One of the seamier aspects of medical tourism is on the wane, but sadly not yet killed. While countries are cracking down on legal commercial transplantation, an illegal trade has been taking its place in other developing nations. China will investigate illegal organ transplant operations provided for 17 visiting Japanese and punish hospitals and medical workers involved. China prohibits transplants for foreigners, as it cannot keep up with demand for its own citizens. The country had just a little more than 10,000 donors for the more than one million people who need transplants every year. China performs the second-largest number of organ transplant operations in the world, behind the United States, with some 5,000 operations each year. The United States now has more than 100,000 on the national organ transplant waiting list, with an average wait of five years; the result of an aging and increasingly unhealthy population. Deputy health minister Huang Jiefu said the 17 Japanese had come to China as tourists. China resolutely opposes organ transplant tourism. China prohibits organ transplants for foreign visitors on tourist visas. Medical institutions and staff who carried out the organ transplants against the rules will be severely dealt with according to the law." Last year, China penalised three hospitals for illegally selling human organs to foreigners. In May 2007, China issued the Provisions on Human Organ Transplant. So far, the ministry has granted over 160 medical institutions the license to conduct such operation. It has deprived some hospitals of the license. The MOH has ordered domestic hospitals not to perform organ transplants for foreign tourists. Those who want to conduct such operations must acquire official approval from provincial health departments, and provincial health departments must report to the MOH before giving approval to the applications. Domestic hospitals must also prohibit their doctors from performing organ transplants while travelling overseas as a tourist. For years, wealthy patients in need of replacement organs have turned to the shadowy, for-profit trade in human organs in the developing world, but the international medical community is having some success in pressuring foreign governments to crack down on the practice. Dr. Luc Noell for the World Health Organization in Geneva, reports that the commercial organ trade has thrived in countries like India, China, Pakistan and the Philippines as a result of increased demand from countries like the United States. The richest countries are driving demand in the commercial trade in human organs, most commonly kidneys.The WHO passed a resolution in 2004 opposing for-profit organ trading. At the time, several countries were performing transplants for foreigners. In the Philippines, the practice of paying poor people to part with a kidney was widespread. In China, a web site for BEK-Transplant, a transplantation clinic, offered a price menu in English and Arabic for foreigners shopping for a life-saving organ. For a non-Chinese patient, kidneys went for US$70,000. The website is now defunct as China and other countries have begun cracking down on transplant tourism. Last year, Pakistan made into law an ordinance banning commercial transplants and created a new authority to monitor the transplant process. It resulted in a 70 percent drop in transplants from a high of 2,000 a year to 600, the other 1,400 were foreigners.

Apollo Hospitals in India has begun a pilot exercise with US-based insurance company Anthem Blue Cross and Blue Shield, a subsidiary of Well Point. The deal has been arranged by US agency Healthbase. The arrangement is for a six-month pilot scheme for one small subsidiary, not all of WellPoint or all customers of Anthem Blue Cross and Blue Shield. The deal only involves one company, Serigraph, with 700 employees and only two Apollo hospitals, in Delhi and Bangalore, will be used. If the pilot becomes a full programme it will be rolled out to all Apollo Hospitals that are JCI accredited. Preetha Reddy, of Apollo Group commented: The programme meets the guidelines set for medical tourism by the American Medical Association (AMA) and we will strive to achieve the best healthcare standards to ensure total success of this programme. All the patients will be routed through a global third party administrator Mondial Assistance, which as top travel assistance business already has links with Apollo Hospitals. Boston-based medical tourism agency Healthbase, which already sends customers to Apollo, will handle all the medical travel logistics and arrangements for members. Saroja Mohanasundaram, chief executive of Healthbase said: Healthbase will assist WellPoint members with coordination of the trip, medical appointment scheduling, digital medical records transfer, and concierge travel service. This pilot project of six months only covers 700 health plan group members and their dependents at US printing company Serigraph, based in Wisconsin. The employer-funded healthcare plan will cover the costs of airfare and accommodation, as well as a dedicated case manager to coordinate travel, medical care plus post-operative care upon return to US. India is merely another option for Serigraph’s employees, and not compulsory. Serigraph’s insurer is Anthem Blue Cross and Blue Shield. Anthem serves members in Wisconsin and 11 other US states, and is one of many subsidiaries and affiliates of Indianapolis-based WellPoint. WellPoint is the largest health benefits group in terms of medical membership in the United States, with 35 million medical members nationwide. One in nine Americans receives coverage for their medical care through WellPoint’s affiliated health plans. WellPoint is a Blue Cross or Blue Cross Blue Shield licensee in 14 states, Wisconsin being one of them. Dr Razia Hashmi of WellPoint said: "Medical tourism is a promising option for improving access to affordable, quality health care. We are pleased to work collectively with Healthbase to deliver an international medical tourism pilot product to our clients who are interested in exploring a medical tourism solution. Healthcare in the US is in turmoil and one of President Obama’s toughest tasks is reforming it. The reforms will affect US insurers, and could even change completely how they operate. This makes a rollout of the medical tourism programme across the Wellpoint organisation unlikely for a few years. The pilot is too small to provide accurate information, so the most likely outcome is that during 2009 it will be continued and extended to other states and other employers. But, the possibility remains that, as in other programmes launched last year, insurers and employers will just use it as a big stick to force US hospitals to cut their prices.

Well-off Myanmar citizens with health concerns are travelling to a wide range of mainly Asian countries for first-rate healthcare at relatively low cost. A major destination is Thailand, which in 2007 received 36,257 Myanmar patients for medical treatment out of a total of 75,183 Myanmar travellers. Thai statistics show that 1.4 million foreigners entered Thailand for medical treatment in 2007, and the number in 2008 is expected to have risen to 1.69 million. There were 100,773 patients from ASEAN countries, of whom the largest group came from Myanmar (36 percent), followed by a quarter from Cambodia. Thailand is not the only destination for healthcare. Some wealthy Myanmar citizens go as far as Germany for medical treatment. But the number of visitors going to Thailand for healthcare has increased because of the quality of the medical service, value for money and location. SM Tours is a Myanmar travel agency and a local representative of Thailand’s Phyathai Hospitals Group. Managing director U Maung Maung Swe said Myanmar patients had been seeking medical treatment in Singapore and Malaysia since 1990. Thailand has been rapidly expanding in popularity as a destination for medical treatment since 2000. Most Myanmar patients go to hospitals in Thailand for a medical check-up or an operation. Our company arranges the medical documentation for patients to Phyathai hospitals, arranges appointments and advises patients, he said. Vertex, another agency, is an authorised agent for AMRI Hospitals in Kolkata, India. U Aung Thurein, the managing director, said Myanmar travellers started going to India for health treatment five years ago, mostly for liver ailments or kidney transplants. Myanmar patients chose India because the country has advanced information technology with good medical services, weather and food are similar to Myanmar, and the costs are 40 to 50 percent lower than in Singapore. Dr Su Naing from the Myanmar office of ParkwayHealth points out that cost and value are not the same as Singapore is considered good value as a medical destination for Myanmar patients. He said: Hospitals in Singapore have advanced technology with qualified doctors and good facilities, but the costs are 50 percent higher than in Thailand. ParkwayHealth Information Centre (PHIC) opened in August last year as an information centre for three hospitals Mount Elizabeth, Gleneagles and East Shore Hospital- all part of Parkway in Singapore. Gleneagles Hospital has successfully operated on ten Myanmar citizens for liver transplants in its Asia Centre for liver disease and transplants. It attracts 10 to 15 patients a month from Myanmar for liver disease related treatments. Most Myanmar patients who go to Mount Elizabeth Hospital are cancer patients, with 15 to 20 patients from Myanmar a month. As yet there have been no Myanmar patients at East Shore. PHIC gives medical advice to patients who want to receive health treatment at any of those three hospitals, and helps them with travel arrangements.

Treatment Abroad, the UK’s leading online health information guide for medical tourists has released its 2009 Treatment Abroad PriceWatch survey. This study of prices for medical travellers across 180 clinics and medical tourism operators in 39 countries reveals that patients can make savings of 80% on some common medical treatments. The aim of the study is to provide an overview of price differentials and to highlight where savings can be made. For example, varicose vein treatment in Poland is 84% cheaper than in the UK and a trip to Cuba for a forehead lift could save 87%. Other cosmetic and elective procedures are considerably cheaper overseas and savings of more than 85% can be made on some dental procedures with an average on all procedures surveyed elective surgery, cosmetic or dental coming in at 55% cheaper than in the UK. The data has been collected from hospitals, clinics, doctors and dentists overseas, from medical tourism agencies and from medical tourism web sites that target the UK market. Treatment Abroad conservatively estimates that 80,000 people left the UK for treatment in 2008 and this number is expected to grow. Patients are choosing to travel abroad for a wide range of medical treatments that includes elective surgery, cosmetic surgery, dentistry and diagnostic services and infertility treatment. Other factors that are influencing patients to leave the UK for treatment are concerns about postoperative infection in UK hospitals, the length of local NHS waiting lists and the comparative high cost of private healthcare in the UK. Prices in the PriceWatch study were calculated by comparing the average cost of the operation or procedure in the UK but do not take into consideration travelling or post operative accommodation costs or costs for a travelling companion. Keith Pollard of Treatment Abroad says; Considerable savings, compared to the average UK private treatment cost, can be made by choosing to have many of the common procedures overseas. The full survey can be purchased from Treatment Abroad for £350 plus VAT.

What began as a single worldwide medical tourism guide for medical tourists has become a mini-industry of country guides, and the world version has been updated. Patients Beyond Borders, considered the Lonely Planet of healthcare tourism, has just issued a country guide to Malaysia, while ones on Thailand and Turkey are coming out soon. The guides are published by Healthy Travel Media, an independent imprint based in Chapel Hill, USA, that publishes books, eBooks, and web-based consumer reference information on medical tourism and wellness travel. The books are available online and from many bookstores. All are in English, but the Singapore edition is also available in Arabic.Author Josef Woodman, of Healthy Travel Media, welcomes suggestions and collaborative ventures. Patients Beyond Borders: Malaysia Edition has been produced in collaboration with Malaysia’s Tourism Ministry and the Association of Private Hospitals of Malaysia (APHM). The 240-page guidebook features 16 colour pages and offers an in-depth overview of Malaysia’s 20 plus international hospitals, selected health travel agents, recovery and guest accommodations, and area travel information. Patients Beyond Borders: Thailand Edition, will be published in September 2009.Produced in collaboration with the Tourism Authority of Thailand and supported by hospitals and related government and private organizations, the 222-page guidebook features 32 pages of colour inserts and an overview of Thailand’s international hospitals, selected health travel agents, nearby recovery and guest accommodations, and area travel information. Patients Beyond Borders: Turkey Edition will be published in a few weeks in association with the Accredited Hospitals Association of Turkey (AHAT). The 280-page guidebook will offer an in-depth overview of Turkey’s leading hospitals, selected health travel agents, accommodation, and essential medical travel information.Included will be sightseeing information on Turkey and the region, with maps, illustrations, and 24 pages of colour inserts. The series has become essential to the bookshelves of any medical tourism agency; the rest of the series is- Patients Beyond Borders- Korea Edition was developed in collaboration with Korea Health Industry Development Institute (KHIDI). This 220-page guide features leading hospitals and clinics, with up-to-date information on treatment specialties, accreditation, transportation, communication and more. Now in its second edition, Patients Beyond Borders-Singapore Edition is published in association with Singapore Medicine. The 250-page guidebook features a fully updated, revised, in-depth overview of Singapore’s hospitals and clinics serving international patients, and it now includes 16 pages of colour inserts showcasing Singapore’s world-class facilities and attractions. Patients Beyond Borders -Taiwan Edition is supported by the Taiwan government, hospitals, and related private organizations, under the umbrella organization Taiwan Task Force on Medical Travel. The 304-page guidebook offers an in-depth overview of Taiwan’s 19 international hospitals, selected health travel agents, nearby recovery and guest accommodations, and area travel information. Patients Beyond Borders -Second Edition provides an international overview of medical travel including a listing of the world’s best international hospitals and clinics, a convenient hospital and treatment finder, guidance on how to plan and budget a medical trip as well as information for travel companions. Completely revised and expanded since the first edition.

A wellness village being developed in Costa Rica called The Rincon, is preparing a marketing plan that will particularly target American expatriates and retirees. The plan is to provide support for wellness/wellbeing in three ways:* Provide a wellness director to support lifestyle adjustments using onsite programmes and services and to coordinate outside services* Create a network of outside service providers including local Costa Rican hospitals and selected medical professionals* Establish an advisory board of local/international physicians/health professionals to provide community and individual advice and counsel In 2007, a mountain ranch property in Northern Guanacaste was selected as the site to create a vibrant, life-enhancing community. The property is located at the base of the Rincon de la Vieja Volcano, where today many enjoy the healing effects of the natural thermal waters and volcanic mud. Grounded in the core values of sustainability, the community is being planned as a wellness village to provide an authentic and affordable option for fulltime or occasional living in Costa Rica. The Rincon is about 45 minutes from the Liberia International Airport in Guanacaste, Costa Rica. Plans for development of the community include over 500 residential units to be built in clusters; a central plaza for commercial activities; a wellness centre that includes a clinic, a spa, fitness center, and areas for alternative and complementary therapies; recreation facilities including pools, tennis courts and stables; and gardens. The Rincon will foster a lifestyle of health and vitality with a focus on the core values of sustainability, wellness, personal relationships, intellectual stimulation and contribution to the larger community. A wellness director will be available to arrange onsite and offsite medical and therapeutic services. The wellness centre will provide a medical clinic, spa services, plus facilities for exercise, yoga and alternative and complimentary health practices. Thermal hot water springs are available nearby. Trails throughout the site will promote walking and outdoor activities. Less than an hour from the community, are two private hospitals offering world-class health care Clinica Biblica and CIMA Hospital, both hospitals accredited by JCI. Organic and hydroponic vegetable gardens will complement agricultural production in the area assuring residents of an abundance of fresh food options. There is an abundant supply of pure water from wells and springs on the property. The property was acquired in April 2007. The project is finalizing plans for Phase One development, which will include the spa. Subsequent phases will add the other facilities. Contact has been made with a dozen leading international real estate marketing companies, of which several will be asked to prepare a proposal for the sales and marketing campaign. In June 2009, a project representative went to the LOHAS forum in the USA. LOHAS, an acronym for Lifestyles of Health and Sustainability, is a market segment focused on health and fitness, the environment, personal development, sustainable living, and social justice. Research shows that one in four adult Americans is part of this group, 41 million people who buy on sustainability issues, not the lowest price. LOHAS has a tremendous following internationally, particularly in Germany, Japan, Taiwan and Hong Kong.

The Malaysian Health Ministry is setting up the Malaysia Healthcare Travel Council (MHTC) to promote and develop the health tourism industry for the country and position the country as a healthcare hub in the region. Health Minister Datuk Seri Liow Tiong Lai says, It will serve as the primary agency to promote and develop the health tourism industry. The Government is concerned about the health development in Malaysia. The country is now ready to elevate itself to another level which is medical tourism. The council will be initially established as a department in the Ministry of Health and be answerable to an advisory committee, that will deal with policy issues and set direction for the healthcare industry, chaired by Liow and co-chaired by Tan Sri Nor Mohamed Yakcop of the Prime Minister’s Department. The MHTC committee will comprise representatives from the government and private sector involved in health. Malaysian Prime Minister Najib Tun Razak has identified health tourism as one of the strategies for rapid, sustained and higher economic growth. Malaysia received 375,000 medical tourists in 2008, according to the Association of Private Hospitals of Malaysia, and the figure is expected to be higher this year. Liow adds "Medical tourism has 20 percent growth every year and we still expect 10 percent growth this year despite the economic downturn. We are also promoting eye-care, besides dental and normal medical care in order to boost the country’s health tourism industry. The council will be established as a corporate entity under the Companies Act 1965 after three years to ensure that the council’s operation is smooth and stable. One of its first jobs will be to investigate concerns that strict regulation by the Medicine Advertising Board on advertising for health tourism. Liow comments These are very old policies that could stagnant the industry. With this new Government policy, we will have to overhaul all existing policies on medical advertising. Liow also says that making the Malaysian healthcare system safer had always been a key goal of his ministry and a core element of its many quality improvement activities. He points out that Malaysia is a strong supporter of the World Health Organisation (WHO)’s World Alliance for Patient Safety and became one of the earliest signatories, in May 2006, "The achievement of patient safety is a major challenge for everyone in the Malaysian healthcare system. While much has been done to improve safety, much more remains to be done." The ministry will be launching its Safe Surgery Check list for hospitals later this year .One of the accepted best practices for patient safety is to establish a no-blame reporting culture by initiating an incident reporting and learning system for adverse events or near misses. For the government hospitals, a set of 22 clinical incidents have been developed in 2008 using the WHO International Classification for Patient Safety. Ministers say that efforts to promote medical tourism will not affect the quality of healthcare enjoyed by locals, as the main provider for healthcare tourism is the private sector.

There are now three major US agencies promoting domestic medical tourism, North American Surgery, Healthbase and Healthplace America. North American Surgery specializes in helping uninsured and underinsured Americans to obtain elective surgeries at prices up to 50% less than usual hospital charges. The target market is individuals or self-insured businesses that pay directly for surgical procedures when price is a major concern. The North American Surgery network of US health care providers offers access to high-quality surgical procedures for cardiac surgery, spinal surgery, general surgery, orthopaedic surgery, women’s procedures and more. The company has become an accredited member of the Self Insurance Institute of America (SIIA); the county’s leading industry association representing companies involved with self-insured health care plans. Members include many self-insured Fortune 1000 employers as well as all major third party administrators. Anyone targeting US medical tourists needs to be able to counter the arguments that North American Surgery makes; You don’t need to fly to India or Thailand. Flying half way around the world is no longer the only way to find significant savings on surgery. Before you consider booking a flight for offshore surgery, ask yourself the following questions:    1. Am I prepared to accept the significant risk of having a deadly thromboembolism? According to a report by the prestigious Mayo Clinic, it can be extremely dangerous to take long-haul flights before or after undergoing certain medical procedures.   2. Am I comfortable with receiving blood transfusions in a foreign country, without knowing what, if any, controls there are on the source of the blood?   3. Am I prepared to undergo surgery in a foreign country, knowing that the legal protection and legal recourses, which we take for granted in the U.S., may be non-existent in that country? Filing a malpractice lawsuit in many foreign countries is simply not an option.   4. Am I prepared to expose myself or a loved one to potentially fatal tropical infections in a foreign hospital? Hospitals, ironically enough are not always the safest places to be if your immune system is compromised. Hospitalization in foreign countries can expose you to a wide spectrum of viruses and bacteria, many of which are not commonly seen, and can therefore be difficult to diagnose or treat in U.S. facilities.   5. Am I prepared to accept the risk of being targeted by political extremists? Instead of travelling offshore, North American Surgery Inc. offers health care options that are a quick flight or drive from most of the U.S. Your surgery is then performed by American surgeons in American facilities. Healthplace America the market leader in domestic medical travel, has appointed Robert A. Yungk, formerly with hospital group Tenet Healthcare and healthcare consultants Mercer, as Chief Executive Officer, " I look forward to helping the organization continue its growth and revolutionizing this country’s approach to managing the cost and quality of surgery care." The Chicago based company plans to expand cost effective domestic medical travel for surgery services.

Bhutan’s latest Draft Economic Development Policy seeks to open up the entire health sector to private investment and competition, on hospitals, doctors, nurses, equipment and medicine. The aim is to improve heath services and make the country a destination for health tourism.Health secretary Dasho Gado Tshering says, How long can we sustain the high costs of free health care on one side and the increasing demand for quality on the other. Every year the cost of medicine, equipment, diagnostics and treatment is becoming costlier. There are a growing number of affluent people in the country who want better health care and go abroad for health check ups. It will reduce the pressure on government hospitals as there are many people who want and can afford private hospitals. The development plan is to promote Bhutan as a wellness and health destination. It seeks up-market medical tourists by building new high-end luxury diagnostics and treatment facilities including wellness centres, spas, traditional medicines and hospitals. The aim is to make medical tourism a major economic service, with immense potential to generate employment and earn foreign exchange. Any new hospitals will have to keep a certain number of beds for Bhutanese patients.The government’s planning unit wants direct investment from overseas companies and individuals, backed by the right regulations, to make the environment friendly for them. The policy will also allow private sector hospitals to bring in foreign doctors and nurses.Bhutan is not a rich country so suffers from a shortage of doctors, nurses and hospitals. When trained, doctors often go overseas. The government will develop incentives to retain doctors through pay, training, and continuing education. The country cannot afford to develop the industry itself, so rather reluctantly is turning to the private sector. Part of the plan is to encourage proper hospitals and clinics, with modern equipment and staff, compared to the current position of lots of small one-room clinics. The Kingdom of Bhutan is a landlocked nation in South Asia at the eastern end of the Himalaya Mountains. The country is bordered to the south, east and west by India and to the north by China. Bhutan is one of the most isolated and least developed nations in the world. Foreign influences and tourism are regulated by the government to preserve the nation’s traditional culture, identity and the environment. There are some hospitals in India, particularly in Calcutta, that increasingly seek medical tourists from neighbours including Nepal, Bhutan, and Bangladesh as these countries have less developed medical facilities, and travel to India is very easy. Bhutan nationals if entering India by land or air from the Bhutan border do not require a passport or visa for entering into India but are required to possess authorized identity proof.In June, the Tourism Council of Bhutan visited Phyathai Hospital in Bangkok, Thailand, for a full tour of the hospital, individual health check-ups, and a long discussion with the management team on medical tourism.

There is a tendency for some countries, hospitals and agencies targeting Europeans for medical tourism to treat Europe as one mass. But attitudes to healthcare in Europe, not only vary from America and Asia, but differ between countries. European consumers share a high interest in healthcare, but hold varied views on many health issues, says a new TNS Healthcare study of 2500 Europeans in five countries. It says that more than 90% of consumers across the five major European markets - the UK, France, Italy, Germany and Spain - share an interest in health, European woman are significantly more concerned with health than men, with 95% of females expressing interest in health issues compared to 89% of males. Age also makes a difference, with 55% of those older than 55 expressing an interest in health compared to just 44% of those between 18 and 24. Louise Tamblin at TNS Healthcare UK says, "The study indicates that, in all countries, most people take health for granted while they are young, particularly if they have no health issues. Those who do suffer from any medical condition-even if it’s minor-become significantly more interested in health than those who do not. Europeans share the same views on many health issues. For example, the majority of consumers in all countries agree that they only go to the doctor when necessary. They also believe that they know when to visit a doctor and when to self medicate. The survey reveals large differences among countries and between consumers and physicians in the same country on many aspect of the physician relationship. While 64% of consumers in the UK say that they would rather buy a medicine than visit a doctor, only 18% of that country’s physicians agree. Spain comes out at the opposite end of the spectrum, with just 33% of consumers saying they would prefer to buy a medicine than visit a doctor--and only 10% of physicians agreeing. There also was broad disagreement on whether it is risky for people to treat minor ailments without seeing a doctor first. Results are based on an on-line survey of 2500 consumers 18 and older (500 per country) in the UK, France, Germany, Spain and Italy. The study was conducted in April 2009. TNS Healthcare provides market research consulting worldwide. Neil Thompson of UK based private medical insurance provider National Friendly, recently went to Europe to explore the impact of EU legislation on healthcare, and says the implications of the directive on cross-border healthcare have yet to be fully explained, Nobody quite knows what will happen if somebody does elect to go overseas for treatment and the bill is higher than it would be in the UK. If a knee operation was £4,000 in France and £3,000 in UK, who would pick up the extra £1,000? Arguably anybody who had an insurance policy might expect that their insurance provider to meet the excess. This is one of many questions as yet unanswered in the Europe Parliament.

India was a pioneer in medical tourism, but last year’s terrorist attacks plus rising airfares and increased competition, has slowed the medical tourist trade. An uncoordinated approach to promotion by an ever-increasing number of small medical tourism agencies, individual hospitals and some states, all promoting different messages, has not helped. Nearly two months ago the government made promises of help to encourage medical tourism, with announcements still imminent. While we wait, the government has found a way to raise revenue by increasing the price of a service that accounts for a third of India’s medical tourism, cosmetic surgery. In the 2009/2010 budget, from April 2010 a 10% service tax will apply to cosmetic surgery, the first medical specialty to be service taxed in India. According to Dr K M Kapoor, founder of India Plastic Surgery, A big casualty of this tax would be medical tourism in India, which earns India precious foreign exchange from overseas patients. 31 % of medical tourism business comes from cosmetic surgery. By taxing these services, the Indian government would make these procedures more expensive and Indian hospitals would be less preferred as compared to Malaysia or Thailand where governments are promoting medical tourism and cosmetic surgery industry with more incentives so as to get more visitors and revenue. Dr Kapoor adds, New Jersey in US had set a precedent when it became the first and only state in USA to tax cosmetic surgery procedures in 2004. This led to cosmetic surgery patients going to other US states for less expensive surgeries. The tax was repealed finally and now all US cosmetic surgery procedures are tax-free. Taxing cosmetic surgery at this stage, when it is still in infancy in India, would severely hamper its growth. India is also bound to lose its premier position in the medical tourism market, as cosmetic surgery is the biggest attraction amongst all the medical procedures opted for by overseas patients. The total revenue loss in medical tourism and tourism is likely to be far more than the tax collected. Tourism Minister Kumari Selja says that the government will soon announce new policy guidelines for promoting health tourism to India, "Wellness tourism as you know is a new catchword all over world and India has lot to offer. So we will be promoting traditional Ayurveda and Siddha systems and also medical tourism in India has huge potential. We will be organising road shows abroad to attract foreign tourists to our country" She adds that health tourism road shows will be organised abroad beginning with the Scandinavian countries, in the last week of August 2009. Currently, the bulk of the patients come to India from neighbouring countries such as Bangladesh, Pakistan, other Asian countries, Africa and the Middle East. In many cases, the driver for cross border care is a question of quality of care rather than cost itself. The quality of care in India is simply not available in some of the neighbouring countries.

Nigeria’s minister of health, Professor Babatunde Oshotimehin, has said that due to a lack of confidence in the nation’s healthcare delivery system, Nigeria is losing well over $200 million from Nigerians who travel overseas for medical attention, People wait a long time at National Hospital. My colleagues are not courteous to them. Personal commitment to patients is not there. Every year Nigeria loses $200m in medical tourism. The confidence in our system is gone. People don’t think they can get service with us. They go for all manners of treatment that could be confidently treated and handled in Nigeria. We need to build our system like in the UK for people to have confidence. In Nigeria it is only the better off people who travel overseas for medical attention. The country has yet to make concerted efforts to upgrade health care facilities to the standard that would attract patronage from patients outside Nigeria, or stop Nigerians travelling overseas. Most go to South Africa for treatment, but Tunisia and Kenya are gaining in popularity. The House of Representatives recently criticized affluent Nigerians who seek medical services overseas, where their problem is not beyond what the local health care system can properly handle. The House observed that the trend represents a drain on the nation’s scarce resources and a disincentive to the improvement of healthcare services. The House called on the Federal Government to improve the quality of services available in health institutions and discourage the habit of encouraging capital flight from Nigeria through medical tourism by the elite. This may be the first case of a country specifically decrying outbound medical tourism as an economic threat to its own health industry and scarce foreign exchange. Chuma Nnaji of the Ministry of Culture and Tourism, Imo State, comments, In a place like Nigeria, perhaps the greatest challenge to tourism in general is security. Recently there has been an upsurge in kidnapping in Nigeria involving foreign nationals and reports like this will not encourage foreigners to choose Nigeria as their point of destination for a holiday or medical attention.’ Work has begun on the $150 million Justice Karibi Whyte Mega Specialist Hospital in Rivers State. The state-of-the-art mega specialist hospital is expected to be one of the best in sub-Saharan Africa on completion. According to the state Health Ministry, the hospital will replace all overseas referral cases and offer quality medical services of world standard to the people of Rivers State, Nigeria and other African countries. This will reduce the number of patients referred abroad for treatment, and encourage patients to be flown into the country from other parts of Africa for treatment. The hospital been designed to make Rivers State the number one medical tourism destination in Africa as it will include a leisure area that will make it a major tourist attraction. Professor Babatunde Oshotimehin wants to fund health care by a 500 per cent tax on cigarettes and 1000 per cent tax on all alcohol, but other ministers refuse to support the idea.

An Australian group recently went to the Philippines on a Meditour Health Holidays Educational Trip. The group included Australia’s 12 biggest travel agents. They visited the country’s leading dental clinics, aesthetic centres, spas, and resorts with the sole purpose of selling the Philippines for health and wellness holidays, with a focus on dental treatment. The Department of Tourism’s (DOT) Team Asia-Pacific, supported by the Makati Tourism Foundation, in collaboration with Australian Robert Graham, who owns All About Asia, a specialist wholesale travel supplier based in Brisbane, arranged the trip for the group. The aim is to change the idea that the Philippines is not yet on the radar of Australians as a tourism destination, much less as a medical tourism and wellness destination. These Australians left very impressed with Philippine dental, medical, spa and other wellness facilities. All About Asia is a specialist wholesale travel supplier, arranging special airfare and accommodation packages for travel agents, primarily to the Philippines. It works closely with the Philippine Department of Tourism and has been doing so since 1991. The country is eight hours from Sydney and English is widely spoken. Using meditour,All About Asia are sending more Australians for dental treatment, as it is safe, hygienic, and friendly, with highly qualified dentists and huge savings. There are direct flights out of Sydney on QANTAS and Philippine Airlines at least five days a week. There are several flights out of other Australian cities as well. The country’s ambitions have often been frustrated by a not entirely successful pursuit of the American medical tourist, and some in the industry want to move away from what they believe to be a mythical pot of US gold. While some see potential in Europe and America, others argue that the country is failing to attract people from there, apart from those of Filipino descent. Fil-Americans come home to visit from Guam and the US mainland and have treatment at the same time, but they spend little money. So there is an increasing concern that this market has limited potential, while getting other American business is now difficult. Some argue that nearby countries of Vietnam and Indonesia should be targeted, as Asians prefer Asian countries, rather than long-distance European markets that are a hard sell. The country now aims to offer less-expensive medical treatments and wellness facilities to people from Arab and African states on the grounds that the biggest markets for health tourism are the rich Arab economies and African countries that allocate state budgets for medical treatment of their nationals. A private hospital has won a service contract with an Arab state for medical treatment for 80 patients in 2009. Another targeted market is Russia. Every medical tourism destination seems to want well-off American and European medical tourists, but the competition is intense. The healthy debate in The Philippines arises from people stopping to think what countries they can get medical tourists from.

Dr. Fawzi al-Hammouri of Jordan’s Private Hospitals Association, wants American medical tourists to consider Jordan as a destination, Hospitals are offering package deals, including air travel at less than 25 percent of what they have to pay in the US." A new marketing campaign includes a web campaign and a visit to Jordan by eight North American medical tourism agencies, California-based insurer Best Life and insurance advisors Texas Benefit from San Antonio. The agencies are Healthbase, Medical Tourism Corporation, Makewell Meditour, MedVoy, Surgery Network, Health Travel Guides, Global Canadian Healthcare International and Euromedical Tours. The Medical Tourism Association hosted the familiarisation tour which included visits to hospitals including Jordan Hospital, Specialty Hospital, Istishari Hospital, and Israa University Welfare Hospital. The World Bank ranks Jordan number one in the region as a medical tourism destination, followed closely by Dubai and Abu Dhabi in the United Arab Emirates, and Israel. It suggests the kingdom ranks fifth in the world in terms of medical tourism destinations. Jordan draws in Arabs from around the Middle East for medical care. The country’s relatively cheap and high quality health services have been attracting patients from other Middle Eastern and North African countries including Yemen, Algeria, Iraq, Palestine and Sudan. Most foreigners from other countries are treated while on a business or holiday trip, not as medical tourists, but the country wants to open new markets from the US and Europe. It remains to be seen whether Jordan is pursuing another medical tourism pipe dream. Will significant numbers of American and European patients seriously consider Jordan as a medical tourism destination when there are comparable destinations much closer to home? Jordan’s current medical tourism sector revenues are estimated to reach US$650mn by the end of 2009 and the country is keen to reach its ambitious target of US$1bn by 2012. More than 250,000 patients from 84 countries were treated there last year, according to a recent Private Hospitals Association study. The majority were medical tourists; but the numbers do include those on holiday or business trips who were ill or injured during their stay. Jordan has many English-speaking doctors, some of whom are trained or affiliated with top US institutions such as the Mayo Clinic, Cleveland Clinic and Johns-Hopkins. Iran is rather anti-American at present, so is unlikely to join the band of Middle East countries targeting that market. Despite the political situation, the country does want to target health tourists, although who will be brave enough to go there now is an interesting question. The current income from health and medical tourism in Iran is very low and limited to medical tourists from countries around the Gulf .No advertising has been done outside of Iran. Therapeutic springs and hot and cold spas have transformed Ardebil into the hub of water therapy and health tourism of Iran. Every year five million domestic and foreign tourists travel to Ardebil because of its favourable climatic conditions. There are about 60 hot spas and therapeutic springs in the province. Sarein, Sardabeh, Meshkinshahr and Nayyer are among provincial spots for health tourism. 37 tourism sites in the province have been approved by the government as suitable for domestic and overseas tourism, and for limited encouragement of private sector investments.

In the USA, the Democrats have introduced a 1018-page healthcare-reform bill that will create a public health insurance option, require individuals to hold some level of health insurance and levy fees against employers that do not offer insurance. Members from both parties on the Senate Health Committee have agreed it, taking a big step toward President Barack Obama’s goal for a health overhaul that he wants to get through Senate before August. With minor changes as the legislation progresses, this is likely to be the future of US healthcare for the next decade. It may well affect the supply of outbound US medical tourism; if it works as President Obama hopes, the need to go overseas for medical treatment will undoubtedly fall. The reforms will affect any agency or hospital negotiating with insurers, employers or benefit plans. The plans make no provision for overseas treatment, for any state system paying overseas hospitals, or for including medical tourism in either the basic benefit package or government plan. Key points of the plan for US healthcare:  A system of health insurance exchanges through which individuals and small businesses can shop for insurance among private insurers and a new government-run plan. States may offer their own exchange or join with other states to create an exchange. It may be expanded to include large employers. A committee will recommend an essential benefits package including preventive services, mental health services, oral heath and vision for children; and out-of pocket costs will be capped. The new benefit package will be the basic benefit package offered in the exchanges and will become the minimum quality standard for employer plans. A government health plan will be offered through the exchanges and will compete with insurance companies. Proposes that both the exchanges and the new government health insurance start by 2013. An independent agency, the Health Choices Administration, will work with states to oversee the proposed new health insurance exchanges and set benefit standards. Insurers will be barred from excluding coverage for those with pre-existing medical conditions. 9 million people will be insured by the public plan, with 21 million insured by private companies in the exchange by 2019. Another 164 million will be insured through their employers. Employers must provide insurance to their employees or pay a penalty of 8 percent of payroll. Companies with payroll under $250,000 annually will be exempt. Individuals must have insurance, enforced through tax penalty with hardship waivers. The penalty is 2.5 percent of income. Government subsidies for premiums and cost sharing on a sliding scale up to 400 percent. Private insurers who operate Medicare plans will have a quality performance score from 2010, and reporting requirements on quality of care by 2013. Expands Medicaid health care for the poor and long-term disabled to all non-elderly with incomes up to 133 percent of the federal poverty level.  Medicaid payment rates will increase. A new centre will be set up to study the comparative effectiveness of various treatments to help consumers and payers make healthcare decisions that improve quality and value. This will research the effectiveness of drugs, medical tests, surgical procedures and other medical treatments. It will have the power to collect data, both published and unpublished, and to study medical treatments.  94 percent of non-elderly residents (those not covered by Medicare, which starts at age 65) will be covered, compared with 81 percent now. Nearly half of the 17 million non-elderly residents who remain uninsured are calculated to be illegal immigrants who obviously cannot travel overseas for medical care. Even if the legislation does not reduce the number of American medical tourists, anyone offering medical tourism services to US healthcare consumers, insured individuals, insurance companies or employers needs to watch these developments closely.

Another web-based consumer directory has launched. UK based YourSurgeryAbroad.com is a directory of 1300 international hospitals and clinics and medical tourism agencies across 80 countries and 27 treatment areas. The website is simple to use and enables patients to search for clinics by operation type or by country. Initially available in its Beta stage while additional search and listings functionality are added, the site is primarily aimed at patients from the UK and the US. The website provides a basic list of specialists, clinics and agencies for free. Providers can be featured with advanced profiles allowing them to showcase their clinic with images, video content, prices and surgeon info. Adam Nethersole says, YourSurgeryAbroad.com is the most comprehensive collection of hand researched clinics to date, not by pure clinic numbers but by breadth of treatment areas and destinations covered. The site is built and managed by Operations Worldwide, part of Henley Media Group, a private media business. It is funded by advertising and profiles. Hospitals and clinics that want to enhance the size and visibility of their profiles can buy an advanced profile for £750 for cosmetic, dental, eye and orthopaedic treatment and £500 for everything else. The site has some unusual features. Customers can seek by accreditor or memberships, but the site does not differentiate between the domestic and international arms of Australian orCanadian accreditors, and uses ISO certification when ISO never accredits or certifies any hospital, specialist agencies only accredit for individual ISO standards. Many profiles show accreditation only as country/region specific and doctor specific rather than actual national/international accreditations. It is impossible to tell from many profiles if the company is a clinic/ hospital or an agency. On several agency profiles it says the accreditation is JCI, a status that no agency can achieve, and does not differentiate between a hospital that earns JCI status and an agency that mostly uses JCI hospitals. IMTJ asked Victoria Thomas, for comment; CLAIM we can show you clinics and hospitals in more countries than anyone else.Q Other websites cover more countries? RevaHealth offers 99 countries and 110,000 clinics.A Reva is 98% dental so it does not have a comprehensive list of treatments and is not a true comparison. When you search for a treatment we will only offer you countries where the treatment is available. Others will still list all the countries but when you click through it may show no results. Q What is hand researched ?A We desk research every clinic listed. We will check that their site is in English, they have accreditation and that when opening the site it will cause no harm to your computer. Unfortunately the site uses negative marketing to attack competitors Unlike some "similar" (and we use that term very loosely) medical directory websites we include clinics and hospitals for free, and we don’t hide their profiles in the sleepy backwater areas of our website, or tuck them away so you won’t find them. Plus we don’t charge clinics and hospitals to see your emails - which mean they spend more of their money on treating their patients. IMTJ welcomes responses from competing websites.

ISO is often used as a comparable accreditor or certifier to JCI or other international/ national organisations. ISO does not accredit anything directly, nor accredit or certify any hospital or clinic. Approved agencies certify businesses, including hospitals, against one of the 17400 international standards it produces. The International Organization for Standardization (ISO) is not a health care accreditation body; it is a federation of 161 national standards organizations. While concepts within ISO requirements may apply to health care, many of the concepts do not easily apply, especially to the clinical aspects of health care. ISO standards concentrate on adhering to a specified process of quality management designed to consistently produce a service that meets pre-established specifications and on assessing that conformity. The standard that hospitals use is ISO 9001: an international consensus on good quality management practices. It consists of standards and guidelines relating to quality management systems and related supporting standards, regardless of what the user organization does. It is the only standard against which organizations can be certified. ISO 9001 lays down what requirements a quality system must meet, but does not dictate how they should be met in any particular organization. There is a pan-European working group, including health accreditor CHKS, seeking to interpret the ISO 9001 standard for healthcare organisations, with particular focus on risk management and patient safety, interpreting it for healthcare services, as the standard was written in language suitable for industry and not appropriate for healthcare. This complexity is why only specialist organisations such as CHKS are allowed to advise or accredit businesses. The working group aims to provide guidance to get a more consistent approach to interpretation and implementation in healthcare. It also seeks to raise the awareness among health professionals of the importance of a systematic approach to quality management and how this can improve patient safety. Two years on from the first meeting, the group has reached a consensus on the principles pf ISO 9001 and has published a first guide in many languages. After feedback, the group has agreed future needs;*National initiatives to link ISO 9001 other ISO standards need to be co-ordinated.* Work needs to be done to move from vague requirements on management of quality, to more specific guidance on risk avoidance and patient safety.* The worldwide focus on patient safety requires a structured approach monitoring the quality of service as ISO is a moving standard, not one that once achieved can be left alone. Since launch in 1987, there have been updates. ISO 9001:2008, is the fourth edition of the standard that has become the global benchmark for providing assurance about the ability to satisfy quality requirements and to enhance customer satisfaction. It contains no new requirements compared to the 2000 edition, which it replaces. It provides clarifications to the existing requirements based on eight years’ experience of implementing the standard worldwide. Although certification of conformity to ISO 9001 is not a requirement of the standard, it is frequently used by hospitals and clinics to increase confidence in the services provided. No one knows how many of the 950,000 certificates were issued to healthcare organisations.