to three years as well as difficulties with securing expert testimony and accessing medical records. And, overly complex cases may even be transferred back to the civil courts, and in the end, a successful patient can expect only very limited compensation.
As Professor Cortez points out in his article, Recalibrating the Legal Risks of Cross-Border Health Care, medical tourism raises questions about whether patients fully understand the tradeoff they are making when they seek medical care abroad. With such limited remedies available to patients, are these risks potentially exacerbated by a lower quality of care and a higher likelihood of medical mistakes?

Mexico may offer nearby care at lower prices to Americans, but it is struggling with perceptions of drug wars, violence, and poor quality care. This matters a lot, as apart from a few Canadians, nearly all Mexican medical tourists are Americans.
Mexico has long attracted a large number of tourists from all over the world, and medical tourism is rapidly becoming a growing source of new visitors. The country’s doctors and dentists are well-trained and qualified, with many having studied in the US; and Mexico’s proximity to the USA makes it a highly popular destination for Americans seeking a variety of medical treatments at low cost. Dental work is one of the most common procedures, but knee and hip surgeries and cosmetic and reconstructive surgeries are popular as well. Costs can be as low as half of those in the US.
Hospitals and clinics in many parts of Mexico are modern and feature up-to-date diagnostic equipment. Many foreigners have reported that their Mexican dentists and doctors tend to relate to them on a more personal level than health professionals in their home countries.
Tourism in Mexico has suffered from the weakness in demand from the USA and Europe. And no matter how often the authorities stress the fact that the narcotics war has not affected most Mexican tourist areas, the violence has seriously damaged the country’s reputation as a destination.
The North American Free Trade Agreement opened the border to trade in merchandise and services, including medical care. But many restrictions remain; preventing Americans from getting quality care that could be as much as 40 % cheaper.
A report by the U.N. Economic Commission for Latin America and the Caribbean claims that despite its proximity to the USA, Mexico is behind other countries in attracting American patients. Mexico needs to do more both to improve security and to certify hospitals to treat international patients, it says. Only 19 Mexican hospitals are certified by the Joint Commission.
Christopher Wilson from the Woodrow Wilson Center’s Mexico Institute comments, "Mexico needs to get more hospitals certified by the Joint Commission, address violence and the perception of it, and needs to significantly increase advertising in the United States. USA states need to see if changes are needed in insurance regulation to allow policies to cover care in Mexico."
In California, some insurance companies are selling policies to cover care in Mexico, but other states such as Texas ban cross-border schemes. Getting Medicare to cover treatment out of the USA is what local medical tourism advocates seek, but they struggle with Democrats and Republicans arguing that if the government pays for treatment, it wants that money to help revenue and jobs in US hospitals.
The Mexican government set up an office to promote medical tourism in 2012 to tap the American market, but if it still exists it is invisible.

Christus Muguerza, owned by Dallas-based Christus Health, is the largest Catholic health care system in Mexico. But both hospitals in Monterrey, just two hours from the Texas border, have suffered badly by American fear of the drug violence that has become the scourge of Northern Mexico. Many people think twice about crossing the border.

The number of foreign tourists visiting South Korea for medical treatment is increasing but held back by government regulations on local hospitals, claims the Hyundai Research Institute (HRI).
HRI says the country’s weak performance on medical tourism sector is mainly attributable to excessive regulations on local hospitals. South Korean hospitals are not allowed to have foreign patients exceeding 5% of their capacity, and medical specialists with foreign licenses have limited leeway in working for local institutions.
HRI wants government to ease regulations on hospitals by allowing non-medical firms to invest in medical institutions and abolish ceilings on the percentage of foreign inpatients.
Although the Korea National Tourism Organization, says that the number of foreign health tourists to South Korea was 150,000 in 2012, compared to 122,297 in 2011, the figures have problems.
The 2012 figures are estimates rather than national figures and are actually of international patients rather than just medical tourists. They include all foreigners who are non-Koreans who receive no benefits from local medical insurance. This includes American soldiers and diplomats based in the country, plus holiday and business travellers and expatriates treated in the country. In the past the ministry has had to admit that it assumed all non-nationals who had treatment locally and were not covered by Korean insurance, visited Korea for medical purposes, so it did not reduce for other categories such as general tourists, who fall ill. As the country gets nearly 10 million tourists a year, this spinning of the figures could be quite important.
The country accepts that it is unlikely to get many American or European medical tourists and that there is now fierce competition for those from Russia, China, Mongolia and Japan.
So it is targeting nearby poor countries. A dozen Cambodian visitors including journalists, travel agents, and a public health official recently went to Korea to look around major hospitals in southern Seoul. The four-day visit was on the invitation of Gangnam District Office. Other countries being targeted include Vietnam, Ukraine, Myanmar and Kazakhstan. Central government and regional governments as small as districts are promoting medical services in Korea
South Korea has a problem as most Cambodians go to Singapore or Thailand for medical treatment because of proximity and easier entry to these countries. They can go to Thailand or Singapore at any time without a visa.
Busan, Korea’s second largest city, hosted medical professionals, travel agents, and journalists from Almaty, Kazakhstan. Other cities and provinces such as Daegu, Daejeon, and Jeju have been promoting themselves as medical tourism destinations. KTO is trying to promote Korea as a medical tourism destination to the Middle East, but that is a very competitive market
With the most developed medical infrastructure in the country, Seoul is by far the main destination for foreign medical tourists. The capital city took in 77,858 patients in 2011 and Gyeonggi-do attracted 17,092. Next is Busan (6,704), followed by Daegu (5,494), Incheon (4,004) and Jeollabuk-do (North Jeolla Province, 2,104).
The fields of medicine sought by overseas visitors in 2011 are internal medicine (15.3%), dermatology and cosmetic surgery (12.7%), family medicine (8.7%), physical examinations (8.3%), gynaecology (7.7%), and Oriental medicine (5.9%). The proportion of physical examinations, dermatology, and cosmetic surgery is on the decline while internal medicine and oriental medicine have been increasing.

The Polish Medical Tourism Consortium is an initiative of the Ministry of Economy backed by the private sector. It is targeting potential patients, insurance companies, government health departments, medical tourism providers, business organizations and trade associations, interested in sending patients from Russia, Germany, Denmark, Sweden, Norway, UK and USA to Poland.
The government is supporting Polish medical tourism with a promotional campaign funded by the EU. The Ministry of Economy has identified medical tourism as one of fifteen high export potential sectors.
Medical tourism has become the one of the priorities of the Polish export policy from now until 2015. The main advantages being promoted are easy access to high quality services at lower costs than in Western Europe. The costs of medical treatment in Poland can be up to 40% lower than Germany or the UK, and even more compared to US prices.
The activities are organized by a consortium of PAIiIZ (Polish Information and Foreign Investment Agency), EuCP (European Center for Enterprise) and AMEDS Centrum. PAIiIZ is responsible for organization of international conferences, exhibitions and media study visits to Poland. AMEDS recruits candidates to participate in international events and training as well as for the publication of informational and promotional materials; EuCP is responsible for contacts with the ministry and paying for the project.
The campaign sees sponsored participation of Polish hospitals and clinics at medical tourism conferences and exhibitions in Russia, UK, Germany, Denmark and the USA.There are co-branded information and promotional materials for the medical tourism sector plus films, videos, brochures, catalogues and an on-line portal.
There are trade missions and study tours for foreign journalists and foreign companies to Poland; organized training for representatives of medical tourism companies; plus business meetings and match-making sessions with companies, associations, and institutions. The consortium has developed medical tourism packages

Taiwan is doing rather well at attracting health and medical tourists, with a constant supply of new ideas.
In the eastern county of Hualien, traditionally known better for its coastal scenery than medical services, 67 local medical institutions and travel operators have got together to offering high-end medical packages aimed at Chinese tourists. And the local government has set up a Hualien county medical tourism association.
A seven-day package features a combination of Western-style physical checkups and clinical cosmetology, as well as Chinese preventive medicine. A 14-day package features an even higher-end health promotion and anti-aging treatment for double the price, according to a county international medical tourism association established by the local government.

Buddhist Tzu Chi General Hospital in Hualien is famous for making people’s legs slimmer through a calf muscle-trimming procedure, which has been drawing tourists from as far as Brazil. Since 2001, the hospital has conducted procedures on 500 pairs of legs. 20% of medical tourists coming to the Hualien hospital are from China, Hong Kong, Macau, the United States, Canada and Japan.
What is happening in Hualien is mirrored both nationally and locally, with an increased number of local governments, tourist boards, hotels, hospitals and clinics in Taiwan attaching more importance to medical tourism as a new niche market and a way to boost the country’s economy.
According to the Taiwan External Trade Development Council (TAITRA), Taiwan recorded the arrival of 81,462 medical tourists as of the end of the third quarter of 2012, more than double the 39,428 visitors in 2011.
Among those treated in 2012, 60% went to Taiwan to get treatment for their illnesses, 27% for health check-ups, while 13 % for cosmetic surgery, according to TAITRA.
The government plans to set up a service industry experimental zone next to Taiwan Taoyuan International Airport, the country’s main international gateway. It will offer services to international visitors including help to arrange travel, shopping, clinical cosmetology and financial services. The zone is part of the efforts to boost Taiwan’s employment by cultivating the service industry, with high paying service jobs.
The government’s Council for Economic Planning and Development is considering the idea of regional free economic zones to foster the development of Taiwan by providing medical care, medical tourism, industrial innovation, international logistics, training and product sales.
Taiwan’s main target market is China, due to the two countries’ linguistic and cultural similarities. Taiwan launched a 15-day medical tourism visa to cater to Chinese tourists and an e-visa service that will help make things easier for Chinese tourists visiting Taiwan for physical checkups, cosmetic surgery or anti-aging treatments.
Taiwan drew a total of 50,376 medical tourists from China in 2012, says TAITRA, more than half the total; but these are still estimates and final 2013 figures are awaited.

Hungarian Tourism plc is now actively promoting medical tourism globally, but targeted mostly at Western Europe.
Hungary is one of the flagship countries of European medical tourism. A quarter of all medical students at Hungarian universities come from abroad, and many Hungarian specialists teach and practice internationally. The main reasons for Hungary’s leading role in European medical tourism are long experience and practice in the international market. The success story began in the eighties, when Hungary was a popular destination for German and Austrian patients seeking top-quality dentistry and dental prosthetic services of Swiss standards. Since Hungary joined the European Union, medical tourism has become more varied and more international.
The cost of treatment is between 40% and 70% of the cost in the UK, USA and Scandinavian countries. The most popular treatments and procedures for international patients are dentistry, cosmetic surgery, orthopaedic surgery, cardiac rehabilitation, fertility treatment, dermatology, anti-aging treatment, obesity treatment, addiction programmes and eye surgery.
Hungary is easily accessed by low-cost flights from all over Europe. It has the lowest MRSA rates on the continent. Hungary has a number of accreditation and license schemes applying to its institutions, such as the domestic accreditation schemes from the Hungarian Ministry of Health, and the National Health Commission and Medical Service. Several clinics run medical tourism programmes and packages, organising the entire trip including flights, accommodation, transfers and treatments.
There is no age limit by Hungarian law, so even single women can have fertility treatment, and all sperm donors are anonymous. There is no waiting list for IVF. Most of the patients have the first initial consultation with the fertility specialist within a month of first contact.
The country is trying to get away from its image as purely a dental treatment country, so is heavily promoting cosmetic surgery, eye treatment, fertility treatment, anti-aging treatment, and more.
It is not forgetting the important and historic spa, wellness and health tourism angle too. Linking with medical tourism, it is promoting medical spas.
Hungary has more medical spas than anywhere in Europe, A medical spa uses water rich in minerals that medical tests clearly show has health benefits. Thermal water is any naturally occurring spring that emerges at a temperature exceeding 30°C. Balneotherapy is the treatment of a medical condition with water from a medicinal spring – particularly water with high concentrations of dissolved minerals and sediment. Balneotherapy is combined with physiotherapy, electrotherapy and therapeutic massage. This is complemented by related treatments, including drinking cures and inhalation.
Budapest is a spa capital, and there are many type of spas from historic Turkish and Roman to medical and party spas. The country sits on one of the richest geothermal and medicinal water resources in the world. Hungarian springs have supported a bathing culture dating back to Roman times.

The Asia Medical Travel Council (AMTRAC) and the Thai Medical Tourism Association (TMTA) have signed a deal that makes the national medical association for Thailand the first pioneer official member of the Asia Medical Travel Council.
TMTA will make up one of five of the AMTRAC regional bloc members, the first bloc of its kind in the world, which should soon include four other prominent Asian countries that are promoting their local inbound medical travel industry.
AMTRAC’s vision is to ultimately show the world that member countries are able to offer safe and affordable medical treatment comparable to the best in the world, and collectively raise the visibility of Asian medical travel destinations in an increasingly crowded medical travel market. The logic is that they will all benefit by working with each other rather than aggressively competing with each other.
Ultimately, this collaborative network can only spell good news for the patient as the medical travel bloc will collectively look to allay patient concerns by discussing and addressing important and pertinent issues such as patient safety, continuity of care, standardisation of medical records, and accreditation.
Founder of AMTRAC, Wilson Tan says, “This deal marks an exciting time for Asia in medical travel. TMTA will be a valuable member of AMTRAC as will be the other AMTRAC members. They can learn how it has succeeded in achieving the right balance of medical skills and expertise blended with Thai hospitality to succeed in promoting Thailand as a premiere medical travel destination to the rest of the world. Our two organisations have a great deal in common in our values, work ethics and vision to see Asia grow as a medical travel destination.”
The objectives of this alliance are:• To aid AMTRAC members to become recognized as top medical travel destinations.• To help raise professional standard of medical specialists and healthcare providers.• To provide a single platform for medical tourism agencies to learn, update and network with other member service providers.• To develop a higher degree of patient confidence and awareness in medical practitioners and facilities in the Asian region.• To exchange views on topical issues facing the medical travel industry in Asia.
AMTRAC is working to include India, Malaysia, South Korea and Singapore as the remaining four founding members. When all five founders are signed up later this year, there will be an official launch.
The Thai Medical Tourism Association took over from the Thailand Medical Tourism Cluster in 2012, and aims to spearhead the promotion of medical tourism to Thailand.

The Indian Medical Travel Association (IMTA) consists of Indian hospitals, healthcare providers (both modern medicine and traditional Indian medicine), travel and medical tourism industry providers who aim to make India a leading global healthcare destination. Formed in 2010.
The Malaysian Health Ministry set up the Malaysia Healthcare Travel Council (MHTC) in January 2010 to promote and develop the health tourism industry for the country and position the country as a healthcare hub in the region. It serves as the primary agency to promote and develop the health tourism industry. The council is a department in the Ministry of Health.
Singapore no longer has a stand alone medical tourism promotion body so it is unclear who will be the Singapore member; and for this reason it may not become a founder.

Korea International Medical Association (KIMA) is a government-private joint initiative. It is the official organization for Korea medical tourism and supported by the Korean government. The primary purposes of KIMA include promoting Korea healthcare to the international communities and fostering safe and reliable infrastructures to secure transparency of quality of care and patients’ safety.
Although often claiming much higher figures, the five countries combined have 2 million medical tourists between them.

Countries that are attractive to tourists are often very attractive to health and medical tourists, while the problems that affect some countries can also hold back medical tourism.
The fifth Travel & Tourism Competitiveness Report ranks 140 countries according to their attractiveness and ability to develop their travel and tourism industries. The World Economic Forum produced the report in collaboration with Booz & Company, Deloitte, the International Air Transport Association, the World Tourism Organization and the World Travel & Tourism Council.
The 517-page report uses a combination of data from publicly available sources, international travel and tourism institutions and experts. The report’s cross-country analysis of the drivers of competitiveness in travel and tourism provides comparative information that is useful in business decision-making for business. It does not include specific information on medical tourism but does offer vital information on visas, government attititudes to tourism, customer safety and transport infrastructure. The report also contains detailed country profiles for the 140 economies featured in the study, including a guide to the most prominent travel and tourism competitive advantages and disadvantages of each.
Switzerland, Germany and Austria lead the world in terms of their travel and tourism industry competitiveness with Spain, the United Kingdom, the United States, France, Canada, Sweden and Singapore making up the top ten.
France fell four places from third in 2011 to seventh, while Spain climbed to fourth from eighth. Also showing strong improvement were the United Kingdom – up two places to fifth – and Canada, up one place to eighth. Alongside Switzerland and Germany, the United States and Singapore maintained their positions, in sixth and 10th places, respectively. Sweden, the only other country in the top 10 to fall, dropped from fifth to ninth.
New Zealand and Japan improved strongly. Emerging market economies reported mixed levels of progress, with Brazil and India being the only BRIC nations to move up in the rankings. Rising stars include Panama and the Philippines.
With travel and tourism accounting for one in 11 jobs globally, the report highlights that the industry can be a key factor in paving the way for developing and emerging markets to diversify into higher value economic activities. The lesson for medical tourism is that the most successful countries are not those that offer cheap holidays.

The first edition of SafeCare standards for clinics and health centres in resource restricted settings has been accredited by the International Society for Quality in Health Care (ISQua). ISQua’s international accreditation programme provides worldwide recognition for accredited organizations that meet approved international standards.
SafeCare offers a unique set of standards that are realistic for resource-restricted settings while not compromising on quality levels. This has now been acknowledged by this official accreditation of the standards.
The accreditation of SafeCare’s standards provides assurance to ministries of health, donors, funders, clients and health facilities that the organizations using SafeCare’s standards meet the highest international requirements and are focused on continuous improvement. To date the standards have already helped about 300 clinics in five sub-Saharan countries to improve the safety and quality of care provided to an estimated 500,000 patients per month.
The accreditation by ISQua marks a watershed moment in the progress of SafeCare – a formal collaboration of three organizations, Joint Commission International (JCI) based in the U.S.A., PharmAccess Foundation of the Netherlands and the Council for Health Service Accreditation of Southern Africa (COHSASA), to address issues of poor and limited health care delivered in developing countries. SafeCare standards focus on ’bottom of the pyramid’ public and private healthcare facilities such as dispensaries and health centers that make up the main healthcare distribution channel for low-income settings. This type of facility tends to struggle with patient safety and quality demands.
The SafeCare standards are structured to offer a stepwise improvement path. The achieved improvement steps are rewarded through formal certification that could eventually lead to full accreditation. Thus, an improvement path is created that offers positive incentives for healthcare providers to enhance quality. This clear pathway boosts client, investor and regulator confidence in capacity of healthcare providers to steadily enhance their performance. The methodology is supported by real-time data collection tools.
In this first edition of the SafeCare standards there are 824 criteria in 13 areas of service delivery including: management and leadership; human resource management; patient rights and access; risk management; primary healthcare services; laboratory service, medication management; and support services.
Since its inception in 2011, SafeCare has rapidly developed from serving clients of the Health Insurance Fund and Medical Credit Fund, two organizations founded by PharmAccess, and for which it was originally developed, to nearly 300 clinics and hospitals in Nigeria, Kenya, Tanzania, Ghana and Namibia, supporting social franchises and clinics of the police and armed forces. Agreements are being drafted with the Tanzanian, Kenyan and Nigerian governments to apply the SafeCare standards and external evaluation methods to their national healthcare system and insurance schemes. Multinational corporations such as Shell and Heineken have also signed up to SafeCare.
SafeCare receives backing from the Dutch Ministry of Foreign Affairs, USAID, and the African Health Market for Equity (AHME) programme.

Kenya and especially its capital, Nairobi, is now considered the hub for business and development in Eastern Africa. The country expects one and a half million visitors this year. Some people argue that it can become a local medical tourism hub.
While under funded government hospitals in Kenya, generally offer poor quality care, poorly staffed facilities with overcrowding and limited service provision, private healthcare is an improvement, with small but modern health facilities and better-trained medical staff. However, for any serious operations, many locals and expatriates look outside the country for help; South Africa being the most popular, while some go to India and the ruling elite prefer the UK, USA or Germany.
To develop local hospitals capable of developing medical tourism, a significant investment in state of the art health care technology would be required. Many Kenyans are travelling abroad because of lack of high-tech facilities and some perceive hospitals in countries like USA and South Africa as a sure bet to receiving quality healthcare.
With over a thousand Kenyan medical travellers going to India each year, many use the services of local medical tourism agents who handle patient logistics, bookings and medical billing. One such agent is Simon Karo who says the country should have a similar programme where organisations link patients from poorer African countries to Kenyan hospitals to boost medical tourism.
Kenya has some of the best private hospitals in East and Central Africa. The government is spending money to promote tourism and has produced effective destination marketing campaigns. It has also made it easier for visitors to get visas. But official red tape makes it hard to start any new local business. The infrastructure remains undeveloped, health and hygiene need great improvement and the skills of the local labour force are poor. The biggest threat to medical tourism is the security situation, with problems of kidnapping, crime and terrorist attacks even in major cities.
What may drive the longer-term growth in medical tourism on a local African basis, rather than people going to India or South Africa, is political stability. Kenya recently held a peaceful election. There have been calm transfers of power in Uganda, Ghana, Senegal, Zambia and Tanznia.Africa includes seven of the ten fastest growing countries in the world and there is a population of over a billion.
There is a mood that Kenya is among those governments serious about improving the infrastructure, creating private-public partnerships and welcoming foreign investment. With problems in the US and Europe, many local African companies are cutting back on doing business with those regions and concentrating on African countries. Banks are lending as insurance guarantees can protect overseas investors from any political instability.
The public image of Africa tends to be warped by the news headlines, and although for several years Kenya will be an outbound medical tourism destination, there is a potential future scenario where African countries encourage overseas investors to build hospitals that can treat locals and stimulate a regional market in medical tourism.

A research study of US consumers has identified different reasons why various socio-demographic groups would consider medical tourism. The aim of the study is to help medical tourism agents refine their marketing strategies on medical tourism.
’A Survey of Consumers’ Perceptions Toward Medical Tourism’ is a recently published 2011 study by Lydia Gan and James Frederick of the Medical Tourism Research Center at the University of North Carolina.
The research identified demographic groups likely to participate in medical tourism and identified three components (risk-related, social-related, vacation-related) that explain their motivation to travel abroad for treatment. Street sampling was conducted in six locations in North Carolina between June and December of 2010.
522 consumers provided socio-economic data and data about their perceptions toward medical tourism. The research tested several hypotheses about Americans’ motivation to use medical tourism
Among the major findings are: • The uninsured, low-income, and black consumers are more sensitive to risk-related factors than the well-insured, middle- to high-income groups, and white consumers.• The older and the married consumers are more motivated by social-related factors than the young adults aged 18-21 and single. • The more proficient a person is in a foreign language, the less they are motivated by social-related factors.
It has to be borne in mind that this is a “what if ’ study of a relatively small and very localized study of consumers in general, rather than of people who have considered or actually been medical tourists. This means the results are based on often imperfect consumer information that may be statistically correct, but as with most ’ what if ’ surveys, may have little relation to actual consumer purchasing decisions. But, real consumer research in this area is still very rare, so every little helps.
The finding that the uninsured are less likely than the well insured to be motivated by risk factors to travel abroad for treatment argues that if something goes wrong, the uninsured have to pick up the bill for putting things right on their own; so are more concerned with international accreditation, hospital affiliation with US hospitals, high standards of accommodation and their own doctors recommendation. Also they were more concerned about privacy, confidentiality, good infrastructure, political stability and a sound legal system when choosing where to travel for care.
Those on a higher income are more concerned than others with high standards of accommodation, high quality of care, post-care, a safe trip and cost savings.
People over 65 are the most concerned with political stability and a sound legal system, while those aged 51 to 64 were most concerned about good infrastructure. Those aged 41 to 50 and the married, were the most concerned about a similar culture.
Even the authors admit that the study has many limitations. But what it clearly shows is that consumers are not alike, and that differences in income, socio-economic status, culture, and other variants mean that what concerns one person about medical tourism is not the same as the next person and that the ’save lots of money’ basic marketing approach to Americans is far off beam.

As part of a long term plan to be a medical tourism destination rather than just a source of patients, China’s southernmost island of Hainan Province will set up a special zone where overseas medical institutions will enjoy preferential business policies for encouraging medical tourism.
The Boao Lecheng International Medical Travel Zone is on the east coast of the island and near the town of Boao. Hainan governor Jiang Dingzhi argues that the rising standard of living in China could encourage medical tourism, so it is clear that Hainan is mainly targeting Chinese from other regions.
The idea of using the expertise of foreign hospitals and clinics to promote medical tourism stems from the success of foreign owned private hospitals in major Chinese cities in changing the habits of overseas expatriates, so that they now get private treatment in China rather than going to Hong Kong.
The zone, already approved by the state council, will enjoy preferential policies that are seen nowhere else in China. Foreign medical institutions will be allowed to set up business within the zone, while medical joint ventures will not be forced to have a majority or substantial minority local partner. Even if foreign hospital groups are allowed to have full control, it is sensible to have Chinese partners who understand local politics and business problems.
Lower taxes will be granted to imported medical instruments and medicines in the zone, and untested unapproved medical care such as stem cell treatment will be allowed.
Jiang Dingzhi explains, "It is the only travel zone of its kind in the country and I am confident that it will be a success." The tropical island province is also striving to build itself into an international travel destination. According to official local statistics, in 2012 the island had 33 million visitors, with travel revenues of $6 billion.
The zone will be a large one with infrastructure investment from the local government. Timing is unclear, and it is rather ambitious to hope the zone will be operational within two or three years, although construction has already started.

The Wineg-Institute of the Techniker health insurance (TK) has published the fourth annual survey of the TK members about their planned treatments abroad.
Most of those getting planned overseas treatment are retirees between 70 and 79 treated in a German-speaking spa resort. The top four destinations are Italy, Poland, Czech Republic and Hungary.
The three reasons for deciding where to go are: good experience with previous treatment, the combination of treatment and relaxation, plus cost savings.
The results of the survey, concerning the satisfaction with the quality of the facilities and the treating doctors, are very positive. For TK members, access to quality is the main reason for future planned EU treatments abroad
Techniker Krankenkasse (TK) with more than 7 million customers is the largest statutory health insurance fund in Germany. Less than one percent of TK members have ever gone to other European countries for insurer paid treatment; customers are very loyal and rarely if ever switch from one insurer to another.
Techniker Krankenkasse (TK) was a pioneer in enabling its members to seek treatment abroad, and is still one of the very few EU health insurers that allows it. For spas and dentistry, the German customer has to pay a high proportion of the cost out of pocket. For those getting dental treatment abroad, the insurer pays out the same amount, so the balance paid by the customer when the cost is lower, is much less. As the overall cost of treatment is much lower, their own share of the costs is much lower.
But unless the insured customer wants to cover all the costs themselves, they do not have a free choice of country or location. TK and the customer share the costs of treatment only at an accredited health spa, including room and board as well as travel to and from the health spa. TK members can choose a health resort outside Germany, but only one in TK’s network of 26 partners in Italy, Austria, Poland, Czech Republic, Slovakia and Hungary that TK pay on a direct basis. All facilities are inspected on site by TK for their compliance with quality standards. The customer can only get treatment within the EU in a facility within TK’s network
For planned treatment abroad, to get reimbursement after treatment and after they have paid the hospital/clinic themselves; the customer has to supply detailed bills/medical prescriptions-including detailed invoices with names of doctors, treatments and costs listed. TK reimburses those costs that would have resulted from that treatment in Germany, limited to the amount of the bill, minus the additional contribution/co-payments stipulated by German law, and with other approved deductions.
To comply with cross-border insurance law, TK does allow customers to select and pay for any type of treatment that is covered under the insurance and under German healthcare rules. Effectively this means they can go to any EU or EEC country, but the insurer has to pre-approve the treatment and destination, while there are several other pre-approval rules that if not followed means that TK will not repay the bills that the customer pays. The spa treatment is a TK extra so only applies in a TK approved spa.
For any customer that travels to a foreign country for treatment and pays the costs, then they are the direct contractual partner of the foreign care provider. TK rebates the costs but cannot influence the quality or price of the benefits received.
Health insurance is a part of the German social insurance system. All employees are either compulsorily insured or a voluntary member of a statutory health insurance fund. This depends on income level and has no impact on the contribution amount or the benefits they receive. So every German and every foreigner working or living in Germany must have health insurance.

Singapore is again seeing more medical tourists. Figures for 2011 show an increase in medical tourists, while reports from hospitals suggest 2012 and 2013 will be even better.
Two key reasons for the increase are that the city state is promoting quality and service rather than price, and that it sees the growth market as Asia and Eastern Europe, rather than Western Europe or the USA.
Private hospitals have seen substantial growth in the number of foreign patients in Singapore in the last year, driven mainly by Singapore’s expertise in high-end specialist care and surgery.

Parkway Pantai is drawing patients from Eastern Europe and North Asia. Raffles Medical Group has seen a 26% increase in 2012 in the number of foreign patients, with Indonesians making up the majority.
Patients from neighbouring Asian countries now make up the top five nationalities of medical tourists in Singapore as local demand exceeds supply in their home countries.
According to Singapore’s Ministry of Health and the Singapore Tourism Board, in 2011 Indonesians accounted for 47.2%, with Malaysians second at 11.5%, followed by Bangladeshis (5%), Vietnamese (4.1%) and Myanmar (2.7%).
The majority of medical tourists are treated at private hospitals, and the key reason is surgery. As prices have risen in Singapore, it has lost US and Western European business to cheaper countries such as Thailand, Malaysia and India.
The government set out to attract 1 million medical tourists, and Singapore Tourism Board claims 850,000 foreign patients and annual growth of 15% for 2012.The 2012 figures are not medical tourism numbers as they are for international patients that include holiday and business travellers and expats. An official 2008 figure of ’medical tourists’ was also actually international patients and significantly had been massaged by using an unusual definition of ’patient; the 2008 figure was 646,000 medical travellers, but the Singapore Tourism Board acknowledges that the 646,000 includes 370,000 people who had medical treatment; the other 230,000 were family members of the patients who accompanied them and had no treatment.
Singapore admits that 2010 saw a dramatic decline in numbers, although the figures for 2010 have disappeared. Using the same logic as for 2008, the 2012 figures have to be cut by just under 40% to take out family members – reducing it to 520,000. 40% of Singapore’s population consists of foreign nationals, while the figure also includes business travellers and holidaymakers, where Singapore is a very popular definition for both. How many of the ’international ’ patients are true medical tourists is a question, and various bank studies suggest that in places with a high expatriate population that are also popular tourism destinations, as many as two out of three are not medical tourists; so this could take the figure down to 170,000. The authorities accept that business only really started to pick up in late 2011 and has risen in 2012. It seems likely that the real number of medical tourists for 2012 is nearer to 200,000 rather than 850,000.

How do you turn a state run state supported spa that people had to go to, into a modern welcoming health tourism destination?
Mangalia is a national and international interest balneo-climatic resort, on the coast of the Black Sea, at the same latitude with Monaco, San Remo and Nice. It is mainly used for therapy and recovery as it has sulphurous waters, seawater with minerals, therapeutic mud, and other natural advantages.
In a paper in the International Journal for Responsible Tourism, Laura Maria Condur considers how this rather old-fashioned resort and sanitorium can be developed as a modern health resort.
The paper considers whether the management of the Mangalia Balneary Sanatorium can promote the concept of health, medical and relaxation tourism, and change from a state owned and run institution where the state paid for services, to a privately run health tourism location seeking privately paying health tourists from within Romania and overseas.
It has a great location, much expertise and a long history. Over the last 2 years it has become a modern wellness spa offering acupuncture, hydrotherapy, massage, a range of therapies, sauna, seawater pool and more.
The problem is how to turn it from a place where doctors sent patients who had to put up with whatever they were told to do, to one where people choose to pay to go there and select from a range of treatments. It needs to get more patients, and appeal to younger and fitter people. The customer base is now mostly 45 to 64 year old workers, plus pensioners, from cities. One area it now promotes is for the elderly over 65s, called “A time for beautiful oldness” that helps to deal with the problems of old age.
The paper says that to promote health tourism, it is vital to identify the needs, expectations and wants of potential customers. However, it goes on to define this as evaluating the physical and mental condition of the patient and relatives. The research concentrates heavily on the micro management of what to do with the patient once there.
The paper concludes that• Balneology can be developed for health tourism.• It can be combined with complementary therapies and spa-wellness offerings. • It can attract health tourists all year round.• A mix of prevention, treatment and recovery could appeal to health tourists.• It can generate extra income within existing resources.
What the paper omits to mention is how much the terms ’sanitorium’, ’ elderly’ and ’old’ – plus heavy reliance on detailed medical terminology – will put off the modern European health traveller.
The lack of understanding of marketing/advertising/promotion and how such places need to attract people rather than relying on people to find them is a good illustration of a problem common to many places in former Communist bloc Eastern European countries; changing the product is not enough.

The tourism industry has outperformed the global economy in 2012 – growing faster than manufacturing, retail, financial services and communications- says the ’Economic Impact of Travel & Tourism 2013’ report from WTCC.
Tourism has grown its total contribution to GDP by 3% cent and increased the number of jobs by 5 million to 260 million. It means that, for the first time, one in 11 of all jobs in the world are now supported by tourism. More than 10% of all new jobs created in 2012 were from the industry.
Medical tourism is still a very small niche sector within this global industry and it is easy to forget how relatively unimportant it is compared to rivals such as religious tourism, wellness tourism, environmental tourism and holiday tourism.
According to research from the World Travel & Tourism Council, in 2012, tourism’s total economic contribution – taking account of its direct, indirect and induced impacts – was US$6.6 trillion in GDP. This is a rise of US$500 billion year-on-year.
Tourism supports US$765 billion in investment and US$1.2 trillion in exports. This represents 9% of total GDP, 5% of total investment and 5% of world exports.
Among the 20 largest global economies, South Korea, China, South Africa and Indonesia performed best. Growth of less than 1% in Europe and 2% in the USA was counter-balanced by 10% growth in South Korea, 7% in China, 7% in South Africa and 6% in Indonesia. These countries are all expected to grow during 2013, along with Japan, Brazil, and India. Africa and Latin American will also grow quicker than Europe or North America. Successful destination countries will be those that have an infrastructure, facilities and attitude to welcome overseas travellers-particularly the middle class Asian ones who want a good standard of travel, accommodation and destination. WTTC forecasts that China will overtake the USA to be the world’s biggest travel and tourism economy by 2023.
For more than 20 years, with research partner Oxford Economics, WTTC has produced comprehensive economic reports on an annual basis, with updates and special reports to quantify, compare and forecast the economic impact of travel and tourism on 184 economies and 24 regions around the world.
WTTC predicts the tourism industry will expand its total contribution to GDP by 3.2 % in 2013, faster than the 2.4 % predicted for global economic growth. The industry is expected to support nearly 266 million jobs in 2013 and again outperform many other industries.
David Scowsill of WTCC says, “2012 demonstrated again just how resilient the tourism industry is. Despite many economic difficulties, last year, for the first time, we saw more than one billion international travellers pass through the world’s ports, airports, roads and railway stations for the first time. This industry is an important driver for countries’ economic development and growth strategies. Our industry is responsible for creating jobs, lifting people out of poverty, and broadening horizons. But we need international institutions and governments to recognise its strength, to remove restrictive visa and tax regimes and to work with the private sector to stimulate that growth.”
Medical tourism has to take notice of where tourism is growing, and accept that as part of a growing industry it must learn from other sectors of the travel business.

Thailand has become a well-known medical tourism destination, and to remain competitive has relaxed its immigration law to promote medical tourism.
The new regulations allow nationals from Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the UAE, to stay in Thailand for medical treatment up to 90 days without a visa. A medical tourist may be accompanied by up to three individuals who are also Gulf state nationals-such as parents, children, spouse or maid- who also have a 90 days visa exemption. Nationals from South Korea, Argentina, Brazil, Chile and Peru are also eligible for the 90 day visa exception.
Those seeking a 90 days visa exemption must present a document to prove they have a medical appointment issued by certified health institutions in Thailand. And they have to show financial support documents, such as health insurance, issued by authorities in their respective countries. For individuals accompanying patients, they have to show documents proving their relationship with the patient and the accompanying individuals, which can include a birth certificate, marriage certificate, house registration, or I.D. card for a family member. Employees and maids also have to show employment contracts and an affidavit of support form as prepared by hospitals in Thailand.
It is claimed that 60,000 Omanis visited Thailand for medical care in 2012, and with the relaxed regulations, numbers for 2013 are predicted at 75,000.To encourage medical tourism, some of Thailand’s hospitals have established offices in Muscat so they can target Omanis seeking care. Oman Air is adding more weekly flights on the Muscat-Bangkok route.
Thailand is also promoting spa and wellness tourism. The government has set standards and criteria for Thai masseurs and masseuses and for businesses offering Thai spa and/or wellness within the country and abroad. Thai herbal medicine as well as massage and spa services can be offered.
The country’s medical council wants the government to do more to promote medical tourism by offering a cosmetic surgery and tourism package to include airfare, cosmetic surgical services, luxury accommodation and shopping trips. Rhinoplasty, double eyelid and sex change operations are popular with visitors from Asian countries and Cambodia, Laos, Myanmar and Vietnam.
According to Thai newspaper The Nation, local private hospitals, hotels and associations of dentists and doctors have formed ’The Medical Tourism Association’ to promote medical services to foreign patients in Thailand.
Thailand plans to develop its logistics and transport routes to link with neighbouring countries Cambodia, Laos, Myanmar and Vietnam; and is seeking European investors.

Often forgotten among noisier and larger competitors, several small European countries are making progress on medical tourism.
The Algarve in Portugal seeks to promote itself as a destination of excellence in the field of health and welfare. The Algarve has been losing ground in the health and wellness tourism sector to Tunisia and Croatia, where both are winning business that locals think should go to Portugal. Problems in Africa could make people look again at alternatives such as Portugal
João Viegas Fernandes, of the Escola de Hotelaria e Turismo da Universidade do Algarve explains, “Tunisia, due to political decisions made 15 years ago, now has some of the best thalassotherapists in the world” (Thalassotherapy is the therapeutic use of ocean and marine products to restore and remineralize the body). Croatia, Turkey and Morocco are also going all-out to attract tourists interested in non-conventional medicinal treatments and therapies. But, in the Algarve, all we have done to jump on the health bandwagon is offer foreigners and tourists a few private hospitals.”
Belarusian doctors are promoting medical tourism. A few hundred patients come to the tiny state of Belarus each year, and signs suggest it could soon be thousands. While Poland seems low price to Germans, Belarus seems a bargain to Poles.
Price is the main thing that Polish medical tourists are interested in and several Polish travel agencies are promoting Belarus as a destination. Belarus is seeking ways of promoting the country’s sanatorium and spa treatment, as well as medical procedures- calling destinations health resorts rather than sanatoriums may be a vital first step. In Belarusian clinics international patients, in particular the Poles, are primarily interested in cardiology, cancer treatment and recovery, plus fertility treatment.
The Czech Republic is a major European tourist destination and increasingly attracts health and medical tourists. As well as the more traditional spa and wellness tourism, an increasing number of Europeans are going to the Czech Republic for fertility treatment, cosmetic surgery, dental care, laser eye surgery, anti-obesity surgery and simple surgery such as hip replacement.
Spa towns have been a tourist magnet for both people inside and outside of the country for over a century. But medical tourism is much newer. Finally accepting the potential of the market, Czech Tourism is investing heavily in promoting the country as a medical tourism, wellness and medical spa destination. The advertising and marketing promotions are targeting Russia, Germany, UK, Switzerland, Gulf States and even Kazakhstan.
The Czech Republic is trading on its health tourism expertise and reputation for excellence in service and treatment at very reasonable prices; so is attracting customers from Germany, Norway, Ireland and the UK.

A recent news story in the British Medical Journal has caused controversy. Not for what it says, but for how it has been reported.
From national newspapers to online blogs; from radio to local papers, and from national television to websites, the story has been reported in two different ways. What they say shows how easy it is for medical tourism information to fall prey to the views of the original writer and the political prejudices of the media organization.
Using exactly the same released information, one group says "This proves that there are more people leaving Britain to go overseas for treatment than coming here." and the other group says, "Britain welcomes more paying medical tourists than there are people leaving our shores for treatment."
So who is correct? The actual study seems to suggest that there are more people coming in than going out, but that may vary by type of treatment and type of surgery.
The study itself has some obvious limitations:• It is a very small sample based on difficult to analyse basic information; • It only covers private treatment of international patients in a few public NHS hospitals.• It ignores the international patient business generated through London’s major private hospitals and clinics.
Depending on the procedure undertaken, patients who travel abroad may also save the UK resources, suggests Johanna of the London School of Hygiene and Tropical Medicine and colleagues at the University of York.
The research, funded by the NHS’s National Institute for Health Research (NIHR), analyses the effects of UK medical tourism on the NHS, using freedom of information requests to NHS foundation trust hospitals. They found that, despite small numbers of international private patients being treated (6% of the total across a sample of 28 hospitals) these patients were responsible for 35% of total private income in these NHS trusts. They suggest that private foreign patients may be more lucrative than UK patients treated privately within the NHS.
Overseas residents made 31.1 million visits to the UK in 2012, 1% more than in 2011. They spent £18.7 billion on these visits, an increase of 4%. The rise in visits occurred primarily at the start and end of the year, whereas visit numbers during the summer were lower than in 2011. UK residents made 56.6 million visits abroad in 2012, unchanged from 2011. They spent £32.6 billion on these visits, an increase of 3%. The number of visits to Europe was unchanged in 2012 whereas those to longer haul destinations of North America and ’other countries’ fell by 5% and 2% respectively. These official figures do not include any information to suggest how many outbound or inbound visitors were medical tourists.

The Philippines government is studying opportunities in niche services that will allow the Philippines to grow medical tourism. Dental, cancer care and retirement services are among the sectors with high demand, says tourism secretary Ramon Jimenez, “The Philippines must be careful in choosing which sectors to focus on. We should ensure that the best facilities are put in place in the chosen sectors and that the best people are running them. Medical tourism is an area where one develops a reputation quickly. It is something we cannot get wrong. We have to get it right the first time.”
Over the last seven years, the country has had a plethora of medical tourism campaigns and promotional bodies. The campaigns mostly failed, and the promotional bodies got bogged down in internal disagreement, endless discussion within massive committees, and sidetracks concentrating on accreditation. Although a few medical tourists were attracted, the majority are still people who lived or have family in the country. The marketing campaigns were very general and of the basic and now outdated ’Come to us as we are cheap, good doctors, friendly people, nice beaches’ type.
While medical tourism in the Philippines has not taken off either as much or as quickly as the healthcare industry has hoped, there is still a lot of optimism. The Philippine healthcare sector’s biggest players continue to invest in technology, equipment, and buildings, believing in the country’s potential as a medical tourism destination.
While the Philippines’ growth as a medical tourism destination has been slow, it remains steady, consistent, and encouraging for investors as there is a pent-up demand for local healthcare too.
The upgraded The Medical City and Makati Medical Center have both recently established advanced stem cell facilities in the Philippines: The Medical City’s Institute for Personalized Molecular Medicine (IPMM) and the Makati Medical Center’s Cellular Therapeutics Laboratory. These stem cell facilities process the stem cells used in their aesthetic and anti-aging treatments. Makati Medical Center also offers a range of treatment, and now has the first TomoTherapy radiation treatment in the country.
One area that the country has expertise in is cosmetic surgery, but it seems unable or unwilling to promote this niche. As well as specialist clinics, three major hospitals, Makati Medical Center; The Medical City; and St. Luke’s Medical Center are all offering a range of cosmetic treatments. There are also specialist clinics including Medicard Lifestyle Center and the Belo Medical Group – with a network of clinics around the country.
Back in 1993, Dr. Vicki Belo’s Dermatology and Laser Clinic was already catering to foreign patients, particularly to Filipino-American communities. She produced a TV show ’Belo Beauty 101’ featuring various procedures. It continues to air on The Filipino Channel (TFC) and is shown in the U.S., Europe, Japan, the Middle East, and Australia. Despite high levels of promotion to the US, Asia and the Middle East, the numbers of medical tourists to Belo has fallen from a high of 30% of all patients, to 20% in 2012.
According to Dr. Belo, the government, along with Filipino medical and healthcare facilities, need to enhance the country’s image and increase accessibility for foreigners as many foreigners still have mistaken notions about the security situation in the Philippines and about how to get there.
If the country concentrates on the niches of cosmetic surgery and dentistry it competes head to head with many countries in America. If it promotes cancer and stem cell tourism, this can backfire as it uses procedures not accepted in the USA. Is retirement tourism even a part of medical tourism, or a separate beast entirely? How to get beyond medical tourism for Filipino communities overseas is a puzzle that nobody yet has the answer to.

With the help and agreement of investment promotions agency, Jamaica Promotions Corporation (JAMPRO), American Global MD (AGMD) has agreed to build the country’s first luxury medical tourism destination clinic.
The deal is the first result of Jamaica’s new health and wellness tourism policy that seeks to lay out the framework for positioning Jamaica as the newest destination for medical and wellness tourism. The policy came about after a Jampro study of the industry’s potential was completed in 2011, with the assistance of the Commonwealth Secretariat.
The Jamaican government has just agreed to help develop the local medical tourism industry and will be establishing a steering committee with major industry stakeholders to guide the finalization of the policy and regulatory framework.
AGMD is a consortium of American trained doctors and investors, all who have Jamaican links as a result of having previously studied or practiced in the country. AGMD will build a 200-bed hospital and medical clinic that will target the North American and Caribbean markets; delivering services including elective surgery, rehabilitation and naturopathy.
It will be 12 to 18 months before the US$170 million project breaks ground. It has yet to get construction approvals or have the design completed. Under the first phase of the project, a 50 to 75-bed clinic will be built to offer cosmetic surgery, bariatric services and dentistry. It will be in the St James area, but the site is yet to be selected. Local company Implementation is the project manager and they advise that they still have to do the design development process and submission for building permission; In Jamaica that can take anywhere up to 18 months.
Investment minister Anthony Hylton comments. “This investment is in keeping with the government’s commitment to the development of the medical tourism industry as a major area of growth for Jamaica.”

Despite major investment in facilities, marketing and government support, Dubai expects a modest single figure growth in medical tourism in each of the next three years.

Dubai Health Authority and the Department of Tourism and Commerce Marketing are working together to promote medical tourism. Marketing spend at medical tourism conferences and exhibitions as far away as Moscow and Monaco is substantial.
In 2012, Shaikh Hamdan Bin Mohammad Bin Rashid Al Maktoum, Crown Prince of Dubai told many of the organizations that he controls to do everything possible to finally deliver on the medical tourism investment that has been made for the last five years.
The Dubai Health Authority (DHA) and the General Directorate for Residency and Foreigners Affairs (GDRFA) have agreed to simplify and speed up the medical tourism visa process, so that overseas patients who wish to have treatment in Dubai can take advantage of a three-month medical tourist visa, extendible twice, up to nine consecutive months.
Part of the initiative is encouraging global healthcare providers to set up businesses and increasing both government and private investment in healthcare. The Dubai Health Authority has completed a comprehensive capacity survey of public and private healthcare facilities in Dubai under the Dubai Clinical Services Capacity Plan (DCSCP) 2020. Eisa Al Maidour of the DHA explains,” This information will provide investors with the necessary data for investment. The DCSCP will point out the specialities and sub-specialities where investment is needed. The data will definitely make Dubai’s healthcare environment attractive for investors.”
Marwan Abedin of Dubai Healthcare City (DHCC) estimates that 15% of its patients are medical tourists, and that the number of inbound medical tourists in Dubai was up 10% to15% in 2012; this is an estimate only. But growth for 2013 to 2015 is expected to be lower at 7.2 % a year. DHCC states that it attracted 410,000 patients in 2010, and 502,000 in 2011. Latest estimates for 2012 are at around 550,000. At various times DHCC claims 15% or 20% of patients as medical travellers; but this is actually all international travellers, including business people and holidaymakers. Exactly how many are real medical tourists is a question that remains to be answered; it is likely to be around 50,000 and 80,000 and thus in line with other significant destinations.
Most medical tourists to Dubai are from the GCC and the wider region; as well as people from countries including Libya, Iraq, Iran, Nigeria, Tunisia, India, Pakistan, and Russia. The original idea that Dubai would appeal to Americans and Western Europeans has been abandoned.
Part of the initiative is to persuade UAE residents to stay home to get treated, rather than go overseas, and that is beginning to work as the number of UAE based patients were up 12% in 2012. Although the majority of patients living in the UAE prefer to be close to home, many others still prefer to be treated outside the Mena region— in Europe or North America. Some patients do so because the country lacks the specialisations they require, which can be found in other countries; while others do not trust the public hospitals, and the cost of treatment in Dubai is high compared to Asian competitors.

Patients from all over the world are travelling to Latvia to seek cancer treatment, and a recently set up health tourism organization aims to make this country better known.
The tiny country of Latvia is at the forefront of one of the latest cancer treatments that is attracting patients from all over the world. Latvian scientist Aina Muceniece developed the medicine Rigvir.Over the years several clinical trials were conducted that proved the safety and effectiveness of Rigvir in stage four cancer patients. Following the collapse of the former Soviet Union the testing and use in treatment of Rigvir stopped for a few years, but its effectiveness in the treatment of several kinds of cancer, from prostate to bladder, colon, melanoma and lung cancer, had been proven. In 2002 the work began again and since 2005 Rigvir has been used in treatment in hospitals and available in pharmacies all over Latvia. Rigvir activates and normalises the immune system of the patient and is well tolerated and safe.
Aina Muceniece’s daughter now heads Latvian Virotherapy Centre that aims to promote virotherapy and the training of doctors to use the medication. Rigvir has been accepted as treatment for melanoma patients by insurance companies since 2011.
As Rigvir proved to be more and more successful and interest from patients all over the world grew, the Latvian Virotherapy Centre was established to provide treatment and support for those patients. The Virotherapy Centre has developed a programme to ensure treatment is as comfortable as possible. When a new patient seeks the help of the centre the first consultation is done by phone or email and a complete assessment of the medical records and tests is conducted when the patient is still in their home country. The clinic then takes care of all the travel, accommodation and medical arrangements for the patient and makes sure that any additional screening and tests are organised to take place in the Latvian hospital. A full treatment plan and follow up is created by the doctors of the clinic after which the treatment starts. The first round of treatment takes place when the patient is in Latvia, but the follow-up treatments can normally take place when the patient is back at home in their own country. The arrangements to deliver Rigvir to the patients are handled by the clinic as well.
A Latvian health tourism group has been formed with the aim of developing health tourism to Latvia and attracting foreign customers to Latvian health tourism service providers. The yet to be named group includes a wide spectrum of health tourism entrepreneurs, ranging from surgical, medical rehabilitation, resort rehabilitation, health restoration, spa and wellness, to the organic cosmetic industry and higher medical education institutions. Work has begun on the single united Latvian health tourism website. During 2012 group members started to promote the country at marketing events and health tourism conferences and seminars in Russia, Israel and Northern Europe.

Jurmala City Council in collaboration with the Latvian Resorts Association has developed a health tourism strategy for up to 2020 and helped to establish the Latvian health tourism group. Jurmala is the largest resort city in the Baltic States, home to mud bathing and mineral waters.
It will work in six key areas:• Implementation of joint health tourism marketing activities.• Promoting the expansion of export markets.• Developing new and innovative health tourism export products.• Promoting cooperation between group members in the provision of services.• Developing health tourism packages.• Working on industry friendly regulation.
The aim is to increase the number of medical, wellness and spa tourists to Latvia and develop the local health tourism industry. Latvia is already seeing an increase in the number of medical and wellness tourists due to competitive prices and high service quality.
The group includes- Latvian Resorts Association, J?rmala City Council, J?rmala Hospital,P.Stradi?a Clinical University Hospital, Northern Kurzeme Regional Hospital, Liep?ja Regional Hospital, Ludza Hospital, Clinic Zinta, Sanare – KRC Jaun?emeri, T?rvete, National Rehabilitation Center Vaivari, Rehabilitation center of Latgale, Dr. Mauri?a vein Clinic, Belarus, Social Integration State Agency, The Baltic Physiotherapy, Hotel Jurmala Spa,BBH Investments,Baltic Beach Hotel, Liep?ja Olympic Centre, Usma Spa, Nordmed Tour,Kandagar Tour, Organic Life Laboratory, Kiwicosmetics, Latvian Hotels and Restaurants Association, Kurzeme Tourism Association, Saulkrasti County Council, Carnikava County Council, Ventspils Tourism Information Centre, Liep?ja Region Tourist Information Office, State Tourism Development Agency, European Resorts Association, Lithuanian Resorts Association and Estonian Spa Association.

Wellness Tourism Worldwide has made its 2013 forecast of wellness travel trends. Each trend bears relevance to consumers, focusing upon new wellness designs, programmes and service levels in air transit, hotel accommodation and destinations.
Camille Hoheb of Wellness Tourism Worldwide explains, "Health opens the door to a whole new world. We are looking at wellness domains that contribute to better traveler experiences. We think this forecast will encourage individuals and organisations to expand their perceptions on wellness and improve quality.”
The forecast is based on an analysis of factors including consumer and business-to-business surveys, site visits, feedback from travel suppliers, destinations and sellers as well as other research.
• Wellness takes flightTo draw more passengers and increase revenue, airports renovations are featuring sleek ultramodern designs incorporating natural light, art installations, high-end dining and shopping venues as well as a plethora of health and fitness offerings. A wide range of offerings from spas to swimming pools, gardens, walking paths, private napping cabins and cultural centre are all designed to create a kind an atmosphere of terminal bliss.
• Health focused hotelsHotels have realized there is an unmet need for guests to maintain health during travel that goes beyond gyms, pools and spas. Now hotel rooms are designed to alleviate altitude sickness, reduce jet lag, induce better sleep, eliminate bacteria, waterborne chemicals and allergens and purify and humidify the air. Vitamin C-infused showers, dawn simulating alarm clocks and melatonin-producing lighting are other notable features. Guest can access in-room fitness equipment and healthy lifestyle education as well as take-home tips, programmes and wellness apps.
• Digital detoxConsumers are addicted to smart phones, laptops and tablets. So hotels are offering digital detox holidays where people must surrender laptops, tablets and smart phones at check-in. Some destinations are also creating technology free vacation campaigns as a way to market their rural settings. Some spas reward customers who leave their technology alone, extra free services.
• Reconnecting through natureNatural assets are the most critical component to wellness tourism product development. Destinations are beginning to fully leverage their landscape in response for the human need to explore and relax outdoors. There is a growing trend where stressed out workers choose outdoor boot camps to improve fitness and induce weight loss by pushing to the extreme.
• Improving sleepLack of sleep impacts immune, brain and metabolic systems. With spas, hotels, airplanes and airports, sleep has risen from the ignored to the significant. Micro naps in urban spas create a respite from the frantic pace of cities. Private napping cabins offer respite for weary inter continental travellers. Hotel designs have evolved to combat jet lag and to help both business and leisure travellers sleep well and prepare for the day ahead. Airlines are catching on, with redesigned planes for peaceful sleep providing well-appointed linens on a full size bed and turn down service in first class private cabins.
• Spiritual seekersThe interest in non-religious spiritual practices is growing. There is a growing interest in spiritual pilgrimages, retreats, temple stays and workshops. Asia, as the place of origin for mind/body lifestyles, practices and treatments is the home of Traditional Chinese Medicine, Ayurveda, various forms of meditation, yoga and other approaches to healing and wellness.
• Indigenous healingExporting a region’s traditional healing practices gives consumers the opportunity to experience them first-hand at their place of origin. Travelers seeking health and healing traditions at their place of origin contributes to cultural conservation and sustainability, in some cases stimulating economic growth and breathing new life into long forgotten, ancient or undervalued rituals.
• Rewarding wellness travelMore companies plan to increase incentives they offer employees to participate in health improvement programmes.
• Celebrity instructor retreatsWellness travel has taken off. Yoga, Pilates, meditation and fitness gurus have been elevated to rock stars with their own following and are taking their expertise on the road at exotic locations and regional weekend workshops. Spa destinations and resorts offer specialized, themed getaways with famous instructors.
• Intergenerational family travelGrandparents are connecting with grandchildren by travelling. Grandparents are more active and fit, and have sympathy for their own grown children, who often are required to have two working adults to pay the bills. The travel industry has designed programmes to bring families together.

A research paper published on BMC Public Health, ’Australian news media framing of medical tourism in low- and middle-income countries: a content review’, looks at Australian media attitudes to medical tourism, and concludes that coverage was narrow, limited and often biased.
An abstract from the report from joint authors Michelle Imison (University of Sydney) and Stephen Schweinsberg (University of Technology, Sydney) explains:

BackgroundMedical tourism – travel across international borders for health care – appears to be growing globally, with patients from high-income nations increasingly visiting low and middle-income countries to access such services. This paper analyses Australian television and newspaper news and current affairs coverage to examine how medical tourism and these destinations for the practice are represented to media audiences.
MethodsElectronic copies of Australian television (n = 66) and newspaper (n = 65) items from 2005–2011 about medical care overseas were coded for patterns of reporting (year, format and type) and story characteristics (geographic and medical foci in the coverage, news actors featured and appeals, credibility and risks of the practice mentioned).

ResultsAustralian media coverage of medical tourism was largely focused on Asia, featuring cosmetic surgery procedures and therapies unavailable domestically. Experts were the most frequently appearing news actors, followed by patients. Common among the types of appeals mentioned were access to services and low cost. Factors lending credibility included personal testimony, while uncertainty and ethical dilemmas featured strongly among potential risks mentioned from medical tourism.

ConclusionsThe Australian media coverage of medical tourism was characterised by a narrow range of medical, geographic and ethical concerns, a focus on individual Australian patients and on content presented as being personally relevant for domestic audiences. Medical tourism was portrayed as an exercise of economically rational consumer choice, but with no attention given to its consequences for the commodification of health or broader political, medical and ethical implications. In this picture, low and middle-income countries were no longer passive recipients of aid but providers of a beneficial service to Australian patients.
The patient experience and medical outcomes are presented by the Australian media as being of equal importance, with broader concerns of social justice and health equality pushed aside. As medical tourism is increasingly perceived as a viable option for Australians, understanding its appeal to audiences will be increasingly important.
BMC Public Health 2013, 13:109 doi:10.1186/1471-2458-13-109Published: 5 February 2013

A new medical tourism hotel in Nicaragua will help it compete with Costa Rica, Mexico and Panama.
In San Juan del Sur, there are plans for a hotel with 61 rooms, foreign chefs, ocean-view rooms, a four-star rating, and a whole floor dedicated to medical treatment for its guests. The owner of the proposed medical resort, Nelson Estrada, claims that his development will be the first of its kind in Nicaragua, “No one else is offering this. If I can get the necessary investment, work will begin on Solest MedResort, Hotel and Spa by August and the project will open in 2015. Once completed, the medical resort will offer clients a boutique hotel and an extensive range of medical procedures all under one roof. The medical resort will specialize in elective cosmetic surgery, but I hope to expand available treatments in the future.”
Hospital Metropolitano Vivian Pellas in Managua is the only JCI hospital in the country. It is a private hospital treating both international and national patients, including some from the USA and Canada. Arlen Perez of Hospital Metropolitano Vivian Pellas says, “There are few hospitals equipped for medical tourism here. Nicaragua has the same elements as Costa Rica to make medical tourism a success: safety, quality of doctors, easy access and experience. But Nicaragua has the added benefit of being less expensive than Costa Rica.”
While Nicaragua has no statistics for medical tourism revenue, Perez says that most of Hospital Metropolitano’s foreign clientele are US expatriates who reside in either Managua or Granada. The hotel is close to reaching its target of 50 medical tourists a month, although it seems that they are meaning international customers who already live in the country, rather than people who travel there just for medical treatment. The most common treatments are dental work, orthopaedic and cosmetic surgery. In the capital, only Hospital Metropolitano and Hospital Central are actively promoting themselves as medical-tourism options for foreign travellers.

Farmstay El Portón Verde has teamed up with nearby Hospital Metropolitano Vivian Pellas to provide top-flight hospital transport, translation services, after care, recuperation and relaxation in the small bed and breakfast hotel in the hills of Managua.
While neighbours Mexico, Costa Rica Panama, and Guatemala are all attracting medical tourists, in Nicaragua it is still at the very early stages. Promotion so far has been patchy and uncoordinated, with an outdated concentration on the tourism aspects.
Nicaragua is striving to overcome the after effects of dictatorship, civil war and natural calamities, which have made it the second poorest country in America. It has little or no infrastructure. Former Marxist guerrilla leader Daniel Ortega is president. The USA has been vocal in its opposition to Ortega, who is seen as one of the main players in an increasingly assertive anti- US bloc in Latin America; which makes it harder to attract American medical tourists.
60% of all visitors to Nicaragua come from Central and South America, with most of the rest originating from the USA, Canada and Europe. If Nicaragua is to compete on medical tourism it needs a coordinated promotional campaign. The government has indicated support, but has yet to offer any actual financial or marketing assistance. The Nicaraguan Tourism Board (INTUR) is helping Nicaraguan hospitals to create a national association for the promotion of medical tourism, but still refuses to commit any money to the project.

Oman wants to take over from Jordan, and see off the threat from Dubai and other UAE states, as the leading centre of medical tourism in the Gulf and Middle East, but not until after 2016.
The Sultanate of Oman plans to spend $1.5 billion on the construction of The International Medical City. The three-phase project is led by Saudi based Apex Medical in partnership with the Ministries of Tourism and Health in Oman. Completion is expected by 2016 and aims to offer the latest healthcare to locals and medical tourists. There will be a healthcare resort with a luxury hotel and wellness centre. It will include the region’s first purpose-built transplantation and rehabilitation centre, and Oman’s first advanced tertiary care hospital and diagnostics centre. The 5 million square metre project will also include residential space, shopping malls and teaching hospitals.
The development will be vital for the Gulf state’s health care system, which built its last major hospital 20 years ago. The healthcare system of Oman is coming under increasing pressure.
Apex Medical has signed a strategic partnership agreement with Methodist International, the global subsidiary of The Methodist Hospital in Houston, Texas, USA for the development and operations of the International Medical City in Salalah.
Methodist International will coordinate development and set up the management and operation system of the hospital, including the recruitment and training of staff. A clinical and administrative team of consultants from Houston will focus on the development and establishment of clinical, operational and quality standards. Following the opening of the hospital, Methodist International will be involved in a 10-year affiliation focused on quality, training and knowledge transfer management.
Dr Naeema Aziz of Apex Medical says, “International Medical City will open a new chapter in Oman’s healthcare development. It will establish the Sultanate as a regional hub for transplant based medical tourism, encompassing kidney, liver and pancreas transplantation and rehabilitation services.”
Like other Arab states, Oman is heavily reliant on income earned through oil exports. The economy has enjoyed a boom due to high international oil prices. The government intends to spend heavily on its infrastructure.
The hospital is on the waterfront overlooking the Arabian Sea. The first phase will centre on the construction of a 530-bed hospital supported by three proposed centres of excellence in transplantation services, rehabilitative care, and diagnostic services. Phase 2 is a healthcare resort complete with 4-star medical hotel; residential quarters for staff; serviced apartments for customers; and commercial space. The third phase will focus on the development of a medical education complex with medical and nursing colleges, plus a research centre.

Healthcare UK is a new joint initiative between the Department of Health, NHS and UK Trade & Investment to help international customers from both the public and private sectors access the UK’s healthcare expertise. It spans both the National Health Service (NHS) and the commercial sector.
Health minister Lord Howe says, “The UK is a world leader in healthcare, with unrivalled experience and expertise in meeting the health needs of a diverse population. We aim to help our healthcare industries trade more across the globe. It also means more money for the NHS across the UK.”
Healthcare UK will use UK Trade & Investment’s network of professional advisers in nearly 100 countries to:• Provide a single gateway to the UK’s capabilities in healthcare to help international customers access the UK’s healthcare expertise.• Run campaigns to boost the profile of the UK’s health sector overseas in target markets.• Help to produce culturally appropriate propositions.• Enable the formation of consortia of UK organisations to provide complete solutions to major healthcare challenges
Many NHS institutions have an international reputation for excellence, including:• Great Ormond Street Hospital for Children• Guys and St Thomas’s• Imperial College Healthcare• King’s College Hospital• Moorfield’s Eye Hospital• The Royal Marsden Hospital• University Hospitals Birmingham

King’s Health Partners is establishing a day case outpatient based clinic at Shining Towers in Abu Dhabi, and setting up a foetal medicine Clinic in Burjeel Hospital based on the existing world renowned model at King’s College Hospital.
Howard Lyons of Healthcare UK says, “Healthcare UK is intended to help governments to access British know-how and expertise. Emerging nations like China, India, Brazil and some Middle East countries need effective systems to meet the needs of their growing and increasingly impatient populations and are looking to the UK for assistance.”

BMI Healthcare hospitals are continuing to attract international patients to the UK. In the past year BMI Healthcare has seen a 372 % rise in international self-pay patients within its hospitals, while embassy patients have grown by 22 % in the same period. Alaana Woods of BMI Healthcare comments, "The UK is an attractive option for people looking for healthcare. The international market has shown massive growth as patients travel here for procedures that are unavailable, too expensive or too difficult to access in their home countries. In the next year we expect these figures to continue rising."
BMI Healthcare’s international market is split into three groups; government-sponsored patients, insured patients living in or travelling to the UK or self-paying patients. The majority of international patients treated within BMI Healthcare facilities are government sponsored patients from the Gulf regions of the Middle East. BMI Healthcare has invested in facilities such as multi-faith prayer rooms, transport for patients’ families, appropriate food, media and entertainment as well as an onsite Arabic speaking liaison representative.

Indian cardiologist Dr. Devi Shetty and his local partners Gene Thompson and Harry Chandi say that the planned Health City Cayman Islands, under way in East End in Grand Cayman, will not now open for heart surgery until 2014.
The first phase of the health city, which includes a 140-bed hospital, is now scheduled to begin operation in early 2014. The developers had hoped to have the hospital in operation by November 2013, but due to delays in the passing of regulations associated with overseas medical practitioners working in the Cayman Islands, that date has been pushed back.
Dr. Shetty says that with an estimated 40 million people in the Caribbean, some 23,000 need to undergo heart surgery every year, but less than 1,000 actually undergo the necessary operation.
The Health City Cayman Islands plans call for a 150-bed cardiac and orthopaedic hospital to be built from 2012 to 2013; a 360-bed facility for other specialties, as well as medical and nursing schools for 2000 and 1000 students, and a 300-room hotel to be built from 2014 to 2016; a transplant facility with 500 beds to be built from 2017 to 2019; and a further expansion of 1,000 beds from 2020 to 2030.
The Health City Development plans call for 150,000 square feet to be built from 2014 to 2016 (residential, office, retail, restaurant, shopping centre and saltwater air-conditioning plant); 300,000 square feet to be built from 2016 to 2018 (retail, office, assisted living, residential, park); 380,000 square feet to be built from 2018 to 2021 (residential, offices, retail, apartments); and 500,000 square feet to be built from 2021 to 2023 (retail, residential, homes, hotel, condominium).
The Health City Development group is a joint venture, owned 70% by Ascension Health Alliance of St. Louis, Missouri, and 30% by Dr. Shetty’s interests including local partners Gene Thompson and Harry Chandi.
The Shetty group has options to purchase more land at the 600-acre site at High Rock. Eventually, the facility could grow to be a $2 billion, 2,000-bed hospital over the next 15 years.
Although the Cayman Islands government has agreed to give a variety of concessions to the project, these do not include concessions at the construction stage.

The latest academic research into medical tourism is an analysis of the strengths, weaknesses, opportunities and threats of medical tourism to India and South Korea.
Lydia L. Gan of the University of North Carolina at Pembroke; Medical Tourism Research Center and Hongwei Song of the University of Arkansas produced the paper.

Abstract: “Medical tourism is a fast growing trend in Asia, and both India and South Korea have been among the front runners in this industry. Several factors come into play when a country is contemplating engaging in medical tourism as part of its strategy for economic growth. Government support and other areas such as infrastructure, competence of medical staff, the entrepreneurial drive of the middlemen facilitating the process, and the general reputation and political stability of the host country are among key influencing factors. This paper conducts a comparative SWOT (strength, weakness, opportunity, and threat) analysis in India and South Korea with the objective of understanding the various factors that can help or impede the growth of the medical tourism in both nations.”
• International accreditation is a vital factor when evaluating the quality of care in medical facilities for medical tourists.• Affiliation with respected hospitals in Europe or the US makes medical tourists more comfortable with the quality of care in affiliated hospitals.• In Asia there is little or no medical accountability for negligence.• Hospitals benefit from strategic partnerships with hotels and airlines. • Growing prosperity within Asian countries mean that Asian countries can benefit more by targeting these countries, than American or European trade. • Should medical tourism and related foreign exchange revenues be used to benefit under-resourced local health systems, and if not, why not?• Medical tourism can help stop doctors going overseas, but may also move them from public to private hospitals, so damaging the public sector.

South Korea • There is strong government support with many initiatives to promote medical tourism.• The government is planning legal changes to deal with some problems below.• South Korea benefits from established trade links with Japan and China.• English language skills have helped drive medical tourism.• Being one of 4 Asian Tiger industrialized countries helps attract people. • Medical law falls short in failing to protect foreign customers.• There is discriminatory pricing against foreign customers.• A common problem is the inconsistency of cost charging during procedures, which can be higher than quoted prices.• Cosmetic surgery is expensive compared to other procedures.• Success is due to targeting prosperous Chinese and Japanese customers.• The future development of Jeju Island as a medical tourism destination will make it easier and quicker for Chinese and Japanese customers to fly for treatment.

India• The government does little to promote and encourage medical tourists to go to India.• The government has lower import duties, subsidised land, and favourable tax laws to promote local investment in medical tourism.• It is too early to say if the medical visa system encourages medical tourism.• Historic links mean English language skills exist.• Has no medical malpractice laws.• Proving doctor negligence is difficult due to legal red tape, corruption, and hospitals having no complaints procedures.• Poor infrastructure is a problem-in some places patients may have to change flights 3 or 4 times to reach a hospital.• The public transport system and roads are far below Western standards.• Judging the quality of hospitals just from online pictures is impossible.• Most competition is centered on price and this can compromise quality, particularly in the cheaper hospitals.• Many Indian medical tourism agents overplay the quality of care, facilities and treatment.• Many advertising and marketing claims are misleading. • The scarcity of local medical care and cost creates divisions between locals limited to poor public hospitals, and private hospitals that concentrate on medical tourists.• The shortage of doctors and nurses is made worse by most of them working in the private sector.• Expensive healthcare caters to the elites and ignores the local poor.• Is losing out to competitors including Thailand, Singapore, Malaysia and South Korea.

The paper looks at risk areas that are often overlooked -• The lack of follow up care is critical to the continued health of a medical tourist.• Follow up care must be arranged in home countries.• Travel risk includes infection and exposure to diseases.• International flights can expose patients to new germs and bacteria that may increase the risk of infection during operations.• Local epidemics such as swine flu and SARS must not be ignored, as these risks could bring medical tourism to a halt in affected countries.
The paper concludes that as competition increases, the lack of investment and marketing by governments and poor product or service differentiation by government and business, may mean countries that are successful medical tourism destinations now, will be overtaken by those with supportive government policies, a better infrastructure, plus differentiated service and care, with a co-coordinated marketing strategy.
The market is not big enough or expanding fast enough for all those countries wanting to grow or develop medical tourism to succeed. Only those with improved infrastructure, solid long-term strategies, and innovative offerings will maintain sustained growth. Some countries will fail, and although the paper avoids naming which ones are most vulnerable, their analysis suggests India is already struggling.

Nigeria is seen as a source of medical tourists, mostly gong to India but some travelling to the UK. In Gorleston, orthopaedic surgeon Emeka Nnene has begun offering discounted surgery to Nigerians visiting the UK at up to 50% off London prices in an attempt to provide alternatives in the growing medical tourism market. A consultant surgeon at James Paget Hospital, Gorleston in Norfolk, East Anglia with over 15 years experience, Dr Nnene is offering a special service for Nigerians who visit the UK for treatment. Also a clinical orthopaedic tutor at the hospital, Dr Nnene currently takes private consultations at the facility and is seeking to expand this service. He performs a wide range of operations including joint replacements, keyhole surgery and fracture fixation. He also has admitting privileges at James Paget hospital’s private rooms for post-operative recovery and in-patient stay. The hospital is an NHS trust, and as most trusts, also accepts private patients.
Dr Nnene says, “The charges for surgery and in-patient stay are very competitive compared with those in London and in many cases could cost up to 50% less. During 2013 I will be proceeding further in my bid to advance high quality orthopaedic care and making it available and accessible in Nigeria too. I am also involved in partner relationships with hospitals in Nigeria where I can offer the benefit of consultations in Nigeria and also perform some surgical procedures. The first of these centres is the Alba Clinic along Constitution Road in Kaduna and I am co-coordinating with other centres in Abuja and other parts of Nigeria.”
Many wealthy Nigerians, especially political leaders fly to London for treatment on all sorts of ailments, ranging from surgery to routine check-ups. Some London private clinics charge as much as £1000 a day and Dr Nnene hopes to reduce these hefty amounts Nigerians pay for treatment. He also wants to help train Nigerian doctors so that some of these surgical operations can be offered within Nigeria.
The Nigerian Medical Association has added its voice to many politicians expressing concern about the growing trend of medical tourism where affluent Nigerians go abroad for medical treatment that is widely available locally. Dr Nnene adds: “I am also keen to extend my orthopaedic tutor role to Nigeria by providing an up-to date and evidence based approach in lecturing orthopaedics at some Nigerian universities.”
Nigeria is one of the strongest critics of outbound medical tourism, not for religious or ideological reasons. The main problem is government officials and private individuals who go overseas are alleged to spend over N80billion on foreign medical treatment; in a country where imports exceed exports, this is a loss of foreign currency that the country can ill afford. Nigeria is Africa’s leading oil producer; but more than half of its people live in poverty. Nigeria is keen to attract foreign investment, including hospitals, but is hindered by security concerns and an infrastructure troubled by power cuts.
All figures on numbers of outbound medical tourists from Nigeria have to be used with great care; local politicians want to exaggerate the problem, certain countries like to exaggerate how many people they get from Nigeria, some medical tourism agencies want to show a much bigger potential than there is, and some government officials like to underplay how much state money they, their extended families, and assorted friends – are using to go overseas for treatment. And everywhere in Nigeria, the three problems of corruption, tribal rivalries, and poor healthcare provision for other than the select few, all have to be thrown into the mix.

Spain has long been a favorite tourist destination for Europeans, but has not really promoted the country’s attraction for medical and health tourists. That is about to change with a concerted advertising and marketing campaign, plus a new project.
British and Russian health and medical tourists will be the main target of the ’Tourism & Health Spain’ campaign on the Costa del Sol. 30 private health clinics and hotel resorts in the area have joined forces to attract potential foreign tourists who would like to go to Malaga for health or medical reasons. The project was officially launched during the Fitur international tourism trade show, held in Madrid from January 30 to February 3.
Tourism & Health Spain is headed by the president of the Malaga Association of Private Clinics and owner of Malaga’s Chip Hospital, Jesus Burgos. The target profile is a middle-to-upper or upper class patient that may spend around €10,000 per year on health services alone. Malaga province’s private clinics estimate they could receive an annual overall turnover of €250-300 million from health and medical care alone. Added to that, there is the additional amount spent on leisure, food and accommodation by the patients and their families. Both the individual spend, and the total revenue, appear very optimistic in the current European economy; and finding many British people who spend €10,000 per year on health is a tough if not impossible task.
Malaga province’s private health offer includes 4,500 beds in hospitals and clinics, says the Malaga Association of Private Clinics. With drastic cuts in Spanish healthcare spend, and a huge drop in money available to spend on healthcare of the average Spaniard, this sudden enthusiasm for health tourism may include a hint of desperation for some private clinics who may see their very future at risk.

Project Illum is a concept to take over an abandoned hotel and spa development in Jafre, Spain and turn it into a wellness centre. Launched on Indiegogo, a popular crowd funding platform, the project seeks individual investors to save a 1500-acre site. The project aims to attract resources, skills and engage with potential contributors and partners through the Indiegogo campaign. It is supporting the small community of the 452 inhabitants of Jafre to secure the land and ancient spring to redevelop it in harmony with the local people and nature. The project intends to raise $650,000 primarily via public contributions on Indiegogo, to secure the land and current development (already 60% complete), assets and structures.
Illum will be a wellness and healing centre with thermal baths utilising the water from the ancient natural healing spring will a meditation pavilion and surrounding gardens. The project will complete the construction of a 97 suite residential facility with gym, spa and other related health and wellness facilities in 2015. Stan Colders, founder of Project Illum says, ’’It is a big project, but the reward of putting Jafre back on the map as a healing centre and what that would do for the villagers. Colders lives in the UK and sees the project as mainly targeting British visitors.

It is estimated that 15% and 20% of medical tourists to India come from neighboring Pakistan, but increased political tension between the two could restrict or even curtail this business. Indian hospitals worry that visa hurdles might restrict the movement of patients from Pakistan to India for medical treatment. Numbers have already slowed down.
When the British left India in 1947, the partition of the sub-continent – into present-day India and Pakistan – sowed the seeds for future conflict. There have been three wars between India and its Pakistan since 1947, two of them over the disputed territory of Kashmir.
The border between India and Pakistan has been a dangerous area for decades, and incidents in recent weeks leave both India and Pakistan claiming the other was responsible for deaths and injuries to their soldiers. Since 2003 there has been an official ceasefire, but an ill-defined border means that each side claims disputed territory as its own. Tensions within Pakistan, plus border area problems with terrorists, bandits and drug runners make it a permanent tinderbox.
Hospital chains Apollo, Medanta, Max and Sir Ganga Ram all attract patients from Pakistan – primarily for organ transplants (liver and kidney), oncology-related treatment and cardiac and orthopedic surgeries.
Ganga Ram Hospital, normally gets 4 or 5 patients a day from Pakistan, and the number has already fallen to 1 or 2 patients a day. Apollo gets 50 to 60 patients a month from Pakistan, 90% for liver transplants. Raj Raina of Apollo Hospital says, “There could be trouble. It can take 10 days or more for visa processes, so the effect of any problem takes a while to work through.” Pakistan only accounts for 3% of Apollo’s revenue. Medanta gets 8 to 10 patients a month from Pakistan.
The Indian government claims it does not treat Pakistan any differently when it comes to issuing medical or other visas. But hospital officials say that practice and theory often differ, with Pakistanis made to work a lot harder to get visas than other nationalities. Also, patients from Pakistan might avoid India if they have to cross a troubled border.
Hospitals want business from Pakistan as they can charge a premium of 20% to 25% more than fees from local patients. But as recent events show, it is very vulnerable to political tensions between the two countries that may co-exist but do not like either each other or what the other country stands for.

Romania is one of the up and coming destinations for dental tourism. Overseas customers represent a growing percentage of revenue for local dental clinics.
Dragos Popescu, co founder of the Dental Med dental clinic in Bucharest is one of the local pioneers of dental tourism, “Foreigners make up 30% of the clients of the DentalMed clinic in Bucharest; 20% are expatriates living in Romania, and 10% come from abroad specifically for dental treatment in Romania, Of the 5,000 patients treated annually in the clinic, around 1,500 are foreigners. But only 500 are dental tourists. The average percentage of foreign patients in other Bucharest clinics is between 5% and 10%.”
Popescu estimates the local dental services market is worth some EUR 250 to EUR 350 million a year, with foreigners’ share at EUR 25 to EUR 35 million. But only a handful of dental clinics in Romania, most of them located in Bucharest, have the logistics capacity to treat foreigners. But local dentists are now gearing up to treat patients from Western Europe, as standard services in Romania are 20% to 40% lower than in Western Europe.
Popescu worries that if dental tourism takes off that larger firms from Romania or overseas would buy up local clinics or set up their own cut-price chains; but it could be five to ten years before this happens. The market is fragmented, with over 2,500 private dental clinics in Bucharest alone. This private system developed independently from the public health system.
What is also happening is that dentists from other countries are setting up clinics in Romania, as the dental markets in their home countries are already saturated. Dentists are coming from Israel, Italy, Spain, and Greece; which will in turn attract patients from those countries.
Dragos Popescu and his business partner Razvan Popescu recently extended DentalMed with an investment of EUR 1.5 million. The plan is to see turnover advancing to EUR 5 million within five years, from EUR 2 million turnover in 2012. The Romanian investors chose to focus on a single location for their clinic, and plan to expand it with a childrens clinic on the second floor of the existing unit later this year.

South Korea will take away the medical tourism licences of any hospital or clinic that continues to get business via unregistered medical tourism agents. It is also bringing in a state qualification test system for hospital medical co-coordinators. A state-run qualification test system will be adopted for medical tour coordinators who provide foreign patients with general information on treatment and hospital systems. The ministry will also allow more Korean-speaking foreigners to work as coordinators by easing regulations, but they will also have to take the qualification test.
Hospitals that attract people through unregistered medical tourism agencies will be banned from accepting foreign patients for two years, says the Ministry of Health and Welfare. The ministry is revising medical regulations to toughen punishments on hospitals that have deals with unregistered agencies in medical services for foreigners.
The measure follows a growing number of complaints from medical tourists, especially Chinese, who go to Korea to receive medical treatment through unregistered middlemen. Under current regulations, only registered medical tourism agencies can attract foreign clients.
A ministry official explains, “In many such cases, middlemen overcharge patients, luring them with exaggerated ads. They also tell hospitals that they will attract foreign patients and demand 30 to 70% of the medical fees as commission. Some hospitals in financial difficulties or newly opened clinics accept such offers, and the quality of the treatment is not guaranteed. We are taking countermeasures because treatment through illegal brokerages may make foreigners lose trust in Korea’s medical services, consequently dealing a serious blow to Korea’s medical tourism.”
For offending hospitals, the government will cancel their license to attract foreign patients even through registered agencies. They will also be banned from obtaining the license for two years afterwards. Hospitals are required to obtain a license if they want to attract foreign patients through agencies. They do not need one if they do not have business with such agencies.
The ministry will also encourage associations of hospitals or medical tourism agencies to set up their own guidelines against illegal acts in order to boost the credibility of the nation’s medical tourism sector.
The ministry will also encourage hospitals to charge patients medical fees, not the agencies, to stop agents adding a high premium.
The government plans to have 10,000 “global healthcare experts” by 2020 including nurses and interpreters specializing in medical treatment interpretation. The ministry is also considering adopting another license for interpreters specializing in medical treatment. It will also help hospitals and colleges make agreements on hiring graduates majoring in specific languages, such as Arabic and Russian, as interpreters.
The government also seeks to link medical tourism with regular tourism programmes. Medical visas can now be issued to patients and also people who attend on them, such as family members.
The ministry is also developing a debit card with which the patients and the family can get discount on transportation, shopping, tour and medical fees.

Taiwan is attracting record numbers of Chinese medical tourists and has taken steps to increase numbers further.
Taiwan’s National Immigration Agency (NIA) has eased the regulations for Chinese visitors going to Taiwan for medical treatment in order to boost the economy. Chinese nationals who are over 20 years old and have either savings of at least NT$200,000, or an annual income over NT$500,000 can visit Taiwan for health inspections or medical treatment, including cosmetic surgery. These health tourists can bring family members with them.
Taiwan claims to have attracted 100,000 medical tourists in 2012, exceeding the goal set at 60,000 and surging 156% from 39,000 in 2011, according to Walter Yeh of Taiwan External Trade Development Council (TAITRA), “The quality of Taiwan’s medical care is very good, but needs to be promoted to international tourists. The Department of Health approves some 40 hospitals and clinics on the island to treat Chinese tourists, while the Taiwan Joint Commission on Hospital Accreditation, a non-profit and non-governmental hospital accreditation agency, certifies 19 cosmetic surgery clinics for quality of treatment.”
TAITRA says that revenue generated by medical tourism is estimated at NT$70 billion (US$2.33 billion), of which at least 40% is from Mainland Chinese. The value is expected to rise by 20% in 2013.
Walter Yeh of TAITRA adds, “Taiwan’s medical tourism can surpass that of South Korea in five years. The key target markets are Mainland Chinese tourists, and overseas Chinese in North America and Southeast Asia looking for quality, cheaper medical care in Taiwan.” TAITRA is now promoting Taiwan’s medical tourism in metropolitan Beijing and Shanghai.
The relaxation of the visa rules is crucial. Hsieh Li-kung of the National Immigration Agency (NIA) explains, “The regulations for Chinese coming to Taiwan for medical services have been eased to increase economic growth. With this revised regulation, Taiwanese health inspection and medical cosmetology industries will be able to compete internationally. This can also attract more Chinese tourists to visit Taiwan. Allowing Chinese to come to Taiwan to enjoy great medical cosmetology services also demonstrates Taiwan’s ability and development in the industry.”
According to the NIA, medical organizations can request that travel agencies apply to the NIA for business registration so they can use the new rules for tour groups of Chinese going to Taiwan for medical services.

In a recent presentation on marketing Cyprus as a medical tourism destination, Nikos Anastassiades of the local AIMIS Spine hospital concluded:

Strengths • Strategic location at crossroads of Europe, Asia and Africa.• English is widely spoken.• Educated workforce.• Excellent healthcare at good value for money.• Existing tourism infrastructure.

Weaknesses• Not regarded internationally as a medical tourism destination.• Lack of year round regular flights other than from UK or Greece.• Limited medical tourism infrastructure.• Lack of strong marketing of doctors, hospitals, clinics and medical services.• No active government support.

Threats• Turkey is very active competitor on medical and wellness tourism.• Turkey has many JCI hospitals.• Israel, Jordan and Dubai are established medical tourism competitors.• No hospitals in Cyprus have international accreditation.• No active financial backing from government.• Private sector cannot do it alone.• Economic problems.

Opportunities• Excellent tourism infrastructure can support medical tourism.• European medical standards can be promoted.• Clinics and hospitals have spare capacity for medical tourism.• Political instability may stop patients going to some competitors.

Key markets• USA• Middle East• Russia• Ukraine• Other Eastern European countries.• Europe for selected treatment.

Problems • Not seen as a medical tourism destination.• Poor flight connections.• Lack of accredited hospitals.• Adding medical, travel and accommodation costs; total is high compared to competitors.• Online marketing is not enough.

Challenge• For medical tourism to flourish the government must make heavy financial investment.• Accreditation must be achieved.• Hospitals wanting medical tourists must set up marketing departments.• Perseverance ad official support are vital.

Dubai Health Authority has agreed new visa rules that allow medical tourists to stay longer. But in return for this, every hospital and clinic has had to agree the maximum number of medical tourists they can treat.
New visa regulations designed to allow foreign visitors undergoing medical treatment to stay for up to nine months are expected to reinforce Dubai’s appeal as a health tourism destination.
Dubai hopes to take business from Jordan, the regional leader in health tourism, which is being affected by the conflicts and unrest in neighbouring countries such as Syria, Israel and Egypt.
Under the new visa system, foreigners wishing to receive treatment in Dubai will be able to obtain a three-month visa, with their hospital processing and submitting the request and all required documents. Once approved, the initial three-month visa can be extended twice if necessary.
The new system also clarifies the process for hospitals applying for visas on behalf of their overseas customers and sets out a quota for hospitals and clinics registered to provide treatment to overseas patients, limiting the number of visas they may have for medical tourists at any one time.
The Dubai Health Authority has allocated a certain visa quota to all hospitals; aiming to safeguard the interest of tourists and will also ensure that hospitals maintain international standards of services. The quota can be increased only if hospitals can prove that the quality of service to locals, expatriates and medical tourists will not be affected. It is illegal for hospitals to take in more medical tourists than they are allowed, and miscreants risk losing their medical tourism licence.
Essa Al Haj Al Maidour of the Dubai Health Authority says that the new visa regime will make it easier for overseas patients to access the emirate’s health services and reduce bureaucracy.
Dubai’s main competition is from Jordan, Turkey and Abu Dhabi with Turkey far more successful in attracting patients from Europe than the three Arab states.

Switzerland is becoming more popular as a destination for wellness and medical tourism. More private hospitals, spas, wellness centres and clinics are targeting the sector. Differentiating the country from the common misconception of medical tourism being about saving money, Switzerland has an emphasis on quality in an environment that lends itself to general wellbeing. Key destinations include Geneva, Lausanne and Lucerne.
For over a century, Switzerland has been known to Europeans as a destination for top quality healthcare and health relaxation. The reason why numbers have been and are expected to continue to grow is that the country has been targeting travellers from several Middle East countries, and has now turned to attracting Chinese and Russian health and medical tourists. Switzerland and Germany are the market leaders in targeting the higher paying, and often longer staying, quality end of the medical and health tourism sector; both countries being far more organized than competitors Singapore, UK and USA.
Swiss Health has been a very active organiation promoting medical and wellness tourism. Gregor Frei of Swiss Health comments, “5 to 10% of the business now comes from the Middle East. In the last three years we have seen an annual increase from the Gulf of between 20% and 50%. The Middle East is now very important for Switzerland.”
Last year, Swiss Health launched a spin-off organization, Lucerne Health, to promote wellness and medical offerings in Lucerne. The number of visitors booked via Lucerne Health increased by 45 % between 2011 and 2012. Wanqiu Frey of Lucerne Health comments, “We are looking for distributors in different countries in the Middle East and we also plan to share market events with our partners such as Lucerne Tourism, Swiss Health and the Swiss Tourism Board. We are expecting to have one agency in each key country in order to drive more awareness.” The organization produces marketing information in Chinese, Russian, Arabic, English and German.
Geneva’s leading teaching hospital, Hôpitaux Universitaires de Genève (HUG) attracts VIP patients from Saudi Arabia, United Arab Emirates, and Qatar. Alain Fong of HUG comments, “ We attract overseas customers, not for economic reasons, but for the quality. With 65 different medical services available, coupled with arrangement of transfers (including the option of private planes), Arabic speaking staff and translators, and connecting rooms, our private clinic is 60 % full all year round.” Clinique Générale-Beaulieu in Geneva is a private hospital where Middle Eastern patients are between 5 and 10% of the patient total.

Hirslanden has 14 medical clinics across Switzerland and offers personal service to international patients, with private rooms and private nursing, translators, interpreters and a limousine service. The clinics do not need to advertise as most business comes from word-of-mouth referrals. Clinic Lémanic in Lausanne is a cosmetic surgery clinic with a website in Chinese and Russian, and becoming more popular with Middle Eastern patients too,
For 2013, Lausanne Tourism Board’s strategy for the Middle East region is to focus on PR, having appointed an Abu Dhabi based agency. Tamja Dubas of Lausanne Tourism Board says, “Media visits to Lausanne and the region help us in promoting the wellness and medical market in our city.”
Swiss Health has a target of increasing medical and wellness numbers by 50% by the end of 2014, and there is every sign that this target is achievable.

Malaysian singer-composer Michael Wong’s Mandarin hit song Wo Men De Gu Shi has been made the official music video to promote the country as a destination for Chinese health and medical tourists.
In 2005, Wong’s hit Mandarin song Tong Hua (Fairy Tale) became a hit with its theme of tragic love for someone dying. The new hit from the singer is Wo Men De Gu Shi (Our Story), which is about treasuring your health in pursuit of your dreams.
The music video of this song has been made the official music video of the country by the Malaysia Healthcare Travel Council (MHTC) in its bid to promote Malaysia as a top destination for Chinese visitors to seek healthcare. It is believed to be the first time any country has had an official music video to promote medical tourism. It was launched in Beijing.
Wong has been made a travel ambassador for Malaysian healthcare, and claims that the music video is a soft sell way of telling visitors from other countries what services Malaysia has to offer, but also promotes the importance of taking good care of your health, “During the filming at Prince Court Medical Centre in Kuala Lumpur, the crew experienced an incident that stirred our emotions. The doctor who was involved in the shoot was suddenly called on to treat a patient with a critical heart failure condition. We had to clear the set for the medical team to save the patient’s life. We later heard that the patient survived.”
Wong adds, “MHTC watched it and hopes it will send a message on the philosophy of health. Unlike “Tong Hua” where the female lead died, this new song has a happy ending as the girl is treated successfully.”
Two weeks after the launch, ’Wo Men De Gu Shi’ was being played by several radio stations, and then released on popular Chinese video portals including Youku, Tudou, Sina and 56.com.
Dr Mary Wong of MHTC comments, “A lot of Chinese like to visit Malaysia. Many travel for cosmetic surgery, dental and cardiac treatment. We will work with travel agencies, insurance companies and big corporations in China. More Chinese corporations are giving benefits to their employees such as trips abroad that include healthcare screening.”
The number of Chinese nationals visiting Malaysia for healthcare services increased by 50% from 7,357 in 2010 to 11,029 in 2011, with a projection of 15,000 in 2012.
While Indonesia provides the largest number of medical tourists to Malaysia, MHTC has been successful in expanding the market to include visitors from Bangladesh, China, Korea, Nepal and Myanmar. These countries have been identified as having the most potential for growth, so are being targeted.

Medical tourism has an increased profile, and is attracting serious academic study. Much academic research has been hidden away in obscure journals, so a collection of new and republished essays and studies from many serious researchers into the subject is welcome.
April 2013 will see the publication of a book by leading international publishers Palgrave Macmillan; “Medical Tourism and Transnational Health Care” (ISBN 9780230362369) is edited by David Botterill, Guido Pennings and Tomas Mainil. The 272 page hardback costs £55.
David Botterill is a research fellow at the Centre for Tourism at the University of Westminster. Guido Pennings is Professor of Ethics and Bioethics at Ghent University, Belgium. Tomas Mainil is a lecturer at Breda University of Applied Sciences, The Netherlands. All have researched tourism and medical tourism while being extensively published.
The three editors contribute the introduction and explain the reason for the book, “Medicine and tourism have become separated in contemporary popular consciousness. The former implies anything but a pleasurable experience and the latter presumes a healthy disposition for participation. We argue that this popular conception of the separation of tourism and medicine ignores an historical continuity of lineage from the 18th century pursuit of a cure at resorts and spas, through to global patient mobility in the quest for cutting-edge medical interventions in untreatable conditions. Under the influence of transnational health care consumption, two very contrasting traditions of tourism and medicine are now confronting one another. This book provides diverse research attempts to capture implications for medicine, medical ethics, health policy and management, and tourism studies.”

Contents1. Sickness, health, tourism and the ever present threat of death: nineteenth century spa and seasonal travel; David M. Bruce2. A way through the maze: exploring differences and overlaps between wellness and medical tourism providers; Cornelia Voigt and Jennifer H. Laing3. Caring for non-residents in Barbados: examining the implications of inbound transnational medical care for public and private health care; Jeremy Snyder, Valorie A. Crooks, Leigh Turner, Rory Johnston, Henry Fraser, Laura Kadowaki, Mary Choi and Krystyna Adams4. Tourists with severe disability; Angie Luther5. Beauty and the beach: mapping cosmetic surgery tourism; Ruth Holliday, Kate Hardy, David Bell, Emily Hunter, Meredith Jones, Elpseth Probyn and Jacqueline Sanchez Taylor6. Cross-border reproductive care around the world: recent controversies; Wannes Van Hoof and Guido Pennings7. Transplant tourism; Thomas D. Schiano and Rosamond Rhodes8. The European cross-border patient as both citizen and consumer: public health and health system implications; Tomas Mainil, Matt Commers and Kai Michelsen9. Canadian medical travel companies and the globalization of healthcare; Leigh Turne10. The ethical management of medical tourism; Guido Pennings11. Transnational health care and cross-culturalism; Tomas Mainil, Vincent Platenkamp and Herman Meulemans12. The impact of medical tourism in low- and middle-income countries; Melisa Martínez Álvarez, Richard D. Smith and Rupa Chanda13. The Impact of the Internet on medical tourism; Daniel Horsfall, Neil Lunt, Hannah King, Johanna Hanefeld and Richard D. Smith14. Towards a model of sustainable health destination management based on health regions; Tomas Mainil, Keith Dinnie, David Botterill, Vincent Platenkamp, Francis van Loon and Herman Meulemans

There are many things wrong with China’s health service and as yet it attracts few medical tourists, while many more Chinese look overseas for treatment.
But in five or ten years time the situation may be completely different and China could be competing as a top destination.
Liu Zhongmin of Shanghai East Hospital told a medical forum in Shanghai, "Language, international insurance and quality service are the biggest concerns of international patients. But they are gaining increasing confidence in the skills of Chinese doctors."
A 1995 city government survey of expatriates and investors found that 70 % wanted medical care to be available within 20 minutes and wanted health services to be of high quality. Then, most expats went home or to Hong Kong for treatment. Now, most choose to stay in Shanghai.
Expatriates and medical tourists have similar fears. Will they get the quality of care they are used to back home? Will they be able to communicate with doctors treating them? In Shanghai, home to about 300,000 expatriates, such anxieties are eased by the burgeoning number of internationally operated clinics and hospitals, and by the creation of VIP wards in public hospitals. 30 hospitals have set up special wards catering to foreigners. There are also 20 international hospitals and clinics financed by overseas investment and employing some foreign medical personnel.
Public hospitals can be crowded and noisy, with doctors too busy to give any individual patient much attention. Compared with Western hospitals, the process of seeing a doctor and finding services focused on patients lags far behind in China. Patients have to go to different floors for different tests and to pay bills. Doctors who have too many patients have no time to explain diagnoses and treatments carefully.
Western-style services are not cheap. Charges in an international hospital may be ten times the price of those in a local one, depending on the facilities and the treatment given. For the extra money, patients get medical staff that are less harried. Bilingual help is usually available. The wards are quieter. The interior decor is soothing.
Public hospitals have been trying to emulate the Western health-care system by setting up VIP wards. Local hospitals are learning from the Western service concept, but it will take a long time. It is one thing to set up a special area with better decor, but quite another to adopt patient-focused services and assemble highly qualified professional staff.
Among local hospitals in the city, Shanghai East Hospital sees the largest number of expatriates, treating 20,000 a year. Shanghai East, located in the Lujiazui financial district of Pudong New Area, was the first publicly owned medical facility in the city to open a joint venture international hospital, financed with US investment.
The same picture can be seen in 20 cities across China, and while for now they may be happy to concentrate on providing care for increasingly well-off locals and the expatriates working there; sooner or later China is going to look seriously at attracting medical tourists. When it does, Asian countries charging too high a price for their services, will be under threat.

2011 figures from International Promotion for Costa Rican Medicine (Promed) suggest that the number of medical tourists to Costa Rica was 48,000, compared to 36,000 in 2010.
Seven out of 10 private clinics in San Jose provide services to medical tourists, and in Guanacaste, 4 out of 10 clinics do, says Promed.
San Jose has registered 1,223 businesses connected with the medical tourism industry, with an average of 38 procedures annually per centre. In Guanacaste, the total amount of clinics providing services to medical tourists was registered at 109, each attending to an average of 16.3 medical tourists annually.
Promed says that Costa Rica received 48,253 medical tourists in 2011 and that the average amount spent per medical tourist was $7,000; this suggests a revenue value of $338 million. Yet in other recent press interviews Promed claims for 2011 are $196 million on health, with patients spending an additional $84 million in hotels, meals, travel and shopping, and numbers of 40,000.
That San Jose has 1,223 businesses involved in medical tourism may seem hard to believe. But these are not just hospitals and clinics; they include hotels and restaurants. So if a medical tourist uses a medical travel agent, stays at a hotel, eats in a restaurant and goes to a clinic for cosmetic surgery, then each of those four will count the same person.
Timothy Morales of Costa Rican Medical Care comments, “Our business is growing every year, but these numbers are way out of line. This says that 132 arrive every day for treatment. Of course no one works on weekends so that number is 185 people based on a 5-day week. That is 78 new dental patients a day? Each dental patient needs at least one to two hours with 3 to 5 days, so where is the time for all the new people. There is too much over counting. The hotel, the clinic, the agency and the restaurants each count the same patient, which is very misleading.”
Promed defends the methodology of multiple types of businesses counting the same patient, “It is necessary in order to tabulate the total revenue generated by the industry. The dentist and the hotel must both be counted. If the average revenue per medical tourist is $7,000, obviously the same patient is being counted by multiple businesses as that figure is more than the medical cost; but the point of the figures is more to see what the economic impact of medical tourism is as a whole; which that methodology accomplishes, though it could appear misleading.”
This multiple counting system has been used for several years, and finally offers a reason why claimed figures and actual patient volume have been so far apart.
Massimo Manzi of Promed says that 42% of the procedures are related to dental work, whereas 22% are surgery-related (orthopedics, general surgery and gynecology), 16% is preventive medicine, 10% cosmetic surgery and the remaining 10% is other specialities.
Through various interviews carried out with medical tourists who received care at Clinica Biblica, Colina Dental Clinic and Las Cumbres Inn Recovery Center, Promed says that the majority of medical tourists came to Costa Rica as a result of information found on the Internet.
In 2010, Promed reported 36,000 medical tourists, (a 20% increase over 2009), which generated approximately $252 million dollars. But those figures also multiple counted each medical tourist. Promed needs to revise figures to actual numbers of medical figures, with no double counting; which could cut the 2011 figure down to around 20,000. Despite reservations on the confusing figures, it is clear that Costa Rica is becoming more popular as a destination, and nearly all medical tourists come from the USA, with a few from Canada.
The country will have to take more care in maintaining the quality of hospitals and clinics. It only had 3 hospitals, all in San Jose, with JCI status and now it is down to 2. One of Costa Rica’s private hospitals is no longer considered a hospital that is up to the international standards required for international accreditation. La Católica lost international accreditation granted by the Joint Commission International, after it failed an inspection in October.

Turkey will establish free health zones to attract patients from overseas, says health minister Recep Akda?, “With the free health zones, we will make Turkey more attractive as a country offering high quality and affordable health services. 200,000 people visited Turkey in 2011 as health or medical tourists, and just under half are medical tourists. Political and economic stability have made Turkey attractive.” New regulations from the Ministry of Finance give a 50% tax exemption for private sector health tourism revenue.
Dursun Ayd?n of the Ministry of Health says that in the last three years, Turkey’s health tourism industry has seen annual growth of 30%, "In 2011 200,000 patients came to Turkey within one of the three subcategories of health tourism; medical, thermal/wellness and senior tourism. We are expecting the number of tourists in this category to increase by 30% a year and a 100% increase in revenue. Our estimate for 2012 is near two billion dollars.”
Ayd?n believes that the biggest potential in health tourism lies in thermal and senior tourism, "In terms of thermal tourism, Turkey has seen a number of developments and investments. We are working on additional legislative regulations on thermal tourism. We have also worked on legislative arrangements regarding the health standards of accommodation facilities. Thermal tourism is progressing with speed and will grow in Turkey.”
While many countries are attractive to retired people who want to live in warm inexpensive countries, there are few places targeting senior tourism. These people go to Turkey in the dead season, the winter and spring months, and fill accommodation that otherwise would be empty. There is a problem in including senior tourism within health tourism figures as if Turkey includes them it could be argued that Spain could add millions of winter retirees to its health tourism figures, and some senior tourists are not seasonal, but all year round.
A report by the Istanbul Chamber of Commerce states that Turkey must evaluate the important opportunity of health tourism among alternative tourism categories in order to take full advantage of its tourism potential. Turkey is located at the crossroads of continents and is one of the most visited places in the world. The report says:” Research conducted regarding private hospitals active in health tourism suggests that at present it is not sufficiently systemized. The data reflects that either the statistics of private hospitals are missing or that it is not known how much the activity of a hospital impacts the sector as a whole, or even if these hospitals are willing to play an active role in the development of health tourism. Many hospitals follow a pricing policy based on short-term profits and lack a general pricing structure. Advertising and commercial activities are unprofessional.”
The report says that if $700 average spending for each patient is taken into account, health tourism provides significant advantages. For example; if a patient undergoing cancer treatment stays in a Turkish hospital for an average of 30 nights, estimated earnings are 10,000 euros.
Other benefits of health tourism are listed in the report, including: • Providing a solution to low occupancy rates at hotels.• Diversifying the customer base.• Contributing to the formation of a positive image of the country worldwide• Creation of job opportunities.• Diffusing the regional concentration of tourism locations.
The report says that Turkey is doing well but needs to identify target markets and determine strategies for advertising in these markets and the services to be provided, as well as the right pricing policies and collaboration with other sectors and subsectors.

The medical tourism research group at Simon Fraser University in Canada will continue its series of studies into global medical tourism, and has published studies on Barbados and Mongolia. Lead researcher Valorie Crooks, a health geographer, recently received a $635,000 award from the Michael Smith Foundation for Health Research for an eight-year period to further her research.
Her qualitative study focuses on Canadian medical tourism in Barbados, Guatemala, Mexico and India. Crooks hopes to gain a better understanding of the impacts of medical tourism for both Canada and the destination country.
By next year, she and her team of researchers hope to have a guide for Canadians who are considering medical tourism to help them carefully consider their options.
The latest research project for 2012 to 2015 compares the impact on a developing country’s own health care system. The aim is to find out what effect medical tourists from developed nations have on developing nations that they go to. The focus is on the long running argument as to whether medical tourists have a positive or negative impact on the local health system across: health human resources, domestic government involvement, investment, private health care, and public health care.
This project looks at case studies: Barbados; Guatemala City, Guatemala; Monterrey & Mexico City, Mexico; Bangalore & Chennai, India.
A new report,’ An Overview of Medical Tourism in Barbados’ concludes that the local medical tourism industry is very small .The main activity is from Barbados Fertility Centre although other clinics are starting to get involved .The creation of a health and wellness tourism task force and the building of American World Clinics could slowly change that in the future.
A research team travelled to Mongolia in April 2012 to develop a better understanding of the effects of outbound medical tourism in that country. This research was funded through a grant from the Canadian Institutes of Health Research. A short report has just been published: ”Outbound medical tourism from Mongolia”. It does not offer numbers, but says that the main reason Mongolians go elsewhere for treatment is dissatisfaction with and distrust of the public healthcare system, and absence of private healthcare.

After a recent conference of the European Spas Association on the future of health resorts and health tourism companies in the EU, held at Usedom in Germany, a jointly agreed declaration for submission to the European Congress was made.
Known as the Usedom Declaration the ’Future Prospects of European health resorts, spas and health tourism providers’ states;
• They are an essential part of the healthcare and tourism sectors in both their native countries and Europe. • The variety of providers and the wide range of local spa resources and other services they offer is a major asset attracting guests and patients from Europe and elsewhere.• They offer preventive medicine, restore health, and provide optimum, long-lasting physical and mental relaxation.• They need to be recognized by means of transparent, comparable structures as well as quality standards on the basis of state and legal foundations concerning local spa resources which allow the use of different nationally and regionally recognized forms of treatment.• They ought to be subject to comparable criteria and standards of quality regarding services in preventive medicine and medical rehabilitation that address the proper use of local spa resources, including national characteristics.• They have developed complex holistic treatment programmes for preventive medicine and medical rehabilitation. • The harmonization of European law must allow for national legal differences and practices regarding the use of local spa resources.• They are increasingly providing wellness services which are designed to improve guests’ health and which need to be of extremely high quality in order to clearly set them apart from the offerings of other providers and to safeguard and preserve the outstanding reputation of recognized health resorts and health tourism providers in Europe.• They are distinguished by their natural location, appearance and facilities. This contributes to the variety of health resorts and spas in Europe. Maintaining this variety must be regarded as part of quality policy.• They are service providers whose structures, procedures and standards of service must all be of high quality in order to ensure the high quality of the results.• In addition to meeting specific standards of quality in terms of healthcare, they should also meet guests’ expectations in full by means of high-quality offerings in the areas of sport, culture and the arts.

There are more signs that domestic internal US medical tourism is taking off for employers and individuals.

Cleveland Clinic and Boeing have entered into a healthcare deal for the company’s 83,000 non-union employees, dependents and retirees in which doctors perform heart surgeries on employees for a bundled payment, with other types of surgery to follow if this works out.
Newspaper publisher Stephens Media sends employees and their families needing hip and knee replacements to a handful of hospitals across the country, that have agreed to a low fixed rate for surgery and score well on quality of care.
One problem that employers have to solve is finding local doctors to provide follow-up care for patients who travelled elsewhere. Cindy Meyers of Stephens Media comments, “ It benefits us on costs, and our employees feel comfort in knowing the hospital specializes in just what they need." Grocery retailer Kroger has flown nearly two dozen workers to Hoag Orthopedic Institute in Irvine and several other hospitals across the U.S. for hip, knee or spinal fusion surgeries to save money and improve care. At Kroger, employees may pay 10% out of pocket if they choose one of the company’s 19 select hospitals, compared to 25% to 50% out of pocket for other ones. 21 patients have travelled for surgery in 2012, and none have experienced complications or been readmitted to the hospital.
Theresa Monti of Kroger says, “It costs us $30,000 on average for those knee and hip replacement surgeries, 15% less than what we pay at other hospitals. Some people have a hard time getting their heads around the idea of traveling for surgery. But to us it is an opportunity to encourage the use of the highest-quality healthcare while holding the line on costs."
Starting in January, Wal-Mart Stores will offer employees and dependents heart, spine and transplant surgeries at no cost at six major hospital systems across the nation, with free travel and lodging.
Employers can see no logic in hospitals quoting wildly different price tags for routine operations. So businesses are giving workers generous incentives – including waiving deductibles or handing out $2,500 bonuses to steer them to top-performing hospitals offering bargain package prices. When sourcing anything else, employers need fixed prices for their budgets, so more are getting fed up with having to cope with healthcare where what they pay is a lottery.
Bundled deals are common for phone service, cable TV and travel. But an all-in-one price marks a radical departure for the conventional fee for service medical industry in which doctors, hospitals, labs and other providers typically bill separately for each part of a procedure. Then they tack on more charges, if complications and unexpected costs arise.
By bringing a steady stream of new patients, the arrangement can also be a good deal for the doctors and hospitals involved. And by limiting treatment to certain hospitals, employers are getting guarantees of better quality care and personal attention.

BridgeHealth Medical in Denver tried and failed to persuade employers to send patients to India and other overseas destinations for cheaper care, so now concentrates on US domestic medical tourism by negotiating fixed rates with 45 U.S. hospitals. It argues that employers still come out ahead financially, even after footing thousands of dollars in travel expenses.

Vietnam has seen an increase in the number of medical tourists over the last five years. But the country has no plan to develop health and medical tourism in a professional way.
The Central Institute of Acupuncture, headed by Professor Nguyen Tai Thu, has been a pioneer in receiving foreign tourists for healthcare services. Since 2006, in partnership with the Acupuncture Medical Tourism International Group and local travel agencies, it has attracted groups of foreign travelers to Vietnam for acupuncture and oriental medicine. They can also approach a new way of disease treatment – Qi Gong. Most of the clients of the institute are from Europe and America.
Professor Nguyen Tai Thu is frustrated that he has to go it alone with no official support or help. One organization is restricted in what it can offer and has limited money to advertise medical tourism.
Ho Chi Minh City has 100 government owned hospitals and medical centres, plus dozens of privately owned clinics. Patients come from nearby provinces and from Cambodia. Cho Ray Hospital has been attracting Cambodians and reports that the number of Cambodian patients treated at the hospital has increased by 90 % over the four years 2008 to 2011.
Those attracting medical travellers are annoyed that not only is there no government support, but hospitals and travel firms have not cooperated with each other to develop services and increase the revenue.
Some local authorities have realized the benefits that can be brought by medical tourism products. Quang Ninh province offers a tour where travelers can visit the Yen Tu sacred temple and have medical treatment with herbs. Khanh Hoa province has become well known as the place for tourists to visit hot mineral springs, mud baths and herbal spa services.
But health and medical tourism is often no more than an add on to a tour package, not a separate medical or health travel package.
Vietnam has one of Southeast Asia’s fastest-growing economies and has set its sights on becoming a developed nation by 2020. Tourism has increased at a steadily impressive rate over the last ten years. In 2010, Vietnam welcomed nearly 4 million international tourists. Most visitors come from China, with around 10% coming from the USA, Japan and South Korea. Building on this success, the Vietnam National Administration of Tourism is looking to develop and diversify the tourism industry.

A UK insurance broker has launched a critical illness cover where treatment is in the USA, and a health intermediary has launched a health cash plan that will reimburse customers for treatment outside the UK.

Insurance Tailors, an independent London insurance broker, has launched XN GlobalPreferred Care, a critical illness treatment product.
Traditionally, UK critical illness insurance policies have provided a one-off, tax-free, lump sum monetary payment upon diagnosis of a prescribed illness. This payment is designed to help ease any financial pressures that may arise from contracting the illness. This product takes a new approach by replacing money with treatment.
The aim is to maximise the chance of survival, which is the key to recovery from life threatening illness. Upon diagnosis of a covered critical illness, a policyholder is given a diagnosis verification treatment plan by experts at Harvard Medical School in the USA, reducing the risk of preventable medical errors, and an optimum treatment plan is created. Cover is then provided for travel to, and accommodation in the US for treatment and recovery in a top 1% rated US hospital.
Andrew Boldt of Insurance Tailors explains, "In the UK, our ability to treat critical illness is too often constrained by local thinking and financial constraints. It is widely acknowledged that the US is a global leader in research and treatment of critical illness and this offers UK residents access to these world leading treatments and specialist diagnostics."
Versions of this cover have been available in a few other countries for five years. It has been successfully operating in Asia, the Middle East and Europe, but this is the first time it is available to UK individuals and companies.
The diagnosis, travel and treatment are arranged by global patient organization PGH. The insurance is underwritten at Lloyd’s of London.
Andrew Boldt of Insurance Tailors adds, "The launch of this product is in line with our mission to change the way that the insurance industry is perceived; in this case, by bringing to market a product that I believe gives people what they want. As the first buyer of the product in the UK for my own family I can evidence this myself. This product is different to other products in the UK private medical and health insurance markets in that it has been designed with a very specific goal; to optimise the chances of survival and recovery from critical illnesses, including all forms of cancer (other than non-invasive skin cancer and cancer in the presence of HIV). This outcome is made possible by not limiting patients to local treatment, but rather making use of global best practice, research, expertise, technology and innovation.”
Customers benefit from:• The experience and knowledge of the leading experts in any covered condition at Harvard Medical School to review the diagnosis of their condition and create a treatment plan that they believe will provide the best chance of recovery from the condition• A dedicated local care manager is appointed who will be the point of contact throughout the process, overseeing everything from logistics to explanations of medical treatment• Travel to and accommodation in the US is arranged and paid for by the policy• Treatment and recuperation within a hospital rated in the top 1% of US hospitals for the specific condition is paid for directly by the policy.

Perfect Health Cash Plans has a new insurance plan for families, the self-employed and businesses. Surgical Cash is a health cash plan that pays a fixed sum of money should customers need an operation. They can choose the treatment privately in the UK or abroad. Alternatively, they can keep the money and have treatment on the NHS.The customer has to make all arrangements for treatment and travel, whether in the UK or Europe, and gets cash back from the insurers after treatment.
Perfect Health Cash Plans is a specialist health insurance intermediary. Cover is underwritten by Compass Underwriting. Surgical Cash plan is insurance for when people are really ill and require a surgical procedure, but is much cheaper than traditional private medical insurance. Several dental and cash plans in the UK now allow customers to choose whether they get treated at home or go to Europe, but all work on a reimbursement basis where the customer pays out, arranges travel and treatment, then gets some money back from insurers.

Local doctors on Belize were originally opposed to plans to make the tiny island a medical tourism destination, but now support the proposals.
Concerned that their income would suffer if American doctors were flown in to undertake treatment, and piqued at not being consulted before the original plans were made public, members of the Belize Medical and Dental Association (BDMA) were vociferously opposed at first.
Now that they have been included in the planning process, they are behind the initiative. Dr. Joel Cervantes of BDMA says medical tourism will up the standard of healthcare provided in Belize: “As medical and dental experts, our wish is to be involved. Belizean doctors and dentists cannot do all the work as we lack specialist expertise. By having medical tourism come to Belize the standard of medicine practice here both for locals and for our foreign guests is going to be better.”
BMDA has been working with the Ministry of Health on a medical bill that will regulate the medical tourism sector. That bill is expected to go to Cabinet soon. The consultations on medical tourism have been going on for several months. Massimo Manzie, a consultant hired to draft a strategy has delivered a draft of a medical tourism policy, "Belize has a lot to offer to medical tourist. This is a renowned retirement destination for Americans and an English speaking country; so has advantages that customers will not face the same communication problems as in many Latin America countries."
Dr. Peter Allen, Ministry of Health, adds, "We see ourselves playing the role of catalyst and making sure that we can try to create the proper environment through which this industry can prosper – driven by the private sector. We have an important role in creating the appropriate regularity framework to make sure that it is done in a safe way."
Dr. Joel Cervantes, BMDA comments, "We want a proper model to be put into place. Much needed funds will come from foreign investors, and there might be local investors involved."
Mike Singh of the Ministry of Trade concludes, “The vision of the government is to develop an industry that will create employment and also improve healthcare for Belizeans. Many Belizeans actually travel to Merida, Guatemala and Miami for medical attention, as our local services do not satisfy our market. We can bring that business back to Belize and also bring additional international medical patients to Belize.”

Nearly one in two people, surveyed around the world by independent market research group Ipsos, are open to the idea of medical tourism. The Ipsos Public Affairs poll, on behalf of Reuters News, was of 18,731 adults in 24 countries.
It found that 18% would definitely consider it, 36% probably would consider it, 30% probably would not consider it, and 16% definitely would not. This is interesting for medical tourism as it shows that there are two types of customer to target – those who are in favour, and those who may consider it; while time should not be wasted on the half of the population who are against it. One warning on the figures is that the poll assumed that medical services overseas are cheaper, and did not take into account those who will pay as much or more overseas due to quality or availability.
There is also a danger in such surveys that what people say they might do is very different from what people actually do in the real world. So, the absolute percentages may be misleading in terms of the real likelihood of medical travel. It does however provide some insight into how medical travel is viewed in one country compared to another.
According to Ipsos, those from India (35%), Indonesia (32%), Russia (32%), Mexico (31%) and Poland (31%) are most likely to say they definitely would go abroad for medical services. On the other hand, those from Japan (3%), South Korea (5%), Spain (7%), France (8%), Belgium (9%) and Sweden (9%) are least likely to go overseas.
Demographically, younger adults appear more open to going abroad to for medical or dental work. On the global aggregate level, those under the age of 35 (19%) and those aged 35-49 (19%) and more likely than those aged 50-64 (15%) to say they definitely would go.
These findings were part of a monthly poll on a variety of subjects in August 2012. The survey is conducted in 24 countries via the Ipsos Online Panel system. The countries reporting are Argentina, Australia, Belgium, Brazil, Canada, China, France, Germany, Great Britain, Hong Kong, Hungary, India, Indonesia, Italy, Japan, Mexico, Poland, Russia, South Africa, South Korea, Spain, Sweden, Turkey and the United States of America. An international sample of 18,713 adults aged 18-64 in the US and Canada, and age 16-64 in all other countries, were interviewed. 1000+ individuals participated on a country by country basis with the exception of Argentina, Indonesia, Mexico, Poland, South Africa, South Korea, Sweden, Russia and Turkey, where each have a sample 500+.
Nicolas Boyon of Ipsos told Reuters, “The concept of medical tourism is well accepted in many countries. With the exception of Japan there are at least one third of consumers in every country we covered that are open to the idea. Indians, Indonesians, Russians, Mexicans and Poles are the most open to the idea of being medically mobile. People in Japan, South Korea, Spain and Sweden are least likely to be medical tourists. I am intrigued by the percentage of people in developed nations such as Italy, where 66 % said they would definitely or probably consider medical tourism, along with Germany (48%), Canada (41%) and the United States, where 38% of people were open to the idea. Italy and Germany are near Hungary, a popular destination for health. It is a reflection that the medical profession is no longer protected from globalization.”
Boyon added, “The medical tourist industry is dynamic and volatile and a range of factors including the economic climate, domestic policy changes, political instability, travel restrictions, advertising practices, geo-political shifts, and innovative and pioneering forms of treatment may all contribute towards shifts in patterns of consumption and production of domestic and overseas health services."
In India, 86% of young adults said they would consider medical tourism, along with 77% in China, and 71% in Italy. The results are simplistic so have to be treated with caution in that what people say they may consider buying is rarely followed up by actual purchase.

South Korea has been busy with teaching hospital executives about medical tourism, targeting Japan, and working out what it has to do better.
Medical tourism training is usually targeted at agents and employees, but the Korea Health Industry Development Institute (KHIDI) takes a different view. The latest course in Seoul was only for 21 chief executives and directors from top local hospitals. The “First Global Healthcare CEO Course” at the Palace Hotel in Seoul’s Gangnam area was directed at promoting the nation’s medical tourism industry through a special medical course for bosses of the nation’s key medical institutions including hospitals. The course programme included-• The needs and prospects for international cooperation in medical tourism.• Trends of global healthcare.• Strategy for overseas medical market.• Success cases of medical tourism.• Medical tourism policy of overseas institutions.
The government backed course sought to help hospitals to work out their strategy for promoting medical tourism.
Japan is the biggest tourism source market for South Korea while over 70% of tourists to Korea are from Japan, Hong Kong, China and Taiwan. Most medical tourists are Japanese seeking cosmetic surgery. In Korea, there are over 100 such cosmetic and dental surgery clinics competing for business.
The number of foreign medical tourists to Korea was 60,201 in 2009 and doubled to 122,297 in 2011. It is expected to reach 250,000 by 2014 and by 2020 it will grow to 1 million.
At a recent Korean conference on medical tourism, delegates spent time discussing what needs to improve-• Medical tourism needs a high level of expertise. Travel agents are not qualified for that. A lot of trust is required for medical treatment because you invest your health and life into it. So with medical tourism you need specialist medical tourism agencies working with patients and hospitals.• The best medical agencies are run by doctors. Korea needs agents with a medical background who can give consultation and connect patients to healthcare centres in Korea.• A good example is Russia, which has a huge agency in Vladivostok. Doctors do not get paid very well so they become agents. Such professional agents enhance the quality of the tour agents.
John Linton of Yonsei University Severance Hospital adds, “Korean hospitals have many good points but weaknesses as well. The reception areas are crowded, hospitalization lacks privacy, and there is limited time for doctors to examine or speak to patients. For medical tourism to grow and for Korea to attract more foreign patients, Korean hospitals need to do more to meet their needs. We need to separate space and staff for international patients, and doctors and administrators fluent in English must be on call all-day. We need designated professionals for international patients as well as professionally trained nurses.”
Builders have broken ground at Jeju Healthcare Town in Seogwipo City on the island of Jeju.Jeju Healthcare Town will become a destination for medical tourism, including wellness and recreational tourism. The development plan includes a wellness mall, well-being food zone, and healing garden in the second phase; and anti-aging centres in the third phase.

New research suggests that migrants to EU countries may prefer to go home for healthcare, not just for a short time, but for their lifetime after a permanent move to a new country.
The research is based on 2007 figures and is only on one EU country and one country source of migrants within that country. But no similar studies have been done. The question that should fascinate medical tourism, and not within the scope of this research, is whether or not the next generation, and those who were migrants as young children, still have a need or desire to travel to their parents’ home country for medical treatment?
“Use of cross-border healthcare services among ethnic Danes, Turkish immigrants and Turkish descendants in Denmark: a combined survey and registry study” for BMC Health Services Research, is an abstract published in Biomed in advance of the full report. The authors are Signe Smith Nielsen, Suzan Yazici, Signe Gronwald Petersen, Anne Leonora Blaakilde and Allan Krasnik

Abstract (provisional) from BioMed:

Background
Healthcare obtained abroad may conflict with care received in the country of residence. A special concern for immigrants has been raised as they may have stronger links to healthcare services abroad. Our objective was to investigate use of healthcare in a foreign country in Turkish immigrants, their descendants, and ethnic Danes.

Methods
The study was based on a nationwide survey in 2007 with 372 Turkish immigrants, 496 descendants, and 1,131 ethnic Danes aged 18–66. Data were linked to registry data on socioeconomic factors. Using logistic regression models, use of doctor, specialist doctor, hospital, dentist in a foreign country as well as medicine from abroad were estimated. Analyses were adjusted for socioeconomic factors and health symptoms.

Results
Overall, 26.6% among Turkish immigrants made use of cross-border healthcare, followed by 19.4% among their descendants to 6.7% among ethnic Danes. With ethnic Danes as the reference group, Turkish immigrants were seen to have made increased use of general practitioners, specialist doctors, hospitals, and dentists in a foreign country, while Turkish descendants had made increased use of specialist doctors and borderline statistically significant increased use of hospitals and dentists, but not general practitioners. For medicine, we found no differences among the men, but women with an immigrant background made considerably greater use, compared with ethnic Danish women. Socioeconomic position and health symptoms had a fairly explanatory effect on the use in the different groups.

Conclusions
Use of cross-border healthcare may have consequences for the continuity of care, including conflicts in the medical treatment, for the patient. Nonetheless, it may be aligned with the patient’s preferences and thereby beneficial for the patient. We need more information about reasons for obtaining cross-border healthcare among immigrants residing in European countries, and the consequences for the patient and the healthcare systems, including the quality of care. The Danish healthcare system needs to be aware of the significant healthcare consumption by immigrants, especially medicine among women, outside Denmark’s borders.”

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

Glenn Cohen of Harvard Law School has written a new book called, “Patients with Passports: Medical Tourism, Law, and Ethics.” He is lecturing and publishing extracts, but the book will not be published until late 2013.
The focus of his year as a fellow at the Radcliffe Institute for Advanced Study, the book examines three categories of medical tourism:• Services that are legal in the home and destination countries (hip replacement, cardiac bypass); • Services that are illegal in the home country but legal in the destination country (abortion, assisted suicide, reproductive technologies, stem cell treatment); • Services that are illegal in both places (organ sale).
He describes the myriad of problems associated with each category, including quality of care, adequate documentation, doctor-patient relationship, and proper patient information.
The concept of the book is that medical tourism has benefits, but also raises ethical and legal questions. Glenn Cohen comments, “There is a concern that a foreign country’s poor population is being treated at the expense of the host country’s poor residents. When I go to medical tourism conferences, I am always surprised at how many people are in marketing. It seems like an industry much more dominated by the business and the marketing people rather than the healthcare people.”
Part of Cohen’s book focuses on medical practices that are illegal worldwide, such as the sale of human organs. Organized crime often plays an important role in the illicit trade that involves a seller, transportation of the organ from one country to another and a doctor willing to perform the transplant surgery. There can also be serious medical complications. Patients may contract an antibiotic-resistant infection, and many donors report getting sicker and requiring additional treatment after surgery, producing an ever-greater drain on the home nation’s health care system.
In researching the illegal organ donor market, Cohen was most shocked by the blurring of deep cultural divides. “Ethnic rivalries get crossed here. You have Israelis buying Palestinian kidneys.”
Then there are the patients who are willing to travel for medical services that are illegal in their home countries but legal elsewhere. Some terminally ill Europeans travel to Switzerland, where there is no residency requirement and where assisted suicide is permitted.
Some Americans and Europeans travel abroad because parental surrogacy is either illegal at home or is cheaper elsewhere. Such practices raise complicated ethical questions on surrogacy clinics in India, where young women of childbearing age sign contracts and are paid a fee to be artificially inseminated. They are housed in a dormlike facility for the duration of their pregnancies. While there, the women are carefully monitored and must adhere to strict rules.
Some people go to another country, as the treatment is not available at home. This can be simple unavailability or that the home country is not satisfied with the outcome or safety of the procedure. Cohen comments, “I was shocked at the number of parents taking their children abroad for stem cell therapy to treat conditions such as neurodegenerative and other diseases without strong evidence that it works.”
Cohen says that medical tourism has noticeably increased in the past 12 years due to the ease and diminishing costs of travel, increasing healthcare costs, and globalization.

A leading cardiologist is to build a stem cell lab in the Bahamas. Dr. Conville Brown will build the $2.5 million lab at his Bahamas Heart Center clinic.
The plan follows the first cardiac stem cell treatment on the island. In conjunction with the Orlando-based stem cell company Advanced Innovative Medicine, Dr. Brown successfully performed the treatment on a 62-year-old American man who was experiencing heart problems after suffering a heart attack in 1989.The man had advance cardiac disease with blockage of blood going to his heart. A team of 15 people took one year to prepare for the procedure. Dr Brown says, “For medical tourism, it presents a niche because it provides a service for people outside the country which they not get where they came from.”
The procedure is an expensive one. A lot of technology is involved in stem cell therapy. The generation of the development of the expansion of the stem cells is a procedure that generally attracts a price of $20,000 to $30,000 just for the cells. The total price is in the $40,000 to $50,000 range globally. The cost in the Bahamas was significantly reduced.
The Bahamas government is planning to establish guidelines for doctors wanting to practice stem cell research or treatments.
Dr. Brown explains why he is building the new facility that should be ready within 6 months, “We want to set up our own stem cell manufacturing facility. It is all about giving the patient the convenience of a one-stop shop. The patient could come to The Bahamas, have their blood drawn, their cells processed and administered all under one roof and then fly back home; all done at one place at one time with one price and one package.”
The technique, using the body’s own cells, does not have regulatory approval in the USA.

Doctors Hospital is also planning to set up a stem cell lab by early 2013. It has launched an international patient programme at The Bahamas Medical Centre, which is part of Doctors Hospital Health System .The new centre has operating rooms, private patient rooms, an athletic centre and swimming pool facilities. Barry Rassin of Doctors Hospital explains, “ Medical tourism has taken off in parts of Central and South America. We see great potential for the Bahamas. We cannot compete on price with India, Thailand, Mexico or Costa Rica. But we can be 25% to 35% cheaper than average US prices. There are direct flights to here from major US cities.”

The Tourism Authority of Thailand says medical tourism is a key magnet that will draw more tourists to Thailand and help to generate higher tourism spending.
The government has set a lofty tourism revenue target of 2 trillion baht by the year 2015 and that has prompted the TAT to identify segments that could lift revenue. Last year according to the Ministry of Tourism, Thailand earned Bt776, 217 million from international tourism.
Spending per head on medical tourism is high at Bt130,000 per trip with an average stay of one week. Most of the spending goes on medical treatment and 30% for hotel and food expenses. The spending average does not include airline tickets. Vilaiwan Twichasi of TAT says medical tourism enjoys a strong growth rate, “It will play an important role in tourism revenue by 2015.”
TAT views Russia, China and the Middle East as the main sources of medical tourism. Russian visitors are interested in traditional Thai medicine, while cosmetic surgery is the top treatment for Chinese visitors. The Middle East market, the biggest in revenue and numbers, is mainly concentrated on hospitals in the Ploenchit-Sukumvit road area. Travellers from Singapore and Hong Kong seek cosmetic surgery.
TAT suggests numbers of 1.4 million for 2010, but that includes all health and spa tourism. China and Russia offer the best growth potential.
Medical tourism is a rising star as Thailand seeks to boost tourism revenue to 2 trillion baht by 2015. The pressure to hit the 2-trillion-baht target has caused TAT to increase promotion of cosmetic surgery, stem-cell treatment, spas and traditional and alternative medicine.
Cambodia, Laos, Myanmar and Vietnam also hold future potential if the Asean Economic Community (AEC) becomes a reality in 2015.
Thailand sees Singapore as the key competitor for complex surgery, South Korea for cosmetic surgery, and Malaysia as a destination for Muslims.

A new website for people seeking dental implant advice has been launched by the European Association for Osseointegration (EAO). This is the first European wide initiative of this kind.
The website offers 56 answers to the most frequent questions dental implant patients have. The questions are divided under 8 chapters, ranging from the general definition of a dental implant to the specifics of implants and smoking, complications and materials use. The aim is to help people make an informed decision on dental implants
Alberto Sicilia, of the EAO explains, “As dentists, when we meet a patient to discuss treatment options, we try to be as thorough as possible. But patients were lacking a supporting tool for making an informed decision. The website covers most questions they have.”
The EAO is a Brussels based organisation of leading dentists who undertake implant treatment. Professor Søren Schou of the EAO comments, “ The patient is at the heart of everything we do. We are proud to share our knowledge with patients.”
The website and guidebook were funded entirely by the EAO with no external sponsorship, ensuring that it is free of commercial influence.
Both website and guidebook are available in English, French, Spanish, German and Italian. Other European languages will follow. Clever cartoon design has been used on this project for a user-friendly finish. The website also features a practical search tool to find the nearest EAO member, and ten 3D practical educational videos.
The European Association for Osseointegration (EAO) is a non-profit organisation founded in Munich in 1991. It is an international, interdisciplinary and independent science based forum for all professionals interested in implant treatment.
EAO aims to improve the quality of patient care by bridging the gap between science and clinical practice as the leading association within the field of implant dentistry in Europe. It promotes the international exchange of information through networking of dentists and scientists within implant dentistry. It initiates, publishes and promotes research.

The Polish Information and Foreign Investment Agency (PAIiIZ) is organizing a 3 day study tour to Poland for insurance companies, government health departments, tour agents, and businesses who are responsible for sending patients abroad for treatment. The study tour is part of a three year project to promote Polish medical tourism services. The promotional campaign focuses on Denmark, Sweden, Norway, Germany, Russia, UK and USA. Two representatives will be invited from each country. The tour will take place in November/December 2012. Accommodation for 3 nights, meals during the stay, airline tickets, and transport will be funded by PAIiIZ.
To apply for inclusion in the study tour, contact Karolina Dresler, Project Manager, Polish Medical Tourism Promotion, Polish Information and Foreign Investment Agency, tel. +48 22 334 99 62.

A workshop tour of several Gulf countries that highlighted the benefits of going to German hospitals and clinics by the German National Tourist Office (GNTO), and the German National Tourist Board (GNTB), recently ended in Abu Dhabi.
Petra Hedorfer of GNTB comments, ”After the success of the previous years, medical tourism to Germany was once again the marketing focus of this road show. The workshops aimed at showcasing to the local travel industry, media, and medical experts the development of initiatives specifically tailored to meet the needs of visitors arriving from the GCC countries."
Germany has been targeting Kuwait, Qatar and the UAE and this will continue in 2013 as the two organizations expect that there will be an increase in medical tourists going to Germany for the next few years, and one of the biggest suppliers will be Gulf countries, despite the massive hospital building programme in the region. Antje Roeding-Boudier of GNTO explains,” The unparalleled level of collaboration between science, research, industry and hospitals has transformed Germany in a primary destination for medical tourism. Arab patients go to Germany not only for the high level medical infrastructures, staff and technologies, but also for several specialised services. We will continue targeting international patients and supporting the outstanding global reputation of the German medical sector."
Health and medical tourism are a key focus for the sales and marketing activities for GNTB. Since 2010, it has been raising the profile of Germany’s medical facilities through the ’medical travel’ theme and a global cross-media campaign on medical tourism. A brochure promoting medical travel is available in Arabic. In response to positive feedback, the print brochure is being redesigned and the online content is being updated on the 26-language GNTB website.
Over 900 Qatari nationals travelled to Germany for treatment from January to September this year, choosing the country mainly for advanced medical care and rehabilitation. In 2011, 12,600 visas for Qataris were issued for travel to Germany, 5% of which were medical visas. The number this year has gone up, with 18,400 visas issued till September, 5% of which were for medical reasons.
The German healthcare system is working hard to patients from Arabic speaking countries by offering translators, as well as assistance on location, transport and accommodation.
An Armenian newspaper reports an unnamed source of international research, that shows Germany and Israel are the primary choice for those traveling to foreign countries with treatment purposes from Russia and CIS states. Commonwealth of Independent States (CIS) unites: Azerbaijan, Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia, Tajikistan, Turkmenistan, Uzbekistan and Ukraine.
According to the newspaper, so far in 2012 more than 26,000 people from CIS countries have undergone treatment in German hospitals. The reasons for choosing German hospitals go beyond the medical ones. Germany is seen as having a higher level of security than many competitors (fewest terrorist attacks), excellent climatic conditions (CIS residents have fewer problems of acclimatization in Germany compared to hotter countries). The hospitals of Munich are considered the best in the world.
Germany is much dearer than the other most popular destination for CIS countries, Israel. It too has an excellent medical reputation but is less well geared up for medical tourists, while the political tensions and climate are factors against going there. On the other hand Israel offers more affordable treatment and most hospitals have Russian speaking doctors and nurses. The survey suggests that CIS countries are now the vast majority of medical tourists going to Israel; 48% of patients come from Ukraine and Russia, 37% from Turkey, Cyprus, Palestine, and 14% from other CIS countries, particularly Armenia.

Up to 500 Scottish NHS patients may be sent to Europe for surgery as a health board struggles to meet treatment targets.

NHS Lothian said patients would be offered alternative measures at clinics in countries such as Norway, Spain or Belgium because they cannot provide the legal guarantee of treatment within 12 weeks. Those due to receive surgery in December may have to travel abroad for their operations. Between 400 and 500 patients are set to miss the December deadline.
Tim Davidson of NHS Lothian says, " Any patient listed for inpatient or day case treatment from 1 October has a legal right to be treated within 12 weeks. We cannot break the new law. If we keep going the way we are, we could have 400 to 500 patients who require complex procedures who may not be seen. Our job is to try and treat them locally and we will do all we can to ensure that happens. If we cannot do that we will try to do it in Scotland, if we cannot do it in Scotland we will try in England, and after that it is Europe, but we expect the numbers who are offered treatment outside Scotland to be low."
Patients who stay in hospitals outside Scotland may have to stay there for more than a week, but flight and accommodation costs for a family member would also be paid.
NHS Lothian has a poor track record as a recent official report confirmed allegations of bullying in the hospital, financial problems, and that it had provided fraudulent waiting list figures to hit Scottish government targets.
NHS Lothian provides a range of primary, community-based and acute hospital services for the populations of Edinburgh, Midlothian, East Lothian and West Lothian. It provides services for the second largest residential population in Scotland – 800,000 people.
Scotland’s ruling political party, the SNP, argues that NHS budgets in Scotland will only be protected through independence. £100,000 is lost from the Scottish block grant for health for every £1 million that is cut from the UK health budget, figures from the Scottish Parliament Information Centre show.
The SNP said the Scottish Government has a "cast-iron commitment" to protect the principles of the NHS.A new Audit Scotland report showed health boards broke even last year but face more pressure to balance their books in 2012-13, with savings of over £270 million required.
Bob Doris of the SNP says, "Ultimately, the only way for Scotland’s NHS to be protected in the long term is for all of the economic and policy decisions to be made here in Scotland, and for Scotland to be in charge of our own resources with an independent Parliament."
Whether or not Scotland votes to become independent in 2013, as Scotland and England are separate countries with differing rules on the NHS in each, then it can be argued that a Scottish health trust that sends patients to England, is engaging in medical tourism in exactly the same way if those patients were sent to Norway.
In Scotland, NHS patients requiring planned inpatient or day case treatment are now covered by a treatment time guarantee enshrined in law. The new guarantee was introduced at the start of October.
The guarantee means that patients have a legal right to receive treatment within a maximum of 12 weeks from when they are diagnosed and agreed to the treatment.
The guarantee is one of the rights in the Charter of Patient Rights and Responsibilities that brings together, in one place, a summary of the rights and responsibilities that patients have when using NHS services in Scotland.
The treatment guarantee does not apply to NHS patients in England, Wales or Northern Ireland.

A growing number of people in Greece are putting off having dental care locally as a result of cost, while dental tourism is becoming more popular, with an increasing number of Greek dental patients visiting Balkan states to save money on treatment.
Economic problems in the country have forced many to cut back on spending on general living costs and dental care has become an unaffordable luxury for many. The situation is so bad that some dentists have also decided to move abroad for job security and increased income.
Athanasios Devliotis of the Thessalonika Dental Association says that there have been significant reductions in the amount of work for dentists in both urban and rural areas of up to 50%; dentists offering prosthetic services have seen the biggest decline, with some carrying out 80 % less work.
Young dentists have also suffered and this is part of the reason so many dentists are choosing to leave Greece to practice abroad. The number of dentists choosing to move abroad to offer their services is ever growing, with at least 500 having left the country. In 2010 alone, 95 dentists in Attica had certificates issued to supply dental services abroad. In 2011 this climbed to 185 dentists and in the first few months of this year there have been 140 such licenses issued. Another 230 such certificates have been issued to Thessalonikan dentists. Their most popular destination is Britain, followed by Germany and Italy, while there is also a good deal of interest in the Middle East and North Africa
Many social security funds have stopped covering dental care following their incorporation into the National Organization for Healthcare Services. Doctors and pharmacists have terminated all services to this organization as they are owed huge sums of money and every promise of payment has been broken.
The average price for a crown stands at 300 euros; a three-tooth bridge costs 1,000 euros, while an implant sets patients back by 1,200 to 1,500 euros. Foreign patients, many from the UK, consider Greece relatively cheap for dental care, and dental tourism packages have been created.
The latest Greek austerity package will hit the Greek health sector with further cuts to the health system. Savings of €2 billion will mean one in ten doctors and other medical staff losing their jobs in public hospitals.
There are already daily protests by doctors, nurses and patients all over the country as they have all suffered from cuts in wages, cuts to pensions and higher taxes.
According to the aid organization Doctors Without Borders, the funding of public hospitals in Greece has plummeted by 40 % since 2008, while demand for treatment has increased significantly. Serious shortages have developed because health service suppliers are not being paid on time. In some cases, vital operations cannot be carried out because suppliers refuse to provide the necessary medicines and/or equipment. Doctors and pharmacists are already owed €230 million by the country’s biggest health insurance company, EOPYY. As a result, patients must pay in advance at pharmacies and also for some doctors’ services and submit the bills later to their health insurer. Such upfront payments are often impossible for the old, the poor and the chronically ill, meaning they have to do without medicines and treatment. EOPYY has a €1.5 billion hole in its current budget due to the decline in contributions to the company as a result of the recession and rapidly growing unemployment, as well as the partial insolvency of the Greek government. In a developed country, millions of people are now being denied health care.
Many private clinics and hospitals have closed, and others are struggling. Many Greek doctors are expected to move abroad, while those decreasingly few Greeks with money are either leaving the country or increasingly seeking healthcare overseas. Journalists publishing lists of Greek residents who hide money overseas have been arrested, while there are daily violent clashes on the streets; it is a country in political and economic meltdown.

Walmart, the largest employer in the USA, will from the start of 2013, offer insured employees heart, spine and transplant surgery for no out-of-pocket cost, and will pay for their travel at eight hospitals around the nation. An increasing number of national employers are copying the trend.
This is not the company’s first entry into domestic medical tourism as since 1996, Wal-Mart Stores has urged employees and their dependents to use the Mayo Clinic’s three hospitals for organ transplants.
It has been an open secret that the company was planning to extend its use of domestic medical tourism as part of its efforts to control healthcare costs. It had looked at and decided firmly against sending employees to other countries for treatment; for reasons of cost, control, quality and employee concerns.
Wal-Mart’s employee insurance policies have high deductibles and out-of-pocket requirements. By using a hospital in the new network, patients could save as much as $5000.
There are 1.1 million people, including workers’ family members, covered by Wal-Mart healthcare plans in the USA; but not all employees sign up for its healthcare plans, and part-time employees are not eligible until they work for the chain for one year, so there are as many workers not insured as are insured.
Wal-Mart is adding Aetna and UnitedHealth Group as administrators for its medical plans. It already has Blue Cross Blue Shield administer its programmes, and now one of the three companies will handle the process, depending on the location of a particular worker.
Walmart has signed with six of the leading hospital and health systems in the USA; Cleveland Clinic in Cleveland; Geisinger Medical Center in Danville; Mayo Clinic sites in Rochester, Scottsdale/Phoenix, and Jacksonville; Mercy Hospital Springfield in Springfield; Scott & White Memorial Hospital in Texas; and Virginia Mason Medical Center in Seattle.
Sally Welborn of Walmart says, “We have identified health care systems that meet the highest quality standards for heart, spine and transplant surgery. Through these hospital systems, our associates will have no out-of-pocket expenses and a greater peace of mind knowing they are receiving exceptional care from a facility that specializes in the procedure they require. This is the first time a retailer has offered a comprehensive, nationwide program for heart, spine and transplant surgery.”
Walmart’s associates and their dependents who are enrolled in the company’s medical plans will receive consultations and care covered at 100 % without deductible or coinsurance, plus travel, lodging and food for the patient and a caregiver.
Patients must be healthy enough to travel for the surgeries. Four of the designated health care systems — Cleveland Clinic, Geisinger Medical Center, Scott & White Memorial Hospital and Virginia Mason Medical Center, will offer specific procedures for cardiac surgery that include open heart surgery for coronary artery bypass grafting, heart valve replacement/repair, closures of heart defects, thoracic and aortic aneurysm repair and other complex cardiac surgeries.
Three of the health care systems — Mercy Hospital Springfield, Scott & White Memorial Hospital and Virginia Mason Medical Center will perform spine procedures that will include cervical and lumbar spinal fusion, total disk arthroplasty, spine surgery revisions and other complex spine surgeries. Transplants will continue to be provided by the Mayo Clinic.

Lowe’s started offering fully covered cardiac surgery at Cleveland Clinic in 2010 for its 234,000 employees on its insurance plan. The programme expanded to chronic pain management and spinal surgery in September 2012. The number of Lowe’s employees taking advantage of the service has significantly exceeded expectations, with patients from 23 states.
Boeing now has a similar arrangement for heart surgery at Cleveland Clinic for the company’s 83,000 nonunion employees, dependents and retirees.
For 2013 250,000 PepsiCo employees can travel to Johns Hopkins Medicine in Baltimore for heart surgery and joint replacements with no out-of-pocket costs.
HCR ManorCare, with 60,000 employees, has begun offering fully covered cardiac surgery at Cleveland Clinics.
Dallas-based Energy Future Holdings has hired local health care consultants ACAP Health to guide its employees toward local doctors and hospitals with higher-quality outcomes and lower costs.

90% of medical tourists to Costa Rica come from the USA and Canada, and the figure is very similar for Colombia and Mexico.
New figures from the Council for the International Promotion of Costa Rica Medicine (PROMED) indicate that 2012 will close with a figure of 45,000 medical tourists who chose the country for some type of medical procedure. This compares to 40,000 in 2011 and 36,000 in 2010.
On average, medical tourists pay $7,000 for an average stay of 15 days, which represents an income of $300 million annually for the country. These tourists usually travel accompanied by at least one person, which increases travel expenses. Regular tourists on average spend $1,200 per visit.
PROMED says that 90 % of medical tourists come from the United States and Canada, attracted mainly by lower rates on dentistry, cosmetic surgery and orthopedics.
90% of medical tourists to Colombia come from the USA, and all but a handful are Colombian expatriates or their descendants. Mexico is almost completely dependent on US medical tourists.
Government agency ProExport Colombia has selected Stackpole & Associates in collaboration with The Center for Medical Tourism Research to conduct its national medical travel market analysis. Andres Castellanos of ProExport Colombia says, "Their sophisticated market analysis capabilities combined with practical marketing results will have significant impact on the medical travel sector for Colombia".
The country has invested substantial sums in improving and expanding its health care infrastructure, creating the environment to provide healthcare services to increasing numbers of international patients. The marketing project is the next step in raising Colombia’s profile in medical travel.
Irving Stackpole of Stackpole & Associates comments, "At one hospital alone, doctors perform 40 heart transplants per month. This is the type of skill and expertise that Colombia has to offer the world".
Over the next several months, the team including Elizabeth Ziemba of Medical Tourism Training and Margaret Ball, of Health Links International, will be conducting original research to identify the best competitive marketing position for the country.
Dr. David Vequist of the Center for Medical Tourism Research says, "We will capture and analyse primary data on the preferences of potential medical tourists for Colombian healthcare destinations. The results of this research will be vital in the development of the country’s marketing plan.”

MediExcel Health Plan has received regulatory approval to operate in California as a cross-border HMO plan. MediExcel, Mexican-based and doctor-controlled, sells group healthcare cover to US employers in California for workers and eligible dependents to receive healthcare benefits in Baja California.
Recognizing the growing US consumer demand for affordable healthcare in Mexico, a new cross-border HMO Plan is selling group healthcare cover in California’s San Diego and Imperial Counties in September 2012. California law allows Mexican-based health plans to sell group healthcare cover in California and provide benefits in Mexico. MediExcel mainly use Hospital Excel and PRO-MED Medical Group.

CroMedicor, a Croatian web portal for medical tourism, has published an extensive survey of dental prices in EU countries and has compared them with prices in dental clinics in Croatia. Research shows dental prices in Croatia are among the lowest in Europe, while UK prices are among the highest. Treatment in Croatia is 50% cheaper than in Slovenia and 70% less than in the United Kingdom.
Based on research of prices for several selected dental treatments (implants, crowns, veneers, dentures and teeth whitening) in the UK, Germany, Italy and Slovenia, the research says that Croatian dentists charge significantly less than their European colleagues. Among selected countries the UK was convincingly most expensive where prices of some treatments are even 73% higher than in Croatia. By highest dental prices, the UK is followed by Italy, Slovenia and Germany. It was a surprise to find out that prices in neighbouring Slovenia are often double than those of dentists in Zagreb.
For a single tooth implant you could pay 1,800 EUR in the UK, 1,300 EUR in Italian and Slovenian dental clinics, about 1,000 EUR in Germany, while the standard price for a dental implant in Croatia is no more than 800 EUR.
Although other price comparisons for dental work have been done, pricing of dental work and other factors have seen much recent change. CroMedicor surveyed up to 10 dental clinics in the UK, Germany, Italy and Slovenia and noted their prices of individual treatments; so the small sample size means the comparisons are more a guide than statistically accurate.
German dental prices are assumed to be high, but the survey found that Germany’s average dental prices are amongst the lowest in the EU, but still considerably more than in Croatia.

New research that reveals why many locals and expatriates in the UAE still prefer to go abroad for medical treatment, is a potentially devastating blow to Dubai’s attempts to become a major medical tourism destination.
Ineffective communication, a lack of specialist services and the length of time it takes to consult with a doctor are among the reasons residents are seeking medical treatment abroad. Emiratis and expatriates who had gone overseas for health care were questioned for Dubai Health Authority (DHA) and results analysed by the Dubai Statistics Centre
The knowledge, attitude and perception survey on medical treatment abroad among the population of Dubai is the first such survey to be done examining the knowledge, attitude and perception of the patients who traveled abroad for medical treatment between 2009 and 2012.
Laila Al Jassmi of DHA says, "The survey aims at identifying the reasons that lead to patients travelling abroad for medical treatment, and understanding the obstacles patients face and the reasons that hinder their possibility of obtaining health services in the UAE. The survey results will also help understand patient preferences in terms of: price, waiting time and the treating doctor. The analysis of this survey will help us set up evidence-based strategies and policies related to medical treatment abroad; and it will help us in reinforcing Dubai’s status as a destination for medical tourism."
Juma Abdulla Al Hosani of Dubai Statistics Centre comments, “The survey highlighted that the two main reasons for travel abroad are treatment of joint pains, back problems and for oncology services. The survey pointed out that in many cases people are unaware of the facilities available here. It also highlighted the need for better doctor-patient communication, and enhanced customer satisfaction to ensure people are satisfied with their services."
The key findings of the survey include:
The main symptoms/ health issues patients complained of before travelling abroad for treatment-• Joint problems 18.2%• Back pain 9.1%
Before travelling abroad for treatment, patients usually search for the following information:• Treating doctor experience 23.4%• Reputation of the hospital 21.0%• Past patients successful experience 16.6%• Qualifications of the treating doctor 12.0%• Availability of advanced therapeutic technology 6.5% • Availability of treatment 5.6%*• Treatment costs 3.5%• Period of the trip 2.0%• Opinion of family and friends 1.4%• Travel costs 1.2%)• Treatment side effects and complications 0.7%
8% of the people who travelled abroad for treatment do not seek medical advice in the UAE for the following reasons: • Unavailability of medical skills and equipment 56%• Long waiting time 19%• Not knowing where to go 19%• Cost is too high 4%
The top six travel destinations:• Germany 43.1%• Thailand 21.4%• UK 10.6%• India 8.6%• USA 3.9%• Singapore 3.6%
91% showed an overall satisfaction of the services provided abroad:• Singapore 100%• Thailand 96.1%• UK 94.6%• USA 92.9%• India 90.3%• Germany 87.1%
90% would recommend others to seek treatment in the following destinations:• Singapore 100.0%• Germany 90.3%• India 90.3%• Thailand 89.6%• UK 89.2%• USA 85.7%
When asked why they went where they did:• Advised by someone 66%• Welcoming environment (language, food, safe) 36%• Been to this country before 30%• Cost of treatment is less than in the UAE 26%• Easy to get to 15%
The main reasons for needing treatment:• Cancer 19.7%• Bones and joints diseases 14.1%• Cardiovascular diseases 12.5%• Ophthalmology 6.6%• Neurology and neurosurgery 5.8%• General surgery 5.0%• Nephrology 3.9%
During medical consultation, 75% of the patients had questions directed to the treatment doctor and related to:• Qualifications and experience 31.3%• Time needed to recover 23.1%• How long before I can return to UAE 7.3%
The main factors for seeking treatment abroad: • Too long waiting time to get an appointment for consultation in UAE 32.4%• Issues related to privacy 27.6%• Unwanted outcomes re treatment of others 24.8%• Unwanted outcomes re treatment of self 22.9%• Anticipating unwanted outcome from treatment in the UAE 21.0%• Negative and improper behavior of the service providers in UAE 21.0%
70% were inpatients and 30% outpatients. 56% said that treatment for their medical condition is not available in the UAE.19% of people who had treatment abroad had treatment side effects.
Patients who traveled abroad for treatment were impressed by the following factors related to medical services and wish if they were available in the health services in the UAE:• Easy to book appointment when needed 55.8%• Treating doctor listened 94.4%• Polite and kind medical staff 94.9%• Treating doctor talked clearly about condition 48.9%• Reasonable waiting time 42.8%• Treating doctor explained what might happen in the future35.0%• Consultation and diagnostic tests available in one building 32.5%• Treating doctor explained how to live with medical condition 30.3%• Medical staff able to answer all questions 28.9%
The report makes recommendations for Dubai: • Expansion of health services for cancer, orthopedics and spinal surgery • Comprehensive diagnostic, therapeutic and rehabilitative services • Reduce waiting time.• Provide information on service quality including the experience of the treating doctor, reputation of the hospital, previous successful experiences of other patients.• Provide better information on health services, medical staff and medical equipment available • Improve patient privacy • Doctors and other medical staff must focus on the need and requirements of patients.
The conclusion is that although Dubai may have many new hospitals and clinics, the way patients are dealt with; cost and waiting times are still problem areas.
The study surveyed more than 2,000 people – about one quarter of them expatriates – who travelled abroad for treatment from 2009 until the end of 2011. They were asked about their knowledge of, attitude towards and perception of overseas treatment.

Jordan’s medical tourism sector expanded in 2011, says the Private Hospitals Association (PHA). PHA figures show that 240,000 visitors went to the country in 2011 either to receive treatment in private hospitals or to accompany a patient, compared to 220,000 in 2010.Previous PHA figures showed that the sector brought in 220,000 visitors in 2009, 200,000 in 2008, and 190,000 in 2007.
Whether these figures include or exclude international travellers and local expatriates is debatable, but even if they do not, there are concerns for the future. The country no longer gets medical tourists from further away countries, and very few from Europe or the USA. The figure includes 58,000 Libyans who went to Jordan for medical care in 2011; most of these were war casualties. Libya’s outstanding dues to the kingdom’s hospitals are expected soon, but the outstanding debts stood at JD120 million as of August 31, which equates to $170 million. The PHA is also chasing the Palestine authorities for a $40 million debt.
The figures include friends and family members of the patients who accompanied them and had no treatment. A comparable figure for Singapore in 2008 was that of 646,000 ’medical tourists’ only 370,000 visitors went there for medical treatment, the other 230,000 went with them and had no treatment.
After subtracting 58,000 war casualties, this brings Jordan’s figures down to 182,200.If you then take away a third as being non-patients, it brings it down further to 120,000. Most Libyan and many Palestinian patients are paid for by their governments and the victims of armed conflict.
The PHA last year repeatedly warned that regional unrest was hurting medical tourism in Jordan, but turmoil in the Middle East has brought more business to the sector, not less.
PHA director, Abdullah Hindawi, attributes the increase in the revised figures to the influx of injured patients from regional countries that witnessed civil conflict last year. PHA president Dr. Fawzi Hammouri advised, “Jordan’s medical services played a significant role during the Arab Spring by providing medical treatment to injured people and saved lives of thousands, especially from Libya.”
In 2011 the 58,000 Libyans who went to Jordan were the biggest group, while Palestinian, Iraqi, Sudanese and Yemeni patients made up the bulk of the remainder. There are also a few from Saudi Arabia.
How many of these patients were medical tourists as opposed to war victims is another matter for debate. The PHA admits that Jordan’s healthcare sector has become a hub for its ability to respond to regional crises, and in recent has treated many patients injured in conflicts and turmoil in regional countries,
Jordan is almost landlocked. To the North is the at-war Syria. To the West is Israel, which because of historic rivalry and Israel’s many good hospitals, is never going to be a source of medical tourists. Also to the West are two countries that are no stranger to war, Lebanon and Palestine. To the South is Saudi Arabia, which has a massive hospital building programme, so is not a long-term source of medical tourists. To the East is Iraq, another country troubled by war and political tension. Looking at another source of revenue, The Sudan, it is not only a country where there is armed conflict along the border between the Republics of Sudan and South Sudan, there are problems within the countries from political protestors and liberation groups. The situation in Yemen remains volatile with reports of continuing unrest and violent clashes, so that British and US governments are advising against all travel to Yemen, and advising their citizens to leave the country.
So while Jordan is likely to benefit from war based medical travel in the next year or two, it has several challenges to overcome to achieve growth in patient numbers and revenues.
Patients coming from some countries need up to three weeks to obtain a visa to enter. As a result, those who need more urgent treatment turn to other destinations such as Turkey, where they can receive high-quality care with less complex visa procedures. Turkey gives visas to patients upon arrival at the airport, even if those patients are from countries whose citizens usually need to wait to obtain visas. Turkey is Jordan’s biggest competitor.
The PHA is now promoting Jordan in new markets including Chad and Nigeria, while looking at other African countries. But even Chad is a hot bed of conflict and violence, while Nigerian politicians are attacking the concept of outbound medical tourism as damaging to the country’s economy. Jordan has to focus on the Gulf and Africa, as with so many countries in the region either at war, on the brink of war, in armed conflict, or seeing violent demonstrations against Western European countries and the USA, medical tourists from those areas are not going to travel anywhere in the region for medical treatment.

A research report for Israel’s Ministry of Health concludes that nobody controls inbound medical tourism. So poor is the available information that the researchers could find no figures after 2009.
The report also warns that medical treatment for foreign tourists could come at the expense of local patients due to already inadequate manpower and facilities. The conclusion of this short report by the Knesset Information and Research Center is that the Ministry of Health does not properly supervise its implementation and has not passed relevant legislation.
The Ministry of Health sponsored report stated that as the ministry “does not have enough tools and resources to supervise medical tourism, setting down clear rules on what is permitted and forbidden,” supervision and monitoring are needed to prevent discrimination against economically disadvantaged Israeli residents who cannot afford private healthcare.
The Ministry of Health, said the report, uses the same monitoring of medical tourism that it does of medical treatment for locals, no matter who pays for the services and from where the patient comes.
The Ministry of Tourism agrees that there is no authority responsible for medical tourism and that the narrow medical aspect should be separated from the broader tourism aspect. The Ministry of Tourism has now started to make its own arrangements and appears in conflict with the Ministry of Health.
According to the report, while the Ministry of Health does not have up to date and accurate figures on medical tourism in Israel, it estimates that in 2009 there were 23,000 medical travellers seeking cosmetic surgery, elective surgery, psychological treatment, dental care, fertility treatment; consultations; and urgent procedures such as organ transplants and cancer therapy and surgery.
It suggests that 1% of foreign tourists came for medical care in 2009. In 2007, medical tourism brought in about $50 million, and the average medical tourist spent $4,777, compared to $1,083 by an ordinary tourist. But these are still guestimates rather than actual figures. The researchers were very frustrated that they could get no figures or estimates for 2010 or 2011 or 2012. Some people argue that it has been increasing each year, but others argue that Israel’s war like stance over Iran is keeping people away, while local trade estimates for 2012 put numbers at around 25,000.
The Knesset Information and Research Center says that most medical tourists come from Russia and other countries in the former Soviet Union; Eastern European countries such as Romania, Bulgaria and Poland; plus a few from Cyprus, Jordan, Turkey and the USA. There is no evidence that campaigns to attract Jewish Americans have worked.
In Jerusalem’s hospitals and clinics, medical tourists pay for private medical services, as in government and other public hospitals, where private care is not legal; they pay for care via the hospital’s research funds.
The report concluded that it is worthwhile to increase the income of doctors and hospitals by medical tourism, but not be at the expense of Israelis, who through the National Health Insurance system are entitled to equitable healthcare. It also warned that there are too few nurses and doctors in specialties such as anesthesiology, pathology and intensive care.
Deputy Health Minister Ya’acov Litzman has come out publicly in favor of increasing medical tourism, but Professor Eran Leitersdorf of The Hebrew University of Jerusalem has voiced his opposition, “Israel cannot afford this luxury. I fear that tourists will get special treatment and pressure on local hospitals will increase without income being used to expand facilities for Israelis.”

Treatment Abroad has launched the Treatment Abroad Guide to Cosmetic Surgery Abroad – a new, free and independent guide for people thinking of travelling overseas for cosmetic surgery. The guide is the first of its kind in the UK and aims to help people to make a more informed decision by explaining both the potential advantages (including savings) – and the risks of cosmetic surgery abroad.
The guide sets out in easy to understand language everything patients need to consider before going overseas for cosmetic treatment, including helpful checklists of questions to consider or ask your prospective surgeon.
The guide covers important topics such as:
• Which are the top destinations for cosmetic surgery?• How do I compare countries, clinics and surgeons?• How do I compare the costs in different countries and currencies?• How is cosmetic surgery abroad regulated?• Do I need special travel insurance?• What happens with aftercare and if something goes wrong when I get home?
The guide also considers topical issues such as the recent PIP implant scandal and the need to understand issues such as the provenance of any implant or medical device used.
The guide has been written by the team at Treatment Abroad including the UK expert on medical tourism, Keith Pollard, who has worked in the sector for many years and regularly speaks at medical tourism conferences around the world. The guide, like the website behind it, is impartial and aims to give a fair assessment of the pros and cons involved in travelling to another country for treatment.
The Guide to Cosmetic Surgery Abroad can be downloaded from http://www.treatmentabroad.com/cosmetic-abroad/cosmetic-surgery-abroad-guide/ and is completely free. A sister guide, The Guide to Dental Treatment Abroad, will be published shortly.

The Romanian health and tourism ministers see 2013 as the year that Romania must seize the opportunities offered by spa tourism, and look to develop tourism ethics, elderly care tourism and medical recovery tourism. The tourism ministry will promote health tourism as it sees great potential.
Tourism and development minister Eduard Hellvig explains, “Spa tourism is a niche that Romania should not miss and one of the strategic priorities for 2013 will consist of investments in the specific infrastructure, to help the development of this area; because, at infrastructure level, things are not how we would like them to be, what we have to do is to correlate what there is as natural potential in Romania with investments in the specific infrastructure. The underused resources will not bring tourists without help. The development of the health tourism infrastructure and the promotion abroad and in the country can be stimulated.”
Taleb Rifai of UNWTO comments on why health tourism may work, “Romania is qualified in all respects: it has a high level of knowledge and technique in the field, enjoys a strategic location, and among the representatives of the tourism industry there is a high level of expertise. At the same time, there is here a political determination. All these are guarantees for success. UNWTO is committed to support these efforts and I am convinced that, very soon, Romania will become an important health tourism destination.”
Romania has more than a third of Europe’s thermal springs as well as spas that offer physiotherapy, acupuncture, electrotherapy and other health services/products. Famous spas include Mangalia in the ancient city of the same name, Neptun, Eforie Nord, Covasna, Slanic Moldova, and Vatra Dornei. There are several around the salt lakes of Ocna Sibiului, offering therapeutic benefits, and others in the Carpathians Mountains. Health minister Vasile Cepoi adds, “We have a big potential of internationally recognized specialists that we do not exploit. Romania can be a destination for dental services, as well as cardiac and cosmetic surgery. More and more people from abroad are interested in dental treatment in Romania, as well as showing an increasing interest in having cosmetic surgery and cardiac surgery here.”
The Health Ministry will certify the level of quality of spa services and develop a quality management system. Vasile Cepoi explains, “We have over 80 health resorts, with more than half being of national and international interest, but the export of health services is extremely low, because the health component is not sufficiently well represented, and the marketing of these services does not provide elements inspiring confidence to the people who might benefit by these services. The health ministry must develop a quality management system inspiring confidence and safety to the people who might benefit by these services and being in line with the relevant standards. The ministry can create a high level of trust through this quality management system we plan to implement.”

Malaysian healthcare is attracting medical travellers from neighbouring Asian countries and an increasing number from developed countries, including the USA, UK, Australia and Japan, combining high quality of services and reasonable prices.
The number of medical tourists in 2011 showed an increase of 48% from 2010, with 583,000 arrivals recorded compared to 383,000 in 2010. Dr Mary Wong of Malaysia Healthcare Travel Council (MHTC) says, "The increase in arrivals is testament to the high quality and affordable medical care we provide. Some of the popular treatments and procedures sought include orthopedic procedures like knee and hip replacement, angioplasty, oncology, in-vitro fertilisation, cardiology, cosmetic surgery and health screening."
The MHTC has set up a medical tourism website and a careline to answer enquiries from foreign patients on Malaysian healthcare services and travel packages in English, Bahasa Indonesia and Mandarin, and provides an e-mail service in Japanese and Arabic. The careline service assists foreign patients to connect with hospitals and clinics in Malaysia.
Indonesian tourists comprise the highest number of those seeking Malaysian healthcare services followed by visitors from Arab nations.
Efforts by the Melaka region to boost the number of Indonesian tourists seeking healthcare services in the state appear to be bearing fruit as more Indonesians are switching their attention from Singapore to Melaka for such services. In 2010, 60% of 280,000 Indonesians went to Melaka for medical treatment
Kuala Lumpur is the destination of choice for Arab tourists. According to KPJ Healthcare (KPJ), Arab visitors made up 8% of medical tourists at the group’s hospitals. Paduka Siti Sa’adiah Sheikh Bakir of KJP explains, "Many choose Malaysia for elective medical procedures particularly cancer, orthopaedic and cosmetic treatment. It is time for Malaysia to promote the medical tourism sector aggressively to the Arab world. KPJ has been actively promoting its services to the Arab community for more than 10 years." KJP offers a range of packaged prices for medical tourists on anything from health screening to surgery.
KPJ is one of the leading private healthcare providers in the region with a network of 21 hospitals in Malaysia and 2 in Indonesia. With more than 2,600 licensed beds, KPJ hospitals treated more than 2.4 million outpatients and 240,000 inpatients in 2011.
Efforts to grow KPJ’s medical tourism segment include more aggressive marketing and promotions abroad. This plus greater participation in international exhibitions paid of with a 40% increase in the number of international patients in 2011. KPJ is targeting to raise the revenue contribution from medical tourism to as high as 25% by 2020. In 2011, this segment generated group revenue of RM45 million, with patients mainly from Indonesia as well as other countries such as Australia, New Zealand, Somalia, Singapore, India, UK and US and the Middle East.
In view of the anticipated increase of patient numbers from both local and international markets, KPJ has drawn up plans to increase its capacity over the next five years, in line with its aim to add 1 to 2 new hospitals a year to its network via acquisitions or greenfield developments. KPJ will be investing RM867 million over the next 3-4 years to develop new hospitals in Malaysia – namely Sabah Specialist Hospital, Pasir Gudang Specialist Hospital, KPJ Pahang Specialist Hospital, KPJ Specialist Hospital Bandar Dato Onn, KPJ Perlis Specialist Hospital and KPJ Muar Specialist Hospital.
Most private hospitals in Malaysia offer accommodation ranging from comfortable to luxurious, including private rooms and suites. Meals are included and rates vary depending on the level of service required as some establishment offer personal butlers or full-time private nurses. Sleep-in facilities can also be easily provided for traveling companions and given Malaysia’s relative low costs yet high standards of living, long–term stays are an acceptable option.

Switzerland is known for attracting high paying Europeans and Arabs for health and medical tourism. The Chinese look set to be the next big market. These Chinese medical tourists seek quality of care, not low prices.
An increasing number of wealthy Chinese are flying overseas for medical treatment, cosmetic treatment and health checks. There are long waiting times in Chinese public hospitals and specialist services are not available in many areas of this huge country.
With the rising affluence and mobility of the country’s emerging middle class, there has been a significant increase in the numbers of Chinese traveling overseas as medical tourists in the past decade. Around 60,000 Chinese people travel abroad annually for healthcare services, especially for anti-aging therapy, cancer screening, to give birth and for treatment of chronic diseases, according to Yang Jian of the Shanghai Medical Tourism Products and Promotion Platform.
Several Chinese medical tourism agencies have been set up to offer services to the lucrative high end market that can pay well for additional services such as interpreters, tour guides, a first-class air ticket, a private driver and even specially prepared Chinese or local cuisine.
While local countries such as Taiwan and Singapore are favoured destinations, an increasing number are going further away such as for anti-aging treatment in Switzerland and cancer screening in Japan. Diabetes and chiropractic-treatment tourism to Germany, and cosmetic surgery trips to South Korea are both popular.

Clinique Biotonus Bon Port in Geneva, Switzerland, mainly provides treatment for intense fatigue, burnout and problems linked with aging. The clinic began to get Chinese patients in 2006, and this has steadily increased from 50 a year in 2006 to 200 a year in 2012. The influx of Chinese patients has brought changes to the clinic. Most doctors and nurses can speak at least two or three sentences in Mandarin and the menu now includes Chinese favorites such as porridge and pickled cabbage.
Those Chinese medical tourists choosing Europe tend to be successful entrepreneurs, and book via a handful of specialist Chinese agencies that tailor-make services for higher end well-off medical tourists that are prepared to pay top-dollar but expect top quality service on medical treatment and all the other aspects of the trip.

The Philippines Department of Tourism expects to have a national medical tourism plan, highlighting the services offered by local clinics and hospitals, by 2013.
One area that DOT secretary Ramon Jimenez wants to promote is stem cell therapy. "To get people to travel for medical tourism we have to offer greater value for money, superior service and specialities that are not available at home.” Jimenez is a strong supporter of stem cell therapy as his wife Abby has a rare but mild motor neurone disease, and uses stem cell therapy treatment herself. The Medical City is one of the few hospitals in the Philippines that offers this type of therapy and Jimenez hopes to promote this to other countries. Stem cell therapy entails taking stem cells from a patient, a compatible donor, or from other sources. These cells are then modified to fit the specifics of the patient’s condition, and are injected into the patient’s body. Stem cells can come from three sources: bone marrow, peripheral blood (referring to blood circulating the body), and blood from the umbilical cord. Apart from the Medical City, other hospitals in the country providing stem cell therapy are the Makati Medical Center, St. Luke’s Medical Center in Taguig, and the Kidney and Transplant Institute. A six-month programme for stem cell therapy in the Medical City is about a third of what it would cost in the USA.The Medical City hospital has had 315 patients who have undergone stem cell therapy since 2005, of which 54 people are from abroad, including the USA, Norway, Singapore and Malaysia. Aside from promoting stem cell therapy, possible areas that could be part of the medical tourism plan are cancer treatment, orthopedics, and dentistry. The plan for promoting medical tourism in the country internationally will be through the form of road shows and direct selling of the concept.
Having struggled for some time to attract more Americans, Europeans and Asians to the country, the general view is that the key target market should be the 10 to 12 million Filipinos who live overseas. It will be 3 to 6 months before the plan is ready. One reason for the delay is that the three partners – the Department of Trade and Industry, Department of Health and the Department of Tourism, all have to agree how to proceed after so many failed campaigns in recent years. The plan is likely to promote cities such as Cebu which aim to offer high quality medical services and facilities to medical tourists. Two hospitals from Cebu, the Perpetual Succour Hospital (PSH) and Cebu Doctors University Hospital (CDUH), and the Cebu Health and Wellness Council want the province to become the preferred medical tourism destination in the country.
Those involved all agree that to succeed, the country needs to improve its infrastructure and develop policies to improve the country’s positioning as a medical tourism destination. The Philippines government has suggested a target of $3 billion revenue from medical tourism by 2015, but this seems little more than a figure plucked out of thin air, with no idea of how to achieve that.

Metro Pacific Investments Corp (MPIC) is in talks with a number of Quezon City and Manila-based hospitals for possible acquisition or investments, as the country’s biggest hospital group continues to expand its chain.
MPIC, through its hospital group, is eyeing the acquisition or management of several other hospitals in Metro Manila as well as in other parts of the country. The MPIC group now has seven hospitals in its network. The group owns Makati Medical Center, and manages Cardinal Santos Medical Center in San Juan and the Our Lady of Lourdes Hospital in Sta. Mesa. Manila. MPIC has also invested in Riverside Medical Center in Bacolod and Davao Doctors Hospital in Mindanao. It has recently bought Asian Hospital in Alabang, Muntinlupa
MPIC once saw medical tourism as a key growth area but now president Augie Palisoc says, “Medical tourism will be a good medium to long-term for our hospitals but this is not the priority. The main objective is to improve the quality of our hospitals so that they can provide good care for our own countrymen.”

Prices of dental implants in the UK are falling but are still relatively high compared to elsewhere. Patients seek treatment around the UK or in European countries such as Hungary, Poland and Spain.

The Dental Implant Cost Survey 2012 by Dental Implant Advisory shows that prices in the UK are falling, but due to a lack of consumer information many patients are still paying too much.
The survey looks at price trends for dental implants and also examines the state of dental tourism. The average price of a dental implant in the UK has fallen to £1,868.The most striking finding was the range of prices being charged.
Dental implants are now available in the UK for £995. The price reduction has been driven by two factors. More clinics are providing implants exclusively. These clinics are more likely to compete on the basis of price. Several foreign dentists, particularly from Hungary, have set up clinics in London and are willing to provide implants for a lower price.
On average dental implants are cheapest in Scotland and London. The average price in Scotland was brought down by a number of low cost clinics operating in its main cities. Price competition amongst a growing number of clinics has driven the price down in London.
Wales is the most expensive place for dental implants in the UK. Other expensive regions include the Midlands, Northern Ireland, the North East and Yorkshire.
The average cost of a dental implant in Hungary is now £749. The availability of cheap dental implants in the UK means people are less inclined to travel abroad to have dental implants. Dental tourism has moved on to a second stage. As the cost savings are less, patients are less willing to travel. A number of Hungarian dentists have established clinics in London to make up for the shortfall. This has contributed to even lower prices in the UK.
The study was conducted in August 2012. The sample consisted of 100 cosmetic dentists in the UK and Hungary.
The dental implant market in the UK has changed much in recent years. Firstly, a number of cosmetic dentists have begun to specialize in dental implants only. They are willing to accept a lower margin on implants and benefit from a network effect. The second change has been a structural change to the dental tourism market. A number of dental Hungarian dental clinics have opened branches in the UK and are carrying out treatments from their London clinics.
This is having a positive effect on the market for consumers and prices have been dropping as a result. Whilst some dentists are still expecting £3,500 per implant (including crown), there is an ever increasing number of clinics offering competitively priced implant services.
Dental Implant Advisory helps dental implant patients to find affordable dental implant clinics and also assists with dental tourism arrangements. It is building a network of partner implant clinics in the UK and Europe. Partners are selected based on their credentials and value for money. The network can arrange consultations partner clinics in London, Reading and Edinburgh, with Manchester being added soon. It also offers partner clinics in Spain, Budapest, and Hungary
The agency argues that travelling for dental work has both advantages and disadvantages and it is up to customers to decide which the best solution is for them.

A series of recent research reports on Asian destination countries shows that while medical tourism is growing, actual numbers are lower than often claimed.

Renub Research has individual reports on India, Malaysia, Philippines, Singapore, South Korea, Taiwan, and Thailand.
Each report covers-
•Number of medical tourists 2008 to 2011
•Estimated numbers 2012 to 2015
•Medical tourism market
•Major drivers and roadblocks
India was one of the first countries to recognize the potential of medical tourism but at best only has a 20% market share of the Asian market. Between 2009 and 2011 the number of medical tourists in India has grown by 30% in total; not the annual growth of 30% assumed by some optimistic Indian organizations. It is estimated that by the year 2015, India will receive nearly half a million medical tourists annually.
Malaysia has grown its reputation as a preferred destination for medical tourism and has seen impressive growth. Political and economic stability and the government’s efforts to promote Malaysian healthcare abroad has paid off. The number of medical tourists has grown by an average of 23.6% annually for the period 2003 – 2011. The Malaysia medical tourism market has grown more than 8 fold in 2011 compared to its market in 2003.
The Philippines achieved 100,000 medical tourists in 2010. The medical tourism market is expected to grow at 9% a year from 2012 to 2015. The government of Philippines has many initiatives to boost medical tourism. The report says that by 2015 the number could reach 2015, but if you use the 9% a year growth this only achieves 150,000 by 2015.
Singapore is one of the leading medical tourism destinations in the world. Singapore medical facilities are considered to be the best in Asia but treatment costs are higher than Asian competitors. In 2011 Singapore had nearly 30% of the medical tourism market in Asia. Singapore medical tourist arrivals are expected to be more than 1 million by 2015.
South Korea is a fast-growing medical tourism destination. South Korea had more than 6% of the Asia medical tourism market in 2011. It is predicted that South Korea will compete strongly with other Asian rivals. It is forecast that by 2015, South Korea will attract more than 300,000 medical tourists.
Taiwan started to develop its medical tourism sector in earnest only four years ago. But its medical tourism has become one of the biggest attractions for mid to high-income Chinese tourists. Other countries such as India, Thailand and Singapore are all targeting the Chinese. Taiwan is emerging as the best choice for Chinese tourists due to no language barrier, reasonable cost and a sense of warmth and familiarity between Chinese and Taiwanese people. In 2011, the number of medical tourist arrivals in Taiwan was close to 20,000. The country’s medical tourism market is expected to increase at 7% a year from 2012 to 2015.
Thailand is the leader in medical tourist arrivals with more than 40% of the Asia medical tourist arrivals in 2011. It is expected to more than double numbers by 2015. Thailand is a favoured medical tourism destination due to state-of-the-art medical facilities, personalized hospitality and reasonable medical costs.

A new report warns that inequality between and within European countries on health care is resulting in huge social and economic costs to the region, and progress towards reducing health inequalities should be one of the main criteria by which the effectiveness of health systems and governments are assessed.
The Review was commissioned by The World Health Organisation and published in leading medical journal, The Lancet. It cautions that despite recent progress towards reducing health inequalities in many European countries, significant health disparities remain – both between countries and within them – and that urgent action must be taken if these inequalities are not to worsen.
While several countries in Europe enjoy some of the best and most equitable health provision in the world, other countries in the region still have a long way to go before the health of their citizens reaches the level of those in nations with better developed health systems. All European countries experience some degree of health inequality within their population, and the Review provides a practical set of policy recommendations that, if implemented, would allow all European countries to improve their progress towards health equality, regardless of their current status or income.
According to lead author Professor Sir Michael Marmot, of the Institute of Health Equity in London, “Taking action to reduce inequities in health would improve the prospects for health and bring wider social and political benefits that enable people to achieve their capabilities. Health inequality needs to be one of the main criteria by which we assess the effectiveness of countries’ health systems, and the effectiveness of government as a whole.”
Central to the report’s policy recommendations is that health is largely determined by social factors such as employment, education and welfare systems. Health inequalities cannot be reduced by focusing exclusively on the provision of health care.
Professor Sir Michael Marmot adds, “Action is needed on health inequalities across the whole of government, and while health ministers clearly have an important role in ensuring access to high-quality health services, they must also take a leadership role in advancing the case that health is an outcome of policies pursued in other areas.”
The Review was commissioned by the World Health Organisation (WHO) European office to provide an evidence base for its Health 2020 strategy, which aims to provide a political, administrative and scientific framework to allow all 53 countries in the WHO European Region to take action on the social factors that determine health.
Zsuzsanna Jakab of WHO states, “Persistent and widespread inequalities in health occur across the whole WHO European region. Health as a key and unique resource for human and societal development has undoubtedly improved overall, yet substantial health inequalities remain, which are worsening. These inequities are unnecessary and unjust, and tackling them should be a high priority at all levels of governance in the WHO European Region. What is needed now is leadership, new types of governance that support whole of government and whole of society approaches, and capacity for implementing solutions that can make a difference.”
Professor David J Hunter of Durham University suggests, “It may seem the wrong moment to launch an ambitious European health policy framework and strategy and invite governments to adopt it. But WHO’s argument is although the economic and fiscal crises facing Europe present major challenges, they also present opportunities to renew efforts to improve the health of European people. The argument that lies at the heart of Health 2020 is that good health is essential for economic and social development.”
WHO issues its European health report every three years. The 2012 report explains why the Health 2020 strategy needs to be taken seriously. Although people across Europe are generally living longer, often in better health, these improvements are not being shared equally.
With drastic cuts being made to health services in Greece, Spain, Portugal, and Ireland, cutbacks in the UK, and expected cuts in other countries including Italy, it may seem a spectacularly badly timed initiative.
For medical tourism, it emphasizes that there is and will be potential in Europe for many years to come; the hard part will be working out where and for what services. If nothing else, it emphasizes that you cannot market to Europe, you have to tailor the message and product to each country.

Leading British hospital group BMI Healthcare is developing international services to attract more overseas patients. Although it has many hospitals around the UK, most international visitors go to the 12 hospitals and clinics in London, the centre of the UK medical travel trade. Over the last year and a half BMI Healthcare has focused attention on developing international business, with a goal of treating many more international patients. In the last 2 years it has seen an 82% growth in the number of international patient treated. Most of these are traveling for procedures unavailable, too expensive or difficult to access in their home country.
The international market is split into three groups; government sponsored patients, insured patients living or traveling in the UK or self-paying patients from overseas.
The majority of the patients at BMI are government sponsored patients from the Gulf regions of the Middle East. This has meant an investment in infrastructure, with multi faith prayer rooms, a car service, appropriate food and media as well as on site Arabic speaking liaison. It has recently produced a brochure in Arabic.
BMI Healthcare treats international patients from embassies and international insurers as well as patients choosing to pay for their own treatment.
International patients from around the world are supported by patient coordinators in an international patient centre. This helps international patients with accommodation, local travel arrangements, interpreting services, arranging medical appointments and hospital admission in all UK hospitals and treatment centres.
The BMI Healthcare Embassy Appointment Line is an exclusive centralised appointment service for London based health offices that provides a direct outpatient booking service with any of its 7,000 consultants. It can also arrange admission to any hospital and ensure that consultant appointments, transport and translation services are coordinated for patients from London based embassies.
The company has launched a range of hospital package prices for a range of routine procedures. These packages include all the normal investigations and procedures for a particular operation for a fixed length of stay. Prosthesis is usually excluded from the package as this can vary in price depending on the individual needs of the patient and the consultant recommendation.
BMI Healthcare treats a large number of self-paying patients from overseas. Each year the group sees over 1 million outpatients and perform over a quarter of a million operations; although it is reluctant to reveal how many are from overseas.
The group is Britain’s leading provider of independent healthcare with a nationwide network of hospitals and clinics performing more complex surgery than any other private healthcare provider in the country. It also offers cosmetic surgery, fertility treatment, weight loss treatment and health assessments.

A new research project reports that while South Africa is often portrayed as a cosmetic surgery destination for Europeans, the reality is that by numbers and value, 85% to 90% of medical tourism to South Africa is from the same continent, and is not related to cosmetic surgery.
The research does not use its own statistics but relies exclusively on official figures from a survey of samples of outgoing travellers at airports. These figures on purpose of visit are then statistically calculated using total tourism figures. This means that they are not ’real’ figures on medical tourists but a projection based on a relatively small sample. To be fair to the source and the research, the conclusions on who goes to South Africa, why and from where are robust, but their numbers on those from European countries are highly dubious when compared to other figures.
’ Patients Without Borders – medical tourism and medical migration in Southern Africa’ is policy paper 57 from the Southern African Migration Programme; by Jonathan Crush, Abel Chikanda and Belinda Maswikwa.
It takes the premise that South Africa is most often marketed by medical tourism agencies as a cosmetic surgery destination for Europeans, and shows that much travel for surgery takes place without agency intervention from local African countries; so the European cosmetic surgery business is just one small segment.
The reality of medical tourism in South Africa by numbers and income is that it is dominated by medical travel from African countries – mostly middle-income Africans seeking specialist diagnosis and treatment. Total numbers grew from 327,000 in 2006 to 500,000 in 2009, but fell to 370,000 in 2010 and is now estimated at between 300,000 and 350,000 a year.
According to the research, the main sources are neighbouring Lesotho (140,000), Swaziland (47,000), Mozambique (38,000), Botswana (55,000) and Zimbabwe (17,000); where public and private health provision is in crisis; so people are traveling for availability of and quality of treatment, not for price reasons. African countries account for at least 90% of the total spend of rand 1.5 billion. While much of this is privately arranged, the South African government does have formal deals with 18 African countries where many pay for treatment for their citizens. South Africa even helps out with special funding mechanisms, but these are plagued by corruption on both sides of the border.
The average length of stay for Europeans is 8 nights as some do stay on as tourists. But the tourism element does not figure in medical travel from African countries; the average stay is 4 days, but only a day for Botswana and Lesotho. Most go to private hospitals and clinics, or for private treatment at public hospitals. Cosmetic surgery is targeted at American, Dutch, British and German medical tourists.
The European and American tourism departure survey figures from Statistics South Africa and South Africa Tourism are highly suspect. According to the data, the annual average for medical tourists from 2003 to 2008 was 20,000 from the UK, 6,500 from the USA, 3,500 from the Netherlands, and 8,000 from Germany, with much smaller numbers from Australia, Canada, France, Italy and Sweden. Comparing the 20,000 figure for the UK with official outbound figures from the same period, shows that either these figures are hugely exaggerated or include holidaymakers, business travellers, expats, and people visiting family. For example, in the period 2003 to 2008, the total number of outbound UK medical travellers was between 40,000 and 70,000 (according to the UK’s International Passenger Survey); many of these went for dental treatment in Europe. That South Africa accounts for between one in two and one in three British medical tourists is unsustainable in the face of other evidence.
One of the problems on the European business is that there is a strong likelihood that after 2009, this cosmetic surgery tourism has fallen drastically due to the economy and price competition from nearer countries. This new research does a great service to the South African medical community as it shows clearly that the future of inbound medical tourism is about offering diagnostic and medical services to Africans. The report admits that few local hospitals take medical tourism seriously as it is a sideline when hospitals will be busier from the introduction of universal healthcare in South Africa.
It suggests that the revenue potential of medical tourism means that it needs government support and purpose built health and medical facilities targeting the medical tourist. It also suggests that in the future there is huge potential to attract middle class medical tourists from further away in East and North Africa
The project has plans for other research looking at what drives people to become medical travellers, and why they choose South Africa.
The country has been involved in medical tourism since 1994. But has moved from mostly cosmetic surgery tourism to mostly medical travel for essential surgery. While rivals may shout louder, it is easy to forget that it is regularly the 5th or 6th biggest global medical tourism destination, despite very little official support.
This Southern African Migration Project paper can be downloaded free from-
http://www.queensu.ca/samp/forms/form.html

AWC will open a hospital on Barbados for international medical tourists and locals. Winners Development, in partnership with American World Clinics (AWC) will jointly develop an international medical centre on Barbados. The $100 million project will be on a 21.5 acre site in St. Peters, Barbados and represents AWC’s first site.
American World Clinics is based in Glendale, Arizona, USA, and has created a unique business model designed around the exportation of US acute care medical expertise to desirable global locations.
The surgical specialty hospital will serve both international medical travellers and local patients in the Caribbean region. It will have 60 inpatient beds, ICU capabilities, 12 operating rooms, an interventional lab, and state of the art facilities for diagnostics and therapeutics. Multidisciplinary clinic space, including dental and concierge medicine, will be located next to the hospital. Later on a health and wellness spa run by a major spa group will be added.
Winners Development has created and collaborated on hospital and healthcare projects throughout the US. Winners will manage project funding, construction and campus development with AWC providing operational expertise, staffing, and marketing for AWC-Barbados.
Much of the project is still subject to local planning regulation and other factors still to be discussed with the Barbados government, such as whether local doctors will be used or American ones flown in. AWC advertising to US doctors suggest that while some will be full time in Barbados, many will be able to fly in for short periods and keep running their US practice.
Most doctors and dentists will come from the USA, but others will be considered. All doctors and dentists must obtain Barbados credentialing: The Barbadian government has assured timely review and licensing. All doctors and dentists will become a member of AWC-Barbados. Membership levels are: founding member, member, fee-for-service contract, or employee. An annual 30-day minimum practice period, either full- or part-time, is required at all membership levels.
Winners Development is a privately held real estate development company with experience in the development and construction of large-scale healthcare projects.
The original planned opening date was 2013, after AWC obtained in principle agreement from Barbados officials, but it has now been pushed back to 2014 or 2015. AWC-Barbados will be the first of a series of overseas hospitals primarily to attract and serve international medical travellers.

A new academic study on Chinese medical tourists who go to Taiwan suggests that they are looking for value for money. This in turn is a mix of medical quality, service quality, price and ’enjoyment” of the whole process.
Hsiu-Yuan Wang of Chung Hua University has produced a research paper ’Value as a medical tourism driver’ for Emerald Group Publishing.

Purpose
The study contends that customers’ perceived value can drive medical tourism. To demonstrate this, this article proposes and tests a research model capturing elements of perceived benefits and sacrifice that, by affecting the perceived value of medical tourism products, influence the buying intention of potential customers.

Design/methodology/approach
Potential medical tourists from China are researched due to their cultural similarity to Taiwan, and the absence of a language barrier. Data from 301 usable questionnaires were tested against the research model using the structural equation modeling approach.

Findings
The results indicated that perceived value was a key predictor of customer intentions. As for benefits, perceived medical quality, service quality and enjoyment were critical components that significantly influenced the perception of value. Regarding sacrifice, the effects of perceived risk on perceived value were significant.

Research limitations/implications
The study targeted potential medical tourists. Therefore, a validation using another large sample of actual medical tourists is required to generalize the findings.

Practical implications
The findings can assist governments in developing policies that promote medical destination and provide insights into research on how destination countries can make medical tourism a win/win option for themselves and international patients.

Originality/value
The author claims that the proposed model is original and “Unlike most prior papers which take a conceptual approach to medical tourism, this study contributes to an understanding of the factors that influence the travel intentions of medical tourists through its empirical investigation, and especially in its targeting of customers’ value perception.”
This is valuable research that shows how price-driven medical tourism marketing is now out of date.

The study can be bought from

http://www.emeraldinsight.com/journals.htm?articleid=17053573

The demand for Finnish health services from Russian visitors has grown rapidly in recent years and the market is expected to triple in numbers by the end of this decade.
Marco Roth of FinnMedi Oy explains, “The demand for health services is growing together with an increasing number of tourists. In 2011, 12,000 visitors spent money on medical services or medicines. Russian health tourists choose Finnish health services because of their high quality, safety and competitive price. In addition to the geographic proximity, fast access to care is also valued. Most places also have health services available in Russian.”
FinnMedi is developing a health and wellness cluster as it already has links to university hospitals, life science companies, as well as public and venture capital funding; it also offers advice to start-up health companies.
Finnish hospitals and health care service providers offering medical care have set up Health Care Finland to attract more customers from Russia. Hospitals offer specialist cancer care, orthopaedic treatment, cardiology, joint replacement and fertility treatment.

Norlandia Care has a patient hotel for self-sufficient patients, relatives and ordinary hotel guests to stay. Norlandia Care is the largest operator of patient hotels in the Nordic Region. It offers healthy and interesting food based on a philosophy that promotes proper nutrition. The one in the city of Tampere has 130 rooms and is near several hospitals.
In 2011, Russian visitors to Finland spent EUR 670 million on products and EUR 220 million on services, of which EUR 15 million went on health care. Hospital specialists and directors in the South Karelia region of eastern Finland have been receiving an increasing number of email enquiries. The services with the biggest demand are cancer treatment, surgery and dental care.
Memira, the market leader in the field of refractive eye surgery in northern Europe, is opening its first clinic in Finland. The clinic in the city of Vaasa on Finland’s western coast was selected due to its Finnish and Swedish speaking population and good economic situation. Memira has 50 eye clinics in Norway, Sweden, Denmark and Germany. Memira is investing about EUR 1.2 million in the new clinic in Vaasa which is expected to open in October or November this year. The company is also looking for suitable premises in some other cities in Finland. Memira, carries out 40,000 surgical eye treatments annually in the Nordic countries, covering everything from eye laser to intraocular surgery.
Finland’s long experience of trade in Northern Europe, combined with its historical and cultural ties to neighbouring countries, makes it a business gateway to Russia. Over 90% of Finns under thirty speak English, while Swedish is Finland’s second official language in addition to Finnish. Many Finns also speak Russian.
Finnish travel companies are establishing a presence in the Russian social media as a way of attracting more Russian visitors. Finnish spas, ski resorts and cities have joined Vkontakt (VK), which is similar to Facebook and the largest European social network with more than a 100 million active users. Russians are among the most active user of social media in Europe. Social media is especially important for Russians, according to Miikka Raulo of Jyväskylä Innovation. He believes that social media is better suited to serving Russian customers than traditional advertising.
According to Invest in Finland, Finland’s public healthcare system is a unique and comprehensive ecosystem. Primary healthcare and secondary care are networked into a comprehensive system that includes central and university hospitals as well as healthcare centres.

International Medical Travel Journal has been appointed as the Official Journal of the inaugural International Medical Travel Exhibition and Conference, IMTEC, taking place from 22 – 23 March 2013 in Monaco.
IMTEC 2013 will bring together, under one roof, country pavilions, service providers, purchasers and experts on medical travel across the globe making it the only genuine international medical travel event to date.
In the run up to IMTEC 2013, IMTJTM will be bringing you regular updates on themes, speakers and plans for the event.
For the first time in the medical travel sector, one of the world’s major conference and exhibition companies is taking the sector seriously and fulfilling the need for an independent, and professionally run event to bring the industry together.
The event is organised by Informa Life Sciences, one of the biggest conference and exhibition organisers worldwide. The Life Sciences division consists of 20 exhibitions yearly covering the European, African, Middle Eastern and Asian markets. Over the course of the year, these events attract over 5,000 exhibitors, 120,000 visitors and 13,000 delegates. Their experience with the organisation of medical travel events across the Middle East and Asia (such as Arab Health), coupled with Informa Group’s extensive database with a global reach of more than 26 million, will ensure a successful and fruitful medical travel event for 2013.
Why Monaco?Aside from being one of the most sought after tourist destinations, Monaco provides a perfect neutral platform for this global medical travel event, as it has no medical travel aspirations for itself, meaning an even playing field for all participants.
By bringing together the entire global healthcare travel market under one roof, IMTEC will challenge the traditional method of travelling from domestic show to domestic show, saving you time, effort and money.

Why attend IMTEC?IMTEC will host a 1,000sqm exhibition with support already from many different companies spanning over 3 different continents.
Alongside the exhibition there will be a large multi-track conference catering for 800 plus delegates and focusing on topics such as healthcare marketing, customer experience, the role of quality and accreditation in medical travel, case management, insurance, the EU Directive, cross-border healthcare regulation, telemedicine amongst others IMTEC will also introduce hosted buyers to the conference. These buyers are responsible for sending large numbers of patients abroad for healthcare treatment and will be looking to source new healthcare providers at the event.
How do I book?IMTEC is a perfect platform to the medical travel world to meet, network and do business. For more information on this pioneering event, please visit www.medicaltravelexhibition.com. You can also download the brochure, download the booking form or book online.

Chinese visitors to Taiwan for medical tourism are to get e-visas, while Thailand has eased the visa process for 6 Middle East countries.
Taiwan has launched an e-visa service on a trial basis for people from China visiting the country for physical checkups, cosmetic surgery or anti-aging treatments. The National Immigration Agency (NIA) will screen applications and issue visas to Chinese nationals within 48 hours. Chinese nationals previously needed five working days to get a visa.
Thirty-nine hospitals and clinics that target medical tourists can apply online for visas for their Chinese patients.
Taiwan is promoting medical tourism at two major airports in China and one in Vietnam. The Taiwan External Trade Development Council (TAITRA) has put up billboards at Shanghai Pudong Airport and Beijing Capital International Airport in China, and at Tan Son Nhat International Airport in Vietnam. The new advertising is aimed at attracting high-end consumers in major cities in China and Vietnam.
In January, Taiwan began issuing medical travel visas for independent Chinese tourists, allowing them to stay up to 18 days for health checks or cosmetic treatment at 39 certified hospitals. In the first eight months Taiwan issued 10,000 such visas.
China is now the largest Asian market for cosmetic surgery, with 3 million customers a year, and rising. 100,000 Chinese visitors travel to South Korea for cosmetic surgery, and Taiwan seeks to take part of this business; the big advantage it has over South Korea is the common language. Both countries argue that each is cheaper than the other.
The Taiwanese authorities estimate a total of 50,000 medical tourists in the first eight months of 2012, of which 20,000 are from China.
Travel agencies in Taiwan are selling trips to wealthy Chinese customers, which combine medical treatment such as checkups and cosmetic skin care with gourmet slimming meals, cultural experiences, and even agricultural visits.
Thailand is offering 90-day visas on arrival to citizens of six Middle Eastern countries for private health treatment in a bid to boost medical tourism. The previous limit was 30 days.
The visas are available to nationals of Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and the United Arab Emirates, as long as they can show medical records and proof of an appointment at a hospital in Thailand. They may be accompanied by up to four relatives.

The high cost of many medical procedures in Alaska has led to insurance company Premera Blue Cross to pay air fare, hotel and other expenses for customers to undergo the same treatment in Washington state at far less cost.
Premera covers 1.5 million people—from individuals and families to large employer groups. It only offers cover in Washington and Alaska, insuring half the market in Alaska, so is uniquely placed to compare the two locations.
The insurer has researched which procedures are safe for travel and can be done less expensively in Seattle hospitals.
A new policy that includes domestic medical travel, targets customers looking for options that maintain quality and get better control of costs. Going Outside is voluntary so patients are not forced to travel outside Alaska. The travel benefit is just for a set list of procedures, including knee and hip replacements, breast lumpectomies, laparoscopic gall bladder removal and cardiac angioplasty.
To start with, Premera is only offering the benefits to self-funded employers who between them insure 32,000 people. Employees get a reduction in co-payments and the employer saves money too.
A report for the Alaska State Health Commission shows that the average allowable doctor’s fee can be up to three or four times higher in Alaska than in five comparable states. The study by actuaries Milliman surveyed costs in Alaska, Idaho, North Dakota, Oregon, Washington and Wyoming. Some simple procedures can cost three or four times more in Alaska than elsewhere. But for more complex and long term treatment, savings can be low or even negative. Milliman said average hospital costs in Alaska are 138 % of the average of the five comparison states.
Some self-funded plans in Alaska already cover it of state surgery, simply because Alaskan costs are far higher than nearby states.
Domestic medical tourism agency BridgeHealth has helped Alaskan teachers save money by seeking simple surgery in other states. The National Education Association Alaska health plan covers 17,000 teachers and dependents. Anticipated savings have kept insurance premiums static. The state of Alaska is now considering a similar deal to cover the costs for a companion to travel with someone undergoing surgery, and to help people find health care in other states.
Domestic medical travel is very much on the minds of many employers. Opponents of Obamacare argued that employers would stop offering insurance, but the latest surveys shows this is not and will not be happening. A Towers-Watson survey of 512 companies each employing more than 1000 workers, shows that these companies spend at least $5 million in health benefits annually. When asked how likely it was that they would drop coverage in 2014 and send employers to the new health care exchanges, not a single one planned to drop cover.
But the survey shows that health insurance is expensive, costing employers $15,073 on average to cover one employee and their family. So seeking to reduce costs by offering specific treatments in other states is attractive. There now seems no appetite at all for companies of any size to look at sending people outside the US for treatment. If the Republicans win the election and if they seek to, and are able to, reverse the healthcare reforms, there still seems no appetite for companies to look at overseas treatment. Most indicators show that small, medium and large employers are rather fed up with being buffeted by politicians changing healthcare for ideological reasons, so are seeking to keep or arrange insured or self-funded healthcare that is not subject to frequent change.

There are signs that US inbound medical tourism is slowly changing from an ad hoc business, to one where selected hospitals are actively targeting overseas medical tourists with planned marketing.
With its location plus business and cultural links to other countries, Miami is a leading city for inbound medical tourists. Baptist Health South Florida gets 12,000 patients from more than 100 countries annually using their international patient department. 70% come from the English- and Spanish-speaking countries of the Caribbean, Central America and the northern part of South America. An increasing number come from the Middle East. The hospital works hard to attract overseas patients by having a very strong educational presence in the different markets, including in-country symposiums and providing access to medical education at US hospitals. The logic is that just targeting individual customers is a very short-term measure, while long-term success is achieved by building strong links with overseas doctors and hospitals that may lack the ability to treat patients for complex problems at home. One speciality is cutting-edge care on cancer and cardiovascular disease.
Oncology is another specialty that it plans to expand with a new cancer centre. Baptist provides concierge services for international patients and family members traveling with them. Many patients have second homes or family members in South Florida. It has agreed preferred rates at a number of area hotels, and even owns some one- and two-bedroom furnished apartments for families and patients needing an extended stay. The hospital can arrange a pick up at the airport, offers a new VIP/international waiting area, specialist international medical team and patient advocates who speak a number of languages. In emergencies, patients are flown in by air transport and a heliport is planned at the University of Miami hospital in the near future.

UHealth, the University of Miami Health System, has relationships with overseas embassies in the hospital’s key markets of the Americas. Baptist Health is famous for sports medicine so attracts high-profile athletes from all over the world. Three years ago, a number of health-care organizations, including Baptist Health and UHealth, banded together to brand Miami as a medical tourism destination. This marketing effort, Miami Health Care, is overseen by the Greater Miami Convention and Visitors Bureau
The Southern Florida patient services department of the Leukemia and Lymphoma Society supports international patients from Latin America and the Caribbean by providing patients with information on their disease and helping them travel to the US for care. 18 months ago, the society opened its first office in Puerto Rico as anyone in the Caribbean needing allogenic bone marrow transplants have to go to US hospitals.

Riviera Health Resort in Coral Gables is a new 223 -bed post-acute and rehabilitation boutique hotel that markets its services to international patients as well as locals. Offering an array of complex care services, the five-storey Mediterranean-style Riviera Health Resort caters to the needs of guests that require short and long term care as they transition from the hospital to their home, with a particular emphasis on post-stroke and hip and knee replacement recovery.
Mount Sinai Medical Center in Miami Beach is popular as the international health section promotes recovery on the beach.

As Health City Cayman Islands and New River Medical Centre in Nevis break ground, both hope to open in 2013 to medical tourists.
Dr. Devi Shetty, his partners and local politicians broke ground at the East End site of Health City Cayman Islands, the new medical tourism centre due to open in November 2013. Dr. Shetty commented that his lower-cost, high quality hospital in Grand Cayman to deliver would not be the cheapest hospital, but ’the safest hospital in the region”.
US partner Ascension Health Alliance will provide facilities planning, supply chain management and biomedical engineering services, while Dr. Shetty’s group will run the the $2 billion hospital project hospital. One innovation will be remote monitoring of intensive care patients by internists in India, who due to the time zone difference between India and Cayman, are working while it is nighttime in Cayman, when local internists would not normally be working.
The first phase is the construction of a 140-bed hospital, which is scheduled to be operational in November next year, limited to cardiac surgery, cardiology and orthopaedics. Eventually, if all planned developments are completed, it will have 2000 beds by 2163. This would need huge improvement of facilities at Owen Roberts International Airport in Grand Cayman. The aim of the hospital is to attract medical tourists from the Caribbean, Latin America and the USA for cancer treatment, open heart and bypass surgery, organ transplants (if the local laws can be amended), angioplasty and orthopaedics. It will also mean that fewer islanders have to travel to the US for treatment.
In Nevis Island, ground has been broken at New River, for construction of New River Medical Centre. On completion in 2013 it will be the region’s first medical and rehabilitation centre. The $15million wellness centre is a partnership with the US based Princeton Health Care of Atlanta, Georgia. This too seeks to stop St. Kitts and Nevis islanders going overseas for treatment and attract patients from other islands and the USA. The 22-bed centre will focus on simple bariatric surgery, orthopaedic, cosmetic and dental surgery.

The UK government is launching a new initiative to sell NHS services overseas. Hospitals are to be encouraged by the government to sell their services abroad, setting up clinics to pull in much-needed cash for the health service from overseas.
Healthcare UK is being set up in the next few weeks by the Department of Health and UK Trade and Investment to act as a consultant for hospitals and potential overseas clients. The body will also represent private healthcare firms including health insurer Bupa.
The logic is that the NHS could learn from the success of major American brands, such as Mayo Clinics and Johns Hopkins that have established themselves abroad in several countries in partnership with local providers.
Health minister Anne Milton says,” This is good news for NHS patients, who will get better services at their local hospital as a result of the work the NHS is doing abroad and the extra investment that will generate. The NHS has a world class reputation and this will make the most of that to deliver real benefits for both patients and taxpayers."
But critics of the healthcare reforms that are effectively cutting what the government spends on the NHS are uncomfortable about NHS hospitals drumming up private custom overseas. Katherine Murphy of the Patients Association says, "The guiding principle of the NHS must be to ensure that outcomes and care for patients comes before profits. Waiting times are rising and trusts are being asked to make £20 billion of efficiency savings, this is a distraction."
Andrew Hine of KPMG comments,” The precedent for exporting the expertise of the NHS has existed for some time, as many of the health services offered have long been used to treat patients privately within the UK. Not only does it afford the NHS a chance to develop a sustainable revenue stream; it will allow one of the world’s largest employers to attract and retain top talent by offering global career opportunities. The NHS has proven time and again that it can deliver. It should be given the chance to do so once again through this initiative because, with the income that can potentially be generated, Britain will cement its place on the world healthcare map and UK patients will benefit as funds are boosted to enhance healthcare on the domestic front.”
A handful of private and NHS organisations already operate internationally. Moorfields Eye Hospital, Imperial College London and Great Ormond Street hospital are all in the Middle East. In reality, the total income that UK hospitals generate from business overseas is tiny. The UK government says that all profits made by British hospitals abroad would have to go back into the UK, while investment could only come from the revenue they make from private patients. But the UK government cannot dictate how overseas governments deal with tax or revenue. While medical tourists bring income to the UK, overseas ventures are more complex and if they do start to earn money overseas, overseas governments may heavily tax any profit or simply refuse any money to be sent back to the UK.
In 2010, the UK government set up NHS Global to help the health service make the most of the global market for healthcare; it was almost a clone of the new UK Healthcare, cost a significant sum to set up, and produced a total of zero income on zero projects before closing. Only a handful of the UK’s hundreds of hospitals are in a position to start offering services abroad.

In a move to cut down on alleged ’free medical tourism’ by
holidaymakers, non-Spanish residents and part-time overseas residents
who go to Spain for the winter, Spain has quickly introduced new rules
to combat this and reduce its healthcare costs.
All EU citizens who are moving to Spain for longer than three months now face added paperwork under new residency requirements. For anyone not employed in Spain by a company that contributes to the Spanish national healthcare system, they may have to prove that the have health insurance. In an effort by cash-strapped Spain to save €1billion a year on health costs, EU citizens applying for residency in Spain may be required to produce evidence of sufficient financial means to support themselves and dependants, as well as proving that they have health insurance.
Although a national law, it is administered by the regions, often down to town level. The new rules as to who is and who is not entitled to free healthcare are open to local interpretation, and as it is the regions that pay the health bills, there is suspicion from local expatriates that it will be a case of ’guilty until proven innocent’ for any EU nationals seeking to access free healthcare, or even seeking residency.
Anette Skou of Mijas Foreigners’ Department, specifies: "If you are not working, you must present a private insurance document or an S1 from the public health service from your home country, plus proof of income (which includes a pension) of no less than 5008 euros annually. A further 8,763 euros is also required over and above the 5,008 euros per dependent family member. Failure to produce the correct documentation could result in residency applications being rejected.”
The Government is rolling out this policy, as it believes it could save up to one billion euros annually on providing healthcare to foreigners who are not entitled to it.
Under European laws any EU citizen is entitled to receive medical attention in any other member state. But Spain’s government is justifying the new residency requirement by drawing on a 2004 EU directive on "free movement" which gives member states the authority to define, "without prejudice to national border controls" – meaning EU countries can restrict entry to other citizens of other member states.
Other cash strapped countries that have EU expatriates and many temporary EU residents, such as Portugal, Greece and Italy, will be watching closely to see if they too can tighten up on their provision of free health care.
Basically, Spain is ignoring a whole host of EU rules, agreements and directives in an attempt to save money. If, as seems likely, they get away with it, others will surely follow suit.
Spain has always been the harshest critic of EU cross-border healthcare, and in the unlikely event that they will pass the required laws in 2013, national and local clampdowns on treating non-Spanish patients will render it meaningless.
The possible good news for medical tourism is that once the myth or reality of ’free health tourism’ is put to rest, then paid for medical tourism can operate in a clearer environment.

There is growing evidence that India is at last realizing that the growth of its medical tourism relies not on the out of reach potential of US and Western European markets, but on more local custom.
Kolkata has the potential to be developed as a major medical tourism destination in South Asia. Debashis Sen of the Urban Development Department, West Bengal, explains,” There is great possibility of turning Kolkata into a health tourism hub for South East Asian countries, Bangladesh and Nepal.”
The state government has allotted land to new ventures including Chittaranjan National Cancer Institute, Shankara Nethralaya, a global organ transplant hospital, and several other speciality hospitals in Rajarhat New Town. Tata Memorial Centre for cancer research in Rajarhat is a new major hospital that is also developing a trauma care centre and school of paramedical science.
The key to the development of Kolkota as a medical tourism destination is low priced surgery and specialist care with minimal customer services that is suited to poorer nations with few facilities such as Bangladesh, Nepal and others in Asia.

Thomas Cook (India) is tying up with major Indian hospitals to launch medical tourism packages by the end of 2012. The travel firms argues that outside of Asia, those who do travel to India for major medical treatment, number no more than 10,000; and almost all these are non-resident Indians.
Madhav Pai of Thomas Cook explains, “We are trying to tap this potential in Gujarat, Delhi, Chennai, Mumbai and Bangalore.” The company has already tied up with Seven Hills Hospital in Mumbai and is in talks with others including Apollo and Hinduja Hospitals.”
There is a problem for India though. While fast growth countries Brazil, China and Russia have, are and will spend huge sums on developing the infrastructure of broadband, electricity, rail, road and airports, India, the fourth member of the BRIC countries, has lagged far behind. Mostly, the problems have not really affected hospitals or medical tourism, but a recent serious problem may make people think twice about going to India.
In late July and early August, much of India lost electricity in back-to-back grid failures, with massive traffic and railway jams. Larger than both the August 2003 blackout on the U.S. East Coast and the March 1999 southern Brazil blackout, the grid failure plunged 640 million people back to life before electricity. On the first day 360 million people—equal to the population of the USA and Canada combined—lost power across seven states in northern India when excessive demand and a shortfall in hydropower overwhelmed the electricity grid. 12 hours later, power resumed in the capital, only to fail again the next day.
The second blackout was even worse, with the chaos spreading to Kolkata and other parts of eastern India. The failures were enough to disrupt even well prepared hospitals. New Delhi’s Ram Manohar Lohia Hospital has a backup generator to ensure that lights stay on when the network fails. The disaster plan was not able to cope with a second big blackout coming a day after the first that knocked out power to much of northern India. With less than three hours of electricity for the intensive care unit, the hospital had to make plans to shift critical patients to other hospitals.”
Officials blamed forces beyond their control, such as the weather. But electricity production depends heavily on coal, where supplies are struggling to keep up with demand. Another serious problem is that between 30% and 50% of the electricity produced by India’s power plants gets siphoned off by people who don’t pay for it, while the entire industry has problems with corruption.
Because India works on a mix of national and local government, any infrastructure project becomes a tug of war between the national government and the state as to who will pay for anything. The slow speed of Indian politics and bureaucracy, mean that while the country has benefited from economic growth, the vital infrastructure of rail, road, air, and power has not kept up. Nor have building and safety regulations. Corruption is still a problem both on new projects and on enforcing laws at local level.

Concerned at the currency loss from the billions of naira that Nigeria spends on overseas medical treatment for thousands of Nigerians, the Federal government has attacked the principle of outbound medical tourism. Indonesia has a similar problem. Both countries plan to increase the health budget to improve the quality of services at home.
Nigeria’s Minister of Health, Professor Onyebuchi Chukwu, has launched a raft of health investment initiatives, and eventual universal health coverage, but even if they all work and give Nigerians the decent health system they badly need, it could take a decade or more to reach fruition.
Meanwhile, Nigeria’s balance of trade is suffering due to the amount of currency going overseas to pay for medical tourism. According to the government, Nigerians spend N180 billion annually on foreign medical trips. In recent years there has been a dramatic increase in medical tourism by Nigerians, due simply to the lack of enough appropriate and modern facilities all over Nigeria.
Dr Ufuoma Okotete of Diamond Helix, a Lagos based medical tourism agency that helps Nigerians seeking overseas treatment to connect with hospitals and doctors abroad, mostly to India as it is the local agency of Apollo Hospitals, argues that with the current state of the nation’s health sector, it is practically impossible to stop Nigerians from travelling abroad for medical treatment for brain surgery, open heart surgery, complex eye problems, and micro dissection surgery. The agency also sends people to the UK Germany, South Africa, the USA and Dubai. Dr Ufuoma Okotete explains, “What we lack in Nigeria is the infrastructure. Even if you bring these doctors to Nigeria to carry out surgery here, they will need technical assistance, a team of doctors, nurses and other healthcare professionals to do the job; well equipped intensive care units and lots more that is lacking in Nigeria.”
President Susilo Bambang Yudhoyono of Indonesia has told wealthy Indonesians to stop heading overseas for medical treatment because it only benefits neighboring countries. He is asking his own ministers need to set an example for the rest of the nation and only seek treatment at home. He argues that the country does have enough high quality hospitals and doctors. The president admits that it is beyond his powers to actually stop anyone seeking medical help abroad. His comments may have been taken seriously in Indonesia if he applied the same rules to his own family. Among those who sought medical care overseas was Yudhoyono’s wife, Ani Yudhoyono, who went to the USA as recently as June 2012 to undergo treatment for a nerve problem in her neck at Allegheny General Hospital in Pittsburgh, Pennsylvania.
According to the health ministry, 600,000 Indonesians leave the country for medical treatment every year. They spend an estimated $1.2 billion on treatment in nations with modern, and better-equipped, health facilities.

Local politicians have talked up the potential of Belize as a medical tourism destination that could rival Costa Rica for American business, but is it possible?
The country offers dental tourism to Americans and is considering expanding medical tourism, but local doctors are not convinced that there is spare capacity.
Formerly known as British Honduras, Belize was the UK’s last colony on the American mainland and still maintains strong ties with Britain. Belize is not a medical tourism destination by any standards, though proposals to build facilities and begin promoting it are being considered. Belizean doctors generally come from abroad, some as volunteers to help the locals, and the vast majority work in publicly funded clinics or hospitals with very little time and resources for special care. However there are a few doctors that run their own private medical and dental practices, with some even advertising to foreigners. A few people have visited Belize as medical tourists, often enjoying Belize’s laid-back atmosphere as a great place to recover.
But the island only has a population of 138,000 and few towns, so talk of rivaling Costa Rica, which has cities, a population of 4.7 million, internationally accredited hospitals etc is optimistic!
Most available medical procedures are cheaper in Belize than in the USA but most locals and permanent residents head north to Mexico for treatment, where costs are lower, facilities are better and more procedures are available. Facilities, equipment and doctors in Belize are in extremely short supply, so the range of available treatments is limited at best.
The government plans to promote medical tourism and is encouraging overseas investors to set up in the country, but the investors want to bring in US doctors, which the locals oppose. The Belize Medical and Dental Association (BMDA) does not support medical tourism.
Belize has a problem with violent crime, much of it drug-related, and the trafficking of narcotics to the US. In 2011 Belize was added to a US blacklist of countries considered to be major producers or transit routes for illegal drugs.

The Inter-American Development Bank (IADB) and the Belize Trade and Investment Development Service (Beltraide) recently held a public workshop on medical tourism.
The IADB hired a Costa Rican medical tourism consultant, Massimo Manzi, who presented an overview of the study he is leading at this workshop. Beltraide is committed to developing a sustainable medical tourism approach that will benefit Belize, and Belizeans.
Manzi emphasized what Belize must do to become successful long-term in this challenging market. He confirmed that there is great opportunity for Belize in this market. He pointed out that the price of entry is high and that unless it had the backing of local doctors it was doomed to fail. Belize has few specialist doctors and few hospitals, with no international certification.
Belizean doctors argue that the government has yet to institute medical laws and regulations. Dr. Joel Cervantes, of the Belize Medical Association stresses that since 1999 his organization has pushed the Ministry of Health to pass a Health Act, and health regulations. As of yet nothing has been passed. He states that this first step must be accomplished prior to proceeding with any medical tourism plans in Belize.
Locals, including doctors, have accused the government of not waiting for the study or any local agreement, and issuing permits for future medical tourism facilities. The doctors are very unhappy that some of the permits do not expect to use any Belizean doctors or nurses. After the workshop, the government has tried to backtrack by claiming that the permits have been put on hold until Belize’s medical tourism plan is completed; but some local doctors do not believe the politicians.

With a rising elderly population globally, two international accreditation organizations have launched programmes for long term care and rehabilitation.
Although as yet few people go overseas for long-term care, there is a tendency for some colder nations such as those in Scandinavia, to send older people needing care to warmer ones for the winter. One possible future trend could be for people to go, or be sent by relatives, to another country for long-term care as the basic cost in the USA and some Western European countries is now enormous. This is a matter for major debate, as some Western Europe countries totally disagree with people being sent to care homes, as they believe that they should be cared for at home within their families.

Temos has launched its Quality in International Rehabilitation Care programme and accredited the first centre, in Greece. The assessment includes the therapeutic, medical and non-medical services for rehab care containing the systematic and continuous processing of patients, the identification, analysis and improvement of quality of structures, processes and results in rehab services.

Animus Recovery and Rehabilitation Centre in Trikala opened in May 2008. It looks after people who have accidents or diseases, and then either need outpatient treatment or hospitalisation for their recovery and rehabilitation. Animus is being extended to offer space for more patients.
Animus actively seeks medical tourists considering rehabilitation services in Greece. The Temos certification is part of the plan to get international exposure and trust in a sector that has a poor reputation. The process of applying to Temos has helped Animus improve standards and hopes the quality approval will give it a significant competitive advantage.
Long Term Care is the newest JCI accreditation programme, designed to address the care of individuals needing long term care. JCI accepts that the needs of people in hospices, seeking temporary care, needing home care and permanent or on-off long term care are increasingly fractured. So it is developing specific care standards for each sector to replace an overall care one.

Although cosmetic surgery is a major mainstay of international and national medical tourism, it is rarely properly regulated and although it has many experienced and well qualified practitioners, as a cash quick industry it has more than its share of unqualified “amateurs” undertaking work.
Problems with cosmetic surgery and cosmetic dentistry have often undermined any good press that medical tourism gets. So all countries where cosmetic surgery is a major component of medical tourism should take notice of a UK government review that will look at all aspects of the cosmetic surgery industry, including whether or not advertising should be restricted, controlled or even banned altogether.
The UK cosmetic surgery industry is under scrutiny and could find itself operating under tighter restrictions following a major review into cosmetic surgery and procedures launched by the Department of Health and led by Professor Sir Bruce Keogh.
It will look at many issues including whether the right amount of regulation is in place, if people have the right amount of information before going through with surgery and how to make sure patients get the right aftercare.
People are being asked to give their views on, and share their experiences of, the cosmetic surgery industry and cosmetic procedures. The call for evidence is asking for people’s views on:• The regulation and safety of products used in cosmetic surgery;• How best to ensure that the people who carry out cosmetic surgery operations and procedures have the necessary skills and qualifications;• How to ensure that organisations have the systems in place to look after their patients both during their treatment and afterwards;• How to ensure that people considering cosmetic surgery and procedures are given the information, advice and time for reflection to make an informed choice.
Professor Keogh says,” The recent problem with PiP breast implants has shone a light on the cosmetic surgery industry. Many questions have been raised, particularly around the regulation of clinics, whether all practitioners are adequately qualified, how well people are advised, aggressive marketing techniques, and what protection is available when things go wrong. I am concerned that too many people do not realise how serious cosmetic surgery is and do not consider the life-long implications and potential complications it can have.”
Some organizations favour the introduction of tough rules on cosmetic surgery advertising. Elli Moody of UK Feminista suggests, "This offers a vital opportunity to stamp out the unethical and aggressive advertising techniques deployed by the cosmetic surgery industry. These adverts are a public health hazard. Their sole purpose is to persuade people to undergo medically unnecessary invasive surgery in order to boost profits. By frequently portraying surgery as quick and easy, they recklessly trivialise risks that include postoperative infection, blood clots and, in rare cases, death. Cosmetic surgery adverts also ruthlessly prey on women’s widespread unhappiness with their bodies, making false promises of confidence and self esteem."
Fazel Fatah of the British Association of Aesthetic Plastic Surgeons (BAAPS) comments, ’We have been campaigning for many years for better regulation of the cosmetic surgery sector to protect patients. We would like the review to draw a clear line between cosmetic treatments that are seen as a commodity and cosmetic surgery that is serious medical treatment that must be provided by fully trained and qualified surgeons. We want the review to look at advertising if an outright ban is not achievable, then a new strict code of advertising is badly needed to protect patients."
An opposition MP has called for better regulation of the cosmetic surgery industry. Labour MP Ann Clwyd has introduced a bill to the House of Commons seeking to establish minimum standards for the practice of cosmetic surgery. The Cosmetic Surgery (Minimum Standards) Bill would cover surgical and non-surgical cosmetic procedures and would place a ban on cosmetic surgery advertising.
Ann Clwyd says, "The medical profession has always been controlled and regulated by strict ethics, but the voluntary codes of practice have been breached by some operators to make quick easy money. Responsibility clearly lies with the government to take action as soon as possible to stop any more innocent people being subjected to butchery at the hands of some greedy, unscrupulous and incompetent people and to introduce the kind of regulation for cosmetic surgery that is long overdue."
There are measures and standards to help regulate the industry, but some cosmetic surgeons operate outside these voluntary regulations. Some treatments and procedures are unlicensed for cosmetic use but can be given at the discretion of doctors, or ’off licence’ in some clinics.

“Medical Tourism: The Ethics, Regulation, and Marketing of Health Mobility” a new hardback book costing £85, from major publishers Routledge, is edited by Professor C. Michael Hall of the Department of Management, University of Canterbury, New Zealand.
The author explains, “Medical and health tourism is a significant area of growth in the export of medical, health and tourism services. Although spas and improved wellbeing have long been part of the tourist experience, health tourism now includes travel for medical purposes ranging from cosmetic and dental surgery through to transplants and infertility treatment. Many countries actively promote and compete for the medical tourist, while many developed countries also provide niche private services. However, the field of medical tourism is increasingly being subject to scrutiny and debate, particularly as a result of concerns over regulatory, ethical and wider health issues.”
The publisher adds, ’Drawing on a range of theoretical and methodological perspectives, this book is one of the first to critically address the substantial political, philosophical and ethical issues that arise out of the transnational practices of medical tourism. Through a series of chapters the book engages with key issues such as the role of regulatory and policy structures in influencing medical and health tourism related mobilities. These issues are investigated by considering range of developing and developed countries, medical systems and health economic perspectives .The book adopts a multi-layered perspective to not only investigate the business and marketing practices of medical and health tourism but places these within a broader framework of contemporary globalization, policy and practice. By doing so it opens up debate of the ethical space in which medical and health tourism operates as well as reinforce the wide ranging perspectives that exist on the subject in both the public and academic imagination.”
Contents-1. Development and implications of medical mobility 2. Quality, safety and risk in medical tourism3. Economic, social and institutional impediments 4. Medical tourism, xenotourism and client expectations5. Impacts of health policy on medical tourism in Germany6. Thermal versus surgical medical tourism in Hungary7. Health spa tourism in the Czech and Slovak Republic 8. Macao’s cross-border medical tourism9. Branding medical and health tourism in Germany10. Korean health tourist behaviour11. Thailand, Singapore, Malaysia, and India 12. The promotion of Malaysia as a destination13. The future
Another book in preparation is “Patients with passports-medical tourism, law and ethics” by Glenn Cohen. Oxford University Press will publish it.
Glenn Cohen explains, “This book will be the first comprehensive analysis of the legal and ethical issues raised with multiple varieties of medical tourism—for services that are legal in the home and destination country (e.g. hip replacements, cardiac bypass), for services that are illegal in the home country but legal in the destination country (e.g. abortion, assisted suicide, reproductive technologies, stem cell treatments), and for services that are illegal in both places (e.g, organ sale).”
Cohen is seeking the assistance of student research partners who will be responsible for page proofing, gathering materials, and managing media contacts. They will learn about bioethics and the globalization of health care.

90% of Arabs who leave the Middle East to have cosmetic surgery performed come to Europe, and more than half of them choose London for their treatments.
Leading cosmetic surgeon Professor Laurence Kirwan explains why, ”London is famous for many things and this includes top-notch cosmetic surgery. The women come from very wealthy backgrounds and can afford to go anywhere in the world so choose the place with the best reputation.”
Professor Kirwan has set up a monthly consulting surgery in Abu Dhabi as more Arab and Middle Eastern women become more open to the idea of cosmetic surgery. He already has an international presence with clinics in Harley Street in London, as well as New York and Connecticut in the US. He is sought out by wealthy clients from the Arab world and expects his consultancy will be in high demand in Abu Dhabi.
Arab women are influenced by what they see in the media and want to feel good and look beautiful. But cosmetic surgery is outlawed in some Arab states, which is why many Arab women go overseas for treatment.
While the private health sector in the UK continues to be a magnet for private patents from all over the world, how successful NHS hospitals will be in attracting private patients from the UK and overseas is still an unknown.
The government has given all NHS hospitals the opportunity to earn more from private patients by lifting the cap on hospitals’ private income. The new limit on income hospitals can derive from private patients, drugs sales or intellectual property is 49%, which in practice means that it now offers no limitation on their potential.
The new limit applies from October and the increase is based on the logic from health secretary Andrew Lansley, “The existing limit prevents foundation trusts from pursuing the kind of innovations that will benefit patients in the future and put more of our hospitals on the map internationally".
Cosmetic surgery across the world has been criticized for the number of unqualified or under qualified individuals undertaking what is in effect a medical procedure. An opposition MP has called for better regulation of the cosmetic surgery industry.
Labour MP Ann Clwyd has introduced a bill to the House of Commons seeking to establish minimum standards for the practice of cosmetic surgery. The Cosmetic Surgery (Minimum Standards) Bill would cover surgical and non-surgical cosmetic procedures and would place a ban on cosmetic surgery advertising.
Ann Clwyd says, "The medical profession has always been controlled and regulated by strict ethics, but the voluntary codes of practice have been breached by some operators to make quick easy money. Responsibility clearly lies with the government to take action as soon as possible to stop any more innocent people being subjected to butchery at the hands of some greedy, unscrupulous and incompetent people and to introduce the kind of regulation for cosmetic surgery that is long overdue."
There are measures and standards to help regulate the industry, but some cosmetic surgeons operate outside these voluntary regulations. Some treatments and procedures are unlicensed for cosmetic use but can be given at the discretion of doctors, or ’off licence’ in some clinics.
Surgical practice in the UK is regulated by the General Medical Council and practising surgeons should be enrolled on its specialist register. But some concessions are made for private cosmetic surgeons who have been practising since before April 2002. By satisfying certain criteria, these doctors can practise without the need to be on the specialist register. More worryingly, are the number of health clinics that offer semi-surgical or non-surgical procedures with no qualifications.
Reputable cosmetic surgeons welcome the proposal, but the general view is that the ban on advertising is never going to happen and is only in the proposal so that the government can drop it as a political trade–off and enact the legislation.

The Kingdom of Saudi Arabia has done much to add to and improve local hospitals to make them up to date; but has had little success in attracting medical tourists.
Many locals go overseas for treatment, and even for medical check ups. Numbers doing this has gone down by 20 to 30% in the last three years. But it is unclear whether this is due to better provision at home, or the global economy causing fewer to afford overseas treatment. Saudis tend to go to high cost countries such as the UK, Germany and Switzerland.
The country has relied heavily on the logic that building new hospitals and seeking international accreditation will automatically bring in medical tourists. But with most Gulf nations pursuing a similar strategy, this alone does not bring in medical tourists. The state and hospitals have been reluctant to advertise or market the country properly.
Dr. Sami Badawood of Jeddah Wellbeing Affairs says that the country needs to do more to attract medical tourists from other Gulf nations. "There are plans to develop a brand for medical tourism in Jeddah. The strategic five-year plans seek to create a medical city in Jeddah that has many medical services. To do this we need much more private sector investment." Jeddah has 40 hospitals and a growing number of private clinics. But as India and Dubai are showing, medical cities or medical tourism clusters are part of an outdated concept that never did and probably never will, bring in sufficient numbers of medical tourists to justify the huge investment expense.
The Ministry of Wellbeing and the Jeddah Governorate are to hold a workshop on how to create a plan to increase medical tourism in Jeddah. They may carry on independently or seek the help of the Saudi Commission for Tourism and Antiquities (SCTA); which works with public and private interests to promote tourism. The country needs to attract medical tourists and increase the capacity and resources of private hospitals.
Saudi Arabia has many local competitors; particularly Jordan and the UAE. Korea, Malaysia, Thailand, India, the Philippines and Eastern European nations are attracting substantial numbers of medical tourists from the Middle East.
Saudi Arabia gets medical tourists seeking pediatric and obesity remedies and eye surgery. Cosmetic surgery is increasingly popular but is much more expensive than in India, Egypt or Lebanon. Costs generally are far higher than Asian competitors. One area that could be developed is stem-cell therapy and infertility therapy; but both face local cultural and religious obstacles, while the nations opposition to women being involved in anything other than child rearing and housework, and strict dress codes, would make it a very uncomfortable destination for couples seeking fertility treatment. The normal local procedure of only talking to the husband about even the most intimate female medical details may not be very attractive.
Public and private sectors are not working together to promote medical tourism. Saudi Arabia is a Muslim country in which Islamic law is strictly enforced. Islamic codes of behaviour and dress are also rigorously enforced. Anyone involved in a commercial dispute with a Saudi company or individual may be prevented from leaving the country pending resolution of the dispute. The Saudi legal system is different; suspects can be held without charge and denied legal representation. The Saudi authorities often detain witnesses and victims of crimes, as well as the culprit. All visitors require a visa to enter Saudi Arabia. Visitors may be refused entry to Saudi Arabia if their passport contains evidence of previous travel to Israel. Saudi law requires female visitors to have their sponsor meet them on arrival.
Saudi Arabia is a classic case where culture and local politics mean that the potential for inbound medical tourism is limited. Although the local culture may not cause problems for some Gulf states; those with more westernized ideas can be put off. For most Americans, Asians and Europeans, the culture will stop it being considered as a medical tourism destination.

The problem of making comparisons of overseas prices against US prices, and one reason that US domestic medical tourism is growing, is shown by a new report. The report shows that US hospitals in areas with the highest prices charged 2.7 more times than hospitals in the lowest-priced regions. These are 2010 figures; so do not take into account, price cuts and package rates of those US hospitals targeting domestic medical tourism. And they only refer to California, a rather well-off state; it is known from other studies that hospitals in other US states can offer higher or lower prices than in California.
Hospital prices significantly vary for surgical procedures, with location and market power playing an important role in marking up prices, concludes a new report from independent consumer advocacy group CALPIRG.
A new report by CALPIRG Education Fund found large discrepancies between what California hospitals charge for common surgeries, such as caesarean section births and knee replacements. The significant price variations, which appear unrelated to quality of care, could provide important insights into how to lower the rising costs of health care in California.
The report, ’Your Price May Vary: Geographic Variation in Hospital Charges in California’, examines statewide data from the California Common Surgeries and Charges Comparison database – a record of the prices charged by hospitals for common, elective, in-patient surgeries widely performed at hospitals across the state.
Daniela Uribe of CALPIRG Education Fund comments,” Overcharges are unacceptable for a service as important as health care. Consumers, whether it’s on their own or through higher insurance premiums, should not be paying 250% more for the exact same surgery at different hospitals. According to this data, a pregnant woman in the Bay Area could take a private jet to Fresno, stay at the nicest hotel in the city, and still save thousands of dollars on her birth. In health care, higher prices do not reflect greater value. Consumers deserve clear, easy-to-access information about both the cost and quality of care in order to make sound judgements about their health. Exploring variations in the charges for providing health care is potentially one of the most effective ways to identify cost-saving strategies and put pressure on high-cost providers to do business in a way that is more economical for their patients and insurers.”
The report found that:• Surgery charges were 2.7 times more expensive in the highest cost region vs. the lowest cost region. Surgery charges were highest in the Alameda and San Mateo areas. The Fresno and Orange County regions charged the least.• San Jose-area hospitals charged an average of $144,900 for angioplasty, while Bakersfield hospitals charged $44,400.• The typical patient in the San Mateo region was charged nearly $48,000 for a Caesarean section. The typical patient in the Fresno region was charged less than $13,000 for the same surgery.
Even within the regions, prices widely differed. In the Bay Area:• The most expensive planned c-section surgeries were at Seton Medical Center, which charged $54,866, in comparison to $21,498, at Santa Clara Valley Medical Center.• The most expensive knee replacement surgeries were at Regional Medical Center of San Jose, which charged $165,200, in comparison to $59,824 at Alameda Co. Medical Center—Highland Campus.
Other research has concluded that price variations are not correlated to the quality of care or patient income or health status. Additionally, cost of living differences by region only partially explain the regional variations in common surgery charges. Rather, research suggests that variation in charges could have more to do with which hospitals have more leverage and greater market power, particularly with the insurance industry.
CALPIRG Education Fund recommends:• The state of California should make information about both the cost and the quality of care at each hospital accessible to consumers and policy-makers.• Hospitals should disclose their accepted payments and discounts, rather than just their sticker price for common procedures, to enable consumers to shop around and to enable policy-makers to better understand how California might control the cost of providing quality health care.

Nadeem Esmail of the Fraser Institute think tank claims that 46,169 Canadians left the country to get medical treatment elsewhere, mostly in the USA, in 2011.
According to Nadeem Esmail, "In some cases, these patients needed to leave Canada due to a lack of available resources or a lack of appropriate procedure or technology. In others, their departure will have been driven by a desire to return more quickly to their lives, to seek out superior quality care, or perhaps to save their own lives or avoid the risk of disability. Clearly, the number of Canadians who ultimately receive their medical care in other countries is not insignificant."
The reason many go abroad is shown in another report by the same author. Data from the Fraser Institute’s annual survey of hospital wait times found that Canadians waited 9.5 weeks, on average, from an appointment with a specialist to receiving treatment in 2011, up slightly from 9.3 weeks in 2010.
Another think tank, Atlantic Institute for Market Studies (AIMS), suggests that Canadian hospitals should pursue more medical tourists. It argues that although Canada has a universal access health care system that strives to provide quality care for every Canadian, there is demand for private healthcare. There has been an increase in the number of private clinics across the country. These provide diagnostic services, fertility treatment, gynecological and urological procedures, weight-reduction and vascular surgeries, neurosurgery and ophthalmology, plus a wide range of sports-related remediation and an array of cosmetic procedures. These services are provided to Canadians who can afford to leapfrog the creaking public health system and to patients from other countries.
AIMS argues that politicians should stop attacking private healthcare and restricting private health insurance and help promote private treatment in Canada to Canadians and others. It argues that this would reduce the number of Canadians going overseas for treatment and that the country can actually profit by actively encouraging inward medical tourism.
In Quebec City, luxury hotel Fairmont Le Château Frontenac has partnered with a private radiology clinic, Clinique de Radiologie et Imagerie médicale de la Capitale (RIMC), to offer what it claims is the first medical tourism package in Canada. It is only available to Canadian residents.
The package includes accommodation in a Fairmont room (minimum of two nights stay), breakfast for two, a 60-minute Swedish massage for two at the Payot Institute and round trip transportation between the hotel and the clinic. RIMC offers mammography, bone densitometry, taco lung, abdominal and pelvic ultrasound, virtual colonoscopy, and scans.

Just as it starts to recover from the last conflict, Lebanese medical tourism is being damaged by the problems of neighbour Syria.
Tourism and medical tourism to many countries in the region have been suffering from the civil wars and uprisings in Syria, Libya, Egypt, Tunisia, Bahrain and other countries. Even if the country itself is peaceful, the perception of tourists means that it takes a long time for normality to resume. Medical tourism tends to be harder hit, as while a normal tourist can get home quickly if danger erupts, it is not so easy if you are being treated in hospital. So medical tourists are being more careful about where they go.
The Beirut Eye Specialist Hospital (BESH) has suffered from this heightened risk, even though Lebanon itself is peaceful. Since problems began in Syria, the number of patients from Syria has dropped to a trickle and numbers have fallen from across the Arab world.
Like it or not, medical tourism exists in the political and economic world around it, not in a protected bubble. Lebanon has an extra problem in that many medical tourists from the Arab world came through Syria. Economic problems at home are also reducing overseas numbers.
While competitors Dubai and Jordan have huge government support for medical tourism, the handful of hospitals and clinics in Lebanon have no support at all. Politics led to many Libyans going to Jordan for medical treatment, and the difficulties of getting paid may mean that Jordan regrets how much they pushed for that business.
Although some Gulf countries pay for some of their people to get treated overseas, Lebanon is totally dependent on self-pay patients.

India is becoming a favourite destination for Omani medical tourists; there has been a steep rise in the number of visas being issued to India-bound Omanis.
From January 1 to June 30 this year, the number of medical visas issued to Omanis has jumped three fold. The statistics reveal that India is becoming a prime destination for Omanis who opt for advanced treatment. According to the data: Tamil Nadu, Andhra Pradesh, Kerala, Maharashtra and New Delhi are the top five destinations where Omanis visited for medical treatment during the last six months.
The Indian Embassy in Muscat issues medical, tourism, business and student visas for Omanis. Omanis travels to India to seek treatment for cardiovascular, gastroenterology, orthopaedic, oncology, ophthalmology and dental ailments.
Low price is one attraction. Another is that due to cultural similarities and historical ties, many Omanis feel at home in India. The processing of official papers for going to India for medical purposes is much easier than any other country.
An Omani medical tourism agency says that visa enquiries for treatment in India are very high. Hassan Mohsin Al Lawati of Al Furdha Services says, "More and more Omanis want to visit India as it is an affordable and trusted destination for medical care. Most customers sent to India are quite happy after their return. During the last six months, we have assisted more than 50 Omanis to go for treatment in India.”
The government of India is planning to provide visa on arrival facilities to Oman and other GCC nationals as part of a major drive to attract tourists from the Gulf region. India is already providing visa on arrival facility to 17 nationalities.
The Indian state of Rajasthan seeks to attract patients from neighbouring countries as the state government has started working on formulating a separate policy on medical tourism.
In an initiative aimed at positioning Bhubaneswar as a complete health destination and promoting medical tourism in a big way, Odisha plans to develop an integrated health city. The health city will be built on the outskirts of the city on 150-200 acres of land. Industrial Infrastructure Development Corporation of Odisha (Idco) has prepared the concept note for the project.
PK Jena of Idco explains,” The proposed health city is at a conceptual stage and will have various components including super specialty hospital, medical college, residential zones, high-end diagnostic centre and common infrastructure facilities. Destinations like Gurgaon, Chennai and Hyderabad already have health cities while one such city is soon coming up in Vishakhapatnam. A health city in Odisha will help us pull medical tourists to the state.” Medanta- the medicity in Gurgaon founded by cardiac surgeon Naresh Trehan is spread across 43 acres including a super specialty hospital, research centre, medical and nursing school.

Poland aims to use the Euro 2012 football tournament to kick-start promotion of a profitable tourism segment – health and medical services. If the new promotion campaign is successful, it will turn Poland into one of the most popular health and medical services destinations in the world.
A consortium of PAIiIZ (Polish Information and Foreign Investment Agency), EuCP (European Center for Enterprise) and Ameds Centre is promoting health, medical and wellness tourism through a full scale campaign that will include an international advertising campaign, attending specialty fairs, plus organizing trade missions and tours for journalists and medical tourism representatives.
Most medical tourists come from Germany, Scandinavia and Russia. Many of those from the UK or USA are Polish emigrants. The most sought out services are dental treatment, cosmetic surgery, neurosurgery, cardiovascular treatment and orthopedic services. The other part of the business is wellness resorts, spas and health centres, all popular with foreigners. Polish medical services are attractive to foreigners because of their prices – much lower than in Western Europe and the USA. And foreign clients pay better than the Polish National Health Fund.
There is some debate in Poland as to the effect of the EU cross-border healthcare law when it comes into force on October 25, 2013. The new law will ensure patients’ rights to access treatment across EU borders. Some argue that it will double the medical tourism business of Poland, but others argue that in the current EU climate, getting money out of foreign governments will be hard work; while the numbers of state or private insured patients travelling will not be very high.
The government and the Polish Association of Medical Tourism say that 2011 saw between 250,000 and 300,000 medical tourists, and this will increase by between 12 and 15% in 2012 and onwards. Part of the new promotion includes a fund to help agencies and hospitals promote medical tourism.

In another attempt to promote medical tourism in the emirate, Dubai Healthcare City (DHCC) will open specialised centres for oncology, genetic disorders and diabetes and add facilities for rehabilitation, paediatrics and integrated medicine.
Last year, DHCC recorded a sharp growth in total patient numbers, attracting 502,000 patients in 2011. It is claimed that 15% of these patients are medical tourists compared to 10% of a total of 412,000 patients in 2010. But the 15% who are “international patients” includes expatriates and those on holiday. 85% of the UAE population, and 90% of the Dubai population are expatriate. DHCC has yet to provide statistics that identify real medical tourist numbers.
The costs of healthcare in Dubai are higher than in Asia, but DHCC claims that it is cheaper than in the USA. 90% of the medical staff are expatriates and change often, so building up any expertise that is not available in other Gulf countries is difficult. They have modern hospitals, the latest equipment and a good infrastructure, but the challenge is to offer something that persuades people from Gulf countries to go there rather than other local states or countries that have scores of new hospitals too.
Dubai’s biggest challenge is to convince its own people to stop going abroad in their thousands, often paid for by their own state health insurance. It will not attract Europeans or Americans in enough numbers to justify what has been a huge investment by the state owned DHCC.The entire population is only 2 million and according to their own official statistics is 1,523,000 males and 455,000 females, the discrepancy due to the number of expats there on a temporary basis who leave their families at home.
A delegation from the Libyan ministry of health has visited Dubai Healthcare City to raise awareness about the status of the Libyan healthcare sector and engage in dialogue with healthcare institutions in the UAE. It is unknown if Libya wants to send people to Dubai or consider building a Libyan version of DHCC.If the former, it should note what has happened in Jordan.
A year since they received the first batch of injured Libyans who went to Jordan seeking healthcare, and after providing treatment to around 55,000 patients, private hospitals are still waiting to be reimbursed. A dispute between the hospitals and Libyan authorities over medical bills that amounted to more than US $200 million is still dragging on.
The dispute involves the mechanism of auditing these bills, with numerous committees being formed and dissolved. Fawzi Hammouri, president of the Private Hospitals Association (PHA) told the local press, "We are no longer in contact with Libyan authorities, which promised to get back to us after reviewing and auditing the bills. They do not even ask for the new bills for treating their citizens who are still in our hospitals," Libya has paid some bills but still owes $130 million.
This publicity has prompted Libya to hire a Jordanian medical management company to help process financial claims filed by Jordanian hospitals that have treated around 55,000 Libyan patients over the past year. Following a meeting between Fawzi Hammouri, and Libyan Health Bureau director Ali Bin Jalil, an agreement has been made to pay all bills within a 30-day deadline after auditing is completed as stipulated in the Libyan-Jordanian Medical Cooperation Protocol. The audit process will weed out any bills that are not part of the agreement or where there is proof of loading by a hospital.
The bills are still increasing, as there are 2000 Libyans are currently receiving treatment in the kingdom’s hospitals and clinics. And these bills are just for medical expenses. Local hotels that accommodated thousands of Libyans, have received $ 56 million from the Libyan authorities. Michael Nazzal, president of Jordan Hotels Association says that the Libyan authorities are cooperating and the remaining dues stand at $70 million.

The Philippines Department of Tourism (DoT) is urging British businessmen to invest in Philippine medical tourism. The DoT has also pitched to local developers, and travel and tourism businesses for wellbeing, wellness and leisure holiday packages.
The government is committed to promote investment for tourism by relaxing investment regulations and supplying incentives, investing in infrastructure development and advertising activities; and simple access to and from significant international cities within the region. The Tourism Act of 2009 is a measure created to create the Philippines much more globally competitive by creating tourism from the country’s engines of investment and employment, of growth and national development, and the provision for tourism enterprise zones to become established in strategic locations to attract foreign investors.
To attract interested investors, The Joint Foreign Chambers (JFC) has made recommendations to the government on how it can improve inbound medical travel. It says that promoting medical tourism is not enough; the tourism and taxation regimes much work positively too. JFC says that the government should remove taxes on foreign airlines and implement 24/7 operations in international airports and seaports. It wants them to develop and implement national and destination plans. JFC says that promotional resources should highlight international medical travel and promote transparency of medical packages. The government should develop and implement national policy on wellness and medical travel. It should offer seamless travel of medical travellers by issuing longer medical tourism visas for patients and their companions and streamlining procedures.
The JFC is the latest in a long line of organizations telling the government that endless committees with yet new promotions are useless unless backed up by joined up thinking on promoting tourism and investment.
The Philippines, while having had foreign patients for over 30 years, has only recently launched a concerted effort at medical tourism advertising. Medical tourism continues to grow, with the number of medical tourists rising from 60,000 in 2007 to about 100,000 in 2008.It is thought that post-recession figures dropped in 2009 to 70,000 or less and have not recovered, which is why there are no official figures for 2009, 2010 or 2011. The DOT target is for 200,000 medical tourists by 2015, but this more a hope than any real figure.

The Medical City is a local pioneer of medical tourism, has assumed the management and operations of the Great Saviour International Hospital and also the Global Medical Network in Iloilo, in anticipation of a full purchase of both before year’s end. TMC has acquired existing sister sites in Luzon, including the Mercedes Medical Center in Pampanga and a network of outpatient clinics in Dagupan, Olongapo and Cavite. TMC is increasing its presence in Luzon and Visayas as part of a national expansion strategy, aimed at offering its distinct brand to a broader patient base including more medical tourists.

The industry, investment and commerce minister, Anthony Hylton, says that all Jamaicans will benefit from the government’s plans to expand the country’s health and wellness tourism offerings as it will not only help to enhance the quality of the country’s health care, but will also contribute to the economy, through the creation of jobs.
The minister seeks to dispel claims that a developed health and wellness sector in Jamaica would seek to widen the gap between the rich and the poor, particularly as it relates to the ability to the most vulnerable to access quality healthcare. Hylton says that the government is working to put in place, a number of projects that would benefit all Jamaicans, especially the unemployed and low income earners, “The poor will actually benefit from what would be centres of excellence created here in Jamaica to do things and to provide services, some of which are not now locally available, and means that they would have to find foreign exchange and travel abroad to get those services. We will bring those services here and they will all be accessible to the wider public."
The government plans to partner with the private sector and doctors to develop the health tourism sector. Hylton explains, "Public/private partnership will be beneficial as doctors are asking the government to partner with them by providing land as part of the investment. In exchange we can leverage certain requirements as it relates to the wider population.”
Dr. Neville Graham of EMedical Global Jamaica argues that health tourism enhances local healthcare and encourages people, who would otherwise go abroad for healthcare, to stay in Jamaica, “It has been proven in Singapore that health tourism means they are now eighth in the world in terms of providing healthcare for their own population."
The government argues that health tourism will mean not only that Jamaicans would stop travelling to Miami or New York for healthcare, but people who have emigrated to the USA or elsewhere will return home for treatment.
The health and wellness segment of the tourism industry is a new growth area with significant potential. But Jamaican governments have been making promises on developing the sectors for many years, with little sign of progress.
According to the government there are two million Jamaicans living overseas, mainly in the UK, Canada and the USA. This is a huge number as the population only numbers 2.7 million. The government sees them not only as a potential market, but also as a source of overseas investment.
The dilemma is that the government may be able to offer land, but does not have the money to develop healthcare facilities and few local businesses can invest serious money. So any progress will depend on getting overseas companies to look to the island for investment opportunities.
Before investors part with any cash, they will want to see the politicians deliver on promises various reforms and the strategies including developing the infrastructure. Problems of lawlessness make it hard to guarantee safety. There are no agencies, trade bodies, travel groups or hospitals actively seeking overseas business.

Radisson Blu Plaza Delhi’s R The Spa has become the first spa in a five-star hotel to be awarded accreditation by the National Accreditation Board for Hospitals & Healthcare Providers (NABH) under the aegis of the Quality Council of India.
Javed Ali of Radisson Blu Plaza Delhi says, "We feel honoured to be the first hotel spa in India to have received NABH recognition. It gives us immense satisfaction to be acknowledged for customer safety and quality of care that R the Spa provides to its guests. With the boom in wellness tourism in India, the customers will use accreditation as a guiding point. Accreditation will go a long way in enhancing the growth and credibility of the spa.”
Dr. Girdhar Gyani of NABH adds, “The NABH accreditation will bring significant benefits to the spa including support from the Ministry of Tourism in marketing it internationally, a listing on the Incredible India website and participation in Ministry of Tourism publications.”
Spread over three levels, the spa features a state-of-the-art fitness studio, spa bar, salon, luxurious spa suites and offers a range of Asian and Western spa therapies. Guests can enjoy suites with aqua beds that offer a floating experience, Vichy showers and hamam tables. R the Spa also features a range of salon therapies including hair care, waxing and threading. The fitness studio at this spa in New Delhi is the city’s most exclusive, state-of-the-art gym, providing fitness programmes designed to help guests maintain their routine while travelling. The gym is equipped with multiple cardiovascular machines, bicycles, treadmills and strength training equipment.
Radisson Blu Hotels & Resorts, part of the Rezidor Hotel Group, currently operates more than 230 hotels worldwide, with another 51 projects under development. Radisson Blu is a first class full service hotel brand. Carlson, a privately held, global hospitality and travel company, based in Minneapolis (USA), is the majority shareholder of The Rezidor Hotel Group. Together, Carlson and Rezidor have hotels in more than 90 different countries, 1,070 hotels in operation and 240 hotels under development.
NABH is part of the Quality Council of India (QCI), an autonomous, non-profit organization set up by the government in 1997 for running a national accreditation programme. NABH is currently offering accreditation to hospitals, small health care organizations, ayush hospitals, blood banks and transfusion services, primary health care centres/community health care centres, wellness centres, dental centres and medical imaging services. NABH standards are internationally recognized by ISQua.
The Ministry of Tourism has initiated several measures to promote medical tourism. This includes promotion to overseas markets and production of publicity materials including brochures, CDs and films, distributed to target markets. Under a market development scheme the ministry offers financial support only to approved medical tourism service providers, i.e. representatives of hospitals accredited by Joint Commission International (JCI) and NABH, plus medical tourism agencies approved by the ministry.

Rehab and addiction treatment are the often forgotten areas of medical tourism. Thailand is seeing an increase in the number of Australians going there for alcohol and drug dependency treatment.
Three years after the opening of The Cabin, an upmarket rehabilitation facility in the city of Chiang Mai, a third of patients are from Australia, and half of those are from Western Australia. Each spends upwards of $12,000 for a 28-day course to kick their addiction; a price much lower than it would be in Australia. It can take 30 patients at any one time and so far has treated over 300 people.
While traditional detox clinics can be very spartan, new centres offer a softer option for recovering addicts in a riverside resort that resembles a five-star luxury hotel, complete with swimming pools, four-poster king-size beds and ensuite bathrooms. Customers of The Cabin range from 18 to 60, but most are aged 30 to 45 and include successful businesspeople, housewives and medical professionals who want anonymity. The drug of choice for most Australians is alcohol, while some have methamphetamine or cannabis addiction. A growing number of patients are hooked on prescription drugs such as painkillers.
Rehab centres overseas can be a great benefit to the patient as it provides anonymity, and crucially breaks the daily cycle by about getting them away from the people, places and things that trigger alcohol or drug use by being in another country. The Cabin uses the 12-step programme, with cognitive behavioral therapy, physical fitness and a focus on dealing with drug and alcohol cravings. It claims a success rate of 96 % for those who complete the programme.
The Cabin has a great deal of experience and success dealing with corporate clients who send their staff because of a proven treatment method, guarantees of confidentiality and anonymity, and competitive pricing and location .So for companies with international staff it can be easier to send a staff member from Hong Kong or Singapore for treatment in Chiang Mai rather than back home to the US or UK and it guarantees greater anonymity. A track record in the corporate sector has seen it gain a solid following of local and regional companies as well as larger multinational and global businesses.
British singer Pete Doherty recently cancelled a string of festival gigs and flew to the remote jungle clinic in a bid to try and conquer his drug addictions of heroin and crack cocaine.

After last year’s analysis of defunct Canadian medical tourism agencies, Leigh Turner from the Centre of Bioethics at the University of Minnesota in the USA has turned his attention to Canadian medical tourism agencies marketing of medical travel. The research is published in PubMed:
Background
Despite having access to medically necessary care available through publicly funded provincial health care systems, some Canadians travel for treatment provided at international medical facilities as well as for-profit clinics found in several Canadian provinces. Canadians travel abroad for orthopaedic surgery, bariatric surgery, ophthalmologic surgery, stem cell injections, Liberation therapy for multiple sclerosis, and additional interventions. Both responding to public interest in medical travel and playing an important part in promoting the notion of a global marketplace for health services, many Canadian companies market medical travel.
Research method
Research began with the goal of locating all medical tourism companies based in Canada. Various strategies were used to find such businesses. During the search process it became apparent that many Canadian business promoting medical travel are not medical tourism companies. To the contrary, numerous types of businesses promote medical travel. Once businesses promoting medical travel were identified, content analysis was used to extract information from company websites.
Company websites were analyzed to establish: 1) where in Canada these businesses are located; 2) the destination countries and health care facilities that they market; 3) the medical procedures they promote; 4) core marketing messages; and 5) whether businesses market air travel, hotel accommodations, and holiday tours in addition to medical procedures.
Results
Searches conducted from 2006 to 2011 resulted in identification of thirty-five Canadian businesses currently marketing various kinds of medical travel. The research project began with what seemed to be the straightforward goal of establishing how many medical tourism companies are based in Canada. Refinement of categories resulted in the identification of eighteen businesses fitting the category of what most researchers would identify as medical tourism companies.
Seven other businesses market regional, cross-border health services available in the United States and intranational travel to clinics in Canada. In contrast to medical tourism companies, they do not market holiday tours in addition to medical care. Two companies occupy a narrow market niche and promote testing for CCSVI and Liberation therapy for multiple sclerosis. Three additional companies offer bariatric surgery and cosmetic surgery at facilities in Mexico.
Four businesses offer health insurance products intended to cover the cost of obtaining privately financed health care in the U.S. These businesses also help their clients arrange treatment beyond Canada’s borders. Finally, one medical travel company based in Canada markets health services primarily to U.S. citizens.
Conclusions
This article uses content analysis of websites of Canadian companies marketing medical travel to provide insight into Canada’s medical travel industry. The article reveals a complex marketplace with different types of companies taking distinct approaches to marketing medical travel.

King Edward VII’s Hospital in London has received an international quality accreditation from DNV Healthcare, as it seeks to increase the number of medical tourists it serves.
The accreditation signifies the hospital has met a stringent set of standards, including clinical, management and environmental safety. It follows a recent Care Quality Commission review that found the hospital is achieving the best standards in patient care. King Edward VII’s Hospital Sister Agnes is an independent, acute private hospital in Marylebone, central London. It has been delivering high quality healthcare since 1899 and is in the heart of London’s West End and has 58 en-suites, private, air-conditioned rooms.
John Lofthouse of King Edward VII’s Hospital says, “The DNV accreditation is an important achievement as it shows we are meeting all requirements for providing the best in healthcare while meeting global quality standards. This world-recognised accreditation will be particularly reassuring to our growing body of international patients, who can feel confident they have access to the best consultants, nurses and facilities.” DNV Healthcare has 140 years of experience in setting safety benchmarks and is responsible for the set of risk management standards used by all NHS trusts in England. The requirements of DNV International Accreditation are based on standards developed by the US Government, and include annual reviews looking at all aspects of quality care and management.
DNV has developed the National Integrated Accreditation for Healthcare Organizations program (NIAHO) that blends ISO 9001 quality management with Medicare’s conditions of participation for hospitals. The result is a more streamlined accreditation process that captures best practices and turns them into standard practices across the organization, leading to sustainable, continual improvement. DNV is rapidly expanding its hospital accreditation services. Over 250 hospitals in the US have now switched to the new NIAHO accreditation delivered by DNV.
DNV has accredited hospitals in the USA, Czech Republic and Singapore. It is working with hospitals in China towards accreditation. Other countries being pursued include Brazil, India, and Thailand. DNV works with Macmillan Cancer Support to assess the Macmillan Quality Environment Mark (MQEM) for cancer care centres through the United Kingdom. The MQEM recognises facilities that give those affected by cancer the optimum environment for their treatment to take place. The MQEM is built on patient and stakeholder input, and focuses on dignity, comfort and respect for those using a service.

While the Prime Minister’s Office (PMO) seeks to expand medical tourism in Israel, both the finance and health ministries, who fear that more medical tourism will mean less service for Israelis, are strenuously opposing it. The tourism ministry is faintly supportive.
The ministries say local hospitals are already overcrowded and understaffed, and there is not enough room in medical wards. But medical tourism reaps a decent income each year for Israel, and both public and private hospitals take part.
Most medical tourists come from the former Soviet Union. An estimated 30,000 patients come to Israel every year for treatment; cancer treatments make up 80% of the market. But this 30,000 figure has now been in use for at least five years, well before the global recession. So the truth is that nobody really knows how many medical tourists there are and if the numbers have been increasing, steady or decreasing. What is clear that while medical tourists used to come from a range of countries, people from Russia and other former Soviet bloc countries now dominate the business.
The director general of the PMO, Harel Locker, met with senior officials from the finance, health and tourism ministries. He asked the participants to put together a plan to increase medical tourism. But the welcome he got was not what he expected. Deputy Health Minister Yaakov Litzman hit out with, "The health system is already operating at full capacity; there are no empty wards with extra doctors. So if we bring in more patients it will come at the expense of Israeli patients."
There is a two-tier price system with medical tourists being charged much higher prices than Israelis, about 50% higher on average. The hospitals argue that they charge medical tourists a fair price while what Israeli hospitals are reimbursed for by the state or health funds is too little. But government officials privately accuse hospitals of profiteering. Health and finance ministries are concerned that hospitals will give preference to foreigners and that this will lead to distortions in the allocation of resources. The ministries also fear that increased private medical care for tourists will lead to inflationary wages for doctors, which could upset the delicate balance keeping the health system functioning. Yaakov Litzman has his own solution: Take private medical tourism out of the public hospitals and move it exclusively to private medical hospitals and clinic. The goal is to prevent medical tourism from cutting into the operations of the public system.
After the meeting where the other ministries wanted to reduce medical tourism in public hospitals rather than increase it, all that a subdued and ego-battered PMO would admit was, "The matter is still under examination."
The hospitals with the largest revenues from medical tourism are the largest hospitals in Israel, including the Hadassah medical centers in Jerusalem, Sheba Medical Center in Tel Hashomer, Rambam Medical Center in Haifa, Ichilov Hospital in Tel Aviv and Assouta Medical Center in Tel Aviv.
State hospitals took in NIS 240 million in revenues from medical tourism in 2011, says the health ministry. This was a 50% increase over 2010.These figures do not include private hospitals or those belonging to Clalit Health Services, such as Hadassah, Assouta or Beilinson Hospital at the Rabin Medical Center in Petah Tikva. These hospitals are estimated to take in more than twice as much from medical tourism as the public ones do.
What attracts hospitals to medical tourism is that the amounts paid by foreigners are 150% of what the hospitals receive for treating Israelis. In addition, tourists usually pay immediately, or in advance, and the hospitals do not have to wait months for reimbursement, as they do from the state. Medical tourism also brings in hefty revenues for the Israeli tourism industry, as most patients are accompanied by family members who then stay in hotels and spend elsewhere, often for extended periods.
Most of the medical tourism industry operates via agencies and perhaps they should ask themselves if it is morally right for hospitals to charge medical tourists 50% more than locals.

A groundbreaking product from Passport2Health, a new entrant to the private healthcare insurance market, combines private UK diagnostics with private treatment abroad. This new medical tourism based plan offers rapid access to private hospitals overseas, including door-to-door, concierge-managed return travel and accommodation for the patient and a companion, plus after-care and travel insurance.
Customers have access to hospitals in Belgium, Cyprus, France, Germany, Gran Canaria, Israel, Malta, Portugal, Spain, and Turkey. Every hospital is selected for its English language capabilities, service quality and patient comfort. All hospitals in the network have been carefully selected and visited personally by members of the team
Pricing reflects the lower cost of European healthcare and efficiencies achieved through its international provider network and outsourced business model. The company operates a small core team with low fixed costs, supported by expert service providers for sales administration, customer service and claims handling, including clinical case management. With typical savings of up to 50% on conventional private medical insurance packages and from as little as £19 per month, the scheme combines high quality private diagnostics in the UK with private treatment overseas. One way savings have been made is to exclude cancer cover, partly because the insurer argues that long-term treatment for cancer is best done at hospitals near to home. It promises greater choice and faster access to affordable private healthcare for the majority of Brits financially excluded from mainstream PMI products.
Passport2Health founder Frank Levene says “For years, millions of people in this country have gone without health insurance for themselves and their families, but with Passport2Health they can now afford to take advantage of the same high quality healthcare enjoyed by our European neighbors.”
Insurance is underwritten in UK at Lloyd’s by Advent Solutions Management on behalf of Sirius Lloyd’s Syndicate 1945. Europ Assistance handles claims and clinical case management. Concierge services are run by Ten Group.UK scans are done by Alliance Medical and post treatment rehabilitation in the UK by Nuffield Health.
Passport2Health has developed its pricing structure to provide an affordable alternative to increasingly expensive personal policies, or a replacement for employee benefits that have been downgraded or withdrawn.
The product is aimed at small and medium sized businesses, the self-employed and individual clients. It is sold through selected health insurance specialists and insurance brokers, as well as direct online.
While the NHS is highly valued for emergency and urgent surgery, elective treatments such as angioplasty, hernias, hip replacements or cataracts can now be treated overseas without joining a long waiting list. Passport2Health says that procedures are scheduled as fast as possible, to suit the patient – normally within two to four weeks of diagnosis.
Customers initially contact their GP, followed by private specialist consultations and diagnostics in the UK. With the exception of cancer, patients are covered for the same types of surgical procedures as many other UK PMI schemes, including a wide variety of treatments in specialisms such as orthopaedics, ENT, cardiology and ophthalmology.
In the UK, there are some health insurances that allow customers to get treatment overseas, but it us totally up to the customer to arrange travel and treatment. All the insurer does is pay a very small fixed cash sum all subject to detailed receipts.
The mainstream UK health insurance market has set its head firmly against allowing non-emergency treatment abroad. There are international health insurances that allow treatment in multiple countries but these are very expensive compared to normal health insurance and are not aimed at the domestic customer, but people who effectively live in several countries over a year. There are insurances in Europe that allow some out of country treatment for specific policy sections-but none that allows full cover to apply across the EU.There are cross-border schemes but these are limited to 2 countries such as USA and Mexico, or USA and Canada.

Allianz Worldwide Care has launched Signature, a private medical insurance plan where treatment can be undertaken inside or outside the UK, in line with the trend for global mobility.
It has been designed for the UK based employees of small, medium and large corporate clients, predominantly those in senior management roles. The plan aims to provide corporate clients with a fully portable and transparent health plan which offers a high level of cover for cancer treatment, chronic conditions, routine maternity, routine health checks, dental and optical treatment. It is far from cheap.
There are two core plans to choose from: Signature Prime and Signature Plus, which cover a range of in-patient and day-care treatments as well as other benefits such as private ambulance, MRI scans and nursing at home. In addition to this, there are a number of optional add-ons to the core plan that cover out-patient treatment, routine health checks, GP visits, dental & optical benefits and maternity treatment.
It includes comprehensive cover for cancer treatment, for as long as it is medically necessary, even if the cancer is terminal. This includes access to licensed treatments not normally approved under the National Institute for Health and Clinical Excellence (NICE).
It includes cover for pre-existing/chronic conditions including on-going maintenance and routine monitoring. And cover includes an option for routine maternity and childbirth that includes complications of childbirth.
There is an option to have treatment overseas for any treatment covered under the plan, as well as cover for emergency treatment abroad. This is in line with the increasing global mobility of people. They now have the option to travel to get the best treatment, if necessary. Plus, for those with homes outside of the UK or who travel regularly on business, they have the convenience of accessing treatment locally.
Direct settlement is in place for in-patient treatment in all UK hospital groups and for out-patient treatment in the majority of UK hospital groups, but not overseas. It does not include any travel or accommodation for the patient and a companion, nor after-care, nor a concierge service.
Claude Daboul of Allianz Worldwide Care says, “We looked at existing plans and our findings demonstrated a distinct need for a product that also supports the geographically mobile nature of our customers. Health insurance in the UK has become very commoditised, so we took a bold approach in developing something new and somewhat revolutionary for the premium end of the market. The competition among employers for senior talent is fierce, and being able to offer a top-end employee benefit such as Signature can make all the difference in terms of attracting and retaining key staff.”
The insurer expects that more insurers will offer cover across borders but points out that few have the capability to do so as they lack the vital international networks. Based in Ireland, Allianz Worldwide Care specialises in providing international health insurance for employees, individuals and their dependants, wherever they are in the world. As a wholly owned subsidiary of the Allianz Group, the majority of services offered by Allianz Worldwide Care are developed, delivered and supported from within the group. This ensures a dependable and accessible service package that makes the most of local knowledge and on-the-ground support.

EURORDIS has prepared a questions and answers document to help people understand the EU legislation on cross border healthcare and to ensure its transposition into national law is favorable to rare disease patients.
EURORDIS is a non-governmental patient-driven alliance of patient organisations representing more than 510 rare diseases patient organisations in over 48 countries.
The document presents in 21 points, the main aspects to look out for when seeking to apply patient’s rights to cross border healthcare. For example, issues such as level of reimbursement, need for upfront payment, need for prior authorisation and reasons for refusal. It answers frequently asked questions such as: “Can I seek healthcare abroad if the treatment is not available in my country?” “Where can we find information on care provided in other Member States?” or “Can we ask for travel and accommodation expenses to be also reimbursed?”
The Directive on Patients’ Rights for Cross-Border Care was officially adopted in March 2011. It aims to help patients exercise their right to reimbursement for healthcare received in another EU country; provide assurance about safety and quality of cross-border healthcare and establish formal cooperation between health systems. This is especially important for rare disease patients who cannot find the right care locally or need to access a centre of expertise in another country.
Member States have until October 2013 to transpose the Directive into national law and adopt appropriate measures. During this process, patients and their organisations have an opportunity to assert the right of every EU citizen to healthcare in another Member State and to make their voices heard when implementing this legislation.
At a recent EURORDIS membership meeting in Brussels, patient advocates discussed why and how a patient organisation should influence the process taking the case of cross border healthcare between Belgium and the Netherlands and the case of Luxembourg.
Yann Le Cam of EURORDIS highlights how a new directive on cross-border healthcare will foster patient mobility and greater cooperation on rare diseases, “The directive clarifies the rules for patients to access healthcare abroad, and is especially important for rare disease patients and their families who cannot find diagnosis locally or need to access a centre of expertise based in another country. According to EU statistics, the demand for cross-border healthcare only affects approximately 1% of public spending on health, while the EurordisCare survey records that 2% of families affected by rare diseases have to seek diagnosis abroad.”
John Dalli, European Commissioner for Health and Consumer Policy adds, ’the directive will help patients who need specialised treatment, for example those who are seeking a diagnosis or treatment for a rare disease. Some rare diseases are not even recognised in some countries, let alone treated. Small countries often cannot offer the same medical services as bigger nations.” Nathalie Chaze of the European Commissions adds, "The basis of this directive is to reduce inequality, to assert the right to be treated in another member state and be reimbursed for it. The directive should benefit rare disease patients who seek diagnosis, treatment or care that do not exist in their state."
Patients seeking healthcare in another country that involves an overnight hospital stay or is highly specialised and costly will need to ask for permission from their national health authority in charge of reimbursement. The great step forward contained in this directive is that this prior authorisation can no longer be denied or postponed indefinitely, which often happens due to low knowledge and expertise on rare diseases by the authorities in charge of granting the authorisation. The good news is that travel for treatment of rare diseases not provided for in one’s country of affiliation cannot be refused.
While the directive applies broadly to all diseases in general, it recognises rare diseases for their specificities (rarity of expertise and patients, scarce knowledge, and limited therapeutic interventions) that require particular measures to organise and disseminate this expertise at the European level – through the European Reference Network – and to support easier patient mobility across the EU to access quality diagnosis and care. These new avenues are extremely important for patients and their families. Article 12 of the directive states that: ’The Commission shall support member states in the development of European Reference Networks between healthcare providers and centres of expertise in the member states, in particular in the area of rare diseases.’

Passport2Health, a new entrant to the private healthcare insurance market, is set to change the shape of UK health cover and challenge the high cost of traditional PMI.
With typical savings of up to 50 percent, and from as little as £19 per month, the scheme combines high quality private diagnostics in the UK with private treatment overseas. It promises greater choice and faster access to affordable private healthcare for the majority of Britons financially excluded from mainstream PMI products.
The UK’s first fully packaged cover for treatment abroad, Passport2Health provides rapid access to some of the finest private medical facilities internationally, including door-to-door, concierge-managed travel and accommodation for the patient and a companion.
Customers have access to some of the finest hospitals internationally, including those in France, Germany and Spain as well as Belgium, Cyprus, Portugal, Gran Canaria and Malta and soon to be added Israel and Turkey. Every hospital has been hand-picked by Passport2Health’s expert team for its exemplary clinical standards, and each is carefully selected for its English language capabilities, service quality and patient comfort.
Pricing reflects the lower cost of European healthcare and efficiencies Passport2Health has achieved through its international provider network and outsourced business model. The product is aimed at SMEs and individual clients and is being sold through selected PMI specialists and insurance brokers, as well as directly via the internet. Customers can deal with Passport2Health via the web, telephone, or through their intermediaries.
In addition to personal plans, Passport2Health will appeal to employers, particularly SMEs, as an affordable and attractive alternative to the spiralling cost of corporate schemes. The product is also ideal for the self-employed seeking affordable health cover, flexibility on dates and the earliest possible return to work.

With a population of just 142,000, the Dutch owned Curacao is hoping to attract American medical tourists to its one hospital, two private clinics, and four dental clinics.
In the Turks and Caicos Islands, at Cockburn Town Medical Centre on Grand Turk and Cheshire Hall Medical Center on Providenciales, a new form of medical tourism has been developed. Here, the patient stays on the island, but the medical team is flown in from the USA. Nine local residents received total knee replacements during a five-day visit by surgeons and staff visiting from Chicago. It was a long awaited relief for the patients, some of whom had waited a decade for the procedure. InterHealth Canada, operator of the two hospitals, contracted the surgeon through Global MedChoices, a US based medical tourism agency. The surgery was a test for a bigger plan to bring American patients to the country to utilize the state-of-the-art hospital facilities for orthopedic surgeries. This is particularly important for the Grand Turk facility, which is currently not used to its maximum potential. Renting the facilities to outside firms would create a potential new revenue stream for the cash strapped government.
In Barbados a group of American investors has decided to transform the derelict St Joseph Hospital in St Peter into a modern facility designed to serve foreign and local patients by recruiting US and Canadian doctors to buy time-share style membership in the renovated hospital and bring their patients there for surgery. American World Clinics (AWC) hopes to open the first stage of the new five-year project as AWC-Barbados in 2014. And a fertility centre in Barbados is successfully attracting couples from Britain and North America.
The idea of an exclusive drug and alcohol rehabilitation facility is being looked at by a Bermuda Hospitals Board (BHB) committee set up to explore opportunities for medical tourism. King Edward VII Memorial began offering a prostate cancer treatment unavailable in the US called High Intensity Focused Ultrasound (HIFU) in 2010, bringing hundreds of American medical tourists to the island. Other specialists are now offering cosmetic and weight-loss procedures at the hospital to patients from abroad in partnership with BHB. BHB subsidiary Healthcare Partners Limited offers concierge services for people going to Bermuda for medical treatment. Top US rehab organization the Caron Foundation already has a base in Bermuda, but Bermuda residents have to travel to the US for the actual treatment as the local clinic is only for contact and aftercare.
So far, despite much talk and promotion, the numbers of medical tourists going to Caribbean islands is very small and overshadowed by the increasing number of locals going to other countries for treatment. Florida hospitals get many medical tourists from the region and are stepping up promotional and marketing activity.
The Caribbean used to be a very important travel market for Puerto Rico but with economic turmoil in the region in recent years, the tourism market has suffered. Air Eagle has restored and added 250 flights from the USA and Caribbean that had vanished during 2007/2008. Mario Gonzalez-Lafuenta of the Puerto Rico Tourism Company says, “Medical tourism from the Caribbean is very important, and we have a new law right now that allows for additional promotions and allows for service providers in Puerto Rico to become more aggressive since they will be receiving incentives – credit incentives and tax incentives – from the government of Puerto Rico. We are developing a whole strategy to enhance and further medical tourism and increasing promotion in our primary markets.”

Jordan’s medical tourism sector is expected to grow this year but badly needs a strategy, says Zuhair Abu Faris of the Jordan Hospitals Association, which represents 23 hospitals, including 10 public hospitals. Although the country reports 170,000 international patients in the last twelve months, the figure includes 50,000 from Libya who are mainly war victims, while the remaining 120,000 also include many expatriates and travellers.
Jordan provides medical services for Arab countries including Libya, Iraq, Yemen, Sudan, Algeria, Palestine and the Gulf states, and several of these are involved in war, civil war or domestic problems. The country has so far failed to get medical tourists to attract significant numbers from Europe, America or African countries.
Zuhair Abu Faris argues that the private and public institutions need to work together to develop medical tourism, "We should formulate a national strategy for marketing Jordanian medical services and establish a national organisation.”
That co-operation is needed is shown by the way the problems of Libya are shunted backwards and forwards between various government departments and private hospitals. The Libyan government is arguing that it did not commit to payments to private hospitals and hotels in Jordan in return for Libyan citizens ’ medical treatment. The Libyan government continues to delay payments until it has audited the bills as it argues that some prices are too high and some bills are for cosmetic and other treatment unrelated to war injuries. The unpaid bill is US$140 million but as many Libyans are still in hospital, that is rising each month.
Dubai is also trying another medical tourism initiative to promote Dubai’s healthcare sector. Qadhi Saeed Al Murooshid of Dubai Health Authority says, “We will work with the private sector and key relevant government departments, airlines and tourism companies to ensure we develop successful medical tourism initiatives for Dubai,” The region is targeting patients from GCC countries, Middle East North Africa region (MENA), South Asia, Western Europe, Baltic States, Commonwealth of Independent States (CIS) countries and parts of Africa.
Iran too has new plans to expand medical tourism in the region. A health tourism committee has been formed with representatives of Foreign Ministry, Iran Medical Organization, Iran’s Cultural Heritage, Handicrafts and Tourism Organization, and the Commercial Chamber of Health Ministry. The committee aims to make health tourism policies, and is targeting Azerbaijan, Afghanistan, Iraq, Kuwait, Bahrain, Tajikistan and Kazakhstan. Iran already gets patients from Iraq, Oman, Qatar and Kuwait.
All three have similar problems in that they are among countries in the region all vying for medical tourists, often competing for the same patients. While they are doing this, an increasing number of wealthy residents of the region are going to Turkey, Germany, Switzerland and other EU countries.
Having new hospitals and the latest equipment is no longer enough to get new business. The price and atmosphere and quality of non-medical service are equally important. Because of the political turmoil in the region, few Americans or Western Europeans are going there as medical tourists; almost all those claimed as international patients are expatriates. One possibility is to target Eastern Europe and Africa, but for most of this business they are competing with Asian countries that offer much lower prices.

Proving that low prices are not the only way to get medical tourists, German hotels and hospitals are attracting an increasing number of customers from the Middle East whose key concern is luxury, comfort and attention to cultural needs.
Germany understands that to attract high-paying medical tourists from certain countries, you must pay attention to their religious, cultural, dietary and other needs. To this sector of the market, price is not important. But what does matter is attention to detail, high-level personal service and very comfortable surroundings. When this type of patient wants to talk to his doctor, they mean now, not in a few hours time when it suits the doctor. Failure to appreciate cultural needs is why many Middle East medical tourists are turning away from certain countries who just offer them their standard service, to places like Germany that understand their needs. Often they bring several family members and stay a long time for treatment and recuperation, so they spend a lot of money-in return they expect to get special treatment.
The Charles Hotel in Munich, part of the Rocco Forte Hotels group, is a leading hotel in the centre of Munich. With a high hospital density, Munich has become an attractive destination for patients travelling from the Middle East. Frank Heller of The Charles Hotel says, ’In 2011 over 70 % of our Middle Eastern guests were booking into our hotel for a medical stay. We collaborate with the best hospitals and surgeons in the city, offering Middle Eastern guests a home away from home while they recuperate in a luxurious and comfortable retreat. To cater to the specific needs of our Middle East guests, The Charles Hotel has an Arabic chef, rooms have a copy of the Koran and prayer mat, and there is an outdoor courtyard where guests can enjoy shisha. Other exclusive services include our personal limousine service and in-house medical concierge.” The hotel also offers luxury spa and wellness services.
Rocco Forte’s Villa Kennedy hotel in Frankfurt, works closely with Dr Ulrich Mondorf, an expert in illnesses common across the Middle East – diabetes, renal and coronary heart disease. Offering tailor-made check-ups for Middle Eastern visitors, Dr Mondorf provides international patients with high-quality medical care in a comfortable outpatient environment, allowing guests to relax and recuperate in a five-star environment. Another Rocco Forte hotel, the Hotel de Rome in Berlin, is within walking distance of top hospitals
German medical tourism is growing at 20 to 30% a year and much of this trade comes from the high spending Middle East. Residents from the UAE alone spend up to $2 billion in healthcare travel annually. Attracted by high quality medical and accommodation, and Germany’s excellent medical reputation, Germany is a leading destination for Middle Eastern medical travelers seeking top quality, safe and easily accessible healthcare.

An EU-funded project, the Adriatic Health and Vitality Network (AHVN), seeks to establish a co-coordinated system of health and medical tourism that spans everything from conventional and alternative healthcare centres to thermal baths and healing spas.

The Adriatic Health and Vitality Network (AVHN) has an overall objective to stimulate sustainable health tourism within and between the partner regions, increasing high-value tourist visits within the interrelated niches of medical tourism, alternative health tourism, spa and wellness tourism, and active lifestyles tourism.

By strengthening networks, the AHVN’s specific objectives are:
• To encourage high quality tourism products integrated with local and regional cultural and natural heritage offerings. This network aims to merge healthy food, good accommodation, recreational activities, medical and wellness services, and authentic culture into unique tourist experience networked throughout the Adriatic region.
• To enhance inland tourism and expand the tourist season, thus relieving some of the pressure from the current focus on high season seaside tourism.
• To train and network health tourism service providers from partner regions for high-quality tourism service delivery.
The project leader is the School of Economics and Business (Sarajevo, Bosnia and Herzegovina), where the project co-coordinator is Natasa Kovacevic. Partners in the project are Association Healthy Entrepreneur (Koper, Slovenia), City of Buzet (Croatia), Hotel Tartini (Piran, Slovenia) and Green Home (Podgorica, Montenegro).

The project is supported by the financial assistance of the IPA Adriatic Cross-Border Cooperation Programme.

As Balkan countries seek to boost revenues in the tourism sector, medical tourism is an increasingly attractive market.

Bosnia and Herzegovina is seeing an increase in dental tourists — primarily from Western Europe, but also from the USA, Australia and New Zealand -to take advantage of high-quality dental work and low prices. Most visitors come during the summer, and despite economic woes, most clinics in Sarajevo, have seen a steady increase in business year on year. Bosnia and Herzegovina is taking business from Croatia and Serbia, as prices are lower. Prices for dental treatment in Germany are five times higher, while in Spain, prices are nearly three times the amount. Like many Balkan countries, dentists use the same materials and have the same standards as Western Europe, with the latest technology and methods.

Many Balkan dental tourists are people who emigrated to Western Europe for better pay. AHVN seeks to widen the market to other Western Europeans. Dr Almir Pestek, of the Sarajevo Economic Institute, says that while the potential is good, BiH’s international image as a politically unstable country keeps tourists away.

The AHVN project expects to integrate a minimum of 50 tourism service providers into an Adriatic-wide medical tourism network, create industry-wide standards to be implemented across the region, and engage in a hard-hitting marketing campaign. There is a need for a comprehensive approach to the medical tourism industry across the region – and the project recognises the benefit of regional integration and support services. Health tourism requires a more active role of tourist associations in promoting this type of service, as well as of each state. Most countries here have developed medical and health tourism with little or no official support. The region has yet to fully tap the potential and if it gets organized will challenge better known competitors in Asia.

Croatia and Montenegro are already popular seaside resort destinations that have high-quality private medical and dental practices. Serbia is particularly strong on dental tourism, and Slovenia is an increasingly popular destination for cheap medical check-ups.

South Korea gets many tourists from Cambodia, Russia and the Philippines, and is now seeking ways to attract many more medical tourists from these countries.
The 24,000 Cambodians who visited South Korea during 2011 included about 100 people going for medical services, most of them high-ranking Cambodian government officials, according to Charm Lee of the Korea Tourism Organization. Lee says that medical care in Korea is less expensive than that in Singapore but more expensive than in Thailand.
Yeongcheon Son Hospital in Busan does get Cambodians seeking treatment and plans to open a clinic in Cambodia as soon as it can find a Cambodian doctor partner for the venture. Ang Kim Eang of the Cambodian Association of Travel Agents says increasing numbers of Cambodian people are starting to be able to afford medical treatment in Korea, “People who have new cars should be able to afford medical treatment in Korea.”
South Korea has set up its first tourism office in the Philippines aiming to target high- and middle-income Filipinos to become medical tourists in Korea. Charm Lee of the Korea Tourism Organization (KTO) says the office will not only promote tourism in Korea but will also help Philippine travel agencies, tour operators and airlines in getting Filipino travelers to Korea by promoting would promote tour packages at reasonable prices for Filipinos, “KTO is targeting high-income as well as middle-class Filipino citizens.”
There were some 337,000 Filipino tourists in Korea in 2011 and the KTO aims to accelerate the trend. Filipinos account for 3.4 % of the total number of 9.8 million foreign visitors in Korea in 2011. Lee explains why Filipinos may want to go to Korea for medical treatment, “Korea’s medical services are at a high level not only for Western medicine but also for traditional Korean medicine. We are very strong on spinal and disc problems and have very high success rate with these specialist treatment. Korean medical tourism offers high quality healthcare at a competitive price. The level of our service and technology is very high but the price is low compared to Europe. We are a bit more expensive than Thailand but our environment is much better and safer.”
The number of medical tourists seeking services in Korea has risen over the years. The number in 2007 was a low 7,900 but jumped to 60,201 in 2009, and climbed further to 81,789 in 2010 and 110,000 in 2011.
Russia is potentially a big market with visitors surging from 1,758 in 2009 to 5,089 in 2010 and 9,000 in 2011. 30,000 from Vladivostok go abroad every year for medical treatment. Three years ago, only a few hundred went from Vladivostok to Korea, but in 2011 there were 9000. Three years ago, Korea set up a medical consulting office in Russia, staffed by doctors.
Advanced Healthcare Partners has partnered with Henghao Consulting to form a medical tourism company with a focus on cardiovascular surgery. It targets patients from China and Russia to travel to Konkuk University Medical Center in Seoul, South Korea. The hospital uses heart valve replacement techniques and equipment developed there by Dr. Meong-Gun Song, where he has performed more than 1300 surgeries using the techniques. AHP has offices in Hong Kong, and in Vladivostok, Russia.

Both Singapore and Bali attract high-paying medical tourists by offering much more than basic hospital accommodation.
Singapore’s Raffles Hospital has designed a new class of private rooms with the culture-specific needs of Middle Eastern patients in mind, providing a more pleasant healing process while receiving quality medical care. Gulf patients are offered a home away from home.
Mohamed Hafez Marican of Singapore Tourism Board says, “Raffles Hospital has taken a very proactive approach to enhancing services for international patients, specifically those from the GCC and Middle East. This patient-centric initiative conveys Singapore’s commitment to providing quality healthcare.”
Each of the new rooms provides Middle Eastern and Gulf in-patients with a multitude of amenities, which aim to aid the patients’ recovery more quickly, and with peace of mind. It includes a Qibla, Quran, and prayer mats; Arabic-language media and entertainment; extra living space for family members and visitors; and a menu offering a variety of Halal Arabic cuisine. The hospital also offers Arabic-language concierge services for patients and their families, including translation services, appointments, and airport pick-ups and transfers. All services are conducted by both male and female Arab doctors and staff.
In Bali, BIMC Hospital Group has a new partnership with the Courtyard by Marriott Bali to provide the country’s first ever medical tourism packages and services to inbound travellers visiting Asia’s most popular island destination.
The hotel is next to the hospital in Nusa Dua. The Courtyard by Marriott Bali has added specific aftercare services in preparation for the launch of the hospital. Jeff Tyler of The Courtyard says, “Ahead of BIMC Hospital opening, we began planning and training for the best of comfort and care the moment a guest returns to the resort from their medical procedure. We carefully looked at services that aid in recuperation such as special diets and nutrition, unique spa and wellness programmes as well as ensuring wheelchair access to all areas of the property.”
The 50-bed hospital is set in a one-hectare site. BIMC Nusa Dua is the group’s second hospital to open in Bali. Within the hospital are a dialysis centre, cosmetic surgery centre and dental clinic. The two-storey BIMC Nusa Dua Hospital is a 30-minute drive from Bali’s Ngurah Rai International Airport.

The government has begun to support Polish medical tourism with a promotional campaign funded by the EU. The Ministry of Economy has identified medical tourism as one of fifteen high export potential sectors.
Medical tourism has become the one of the priorities of the Polish export policy for the period 2012 to 2015. The main advantages being promoted are easy access to high quality services at lower costs than in Western Europe. The costs of medical treatment in Poland can be up to 40% lower than Germany or the UK, and even more compared to US prices.
The promotional programme for Polish medical tourism began in April 2012 and will last 36 months. The budget for the project is a million Euros. The main target markets are: Denmark, Sweden, Norway, Germany, Russia, UK and USA.
The campaign will see sponsored participation of Polish hospitals and clinics at medical tourism conferences and exhibitions in Russia, UK, Germany, Denmark and the USA. And there will be new co-branded information and promotional materials for the medical tourism sector plus films, videos, brochures, catalogues and a new on-line portal.
There will be trade missions and study tours for foreign journalists and foreign companies to Poland; organized training for representatives of medical tourism, companies; plus business meetings and match-making sessions with companies, associations, and institutions.
The activities are being organized by a consortium of PAIiIZ (Polish Information and Foreign Investment Agency), EuCP (European Center for Enterprise) and Ameds Centre. PAIiIZ will be responsible for organization of international conferences, exhibitions and media study visits to Poland. Ameds will recruit candidates to participate in international events and training as well as be responsible for the publication of informational and promotional materials; EuCP is responsible for contacts with the ministry and paying for the project.
New mystery shopping research at medical tourism and hotel/spa facilities in Poland has assessed the standard of care of potential medical tourism customers. Several facilities were contacted by email during spring 2012 and asked for medical/spa help in most common procedures. 7 out of 10 contacts made by potential clients (email or website form enquiry) were lost meaning that approximately 70% of potential clients were not contacted by the medical tourism facility reception or coordinator. This shows more is needed in basic customer contact, plus training on how to collect medical data, personal needs and detailed information from medical tourists.
The response to online enquires was mixed with 2 out of 3 contacted and given detailed guidance. But one out of three were never contacted by phone or email and website information was often poor.
But among hotel/spa facilities the responsive rate was almost 100% as these businesses are more experienced in customer care management. The study shows how new the medical tourism customer care business in Poland is and that it needs to improve standards to those in the hotel/spa/wellness sector.

Many transplants use legally obtained organs, but despite many laws to stop it, the global trade in illegal kidneys and other replacement organs is under scrutiny. An illegal network of organ traffickers is making profits by buying kidneys from vulnerable individuals in developing countries and selling them on to wealthy people desperate for transplants. Doctors and hospitals can make significant profits, often with little risk of legal comeback.
According to the World Health Organization, there are 10,000 illegal transplants around the world each year. So, one in ten of all transplants use illegal organs. People in need of a kidney transplant pay up to £128,000 in countries such as China, India and Pakistan, where organs are harvested from vulnerable people who may receive £3,000 or less. One Chinese organ broker has an advertising slogan ’donate a kidney, buy an iPad’.
The practice of selling kidneys and organs is illegal in most countries. Performing a legitimate transplant is an incredibly complex procedure involving scrupulous medical tests and a range of measures to prevent infection and organ rejection. Purchasing a kidney from the black market offers no guarantees about the quality of the organ supplied or patient safety. Those in need of a transplant should not consider illegally purchasing a kidney, as it places them at great risk.
Trading in organs, either from living or deceased individuals, is illegal in many countries, or goes against the World Health Organization’s ’Declaration of Istanbul’, which sets out the circumstances and principles that should guide organ donation and transplantation. It states, “The allocation of organs, cells and tissues should be guided by clinical criteria and ethical norms, not financial or other considerations. Cells, tissues and organs should only be donated freely, without any monetary payment or other reward of monetary value.”
Organ donation involves extracting organs from living or recently deceased people and offering them to people in need of a transplant. Transplantable organs such as a kidney, heart or lung are surgically removed and transferred to the person in need of the organ through an operation. The most common organ donated by a living person is a kidney, as a healthy donor can continue to lead a normal life with only one functioning kidney. Organs such as a heart or lung can be transplanted after a person has died and there are standards and procedures that allow this to happen if the consent of the person donating the organ is given. The number of people in need of a transplant is expected to rise steeply due to an ageing population, an increase in people with kidney failure and scientific advances that allow a wider range of people to benefit from a successful transplant.
But for every one person getting a legal transplant, there are ten more in the queue, often dying before it is their turn. This increasing global shortage of organs has prompted an increasing number of organs to be donated by living people, both legally and illegally. The most common organ donated by a living person is a kidney, as a healthy person can continue to lead a normal life with only one functioning kidney. Kidneys are estimated to make up 75% of the global illicit trade in organs.
Although many countries have laws against illegal organ transplants, few have the resources, ability or even will to seek out and prosecute offenders. While commercial transplantation is forbidden in China, the authorities are too terrified to challenge the chief suspects, hospitals run by the politically powerful Chinese Army. With foreigners of Chinese descent are prepared to pay up to $200,000 for a transplant, the temptations are great for poorly paid Chinese doctors and officials.
Investigative journalist Scott Carney’s book "The Red Market: On the Trail of the World’s Organ Brokers, Bone Thieves, Blood Farmers and Child Traffickers" is the result of five years spent tracing the lucrative and deeply secretive trade in human bodies and body parts – a multibillion-dollar underground trade where very ill rich people and desperate poor people are both exploited by a well-organised global business that is a mirror image of how legitimate businesses trade around the world.
A report from the Salvation Army has revealed the case of an adult female brought to the UK by a trafficking gang, for the sole purpose of having her organs harvested for sale. The Salvation Army says that this is the first case of this kind that they have come across, although the practice has almost certainly operated beneath the radar for some time.

The Turkish government will soon decide where, or perhaps if, to place one or more new free health zones. The Ministries of Health, Economy, Tourism are deciding the alternative merits of Istanbul, Ankara, Antalya, and Diyarbakir. The logic is to base it on the Dubai Healthcare City free zone so that new hospitals and clinics targeting medical tourists are in one area along with teaching hospitals and medical companies.
Diyarbak?r claims that its economic and health infrastructure for patients and health tourists from Iraq, Syria and Iran, make it the best location. Free zones are areas in which special regulatory treatment exists for companies inside, to promote exports of goods and services. Much may depend on whether or not US investors are prepared to put money behind so far vague promises of interest. Other problems are that Turkey’s health and medical tourism sector is scattered, and may see this as unfair competition; while despite enormous expenditure Dubai has mainly attracted locals and expatriates and very few real medical tourists.
The number of medical tourists in Turkey is now 130,000 annually, and another 250,000 go for thermal tourism, rehabilitation and services for the elderly. Turkey provides both quality and affordable health services. Many people that live in the region travel to Turkey to take advantage of these services. Often overlooked are the retirement communities and services that cater to the elderly population who go to Turkey for many months each year during the coldest winter months at home, particularly from Scandinavian countries.
Another growth area is the increasing number of people going to Turkey for dental treatment. The vast majority of medical and health tourists come from Western Europe, but increasing number come from the former Soviet bloc and Middle East countries – the latter often switching to Turkey from Gulf/Middle East countries that are at war or in political turmoil.

Although exact numbers are not available, indirect evidence from hospitals and clinics and medical tourism agencies says that Costa Rica is getting more medical tourists, almost all from the USA. It is also beginning to get more business from Latin America.
Costa Rican vice president Luis Liberman claims, “We have the doctors, we have the dentists, we have the whole operating system of a public-private medical system that is reaching high quality levels of service and medical care.”
Medical tourism generated $288 million in Costa Rica in 2010, with an estimated 36,000 medical tourists visiting the country in 2011, according to the government. In 2014, the industry is expected to generate 800 million and attract 100,000 visitors to the country. All these figures are ’guesstimates’ rather than actual numbers.
For Nova Dental Advanced Dental Center, 95% of all business is from overseas, and the majority are US or Canadian citizens. At Clínica Bíblica Hospital in San José, 18% of patients are from overseas, and the international services department expects numbers to grow.
Imago, a distance-learning company that offers digital training courses to members of the tourism industry, has added a virtual medical tourism course to train tourism workers to be ready to deal with foreign patients.
But Costa Rica expects growing competition from both Nicaragua and Colombia. Hospital Metropolitano Vivian Pellas in Managua, Nicaragua, is planning to become a destination for medical tourists. Foreigners or Nicaraguans who live outside the country already account for 8% of patients at this hospital. While Colombia has problems on security, Nicaragua can compete with both Costa Rica on price and Mexico on security.
At the very busy Dr. Marco Munoz Cavallini International Dental Clinic in Costa Rica, 90% of the patients are from overseas, and the numbers have risen during 2012. Although the clinic advertises, most new business comes from recommendations from former patients and comments on blogs. Dr.Cavallini comments why he thinks foreign patients are attracted to the clinic, “The wide variety of dental services we offer is a plus. But our relevance comes from having our own on site laboratory. We can assure our patients not only prompt quality rehabilitations but also more efficient procedures that translate in time and money savings for everyone. Additionally, our lab has state of the art facilities, with the most recent and efficient high-tech equipment such as the CAD CAM, which gives the option to digitally design and build crowns, this is the latest computer technology applied to dental restorations. And we have highly trained personnel making high quality temporaries, great looking porcelain crowns and zirconium crowns and bridges. We do many full mouth restorations.”
And the clinic is the only one in the country with an on-site hotel. Dental schedules are coordinated between the clinic and the dental recovery centre so they go from their bedroom straight to dental treatment rooms. It is a small hotel with only 12 rooms, but it has all the comforts including wi-fi, air conditioning, and small refrigerators.

The Japanese government is planning to launch a new system of certifying hospitals and clinics involved in medical tourism, as Japan seeks to establish itself as an attractive destination and belatedly attract visitors from overseas.
Although Japan’s high quality medical care does attract some visitors to the country from Asia, it is only now slowly recovering from last year’s earthquake. Erwin Gonzales of medical tourism agency Japan Medical Tourism reports losing many customers in the wake of the disaster. Japan Medical Tourism had been getting 60 customers a month before the disaster, but afterwards numbers dropped to zero. Numbers began to increase last autumn, but are still only around one-third of pre-quake levels.
A handful of hospitals in Tochigi and Tokushima are offering treatment to Asian customers, but the industry is scattered and disorganized. Kameda General Hospital in Kamogawa claims 1,000 foreign visitors a year, but it is unclear how many of these are actually medical tourists. It is now targeting well-heeled visitors from China, and the international patient centre appointed a Chinese doctor as its supervisor. Most foreign visitors to the hospital pay for their expenses out of pocket, which generates a large amount of profit for the hospital.
By introducing a new medical tourism certification system, the Health Ministry aims to increase the number of hospitals across the country prepared to receive overseas visitors and create an environment where international patients feel comfortable to receive medical care. An independent expert panel will screen hospitals based on various criteria, including whether or not it offers surgery consent forms in foreign languages, a consultation desk for foreign patients, interpreters and vegetarian menus.
The Japan Tourism Agency claims that Japan gets 70,000 medical tourists a year, but how it arrives at this figure, whether or not includes all international patients is a mystery. It is almost certain that the figure includes the more established spa/health and wellness tourist industry. The Development Bank of Japan estimates that by 2020 there could be 430,000 patients from overseas, but this is more a declaration of hope rather than a realistic estimate, and it has been making the same prediction for 4 years.
The government aims at increasing the number of foreign patients as part of its new growth strategy, as Japan lags behind other countries despite its high medical standards. By 2020 it aims to become the top destination in Asia for advanced medical care and checkups, but unless Singapore, Thailand, Malaysia and China all decide to pull out of medical tourism, that is likely to remain a pipe dream.
In January last year, the government created a medical visa for foreigners who visit Japan for medical care. However, the visa had been issued only in 122 cases between January 2011 and May 2012. The spread of medical tourism in the country remains limited due to the Great East Japan Earthquake. Both the visa numbers and general effect on tourism throw great doubt on the bank’s estimate of medical tourism numbers.
Professor Toshiki Mano of Tama University comments, "An increase in the number of foreigner-friendly hospitals would lead to improved medical care in Japan. Japan lags behind other countries in developing a system to accept foreign patients. I believe the certification system will be the first step."

UK online publishers, Intuition Communication, have launched a new medical travel web site aimed at infertile couples. Fertility Treatment Abroad gives infertile couples the information they need to make the right choice of infertility clinic in another country. The site features leading infertility clinics and treatment providers in over 50 countries. It’s a comprehensive online resource for people wanting to find out what’s available, how much it costs, what the success rates are and then to get in touch with their preferred clinics.
A unique feature of Fertility Treatment Abroad is the “Good Practice Score” which is based on compliance with the ESHRE Good Practice Guide for cross-border reproductive care. ESHRE, the European Society of Human Reproduction and Embryology, is working hard to ensure high-quality and safe, assisted reproduction treatment for international patients; Intuition are keen to see the ESHRE Good Practice Guide adopted by clinics, centres and physicians providing fertility treatment to foreign patients. The Good Practice Score applies a rating on 20 different factors to create an overall compliance score for each clinic.

Key features of the site• Search – Patients can search a database of information on over 500 fertility clinics around the world. The initial search is based on a selection by type of treatment and by country.• Filter – Visitors narrow down their search by filtering results according to their preferences, such as number of procedures undertaken, price for IVF, upper age limit, whether sex selection is available, whether donor anonymity applies.• Compare results – Visitors can select a shortlist of clinics and compare profiles, prices, success rates at these clinics. • View clinic profile – Extensive profiles are available for participating clinics. Basic information is provided for non-participating clinics.• Clinic updates – Clinics can update their profile online, and can manage their response to enquiries received through the site. There are opportunities for creating additional content by providing patient stories and infertility articles for publication on Fertility Treatment Abroad .
According to Keith Pollard, Managing Director of Intuition, “With FertilityTreatmentAbroad, we want to help infertile couples to make an informed choice of fertility clinics abroad. There are some excellent fertility clinics offering world-class treatment around the globe but many people struggle not only to find the right treatment option but also to identify the best place for them to go in terms of quality of treatment, patient services and the type of destination.”

Despite safety concerns in a few border towns, Mexico continues to see a boom with Americans seeking low price surgery or dental and cosmetic treatment. There is nowhere else in the world where millions of Americans have access to hundreds of hospitals and clinics where they can drive there and back in one day. Although the Peso is the official currency of Mexico, US dollars are also widely accepted.
The Mexican border town of Mexicali is making a push for more tourists from the American Southwest to visit the city’s dentists, surgeons and doctors. Medical tourists from the USA with the right documents can skip much of the wait on the Mexican side of the border by using a new designated medical tourism lane. Mexicali’s tourism director Omar Dipp, says the new lane is one part of the city’s plan to boost medical tourism by 50%, "You can now drive to Mexicali, take care of your health, and only take 20 minutes to cross the border instead of two hours."
American patients must request a pass from Mexican doctors who are participating in the programme. That pass, plus a doctor’s receipt and foreign license plates, will allow patients access to the special lane. Once in the lane, vehicles can bypass the traffic on the Mexican side of the border crossing, and cut to near the front of the line. Mexicali is promoting the medical tourism lane in Arizona, Nevada and California to persuade more residents there to visit Mexicali doctors. Patients who go to the Mexicali area for affordable medical services also stay in hotels, eat in restaurants, use taxis and attend shows. One problem is that the shortcut only works on the Mexican side, since medical tourists can still be subject to delays from U.S. Customs and Border Protection agents. To avoid abuse, Mexicali tourism officials are requiring participating doctors to sign a contract with the tourism board to ensure they only give passes to foreign patients who are crossing the border. Each pass costs the doctors $4.
Mexico City is raising its profile as a centre for medical tourism with a campaign aimed at residents in Chicago and other cities with large Mexican immigrant populations who need cancer treatment, heart surgery, dental procedures and other health care. The marketing campaign is focusing on Mexican immigrants and Mexican-Americans in the USA, starting in Chicago, Los Angeles and San Diego. Although there are no statistics on how many US patients travel to Mexico City for health care, local health officials say that have been climbing since it began promotions in Chicago and other US. Among the services being promoted in Mexico City are organ transplants, diabetes care, gastrointestinal procedures and fertility treatment, with the costs 40 to 80% cheaper than those in the USA.
A number of clinics in Mexico are located very close to the US border, and many patients opt to travel to these places and return home the same day. The proximity of the location is a major factor for American medical tourists in addition to the significantly lower prices. Cosmetic surgery, obesity treatment and dental treatment are on offer in places such as Tijuana. Crime in Tijuana is a problem but less common in tourist areas.

The first ever national strategy to promote all forms of inbound tourism to the USA, and make it quicker and easier for people to enter the USA as visitors, will help US hospitals promote inbound medical tourism, and may even get people to think twice before looking overseas.
The National Travel and Tourism Strategy promises federal support for travel in a way never before seen in the U.S. The strategy mandates the creation of a National Travel and Tourism Office within the Commerce Department. It also sets an ambitious goal of attracting 100 million foreign visitors annually to the USA by 2021, up from 60 million in 2011.
The new National Travel and Tourism Office gives the industry a major platform for influencing policies across the federal government. The office will be the central driving force for travel and tourism policy in the federal government.
The strategy includes more steps to ease entry for foreign visitors; a promise to better coordinate federal programs that affect tourism, and government support for travel-related research.
Roger Dow of the U.S. Travel Association comments, “The travel industry is very, very excited about this. A national strategy is finally here, and we have been talking about it for 16 years.” Tony Gonchar of the American Society of Travel Agents (ASTA) adds, “It acknowledges the role travel agents play in driving international visitors to the United States. I am pleased to hear the White House’s promise to work more closely with private-sector entities and trade associations in policy development.”
The new strategy recognizes the travel industry’s importance to economic growth and job creation. Travel and tourism contributes $125 billion in service exports to the economy, making it the leading service sector contributor to the balance of trade.
The strategy sets forth an ambitious goal of making the USA the world’s top travel destination by the end of 2021. If it succeeds in attracting 100 million international visitors annually, they would spend an estimated $250 billion.
The strategy also includes the first ever promotion to encourage Americans to travel across the states, and this could give a new impetus to domestic medical tourism.
The 10-year five areas of focus are:• Promoting the United States by capitalizing on the growing demand for travel and tourism in the USA, creating a positive and welcoming message for international visitors.• Enabling and enhancing travel and tourism to and within the United States by working to reduce institutional barriers to the free flow of trade in travel services; expanding the Visa Waiver Program; enhancing U.S. visa processing; expanding trusted traveller programmes and expediting screening initiatives; and improving the processes for arrival and aviation security screening initiatives.• Providing world-class customer service and visitor experiences that will inspire repeat visitation and positive word-of-mouth.• Coordinating across government to prioritize its support for travel and tourism, better coordinate Federal policies and programs, engage more deliberately with partners, encourage coordinated Federal participation in public-private tourism collaborations and establish a national travel and tourism office to provide leadership and focus within the federal government.• Conducting research and measuring results to ensure continual progress on the important goals and strategies outlined in this National Strategy.
In key growth markets for international travel, such as China and Brazil, visa interview wait times have already dramatically decreased. The Department of State is making improvements to existing facilities in key markets such as Mexico and India and investing in two new consulates in Brazil. A new pilot programme for first-time visitors to the United States is streamlining the visa renewal process for certain low-risk, previously interviewed visa applicants.
In addition to efforts to streamline the visa process, the Department of State will continue to work closely with Brand USA, the public-private partnership charged with promoting travel to the United States.

Medical tourism has been identified as a lucrative market for many Central European countries.
Tourism promotion agency CzechTourism has launched Internet campaigns targeting Britain, Russia and other post-Soviet states, Germany, Switzerland, and several rich Arab countries. It is promoting the country’s reputation for high quality and low price surgical, dental and cosmetic treatment, with the aim of attracting more medical tourists to the country. Iveta Jakoubková of CzechTourism says, “Most of the interest at the moment is for various types of cosmetic surgery, while obesity treatment is also popular.
The latest advertising initiative follows on from the publication last year of the first comprehensive catalogue of surgical and health treatments offered, the “Medical Tourism Guide Czech Republic”, in English, German, and Russian versions. Foreigners are already attracted to the Czech Republic for various types of operation, including fertility treatment, eye operations, dental treatment, and simple surgery.’
CzechTourism admits that no statistics are kept on the number of visits to the country for various medical or cosmetic treatments offered by specialized clinics or in some of the country’s biggest hospitals, but there is a clear impression that interest in the country is rising in what is identified as a booming market. Estimates put the cost of various health and cosmetic treatments in the Czech Republic at around a third or quarter of what they would cost in Western Europe, Russia or the Middle East.

HealthCzech, another medical tourism portal, provides information about healthcare services available in the Czech Republic and is part of the Treatment Abroad group of specialized medical tourism websites owned by Intuition Communication.
With a growing reputation for excellent dental services and prices 40% to 60% lower than those in the UK or Germany, many Europeans head to Hungary for dental treatment.
The Hungarian Prime Minister Viktor Orban emphasised the growing importance of this sector at a conference on dental tourism at which he announced that it generated some €227 million a year for Hungary. He took the opportunity to sign an agreement of co-operation with medical companies to push the development of dental tourism programmes. Hungary claims that it already has a 40% share of all trips in search of dental services.
To preserve its advantage over other countries, spa and dental tourism is to receive financial incentives of €117 million from the Hungarian Government. The scheme will help to modernise the sector, financing technical improvements, and will also provide grants to Hungarian practitioners to prevent them emigrating at a time of deep economic difficulties in the country. The government hopes to double the number of foreigners coming for dental care by 2014 and to treble it by 2016.

Several African countries want to reduce the flow of outbound medical tourism, mostly to India, and eventually become local medical tourism destinations.
While several African countries are promoting themselves as developing nations where local and inbound investment can flourish, the image that annoys local politicians is that local healthcare is so poor that many have to go abroad. Apart from on the Northern coast, medical care across many countries in Africa is generally poor and patchy, so those able to pay will often look elsewhere.
The Ministry of Health has initiated a policy to make Ghana a health tourism destination in Africa by creating specialized health centres of excellence for the treatment of complicated diseases. The logic is to attract people from all over Africa to Ghana to seek medical care for complicated diseases. The Korle-Bu Teaching Hospital (KBTH) in Accra, the Komfo Anokye Teaching Hospital (KATH) in Kumasi and the Tamale Teaching Hospital (TTH) in Tamale have been earmarked to play a leading role in the health tourism initiative, with the private sector providing the requisite partnership.
Another location will be the Sweden Ghana Medical Centre (SGMC), a cancer treatment centre in Adjirigano, near Accra. It is a modern clinic of international standard. Services provided include curative radiotherapy treatment, chemotherapy, pain control programmes, psychosocial support, clinical trials for treatment improvement, cancer prevention programmes and patient education programmes. When the project is fully completed, the centre will provide more advanced radiotherapy, more basic diagnostic equipment, a 50-bed hospital, a bigger, ultra-modern chemotherapy suit, a patient hotel and the integration of other medical specialties. And another will be the new private orthopedic medical centre at Pantang near Accra.
The ministry claims that the rate of exodus of medical professionals in Ghana to overseas was reducing, with many Ghanaian medical experts returning home.
In Nigeria, the minister of health, Professor Onyebuchi Nwosu, has ruled that public officers will no longer be allowed to travel for treatment that could be handled by hospitals in Nigeria. One of his predecessors, Professor Babatunde Osotimehin, valued the losses Nigeria incured on medical tourism at $200million each year.
The minister argues that while public servants have a right to choose their medical care, it is not right for people entrusted with maintaining medical facilities in the country to use public money to go overseas. But the ban list does not include all elected and appointed government officials in the presidency and the National Assembly.
Professor Onyebuchi Nwosu says that public officers should not use public funds to finance their trips. The key is to mend the infrastructure and engender professionalism in the health sector to discourage wealthy and not-so-wealthy Nigerians from travelling abroad for medical help
It does not help that that some Nigerian doctors make a lot of money from referrals to foreign hospitals. The minister alleges that every month at least 3000 Nigerian patients travel abroad for medical tourism monthly and, about 1000 are mis-diagnosed. Some patients have died on their flight back to Nigeria after some complicated heart surgeries. While some go overseas for surgery, others seek cosmetic treatment or to have babies delivered.

The Cyprus health minister Stavros Malas has travelled to Libya to investigate attracting patients from Libya to Cyprus for medical treatment, “The Libyan government asked us over to discuss the policy of sending public patients to Cyprus as they do mostly in Jordan, but also to a certain extent in Greece and Italy. It could prove to be an economic boost for Cyprus, as well as providing a service to Libya.”
But the Cyprus government has ruled out using public hospitals as Stavros Malas explains, “Public hospitals are already stretched to the limit. Public hospitals cannot respond to this task because of their workload. The Libyan patients will be paying for the service in private hospitals for pediatric surgery, heart disease, brain cancer and oncology.
The ministry may also consider sending Cypriot healthcare experts to help run Libyan hospitals. There is a snag or two; the Cyprus government of Dimitris Christofias was one of the few open supporters of the deposed dictator Gaddafi. The minister of health is pushing a private sector initiative when the public sector is in crisis.
Private Cyprus hospitals are buckling under the pressures of the financial crisis, maintaining minimum nursing staff or even being forced to close, according to Marcos Agathangelou of the Pancyprian Association of Private Hospitals, “The last two to three years have been bad and especially during 2011, which was the worst year that private hospitals have seen. The situation is unprecedented and insurmountable. 60 out of 130 of the smaller private hospitals have been forced to close over the last few years. One of the main causes is that a lot of these hospitals rely on medical tourism and as a result the services they provide are seasonal. There are private hospitals in Paphos and Ayia Napa where for six months they maintain the same level of nursing staff even though there is a 90 % drop in the number of patients. An increased number of Cypriots are now using state hospitals too, resulting in many private hospitals losing a significant number of Cypriot patients. There are hospitals that have gone ahead and fired some of their nursing staff and are maintaining a minimum number in accordance with the law, just so there are enough nurses to ensure the safety of patients.”
The Cyprus delegation to Libya wants to reactivate agreements they had with the Gaddafi regime. When in Libya, Stavros Malas gave more information on the talks, “We want to explore ways of offering our medical services not just to Libyan patients that were injured during the war, although that is also a possibility, but we are here to offer specialist services to adults and children in orthopedics, eye specialists, spine surgery and MRI diagnostics. We want to organize a tight well-regulated service in Cyprus for Libyan people. We have enormous capacity in the private sector under the coordination of the government. The private sector has agreed to offer these services not on comparative bases but all offering the same services at the same prices.”
There is one area that Cyprus hospitals may want to clarify. The Jordanian government offered a similar deal on behalf of private hospitals, rather than allowing direct negotiations. But Jordan’s private hospitals are struggling to get paid the money owed by the Libyans and the Jordanian government does not guarantee any bad debts. Perhaps the Cyprus hospitals should insist on a deal that is negotiated for them by the government, with bills paid by the Libyan government, that the Cyprus government guarantees to pay up if the Libyans default or delay on payment.

Local doctors argue that Pakistan should promote medical tourism as it offers excellent treatment at very low costs. It used to attract more patients from overseas, but after legislation came into place to regulate the illegal trade of selling kidneys, numbers plummeted.
At present, almost all medical tourism is outbound. Pakistanis travel abroad for treatment even when Pakistan has specialists and high-quality hospitals where comparable care is available. The cost of infertility treatment abroad can be many times that at home. It does get a tiny handful of patents from the UK and USA and the Middle East, but most foreign patients are of Pakistani origin.
Dr Samrina Hashmi of the Pakistan Medical Association argues there is huge potential for Pakistan in medical tourism, as the cost of treatment in Pakistan is only 50% of what doctors and hospitals charge abroad, “In the past, a sizable number of such globetrotting patients came here for kidney transplants. But it is not cost that puts people off Pakistan, it is safety.” Dr.Hashmi says medical tourism can be a huge opportunity for Pakistan if the government improves the security situation and the infrastructure, and then promotes the country to target markets.
The real stumbling block is that in Pakistan, some doctors work as agents for foreign hospitals; earning commissions if they send affluent Pakistani patients for treatment to their patron hospitals. Dr Mian Atif Fayaz has an office in Lahore and promotes Bumrungrad International hospital in Thailand online and via email. His company, globalhealthtravel.pk, a web-based company gets a processing fee from the patient and a fee from the hospital. Doctors say there is nothing illegal about marketing for hospitals based abroad, but it does little to promote Pakistan at home or abroad.
One of the problems, a lack of quality control, is being tackled. India’s National Accreditation Board for Hospitals and Healthcare Providers will now help hospitals in Pakistan in getting accreditation. Dr Giridhar J Gyani of the National Accreditation Body for Hospitals says, "Four hospitals have shown interest in accreditation by NABH. It is in the pre-assessment stage. The two government hospitals include the National Institute for Child Health and Aga Khan University Hospital and the private ones are the Indus hospital and Memon hospital."
Curiously, the deal began with the initiative of the ’Aman ki Asha’ a campaign for peace between India and Pakistan. The NABH is clear that many changes and improvements in standards will be needed by these hospitals before they are given an NABH accreditation.
Despite being illegal, a network of organ trading and kidney tourism still operates in Pakistan. The kidney business in Rawalpindi and Lahore is estimated to be worth a billion rupees a year. There is no real enforcement of the law and several hospitals are suspected of still being involved.