WikiPortallus: Medical tourism.html

Medical tourism (also called medical travel, health tourism or global healthcare) is a term initially coined by travel agencies and the mass media to describe the rapidly-growing practice of traveling across international borders 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. However, virtually every type of health care, including psychiatry, alternative treatments, convalescent care and even burial services are available. As a practical matter, providers and customers commonly use informal channels of communication-connection-contract, and in such cases this tends to mean less regulatory or legal oversight to assure quality and less formal recourse to reimbursement or redress, if needed.

Over 50 countries have identified medical tourism as a national industry.¹ However, accreditation and other measures of quality vary widely across the globe, and there are risks and ethical issues that make this method of accessing medical care controversial. Also, some destinations may become hazardous or even dangerous for medical tourists to contemplate. [8][9]

History

The concept of medical tourism is not a new one. The first recorded instance of medical tourism dates back thousands of years to when Greek pilgrims traveled from all over the Mediterranean to the small territory in the Saronic Gulf called Epidauria. This territory was the sanctuary of the healing god Asklepios. Epidauria became the original travel destination for medical tourism.

Spa towns and sanitariums may be considered an early form of medical tourism. In eighteenth century England, for example, medtrotters visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis.¹

Description

Factors that have led to the increasing popularity of medical travel include the high cost of health care, long wait times for certain procedures, the ease and affordability of international travel, and improvements in both technology and standards of care in many countries.²

Medical tourists can come from anywhere in the world, including Europe, the UK, Middle East, Japan, the United States, and Canada. This is because of their large populations, comparatively high wealth, the high expense of health care or lack of health care options locally, and increasingly high expectations of their populations with respect to health care. An authority at the Harvard Business School recently stated that "medical tourism is promoted much more heavily in the United Kingdom than in the United States".³

A forecast by Deloitte Consulting published in August 2008 projected that medical tourism originating in the US could jump by a factor of ten over the next decade. An estimated 750,000 Americans went abroad for health care in 2007, and the report estimated that a million and a half would seek health care outside the US in 2008. The growth in medical tourism has the potential to cost US health care providers billions of dollars in lost revenue.⁴

A large draw to medical travel is convenience and speed. Countries that operate public health-care systems are often so taxed that it can take considerable time to get non-urgent medical care. The time spent waiting for a procedure such as a hip replacement can be a year or more in Britain and Canada; however, in Costa Rica, 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 782,936.⁵

Additionally, patients are finding that insurance either does not cover orthopedic surgery (such as knee/hip replacement) or imposes unreasonable restrictions on the choice of the facility, surgeon, or prosthetics to be used. Medical tourism for knee/hip replacements has emerged as one of the more widely accepted procedures because of the lower cost and minimal difficulties associated with the traveling to/from the surgery. Colombia provides a knee replacement for about $5,000 USD, including all associated fees, such as FDA-approved prosthetics and hospital stay-over expenses. However, many clinics quote prices that are not all inclusive and include only the surgeon fees associated with the procedure.⁶

Popular cosmetic surgery travel destinations include: Argentina, Bolivia, Brazil, Colombia, Costa Rica, Cuba, Mexico and Turkey. In South America, countries such as Argentina, Bolivia, Brazil and Colombia lead on plastic surgery medical skills relying on their experienced plastic surgeons. In Bolivia and Colombia, plastic surgery has also become quite common. According to the "Sociedad Boliviana de Cirugia Plastica y Reconstructiva", more than 70% of middle and upper class women in the country have had some form of plastic surgery. Colombia also provides advanced care in cardiovascular and transplant surgery.

In Europe Belgium, Poland and Slovakia are also breaking into the business. South Africa is taking the term "medical tourism" very literally by promoting their "medical safaris".⁷

A specialized subset of medical tourism is reproductive tourism and reproductive outsourcing,⁸ which is the practice of traveling abroad to undergo in-vitro fertilization, surrogate pregnancy and other assisted reproductive technology treatments including freezing embryos for retro-production.⁹

However, perceptions of medical tourism are not always positive. In places like the US, which has high standards of quality, medical tourism is viewed as risky. In some parts of the world, wider political issues can influence where medical tourists will choose to seek out health care.

Health tourism providers have developed as intermediaries to unite potential medical tourists with provider hospitals and other organisations. Companies are beginning to offer global health care options that will enable North American and European patients to access world health care at a fraction of the cost of domestic care. Companies that focus on medical value travel typically provide nurse case managers to assist patients with pre- and post-travel medical issues. They also help provide resources for follow-up care upon the patient's return.

Process

The typical process is as follows: the person seeking medical treatment abroad contacts a medical tourism provider. The provider usually requires the patient to provide a medical report, including the nature of ailment, local doctor’s opinion, medical history, and diagnosis, and may request additional information. Certified medical doctors or consultants then advise on the medical treatment. The approximate expenditure, choice of hospitals and tourist destinations, and duration of stay, etc., is discussed. After signing consent bonds and agreements, the patient is given recommendation letters for a medical visa, to be procured from the concerned embassy. The patient travels to the destination country, where the medical tourism provider assigns a case executive, who takes care of the patient's accommodation, treatment and any other form of care. Once the treatment is done, the patient can remain in the tourist destination or return home.

International healthcare accreditation

In the United States, Joint Commission International (JCI) fulfills an accreditation 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, cost, intent and the skill and intensity of their marketing. They also vary in terms of cost to hospitals and healthcare institutions making use of them.¹⁰ A forecast by Deloitte Consulting regarding medical tourism published in August 2008 noted the value of accreditation in ensuring quality of healthcare and specifically mentioned JCI, ISQUA and Trent.[10]

Many international hospitals today see obtaining JCI accreditation as a way to attract American patients.¹¹ 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. As a result of competition between clinics for American medical tourists, there have been initiatives to rank hospitals based on patient-reported metrics.¹²

Risks

Medical tourism carries some risks that locally-provided medical care does not. Some countries, such as India, Malaysia, or Thailand have very different infectious disease-related epidemiology to Europe and North America. Exposure to diseases without having built up natural immunity can be a hazard for weakened individuals, specifically with respect to gastrointestinal diseases (e.g Hepatitis A, amoebic dysentery, paratyphoid) which could weaken progress, mosquito-transmitted diseases, influenza, and tuberculosis. However, because in poor tropical nations diseases run the gamut, doctors seem to be more open to the possibility of considering any infectious disease, including HIV, TB, and typhoid, while there are cases in the West where patients were consistently misdiagnosed for years because such diseases are perceived to be "rare" in the West.¹⁶

The quality of post-operative care can also vary dramatically, depending on the hospital and country, and may be different from US or European standards. However, JCI and Trent fulfill the role of accreditation by assessing the standards in the healthcare in the countries like India, China and Thailand. Also, traveling long distances soon after surgery can increase the risk of complications. Long flights and decreased mobility in a cramped airline cabin are a known risk factor for developing blood clots in the legs such as venous thrombosis or pulmonary embolus economy class syndrome. Other vacation activities can be problematic as well — for example, scars may become darker and more noticeable if they sunburn while healing.¹⁷ To minimise these problems, medical tourism patients often combine their medical trips with vacation time set aside for rest and recovery in the destination country.

Also, health facilities treating medical tourists may lack an adequate complaints policy to deal appropriately and fairly with complaints made by dissatisfied patients.¹⁸

Differences in healthcare provider standards around the world have been recognised by the World Health Organization, and in 2004 it launched the World Alliance for Patient Safety. This body assists hospitals and government around the world in setting patient safety policy and practices that can become particularly relevant when providing medical tourism services.¹⁹

Legal issues

By traveling outside their home country for medical care, medical tourists may encounter unfamiliar ethical and legal issues.²⁰ The limited nature of litigation in non-US countries is one reason for the lower cost of care overseas. While some countries currently presenting themselves as attractive medical tourism destinations provide some form of legal remedies for medical malpractice, these legal avenues may be unappealing to the medical tourist. Should problems arise, patients might not be covered by adequate personal insurance or might be unable to seek compensation via malpractice lawsuits. Hospitals and/or doctors in some countries may be unable to pay the financial damages awarded by a court to a patient who has sued them, owing to the hospital and/or the doctor not possessing appropriate insurance cover and/or medical indemnity.²¹ However new insurance products are available that protect the patient should an alleged medical malpractice occur overseas.²²

Ethical issues

There can be major ethical issues around medical tourism. For example, the illegal purchase of organs and tissues for transplantation has been alleged in countries such as India²³²⁴ and China.²⁵

Medical tourism may raise broader ethical issues for the countries in which it is promoted. For example in India, some argue that a "policy of 'medical tourism for the classes and health missions for the masses' will lead to a deepening of the inequities" already embedded in the health care system.²⁶ In Thailand, in 2008 it was stated that, "Doctors in Thailand have become so busy with foreigners that Thai patients are having trouble getting care".²⁷

Employer-sponsored health care in the US

A few US employers have started offering incentives in their employee benefit packages such as paying for air travel and waiving out-of-pocket expenses for care outside of the US. For example, in January 2008, Hannaford Bros., a supermarket chain based in Maine, began paying the entire medical bill for employees to travel to Singapore for hip and knee replacements, including travel for the patient and companion.²⁸ Medical travel packages can integrate with all types of health insurance, including limited benefit plans,²⁹ preferred provider organizations and high deductible health plans. Insurers are beginning to establish partnerships with overseas health providers to treat their insureds.³⁰ A 2008 article in Fast Company discusses the globalization of healthcare and describes how various players in the US healthcare market have begun to explore it.³¹

Subfields

Dental

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

Fertility

Fertility tourism is the practice of traveling to another country for fertility treatments.³² It may be regarded as a form of medical tourism. The main reasons for fertility tourism are legal regulation of the sought procedure in the home country, or lower price. In-vitro fertilization and donor insemination are major procedures involved.

Destinations

The Americas

Argentina

Argentina is an important destination for cosmetic surgery. Has treated foreign patients in cosmetic surgery for years for its excellent relation between its experienced surgeons and prices offered. Argentina has many surgeons trained and with practice in US and/or Europe. Citizens from US and European Comunity does not require visa.

Brazil

Brazil has long been known as a destination for cosmetic surgery. For non-cosmetic procedures, Brazil is only now entering the global market. However, Albert Einstein Jewish Hospital in São Paulo was the first JCI-accredited facility outside of the US,³³ and more than a dozen Brazilian medical facilities have since been similarly accredited.³⁴ Brazil requires visas for Americans based on a reciprocal arrangement since Brazilians are required to obtain a visa to visit the US.

Canada

Canada has entered the medical tourism field. In comparison to US health costs, medical tourism patients can save 30 to 60 percent on health costs in Canada.³⁵ Canada's quality of healthcare is cited by the World Health Organization as equal to if not better than that of the US in most categories.

Colombia

Colombia has been treating foreign patients for years, especially for cosmetic and eye surgery. Colombia also provides 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 US) 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 US-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 US and Europe. Salaries for doctors, nurses, and supporting personnel in Colombia are about 20% of US 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 a fraction of what they are in the US

Like Brazil, ease of travel and relative proximity from the US and Canada is an advantage. Colombia offers cheaper airfares from the US and Canada (and some European countries) than other more-distant destinations, and does not have the visa restrictions of other countries currently in the medical tourism market.

Costa Rica

Costa Rica has been actively involved with dental tourism, and US insurers have begun contracting with dentists there. In Costa Rica, a knee replacement surgery may cost as low as $10,500 USD compared to nearly $50,000 USD in the United States.

The close proximity to the United States and Canada and a significant English speaking presence make Costa Rica a growing destination for medical travel.

Cuba

Cuba has been a popular medical tourism destination for more than 40 years. Thousands of patients travel to Cuba, particularly from Latin America and Europe, attracted by the "fine reputation of Cuban doctors, the low prices and nearby beaches on which to recuperate."³⁶ In 2006, Cuba attracted nearly 20,000 health tourists.³⁷

Medical treatments included joint replacement, cancer treatment, eye surgery, cosmetic surgery and addictions rehabilitation. Costs are about 60 to 80 percent less than US costs.

Cuba has hospitals for Cuban residents and others that focus on serving foreigners and diplomats. In the 2007 American documentary film, "Sicko," which criticizes the US healthcare system, producer Michael Moore leads a group of uninsured American patients to Cuba to obtain more affordable medical treatment. "Sicko" has greatly increased foreigners' interest in Cuban healthcare. A recent Miami Herald story focused on the high quality of health care that Canadian and American medical tourism patients receive in Cuba.³⁸

The Cuban government has developed Cuban medical tourism to generate income for the country. Residents of Canada, the UK and most other countries can travel to Cuba without any difficulty; a tourist visa is generally required. For Americans, however, because of the US trade policy towards Cuba, travelers must either obtain US government approval, or, more frequently, travel to Cuba from Canada, Mexico, the Bahamas, Jamaica or the Dominican Republic. Cuban immigration authorities do not stamp the passports of US visitors so that Americans can keep their travels a private matter.

Mexico

Americans, particularly those living near the Mexican border, now routinely cross to Mexico for medical care.³⁹ Popular specialties include dentristry and plastic surgery. Mexican dentists often charge one-fifth to one-fourth of US prices,⁴⁰ while other procedures typically cost a third what they would in the US.³⁹

This trend has alarmed American healthcare providers who, fearing a loss of business, warn patients away from Mexico. "The phenomenon has unsettled US-based dentists who tell horror stories of rampant infections, undetected cases of oral cancer and shoddy work south of the border", claims hotly disputed by Mexican dentists. "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".⁴¹ US doctors point out that the Mexican legal system makes it almost impossible to sue Mexican doctors for malpractice.⁴⁰

However, many who travel to Mexico for care report that they are satisfied.⁴¹ 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".³⁹

Indeed "some U.S. dentists ... have conceded to the competition and begun a 'reverse migration' opening offices in Mexico to take advantage of lower costs".⁴⁰ More American insurers are providing coverage for travelers, as the out-of-pocket costs to them are much lower. "With healthcare costs in the United States continuing to rise, many employers in Southern California are turning to insurance plans that send their workers to Mexico for routine care, plans that are growing by nearly 3,000 people a year".

In addition to dental and plastic surgery, Mexican hospitals are popular for bariatric surgery for weight loss, considered an elective procedure that is not covered by some US insurers. A popular bariatric procedure, lap band surgery, which was approved by the FDA in the US in 2001, has been performed for longer by Mexican surgeons.⁴²

Panama

In Panama, health and medical tourism is growing rapidly. Factors drawing medical tourists include Panama's tourist appeal, position as a hub for international travel, and use of the American dollar as the official currency. Many of Panama’s doctors are bilingual, board certified, and accustomed to working with the same medical equipment and technology used in the United States and Europe. On most procedures, Panama offers savings of more than 50% compared to the US and Europe. For example, Dental implants cost an average of $2,500 per implant in the US or Canada. In Panama, the same procedure with board and lodging, personal tour guide, and transportation is available at a much lower cost.¹

Popular procedures include dental implants, plastic surgery, assisted reproduction, cardiology, cosmetic dentistry, pulmonology and orthopedics. Panama's hospitals have affiliations to 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 US. No Panamanian hospitals currently have international healthcare accreditation, whether through US, British, Australian or Canadian sources.

United States

While much attention has been given to the growing trend of U.S. citizens seeking health care in other countries, other evidence points out that the largest segment of medical travelers are headed stateside.⁴³ The availability of advanced medical technology and sophisticated training of physicians are cited as driving motivators for growth in foreigners traveling to the U.S. for medical care. Also, it has been noted that the decline in value of the U.S. dollar is offering additional incentive for foreign travel to the U.S. However, costs differences between the US and many locations in Asia and India far outweight any currency fluctuations.

Several major medical centers and teaching hospitals offer international patient centers that cater to patients from foreign countries who seek medical treatment in the U.S.⁴⁴ Many of these organizations offer service coordinators to assist international patients with arrangements for medical care, accommodations, finances and transportation including air ambulance services.

It should be noted that many locations in the US that offer medical care comparable in price to foreign medical facilities are not Joint Commission Accredited.

Uruguay

Uruguay recently entered the medical tourism market. The country offers internationally recognized medical professionals in one of the safest countries in Latin America, with a well-equipped infrastructure for tourists. A private medical tourism initiative, Uruhealth,⁴⁵ has been created with support from the Ministries of Tourism⁴⁶ and Public Health.⁴⁷ The initiative involves the infrastructure, human resources and experience of two healthcare companies: MP Personalized Medicine (Montevideo)⁴⁸ and SEMM-Mautone Hospital (Punta del Este)⁴⁹.

Asia/Pacific

China

Although not necessarily considered a destination for such procedures as cancer treatment, hip replacement or treatment for heart disease; China is becoming a destination for Westerners who want to take advantage of stem cell treatments that are still considered experimental or have yet to be approved in their home country for conditions such as paralysis.⁵⁰⁵¹

Hong Kong

Hong Kong has 12 private hospitals and 39 public hospitals in 2006, providing 3124 and 27755 beds respectively. A wide range of health care services are offered. All 12 of Hong Kong's private hospitals have been surveyed and accredited by the UK's Trent Accreditation Scheme since early 2001.⁵² This has been a major factor in the ascent of standards in Hong Kong's private hospitals. The Trent scheme works closely with the hospitals it assesses to generate standards appropriate to the locality (with respect to culture, geography, public health, primary care interfaces etc.), and always uses combinations of UK-sourced and Hong Kong-sourced surveyors. Some of Hong Kong's private hospitals have now gone on to obtain dual international accreditation, with both Trent and JCI (and have therefore attained a standard surpassing some of the best hospitals in Thailand and Singapore). Others are looking towards dual international accreditation with Trent and the Australian group. Hong Kong public hospitals have yet to commit to external accreditation.

India

India’s medical tourism sector is expected to experience an annual growth rate of 30% making it a Rs. 9,500-crore industry by 2015 ⁵³. Offering world-class medical facilities at an affordable cost places India in stiff competition with other medical tourism hubs around the globe, namely Singapore, Malaysia and Thailand. What works towards India’s advantage apart from reduced costs and the availability of latest medical technologies is the growing compliance on international quality standards and the fact that foreigners are less likely to face a language barrier upon seeking treatment in India. The most popular treatments sought in India by medical tourists are alternative medicine, bone-marrow transplant, cardiac bypass, eye surgery and hip replacement.

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 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.⁵⁴ India is becoming the destination of choice for US citizens seeking complicated, high-end medical procedures.²

Estimates of the value of medical tourism to India go as high as $2 billion a year by 2012.⁵⁵ The Indian government is taking steps to address infrastructure issues that hinder the country's growth in medical tourism.

Serious political problems during late 2008, including major terrorist incidents in Mumbai which explicitely targetted US and European citizens, have made travel to India less appealing than in the past, and the US State Department web site expresses concerns about the country. [11]

The south Indian city of Chennai has been declared India's Health Capital, as it nets in 45% of health tourists from abroad and 30-40% of domestic health tourists.⁵⁶

Israel

Israel is emerging as a popular destination for medical tourists.⁵⁷ In 2006, 15,000 foreigners travelled to the country for medical procedures, bringing in $40 million of revenue.⁵⁷ Medical tourists choose Israel for several reasons. Some come from European nations such as Bulgaria where certain procedures are not available. Others come to Israel, perhaps most commonly from the US, because they can receive quality health care at a fraction of the cost it would be at home, for both surgeries and in-vitro fertilization treatments. Other medical tourists come to Israel to visit the Dead Sea, a world-famous therapeutic resort.⁵⁷ The Israel Ministry of Tourism and several professional medical services providers have set out to generate awareness of Israel's medical capabilities.⁵⁸

Jordan

Jordan is an emerging medical tourism destination, with related revenues exceeding one billion dollars in 2007.⁵⁹ More 250,000 patients from other countries sought treatment in Jordan that year. This included an estimated 45,000 Iraqis and approximately 25,000 patients each from Palestine and Sudan. An estimated 1,800 US citizens, 1,200 UK citizens, and 400 Canadians also sought treatment in Jordan that year. Treatment costs can be as low as 25 percent of costs in the US.⁵⁹ The kingdom was rated as number one in the region and fifth in the world as a medical tourism hub in a study by the World Bank.⁵⁹

Malaysia

Malaysia has ambitions to develop itself as a medical tourism hub. The country has excellent hospitals, English is widely spoken, and many staff have been trained to a high level in the UK or in the US. There is a highly active Association for Private Hospitals of Malaysia working to develop medical tourism.⁶⁰ However, while Malaysia has a national accreditation scheme (MSQH), few of Malaysia's hospitals currently hold international healthcare accreditation, whether British, American or Australian.

New Zealand

New Zealand is a relatively new player to the medical travel market, focusing on orthopedic, cardiac, general surgery, urological and gynaecological surgical procedures. Like other Commonwealth countries, New Zealand's medical system is based on the British health system. Most of its specialist physicians have received training in New Zealand and the US or the UK, and all use English as their first language. The costs of private surgery are significantly cheaper than the US or the UK, with major procedures like hip replacement, or coronary artery bypass costing approximately 15% to 20% the procedure cost in the US. Many private hospitals in New Zealand are accredited by the national accreditation agency Quality Health New Zealand (QHNZ). QHNZ, like JCI, is a member of the International Society for Quality in Healthcare or ISQua. Medical travel to New Zealand markets itself on its safe, green and politically stable image while sharing a medical and cultural affinity with other English speaking countries such as North America and other Commonwealth countries.

Philippines

The Philippines has been growing as a destination for medical tourism. The US Medical Tourism Association magazine reported that this services sub-sector grew 8.0% in 2007.⁶¹ Philippine medical and nursing curricula are more challenging than in many in Southeast Asia, and many Filipino doctors have acquired their postgraduate or fellowship training from well-known institutions in the US, the UK and other developed countries.^{citation needed} The Philippines is one of a few countries that sends qualified physicians and dentists to the US, a testament to its quality of medical education.⁶²⁶³

Procedures can be performed at a fraction of the amount that a patient would spend on the same procedure in the US or Europe. Some medical centers are accredited by the American accreditation group Joint Commission International (JCI), while others have applied to join the UK-sourced Trent Accreditation Scheme.^{citation needed}

Singapore

Singapore has a dozen hospitals and health centers with JCI accreditation.⁶⁴ In 1997 (published 2000), the World Health Organization ranked Singapore's health care system sixth best in the world and the highest ranked system in Asia.⁶⁵ Singapore has close political links to the USA.

"SingaporeMedicine"⁶⁶ is a multi-agency government-industry partnership committed to strengthening Singapore's position as a medical hub and promoting Singapore as a destination for advanced patient care. Patients come from neighboring countries, such as Indonesia and Malaysia, and patient numbers from Indochina, South Asia, the Middle East and Greater China are growing. Patients from developed countries such as the United States and the UK are also beginning to choose Singapore as their medical travel destination for relatively affordable health care services in a clean cosmopolitan city.

Taiwan

The Taiwanese government has declared its determination for the country to become a medical tourism center. To encourage the development of medical tourism, the Council for Economic Planning and Development, together with the Department of Health, proposed the “Medical Service Internationalization Flagship Program”. It is estimated that the government will contribute NT$44.4 million to construct a platform for the collaboration of the government and the medical sector in promoting medical tourism.⁶⁷

Taiwan was the first Asian state to perform liver transplant surgery successfully and is one of the top five liver transplant centers in Asia. The survival rate is the highest in the world. Taiwan also has one of the three largest bone marrow donor databases in Asia and has several successful cases of international matching. In addition, Taiwan has won a key position in the field of reconstructive and plastic surgery.

Costs for procedures remain comparatively low. For example, the charge for assisted reproduction in Taiwan is about one-tenth of that in the US, and the surgery fee for liver transplant is about one-sixth that in the US. The surgery fee for hip joint replacement is even lower than in Singapore, Malaysia and Thailand. Charges for other medical treatments in Taiwan, such as laser eye surgery, health examination, cancer screening, cosmetic surgery and dental treatment, are also competitive.

Thailand

Serious political problems during late 2008, including mass demonstrations and the complete closure of major airports, have made travel to Thailand less appealing than in the past, and the US State Department web site expresses concerns about the country [12].

Up till now, medical tourism has been a growing segment of Thailand's tourism and health-care sectors. In 2005, one Bangkok hospital took in 150,000 treatment seekers from abroad. In 2006, medical tourism was projected to earn the country 36.4 billion baht.⁶⁸

Treatments for medical tourists in Thailand range from cosmetic, organ transplants and orthopaedic treatments to dental and cardiac surgeries. Treatments also include spa, physical and mental therapies. Thailand offers everything from cardiac surgery to organ transplants at a price much lower than the US or Europe. Thai medicine also features a higher, more personalized level of nursing care than westerners are accustomed to receiving in hospitals at home. One patient who received a coronary artery bypass surgery at Bumrungrad International hospital in Bangkok said the operation cost him US$12,000 (8,200 euros), as opposed to the $100,000 (68,000 euros) he estimated the operation would have cost him at home.⁶⁹ Bumrungrad treated approximately 55,000 American patients in 2005 alone, a 30% increase from the previous year.⁷⁰

Hospitals in Thailand are a popular destination for other Asians. Bangkok Hospital, which caters to medical tourists, has a Japanese wing, and Phyathai Hospitals Group has interpreters for over 22 languages, besides the English-speaking medical staff. When Nepal Prime Minister Girija Prasad Koirala needed medical care in 2006, he went to Bangkok.⁷¹

Today many Thai physicians hold US or UK professional certification. Several Thai hospitals have relationships with educational facilities in the US and UK (for example, Sheffield Hallam University has links with Bangkok}. One Thai hospital, Bumrungrad International, states that many of its doctors and staff are trained in the UK, Europe and the US. Bumrungrad International was accredited most recently in 2005 by an American group in order to ensure an international standard of medical services.⁷² Some of the country’s major hospitals also have achieved other accreditations, and some have achieved certification by the International Organization for Standardization’s ISO 9001:2000 (However, ISO not an accreditation scheme). ⁷³

The US consular information sheet gives the Thai health care system high marks for quality, particularly facilities in Bangkok, although the World Health Organization ranks the Thai healthcare system at number 47, below the USA's ranking at 37 and the United Kingdom's ranking at 18.⁷⁴ The UK's Foreign and Commonwealth Office web site states "There are excellent international hospitals in Bangkok but they can be expensive".

UAE

Hospitals in Dubai and other emirates have expressed an intent to develop in medical tourism.⁷⁵ Some have American-sourced international healthcare accreditation, while others are looking towards the UK, Australia and Canada for accreditation services.

Europe

Cyprus

Cyprus has a high-quality healthcare system modeled on the British system, and several of its private hospitals are seeking to develop medical tourism. Cosmetic surgery and dentistry are the treatments offered most in Cyprus. Many hospitals have medical staff trained in the UK, Germany and other European countries. As of yet, few Cypriot hospitals and clinics have sought international healthcare accreditation.

Germany

Germany has long been a medical tourism destination for people from the Middle East and North Africa. Now with a reduction in tension between East and West, many Russians and other Eastern Europeans are seeking treatment in Germany. British and Canadians, no longer willing to wait for treatment in their home country, are also traveling to Germany for treatment. Americans are also heading to Germany for the latest in spine surgery and novel cancer treatments and much lower prices than they would pay in the US. German hospitals and doctors practice many highly sought after procedures not yet done in the US, Canada, and the UK such as, artificial disc replacement, hyperthermia and more.

Malta

Malta has a strong medical heritage and possesses a high-quality healthcare system modeled on the British system. Malta is part of the European Union, a member of the Commonwealth of Nations, and has the euro as its currency. There are a number of private hospitals within Malta (see List of hospitals in Malta) which are developing medical tourism, especially for UK residents. Some Maltese hospitals have applied to join the Trent Accreditation Scheme from the United Kingdom.

Portugal

Portugal's health care system is highly rated by the World Health Organization's ranking of the world's health systems, rated 12th of 191 countries. This is a European Union country with regulatory bodies that certify doctors and health facilities, thereby protecting patients’ rights. Proximity to the US and Northern Europe reduce patients’ travel risks, while Portugal's mild climate is well-suited for convalescence. English is widely spoken by the majority of the population and Portugal is well known for its low crime rate. Dental clinics and cosmetic surgery facilities are popular. Prices are low when compared with similar procedures performed in the UK or the US. Other medical procedures include bariatrics, orthopedics, cardiology and eye surgery.

Spain

Spain's strong economy over recent years have provided for modern hospitals and well-trained health care professionals, making it an up-and-coming medical tourism destination.

Turkey

Turkey has attracted medical tourists from Europe and is seeking to build on its geothermal resources with expansion of therapeutic spas.⁷⁶ German Hospital in Istanbul operates the country's first ISO-certified IVF center, while Memorial Hospital was the first private hospital to receive American JCI accreditation. As a European country, some Turkish hospitals are looking towards the British Trent Accreditation Scheme.

Ukraine

Ukraine features modern dental clinics with high-quality equipment, materials and effective anesthetics. They provide patients with dentistry services at lower cost in comparison with Western and Russian clinics. Other popular medical tourism offerings in Ukraine include spas, ophthalmology (eye surgery), plastic surgery, and mud baths. As yet, Ukraine medical clinics have yet to seek international healthcare accreditation.

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