Editor-in-Chief: Robert G. Schwartz, M.D. , Piedmont Physical Medicine and Rehabilitation, P.A.;
Associate Editor-In-Chief: Jeffrey Lefko, MHA, Lefko and Associates, Taylors, South Carolina
Medical tourism (also called medical travel or health tourism) is a term initially coined by travel agencies and the mass media to describe to the rapidly-growing practice of traveling to another country to obtain health care.
Such services typically include elective procedures as well as complex specialized surgeries such as joint replacement (knee/hip), cardiac surgery, dental surgery, and cosmetic surgeries. The provider and customer use informal channels of communication-connection-contract, with less regulatory or legal oversight to assure quality and less formal recourse to reimbursement or redress, if needed.
Leisure aspects typically associated with travel and tourism may be included on such medical travel trips.
The concept of medical tourism is not a new one. The first recorded instance of medical tourism dates back thousands of years to when Greek pilgrims traveled from all over the Mediterranean to the small territory in the Saronic Gulf called Epidauria. This territory was the sanctuary of the healing god Asklepios. Epidauria became the original travel destination for medical tourism.
Spa towns may be considered an early form of medical tourism.
Factors that have led to the recent increase in popularity of medical travel include the high cost of health care or wait times for procedures in industrialized nations, the ease and affordability of international travel, and improvements in technology and standards of care in many countries of the world.
Medical tourists can come from anywhere in the world, including Europe, the UK, Middle East, Japan, U.S. and Canada. This is because of their large populations, comparatively high wealth, the high expense of health care or lack of health care options locally, and increasingly high expectations of their populations with respect to health care.
A large draw to medical travel is cost, convenience and speed. Countries that operate public health-care systems are often so taxed that it can take considerable time to get non-urgent medical care. The time spent waiting for a procedure such as a hip replacement can be a year or more in Britain and Canada; however, in Singapore, Hong Kong, Thailand, Cuba, Colombia, Philippines or India, a patient could feasibly have an operation the day after their arrival. In Canada, the number of procedures in 2005 for which people were waiting was 782,936.
Additionally, patients are finding that insurance either does not cover various surgeries or imposes unreasonable restrictions on the choice of the facility, surgeon, or prosthetics to be used. Medical tourism for knee/hip replacements and stem cell therapy have emerged as some of the more widely accepted procedures in medical tourism because of the lower cost, ease of access, and minimal difficulties associated with the traveling to/from the procedure.
Medical tourists may seek essential health care services such as cancer treatment and brain and transplant surgery as well as complementary or 'elective' services such as aesthetic treatments (cosmetic surgery).
According to research found in an article by the University of Delaware publication, UDaily:
|“||the cost of surgery in El Salvador, Panama, Argentina, Cuba, India, Thailand, Colombia, Philippines or South Africa can be one-tenth of what it is in the United States or Western Europe, and sometimes even less. A heart-valve replacement that would cost US$200,000 or more in the U.S., for example, goes for $10,000 in the Philippines and India—and that includes round-trip airfare and a brief vacation package. Similarly, a metal-free dental bridge worth $5,500 in the U.S. costs $500 in India or Bolivia and only $200 in the Philippines, a knee replacement in Thailand with six days of physical therapy costs about one-fifth of what it would in the States, and Lasik eye surgery worth $3,700 in the U.S. is available in many other countries for only $730. Cosmetic surgery savings are even greater: A full facelift that would cost $20,000 in the U.S. runs about $3,000 in Cuba, $2,700 in the Philippines or $2,500 in South Africa or $ 2,300 in Bolivia."||”|
Popular medical travel worldwide destinations include: Brunei, Cuba, Colombia,Hong Kong, Hungary, India, Israel, Jordan, Lithuania, Malaysia, The Philippines, Singapore, South Africa, Thailand, and recently, UAE and New Zealand.
In Europe Belgium, Poland and Slovakia are also breaking into the business. South Africa is taking the term "medical tourism" very literally by promoting their "medical safaris": Come to see African wildlife and get a facelift in the same trip.
However, perceptions of medical tourism are not always positive. In places like the U.S.medical tourism is viewed as risky. In some parts of the world, wider political issues can influence where medical tourists will choose to seek out health care; for example, in late 2006, some patients from the Middle East were choosing to travel to Singapore or Hong Kong for health care rather than to the U.S. because of international tensions.
While the tourism component might be a big draw for some Southeast Asia countries that focus on simple procedures, they are not alone in this market. For example Panama,Costa Rica and India are positioning themselves to become primary medical destinations. India's commitment to this is demonstrated with a growing number of hospitals that are attaining the U.S. Joint Commission International accreditation to help to capture the US medical tourism market, while others looking beyond just the US market to potential clients from the United Kingdom, Europe and Australia may also look towards other international healthcare accreditation schemes for brand advantage.
Singapore also positions itself as a medical hub for health care services, medicine, biomedical research and pharmaceutical manufacturing converge. Singapore has made international news for many complex surgeries in specialties such as neurology, oncology, and organ transplants procedures. Currently Singapore boasts the largest number of U.S. Joint Commission accredited hospitals in the region.
In South America, countries such as Argentina, Bolivia, Brazil and Colombia lead on plastic surgery medical skills relying on the vast experience their surgeons have in treating the style-obsessed. It is estimated that 1 in 30 Argentineans have had plastic surgery procedures, making this population the most operated in the world after the U.S. and Mexico. In Bolivia and Colombia, plastic surgery has become quite common.
Companies are beginning to offer global health care options that will enable North American and European patients to access world health care at a fraction of the cost of domestic care. Medical tourism companies typically provide experienced nurse case managers to assist patients with pre- and post-travel medical issues. They also help provide resources for follow-up care upon the patient's return. While these services will initially be of interest to the self-insured patient, several studies indicate that the rapid growth of Health Savings Accounts in the U.S. will also drive interest to health care in other countries.
Those people considering becoming medical tourists may be assisted in making rational choices by whether hospitals providing such services have been assessed and accredited by reputable and independent external accreditation bodies. In the USA, JCI (Joint Commission International) fulfills such a role, while in the UK and Hong Kong, the Trent International Accreditation Scheme is a key player. The different international healthcare accreditation schemes vary in quality, size, intent and the skill of their marketing. They also vary in terms of cost to hospitals and healthcare institutions using them. They all have web sites.
Increasingly, some hospitals are looking towards "dual international accreditation", perhaps having both JCI to cover potential US clientele and Trent for potential British and European clientele.
- The Society for International Healthcare Accreditation, or SOFIHA, is a free-to-join group providing a forum for discussion and for the sharing of ideas and good practice by providers of international healthcare accreditation and users of the same - the primary role of this organisation is to promote a safe hospital environment for patients, wherever they travel to in the world for health care.
In 2001, the BBC News reported that thousands of patients come to Cuba from as far away as Latin America and Europe, attracted by the "fine reputation of Cuban doctors, the low prices and nearby beaches on which to recuperate." 
A wide range of medical treatments are provided including joint replacement, cancer treatment, eye surgery, cosmetic surgery and addictions rehabilitation. Costs are about 60 to 80 percent less than U.S. costs.
Cuba has hospitals for Cuban residents, and others that focus on serving foreigners and diplomats. Cubans receive free healthcare for life.
In the 2007 American documentary film, "Sicko," which criticizes the U.S. healthcare system, producer Michael Moore leads a group of uninsured American patients to Cuba to obtain more affordable medical treatment. "Sicko" has greatly increased foreigners' interest in Cuban healthcare, especially Havana Hospital, which was featured in the film.
Statistically healthcare in Cuba compare very good to many countries worldwide. The chance of a Cuban child dying at five years of age or younger is 7 per 1000 live births in Cuba, while it's 8 per 1000 in the US, says the World Health Organization (WHO). Cuba has nearly twice as many physicians per person as the U.S. -- 5.91 doctors per thousand people compared to 2.56 doctors per thousand, according to WHO. Life expectancy in the two countries is almost equal. WHO reports that Cuban life expectancy at birth is 75 years for males, and 79 years for females. In comparison, the US life expectancy at birth is 75 and 80 years for males and females, respectively. Cuba's infant mortality rate is equal to that of the US at 6 percent.  
The Cuban government has developed Cuban medical tourism to generate income for the country. There is an ongoing program that sends thousands of Cuban doctors to Venezuela to help its poor residents, and this helps Cuba pay Venezuela for oil.
Residents of Canada, the UK and most other countries can travel to Cuba without any difficulty, and a tourist visa is generally required. For Americans, however, because of the US trade policy towards Cuba, travelers must either obtain U.S. government approval, or, more frequently, travel to Cuba from Canada, Mexico, the Bahamas, Jamaica or the Dominican Republic. North Americans can reach Cuba easily via daily flights from Toronto, Montreal, Cancun, Mexico City, Nassau (Bahamas), Kingston (Jamaica), and Santo Domingo (Dominican Republic). Cuban immigration authorities do not stamp the passports of US visitors so that Americans can keep their travels a private matter.
One Washington Post article Discount Dentistry, South of The Border says "Mexican dentists often charge one-fifth to one-fourth of U.S. prices". This trend has alarmed some American healthcare providers and legislators. "In Texas, legislators explored the possibility of allowing health maintenance organizations to operate on both sides of the border. However, physicians in south Texas lobbied against the changes, arguing that local doctors could not compete with the lower costs in Mexico" .
Indeed one does need to exercise caution as "the Mexican legal system makes it almost impossible to sue them" . However many who take the chance report that they are satisfied with the care received, "They have everything I need," says Luis Gonzales of San Diego, "They're clean. You don't see a difference between a doctor over here and over there". According to a report commissioned by Families U.S.A., a Washington advocacy group for health-care issues, "About 90 percent [feel] the care they had received in Mexico had been good or excellent. About 80 percent rated the care they had received in the United States as good or excellent" .
Indeed more and more American insurers are providing coverage for travelers as the out of pocket costs to them are much lower. "With healthcare costs in the United States continuing to rise, many employers in Southern California are turning to insurance plans that send their workers to Mexico for routine care, plans that are growing by nearly 3,000 people a year".
In Panama, health and medical tourism is growing rapidly. Many factors are bringing health tourists to Panama. The combination of climate, scenic beauty, cultural diversity, strategic geographical position, one of the world’s key offshore trading centers, the hub of the Americas for international travel, the dollar as the official currency….but most important of all, the medical professionals are well trained from institutions around the world, use the latest technologies and medications, and have earned a reputation of quality professionals. Most of Panama’s doctors are bilingual, board certified, and accustomed to working with the same state of the art medical equipment and technology used in the United States and Europe. Medical tourists coming to Panama can stay at a 5-star hotel during convalescence for prices far below those in the United States and Europe. For example, dental implants costs an average of $2,500 per implant if placed in the US or Canada. On most procedures, Panama offers savings of more than 50% compared to the US and Europe.
Getting world-class medical service and vacation time in a luxury setting is affordable in Panama. You can find in this country a wide range of health services and experienced specialist physicians in all areas such as in dental implants, plastic surgery, assisted reproduction, cardiology, cosmetic dentistry, orthopedics, etc. You can even have an “extreme makeover” done and go back to your country not just feeling great but looking like a new person. People are traveling from around the world looking for high-quality health care at accessible prices as well as discovering Panama´s crystalline Caribbean waters, fascinating indigenous cultures, and deluxe resorts on the beach, in the rain forest, and in the mountains.
Many of these patients that have already come to Panama as health tourists, feel at ease immediately because both staff and doctors speak perfect English. They also report that they have been treated with utmost respect and feel doctors are genuinely interested in the person as an individual instead of feeling like a number. All leave Panama very surprised of the country’s professional doctors, hospitals, and advanced technology. These patients feel very pleased with the treatment or procedure received, especially because of the affordable prices and the wonderful vacation they spent in Panama.
Panama's main Hospitals have affiliations to renowned international Organizations such as: Baptist Health International of Miami, Cleveland Clinic, Tulane Health Science Center, Johns Hopkins International, Miami Children's Hospital, University of Nebraska Medical Center, The Kendall Medical Center in Florida, and Harvard Medical Faculty and Physicians at Beth Israel Deaconess Medical Center in USA.
For more information visit [http//:www.pana-health.com]
Jordan is a popular destination for health tourism in the Middle East. Palestinians, Iraqis, Syrians, and Southeast Asians are frequent visitors, rumoredly including Iraq's President Jalal Talabani.
Colombia has been treating patients from all over the world for years, especially for cosmetic and eye surgery. Colombia has also become a recognized provider of advanced cardiovascular and transplant surgery. What often compels persons to seek transplant surgery offshore is not only cost considerations, but waiting lists (such as in the U.S.) or the lack of an organized organ inventory and donor system in the home country. Colombia has such an organ donor and banking system which makes organs available to foreigners with certain legal restrictions. Orthopedic surgeries, such as knee and hip replacements, are done in Colombia with U.S.-made (FDA-approved) prosthetics at a fraction of the cost.
Colombia has many surgeons that have either trained and/or practiced in other countries such as the U.S. and Europe. Salaries for doctors, nurses, and supporting personnel in Colombia are about 20% of U.S. salaries for similar occupations even though they are required to have the same level of education and job skills. Real estate costs related to medical care facilities are also only a fraction of what they are in the U.S.
One advantage of Colombia for those from the U.S. and Canada is ease of travel and close proximity. Colombia offers cheaper airfares from the U.S. and Canada (and some European countries) than other destinations, such as those in Asia, and does not have the visa restrictions of other countries currently in the medical tourism marketplace.
The Philippines has been growing as a destination for medical tourism. Cost savings are significant since foreign patients can benefit from the lower overhead costs and professional fees. Doctor's fees and facility costs are much lower. Thus, procedures can be performed at a fraction of the amount that a patient would spend on the same procedure in the US or Europe.
Philippine medical and nursing curricula are more difficult than many in Southeast Asia and many Filipino doctors have acquired their postgraduate or fellowship training from well-known institutions in the U.S. and other developed countries
New Zealand is a relatively new player to the medical travel market, focusing on non-acute surgical procedures and fertility treatment.
New Zealand is a destination for those international health travellers seeking high quality, affordable treatment in a first world country in world class private hospitals.
English is the main language spoken in New Zealand with its medical system based ,like other Commonwealth countries, on the British health system. Most of its specialist physicians have received training in New Zealand and the USA, or the UK.
The costs of private healthcare are significantly cheaper than the USA or the UK, with packages (airfare, accommodation, medical service etc) for procedures like hip replacement, or Coronary Artery bypass costing in total approximately half of the procedure cost alone in the US.
Direct flights between the west coast of North America and New Zealand are available, taking on average 12-13 hours.
India is known in particular for heart surgery, hip resurfacing and other areas of advanced medicine. The government and private hospital groups are committed to the goal of making India a world leader in the industry. The industry's main appeal is low-cost treatment. Most estimates claim treatment costs in India start at around a tenth of the price of comparable treatment in America or Britain.
Estimates of the value of medical tourism to India go as high as $2 billion a year by 2012.. The Indian government is taking steps to address other infrastructure issues that can serve as a deterrant to the country's growth in medical tourism.
Singapore claims to be Asia's leading medical hub, with advanced research capabilities as well as nine hospitals and two medical centers that have obtained Joint Commission International (JCI) accreditation. This could be part of the reason why JCI chose to set up its Asia Pacific office in Singapore in 2006. In time, Singapore hospitals may look towards other European or Asian-based hospital accreditation systems in an attempt to broaden their market, as JCI's principal appeal is to the U.S. market, only a portion of the potential global clientele.
SingaporeMedicine is a multi-agency government initiative that aims to develop Singapore into a leading destination for health care services. In 2005, some 374,000 visitors came to Singapore purely to seek healthcare.  Many patients come from neighboring countries, such as Indonesia and Malaysia. Patient numbers from Indochina, South Asia, the Middle East and Greater China to Singapore are also seeing fast growth. Patients from developed countries such as the U.S. are beginning to choose Singapore as their medical travel destination for relatively affordable health care services in a clean cosmopolitan city.
Singapore has made news for many complex and innovative procedures, such as the separation of conjoined twins and tooth-in-eye surgery. The successful separation of 10-month-old Nepalese conjoined twins in 2001 put Singapore's medical expertise into headlines around the world. Singapore has since accomplished many more milestones both in Asia and in the world arena. 
Medical tourism is a growing segment of Thailand's tourism and health-care sectors. Lower labor costs translate into significant cost savings on procedures compared to hospitals in the United States, and a higher, more personalized level of nursing care than westerners are accustomed to receiving in hospitals back home. Over one million people per year travel there for everything from cosmetic surgery to cutting edge cardiac treatment. In 2005, one Bangkok hospital took in 150,000 treatment seekers from abroad. In 2006, medical tourism was projected to earn the country 36.4 billion baht.
Hospitals in Thailand are a popular destination for other Asians. Another hospital that caters to medical tourists, Bangkok Hospital, has a Japanese wing and Phyathai Hospitals Group has interpreters for over 22 languages, besides the English-speaking medical staff. When Nepal Prime Minister Girija Prasad Koirala needed medical care in 2006, he went to Bangkok.
Bumrungrad International Hospital makes much of the fact that many of its staff are accredited in the UK, Europe and the U.S. The origins of the U.S. medical system are British, with the American Medical Association acknowledging that Manchester Physician Dr Thomas Percival is responsible for modern medical ethics, and even the founder of Harvard University, John Harvard, was born in Southwark, London. The modern Thai medical system shares in this Anglo-U.S. inheritance, as Prince Mahidol of Songla, the King's father, earned his MD degree from Harvard Medical School in the early 20th century. Prince Mahidol and another member of the Thai Royal Family paid for an American medical education for a group of Thai men and women[source??]. Prince Mahidol also convinced the Rockefeller Foundation to provide scholarships for Thai citizens to study medicine and nursing[source? Dubious given that Rockefeller was in Thailand from the early 1920's and Mahidol was a low-ranked royal, not in Thailand most of the time]. Funds from the Rockefeller Foundation were also used to help build modern medical training facilities in Thailand. The men and women who studied medicine and nursing as a result of Prince Mahidol's efforts [source?] became the first educators for the modern Thai medical system.
Today many Thai physicians hold U.S. or UK professional certification. Several Thai hospitals have relationships with educational facilities in the U.S. and UK (for example, Sheffield Hallam University has links with Bangkok}. The U.S. consular information sheet gives the Thai health care system high marks for quality, particularly facilities in Bangkok. The UK's Foreign and Commonwealth Office web site states "There are excellent international hospitals in Bangkok but they can be expensive".
Thailand offers everything from cardiac surgery to organ transplants at a price much lower than the U.S. or Europe, in a safe, clean environment.
However, there is indisputably a major HIV/AIDS problem in Thailand, as acknowledged by the World Health Organisation  and dengue is becoming increasingly common. Thai hospitals are also notorious for practicing "racist pricing" whereby costs to an American patient are different from a Russian patient or a Middle Eastern patient and some hospitals blatantly advertise 15% discount for Thais (written in Thai script).
Thailand has a growing number of hospitals with JCAHO accreditation. Again, international hospital accreditation may be one way for hospitals to demonstrate their worth, and increasingly Thai hospitals competing for business in this sector may need to expand their international accreditation.
Hong Kong possesses a superb medical infrastructure. A former British colony and now a Special Administrative Region (SAR) within China, it has 12 private hospitals and more than 50 public hospitals. Among the widest range of health care services throughout the globe are on offer, and some Hong Kong private hospitals are considered among the best of their type in the world.
With respect to hospital accreditation, Hong Kong's 12 private hospitals have looked towards a partnership with the UK rather than the U.S. or Australia for international healthcare accreditation needs. All 12 are "Trent Hospitals", having been surveyed and accredited by the United Kingdom's Trent Accreditation Scheme  since the mid-1990s. This has been a major factor in the ascent of standards in Hong Kong private hospitals over recent years. The Trent scheme works closely with the hospitals it assesses to generate standards appropriate to the locality (with respect to culture, geography, public health, primary care interfaces etc.), and always uses combinations of UK-sourced and Hong Kong-sourced surveyors. This has led to a uniquely co-operative approach toward improvement of hospital standards. Some Trent Hospitals have now gone on to obtain dual international accreditation, with both Trent and JCI (and have therefore attained a standard surpassing even that of some of the best hospitals in Thailand and Singapore). Others are looking towards dual international accreditation with Trent and the Australian group.
Roundtrip airfares from North America, South America and Europe can vary from about US$600 to more than US$2000, so calculate that into your medical costs.
Malaysia has considerable ambitions to develop itself as a medical tourism hub. It is well-placed, as the country has excellent hospitals, English is widely spoken, and many staff have been trained to a high level in the United Kingdom or in the USA.
While Malaysia has a national accreditation scheme (MSQH), few of Malayia's hospitals currently boast international healthcare accreditation. Depending upon if they are planning to attract UK/European- or USA-sourced clientele, they may look towards either the UK's Trent Accreditation Scheme or the USA's Joint Commission International (or possibly both).
In the past people from all over the world came to the United States in search of the best health care. Despite political pressures that have impacted the US health care system the United States remains a health care destination. More people travel within the United States as well. This phenomenon is referred to Domestic Medical Tourism. Several hospital systems such as the Cleveland Clinic, Johns Hopkins and the Mayo Clinic are known for their attraction of patients who travel for health care. More recently less well known, highly specialized private practices have contracted with companies like Bridge Health that facilitate domestic medical travel. These practices tend to offer unique services such as stem cell for regenerative medicine that offer distinction .
Risks and rewards
Medical tourism carries some risks that local medical procedures do not. Should complications arise, patients might not be covered by insurance or able to seek compensation via malpractice lawsuits. Some countries currently sought after as medical tourism destinations provide some form of legal remedies for medical malpractice. However, this legal avenue is unappealing to the medical tourist. Advocates of medical tourism advise prospective tourists to evaluate the unlikely legal challenges against the benefits of such a trip before undergoing any surgery abroad.
Some countries, such as India, Malaysia, Costa Rica, or Thailand have different infectious diseases than Europe and North America, and different prevalences of the same diseases compared to nations such as the U.S., Canada, and the UK. Exposure to disease without having built up natural immunity can be a hazard for weakened individuals, specifically for gastrointestinal diseases (e.g Hepatitis A, amoebic dysentery, paratyphoid) which could weaken progress, mosquito-transmitted diseases, influenza, and tuberculosis (e.g., 75% of South Africans have latent TB). International hospital accreditation with Trent or JCI, mentioned earlier, may be of value here when people are trying to choose a destination for their procedure.
Also, travel soon after surgery can increase the risk of complications, as can vacation activities. For example, scars will be darker and more noticeable if they sunburn while healing. Long flights can be bad for those with heart (thrombosis) or breathing-related problems.
However, because in poor tropical nations diseases run the gamut, doctors seem to be more open to the possibility of any infectious disease, including HIV, TB, and typhoid, there are cases in the West where patients were consistently misdiagnosed for years because such diseases are perceived to be "rare" in the West.
For hospitals and doctors seeking to provide medical tourism services, there is the risk of being sued by a disgruntled patient, so medical indemnity services such as those provided by the Medical Protection Society are essential . There is also, unfortunately, great potential for adverse publicity for an organisation if things go wrong, or are perceived to have gone wrong.
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