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.

The private sector of Singapore’s medical tourism industry is looking beyond the Lion City to grow their business. ParkwayHealth, controlled by the US-based private equity firm Texas Pacific Group (TPG), has plans to set up several multispeciality hospitals in India. The group is also tying up with some of the leading healthcare providers in India apart from its plans to build hospitals on its own. Currently, it has an agreement with Apollo Hospitals Group and has bought a 50 percent stake in the Khubchandani Hospital in Mumbai that is jointly owned by the Mauritius-based Koncentric Investments. ParkwayHeath plans to initially invest approximately US$83 million in Khubchandani Hospital. Starting with five or six hospitals in large cities, the former has plans to set up 300-400-bed multispeciality hospitals all over the country. The Khubchandani Hospital, which will be a 1,000-bed facility, is expected to be operational by 2011. The agreement with Apollo Group is intended to help ParkwayHealth develop hospitals across West Bengal. This joint venture currently runs Apollo Gleneagles Hospital, a 325-bed multispeciality hospital in Kolkota. This hospital will cater to Eastern India and neighbouring countries like Bangladesh, Myanmar, Nepal and Bhutan. Another group that believes while some patients will come to you, you can get many more by going to them is Singapore Medical Group (SMG). SMG originally entered the medical tourism market through the Lasik Surgery Clinic (LSC), a specialist centre that treats myopia. The company’s business model, which draws a clear line between management and medicine, has been so successful that SMG has exported the model to the Philippines. LSC Manila is a joint venture with STI Dela Santos, which owns the largest nursing school in the Philippines in Alabang. SMG operates LSC Alabang with Bumungrad Thailand, while LSC Angeles City is a joint venture with Angeles University Foundation. Although it is not a traditional market for Singapore companies, the Philippines is an English-speaking country of 85 million people and refractive surgery is in its infancy. No, we rank No. 1 there in volume with all three LSC clinics combined, said SMG founder Dr Cheryl Baumann. After lasik surgery, SMG pioneered sports medicine in Singapore by partnering with Changi General Hospital to set up the Singapore Sports Medicine Centre. SMG then went on to open The Dental Studio, focusing on cosmetic dentistry, the Singapore Aesthetic Centre, which offers weight management and dermatology treatment, Singapore Vision Centre for patients with eye conditions other than myopia and oncology in The Cancer Centre. This year, SMG expects to establish presence in Japan, China and Vietnam.

RevaHealth.com will continue the expansion of its health clinic search engine. Having originally focused on niche healthcare markets, the company is now expanding into wider local and national healthcare markets and plans to move into the Far East and American markets later in 2009. Dublin-based RevaHealth.com, the registered business name of Global Medical Treatment Ltd, has received a €1.25 million (US$1.62 million) investment, led by Mianach Venture Capital and supported by Enterprise Ireland. RevaHealth.com is a search engine that helps users find and compare health clinics worldwide. Founded in 2006, it currently stores information on over 60,000 clinics in the UK, Ireland and 50 other countries worldwide, but only around 1,000 of these are featured clinics which pay for detailed listings.   Users can search for clinics by treatment and location and easily compare their options before contacting their chosen clinic. "More consumers are going online to research their healthcare options. RevaHealth.com provides a valuable service that gives consumers an easy way to find and compare health clinics worldwide. We now intend to take our proven business model to a wider market," said RevaHealth.com founder Caelen King. The first expansion is into Singapore. King said: "People find it difficult to source clinics in Singapore that offer the particular treatment they are looking for, be it a coronary angioplasty, an eyelift or tooth implants. RevaHealth.com lets visitors easily find and compare over 160 clinics in Singapore, helping them save time and money in finding the best clinic and treatment for their needs." RevaHealth claims to be the world ’s largest medical tourism search engine. Despite being challenged by IMTJ to substantiate this claim on monthly site traffic or other criteria, the company declined to do so. It did offer less than convincing off the record information that attempted to justify this claim. As the responses mentioned leading competitors by name and even refuted that these companies were medical tourism search engines, RevaHealth’s claims was put to competitors. Competitors commented that their traffic figures were higher than RevaHealth’s. Medical tourism has more than its fair share of people making bold yet unsubstantiated claims, and the moral of the story is that if you make claims to be the largest or the best, then, you had better be able to back them up when challenged. Failure to do so just plays into the hands of those opposed to medical tourism who regard parts of the industry as no better than snake oil salesmen making empty claims they cannot substantiate.

At the first International Medical Tourism Congress held in Amman between January 30 and February 2, industry insiders said medical tourism in Jordan is gaining momentum due to its contribution to the national economy. Fawzi Hammouri, president of the Private Hospitals Association and director of Specialty Hospital, noted: Medical tourism experts at the World Bank have ranked Jordan number one in the Arab region and the fifth in the world as a medical tourism hub. The number of foreign patients seeking treatment in the Kingdom stands at over 200,000 per year. We are seeking to maintain and improve this bright image even more through reaching new markets in Europe, Asia and the US. Added Abdullah Bashir, director of Jordan Hospital: "Jordan has achieved an advanced status in the field of medical tourism due to the sector’s medical, human and technical potential, which earned the country an outstanding reputation in the region and the world. Jordan has become the first centre of transformation in the region in medical tourism and aspires to compete on the international level. For one, our hospital provides integrated qualitative services that attract patients from the region and the world." Laith Al Qasem of Usaid Jordan Economic Development Program (Sabeq) also noted that once international hospitals’ accreditation is in place, the sector’s competitiveness will increase the number of patients coming into Jordan.

The International Society for Stem Cell Research (ISSCR) convened a task force of researchers, ethicists, doctors and regulatory officials from 13 countries to set guidelines for clinics offering stem-cell experimental therapy to patients without appropriate transparency, oversight or patient protections. In a report published last month, the US-based group ISSCR noted the growing number of international clinics that are marketing unproven, costly stem-cell therapies to medical tourists and "exploiting patients’ hopes. China is a country where the task force has particular concerns. Task force member Laurie Zoloth said: "There is this tension between the slow progress of medical science and the desperation of patients and the swiftness with which disease overtakes them. Combine that with a flat world and the Internet, it is a recipe for stem cell fakery. Americans could be lured into other countries because of their recognition that stem-cell research might be held back here." The number of patients who have travelled abroad from the US and other countries for stem-cell therapies is unknown, though anecdotally, it appears to be in the thousands. The proliferation of clinics marketing purportedly effective stem-cell interventions online has many experts worried. The ISSCR December 2008 study of stem-cell clinic web sites found that they claimed to treat a range of diseases that go beyond the scope of the early evidence of stem cells’ efficacy, while playing up the benefits and talking little about risks. The study, published in the journal Stem Cells, found that the average price tag for the treatments, excluding travel and lodging costs, was US$21,500. What doctors want is not just patient testimonials, but real data that proves various treatments work. Study group members agree that stem-cell medical tourism and innovation outside the clinical-trial context are not necessarily bad. The guidelines stand in stark contrast with stem cell clinics that claim success with hundreds of patients, yet, never publish results in peer-reviewed journals. The new professional guidelines say clinics providing unproven stem cell-based therapies must have: A written plan for the procedure that includes the scientific rationale and any pre-clinical evidence of proof of principle for efficacy and safety. A full characterisation of the types of cells being transplanted and how they will be administered. Clinical and administrative leadership support for the clinical experiment. Voluntary informed consent for patients. An action plan for adverse events. Insurance coverage or other financial resources to cover complications. Systematic and objective tracking of outcomes submitted to the scientific community for critical review. A timely move to a formal clinical trial after experience with a very small number of patients.

The cost of receiving medical care in Turkey is so low that it is attracting foreign patients. A surgery that would cost 5,000 euros (US$6,292) in many European countries can cost as little as 500 euros (US$657) in Turkey. Europeans’ wallets have shrunk as a result of the global economic crisis, pushing them to seek ways to lower their medical costs. That search has put Turkey on the map as a popular destination for those wanting lower-cost healthcare. One thing that also plays to Turkey’s favour is its high standards in medical care as no less than 24 hospitals and clinics have JCI status, more than in almost every EU country. In 2007, the number of foreign patients in Turkey was 150,000. Last year, the number of foreigners treated in Turkey increased by 40 percent to 200,000. Dr Dursun Ayd?n, president of the Association of Improving Health Tourism (AIHT), said: "Europeans prefer Turkey mostly for cosmetic surgery, invitro fertilization, dental treatment and laser eye surgery. The technology used in Turkey is just as developed as European technology and our doctors are also very successful." AIHT was founded in 2005 and consists of members from health and tourism sectors. In 2008, it printed 5,000 copies of a planned annual health tourism guidebook. The book included details of all hospitals, clinics and others in the health tourism sector in Turkey. The free 160-page guidebook is available in both Turkish and English, and has the support of the Ministry of Health and The Ministry of Culture and Tourism. = Turkey mostly receives patients from the Netherlands, United Kingdom, Belgium and France. There has also been an increase in Middle Eastern patients who have begun to prefer Turkey to Europe. Currently Turkey’s medical tourism market is worth around US$500 million, and it has the potential for many times that. Hospitals gravitating toward health tourism have been quite happy with the growing business and they foresee 2009 to be even brighter than last year. Dr Hasan Kus of Anadolu Health Centre noted: We treated 570 foreign patients in 2007. That figure rose to 1,102 last year. Nearly 30 foreign patients a day visit our hospital. Most of our foreign customers are from Romania, Kosovo, the United Kingdom, the Netherlands, Ukraine, Bahrain, Azerbaijan, Russia and Bulgaria. Most of them are here for treatments in medical oncology, radiation oncology, brain surgery and orthopaedics. Cosmetic surgery, in- vitro fertilization and dental treatment are also in high demand." At the Ac?badem Healthcare Group, which saw at least a doubling of numbers in 2008, Meri Bahar added: "Many foreigners find Turkey attractive both for its lower medical costs and the quality of the health care they receive. Medical tourism in the country is growing like a snowball." The World Eye Group receives 2,000 foreign patients every month, according to Selin Peker. The number of foreign patients has increased 20 percent since October. Most are from Germany, the Netherlands and Scandinavia.

Dubai wants to be the medical hub of the Gulf region by 2015. The logic is that once all the hospitals and clinics are built, its citizens will stop going overseas and medical tourists will start visiting the emirate. Dr Ayesha of Dubai Healthcare City (DHCC) said: "Dubai has already set itself as an internationally recognised tourist destination. It will become an international hub for medical tourism soon as all the major healthcare projects are near their completion dates. DHCC, the world’s first healthcare free zone, aims to become an internationally recognised location of choice for quality healthcare and an integrated regional centre of excellence for clinical and wellness services in the Middle East. The number of visitors to DHCC has exceeded 90,000 with a good percentage from other Gulf regions. I believe the numbers will grow tremendously once DHCC is fully operational by 2011. The increased cost of travel coupled with decreased purchasing powers of patients might have an impact on the number of patients coming in. Though, we do not foresee a significant change in healthcare tourists from other GCC countries. There might even be an increase due to decreased travel to US or Europe for healthcare needs. Currently, we have 122 percent growth rate of patients incoming and we are working in association with the Department of Tourism, doing some road shows and other media campaigns to raise awareness of the healthcare services available in the UAE to the outside world, Dr Ayesha said. By 2012, DHCC may have a superb range of new hospitals and clinics, but it will need to demonstrate to the outside world that they offer excellent quality of care at prices that can compete with Asian and European destinations that already attract medical tourists. Dubai might face an uphill struggle. Based on figures from he upcoming 2009 World Health Tourism Congress:     The ministries of health from the Arab World are the biggest spender of medical travel in the world. Some of them have annual budget in excess of US$200. Each one of them has a medical committee that decides what hospitals and clinics to deal with worldwide.     Insurance companies in the Arab World tend to send a lot of their clients to be treated abroad. They have a network manager who decides where to send clients.

The Ministry of Tourism (MOT) plans to extend its Market Development Assistance (MDA) scheme to cover Joint Commission International (JCI) and National Accreditation Board of Hospitals (NABH) certified hospitals. The MDA scheme offsets overseas marketing costs for travel companies earning foreign exchange. With the MDA scheme, eligible hospitals will be able to apply for financial assistance to cover publicity through printed material, travel and stay expenses for sales-cum-study tours and participation fees for trade fairs and exhibitions. MOT director Dr Prabhakar Dubey said: The MDA scheme for medical tourism is under active consideration and will be applicable only to accredited hospitals. It should be finalised very soon. This will apply to about 60 hospitals. Added Pradeep Thukral of Asia’s leading healthcare group Apollo Hospitals: "The ministry is prompting all players to form a government-industry partnership to strengthen the Indian healthcare brand overseas. Efforts will be made to launch uniform pricing bands and to combine medical packages with travel products. The potential for this is huge. On average a medical traveller spends about US$7,000 as opposed to a holiday traveller who spends US$3,000. It is the right time for the government to provide an impetus to this industry and to learn from countries like Singapore and Thailand, which have collaborated with hospitals to attract patients. In India, 11 hospitals have JCI status and at least 18 are known to be at various stages of seeking or achieving it. On the other hand, the official NABH website lists 23 hospitals and 60 at various stages in the process of achieving accreditation, but it is not up to date. Latest figures show 25 private and 108 state hospitals have achieved NABH status, and over 100 are in the pipeline. While most JCI hospitals and large healthcare groups are in the medical tourism business, many with or seeking NABH status are not and do not plan to be.

The existence of quality healthcare in Guam can boost tourism and stimulate the island’s economy. Once the new hospital project is built, Guam will be an attractive destination not only to regular travellers but also to those needing medical treatments, according to Lionel Chadwick, president of Chadwick and Associates, a consultancy firm based in Monterey, California. Speaking before members of the Guam Chamber of Commerce, Chadwick discussed the economic impact of the US$135-million private hospital being planned by the Guam Healthcare and Hospital Development Foundation, a group founded by volunteers from the business, finance and healthcare sectors. Once built, the new private hospital would make life on Guam a lot easier, Chadwick said, "Healthcare is an economic stimulus. It can promote medical tourism. At the early stages of the new hospital, it may not be able to compete with other hospitals in Asia, but it will attract residents to come back. Off-shore medical travels will be reversed." Guam is an island in the North Pacific Ocean, about three-quarters of the way from Hawaii to the Philippines. The economy predominantly relies on tourism (primarily from Japan) and the US military bases. The island was ceded to the US by Spain in 1898. The military installation on the island is one of the most strategically important US bases in the Pacific. Although it has a civilian government, the country is a US territory, with a small civilian population. The Government of Guam maintains the Guam Memorial Hospital in Tamuning, a free hospital for local people. In addition the US Naval Hospital is located in Agana Heights.

A revised bill now mandates the country’s 44 largest hospitals to allocate five percent of their total 2,046 hospital beds for overseas-based foreign patients, according to South Korea’s Ministry for Health, Welfare and Family Affair. The new rule takes effect in May and aims to help attract 100,000 medical tourists to South Korea by 2012. The bed limit rule does not apply to other hospitals or private hospitals or clinics, which can admit as many people as they wish. Many medical tourists come for cosmetic surgery or other treatments that do not require an overnight hospital stay. About 17,500 foreign tourists received medical services in local hospital facilities from January to August last year, according to data from the Council for Korea Medicine Overseas Promotion, which has 35 member hospitals and clinics. The estimated total for 2008, including cosmetic surgery, is expected to exceed 40,000. The Council has set out to work with large tourists agencies to attract foreigners. The government explained that the quotas were aimed at providing quality services for a reasonable number of foreigners coming to the country for treatment and ensuring there was enough hospital beds for domestic patients. It added that most medical travellers are likely to use single rooms, which Koreans do not use often. The ministry expects such plans to boost medical tourism, which the government has been seeking as a new growth engine. South Korea claims to be less expensive than the US and other developed countries, but until recently, the majority of foreign patients’’ in Korea had been of Korean heritage with foreign citizenship. For cosmetic surgery, the story is different as the overwhelming majority of medical tourists coming from China, Russia and Japan.

The Philippine Department of Tourism (DOT) recently released the official number of foreign patients who visited the country for medical treatment and finally gives a more realistic accurate picture of its inbound medical travel business. In a report on 2008 tourist arrivals, the Philippines welcomed 1,071 overseas-based patients who generated about Php108.8 million (US$2.3 million) in revenues for DOT-accredited medical tourism facilities. The majority of the 885 tourist-patients came from Guam, Palau and Saipan. Other markets were Japan, Korea, and the USA. Average gross receipt per foreign patient was Php101,582 (US$2,136), said DOT. These figures show the country has a long way to go to before it can become a serious player in medical tourism. But the publication of official medical tourism figures is an indication that the industry is maturing. For years, the size of the industry has been the subject of heated debate. The Philippines has long been a battleground between those claiming - purely on estimates with no actual figures - that the country was in the top half-a-dozen destinations and those that rebutted the figures. At one extreme was the Department of Health that said that 250,000 foreigners went to the Philippines in 2006, mostly for cosmetic surgery, while others placed the number to 400,000.  Furthermore, politicians attempting to hype the business claimed 100,000 or 200,000. But again, these were figures plucked out of thin air. At the opposite extreme were academics who argued that the figures were grossly inflated.  Once you take out Filipino workers returning home and expatriate retirees, the figure was only 2,000 to 3,000 a year. There were arguments too about where medical tourists came from.  Several people and organisations claim, without supporting evidence, that the main markets were the USA and Europe. To its credit, the government saw that these public debates and other problems, such as illegal organ transplants and recent medical scandals are undermining efforts to build the country’s medical tourism business. In October 2008 the government began a programme to actually count the number of medical and health travellers. And the government and healthcare facilities in the country participated in major medical tourism fairs in the Middle East, Europe, and the United States. The DOT will host the fourth annual World Health Tourism Congress in Manila next month, which hopefully gives the industry the springboard it needs. Over the last few years, the country’s medical tourism industry has seen countless committees, conferences and politicians pontificating on how to attract medical tourists. The 2008 figures clearly show that the talking must stop and some professional marketing and advertising must be put in place.

Association of Private Hospitals of Malaysia (APHM) board member, Dr K Kulaveerasingam, is projecting a 15 percent increase (compared with the past average of 20-25 percent) in medical tourism receipts for 2009 as fewer foreigners are expected to visit the country for medical treatment. On numbers, this would translate to 485,000 tourists, much lower than earlier APHM predictions of over 600,000. Due to the economic slowdown, some medical tourists may postpone treatments which are not serious such as cosmetic surgery and even hip and knee surgeries, he said. The number of foreigners visiting the country for medical tourism has more than tripled since 2003 to hit a total of 341,288 in 2007. For the first nine months of 2008, over 282,000 foreigners came to Malaysia for medical treatment. According to the 2007 figures, 72 percent of the foreign patients were from Indonesia, 10 percent from Singapore, 5 percent from Japan, 3 percent from Europe and 3 percent from India. Penang, Malacca and Johor Baru are the favourite destinations. Penang Health Association chairman Dr Chan Kok Ewe expects flat growth for medical tourism for the group this year due to the slowdown and relative market saturation. Although we think the outlook is less encouraging, we should use this slack period to prepare for the next growth phase. To do this, we have to cultivate new markets. The majority of medical tourists visiting Penang are of Indonesian origin, who select Penang because of its proximity to north Sumatra, convenience of travel, and ease of cultural and language adaptation. As part of the plan to expand market reach, Malaysia is targeting new markets such as Vietnam, Cambodia, the Middle East, United States, Europe and Canada. APHM is collaborating with the Tourism Ministry to publish in July the Malaysian edition of Patients Beyond Borders to promote Malaysia as a medical tourism destination globally with special focus on the US. APHM is also working on a video on Malaysian healthcare that can be used to promote Malaysia overseas, and brochures that take a more countrywide view of Malaysian healthcare. Research also shows that a medical tourist spends double the amount of normal tourist US$362 compared with US$144 per day. Industry players together with government agencies will have to work hard to ensure that Malaysia can compete with Singapore and Thailand. Sime Darby Healthcare chief executive Elaine Cheong Pek Yin, said one of the ways for Malaysia to better compete is to have a central government agency with dynamic marketing and promotion. Sunway Medical Centre chief operating officer Ch’ng Lin Ling points out that the Health Ministry and Tourism Malaysia will have to team up to promote the image of Malaysia and it is important for travel agents to further promote Malaysia in healthcare.

Korean agencies that refer foreign patients to hospitals could soon be opening up, when the proposed amendment to Korean medical law takes effect. Korean hospitals will be allowed by May to hire agencies to attract foreign patients through their doors. The medical tourism community is worried that the new law still has many restrictions. They say proposed limits on who can act as an agent and the number of patients will be an unnecessary obstacle. Only tourist agencies can refer foreign patients, but not health insurance companies. In some countries such as Russia, insurance companies commonly refer patients to hospitals. Questions remain on whether the agencies can be in Korea or overseas, medical tourism or travel agencies or if there is any licensing. The handful of current agencies in Korea, have promoted cosmetic surgery only. The government said it would boost the local medical industry, but at the same time the restrictions are hindering further development of the country’s industry, said Brian B. Woo, chief executive of Doctour, a Korean medical tourism agency. Singapore agency FlyFreeForHealth has just completed a review on hospitals in Korea and health packages in Korea are now being developed. Opening a foreigner-only hospital is an option, but difficult as medical laws that apply to domestic hospitals also apply to foreigner-only institutions. There needs to be a different set of rules for foreigner-only hospitals. Under medical law, a hospital needs to have a certain number of sickbeds in order to purchase magnetic resonance imaging equipment. This kind of regulation should be relaxed, said Yun Dong-hun at Incheon’s Inha University, which is about to build a foreigners-only hospital. Among other restrictions, agencies can only bring in foreigners who live outside Korea, not those who live in the country. That restriction would cover any non-Korean who has been in the country for over 90 days, as well as ethnic Koreans who hold foreign citizenship but live here. Most foreign patients coming to the country are issued three-month tourist visas, posing difficulties for those who need extended treatment. Chung-Ang University Medical Center has set in motion plans to aggressively attract foreign patients seeking high-quality surgery at relatively low costs. New director-general Ha Kwon-ick has revealed plans to upgrade the quality of the hospital to make it one of the top five medical centres in the country and promote the country’s medical expertise worldwide. The hospital, owned by the Doosan group, is a member of the Council for Korea Medicine Overseas Promotion, the body in charge of promoting medical tourism. A new building with a centre specialising in thyroid and stomach cancer and brain and heart diseases is to be built by 2011. Before that, a 400-bed cancer hospital should be open by the end of 2009.

Spas in casino hotels have hit the jackpot as the most profitable spas in the world. World-class facilities are situated within hotels with hundreds or thousands of rooms, catering to a captive free-spending clientele that appreciates pampering. Operators are now extending the concept to include wellness centres with a wide range of services including cosmetic and dental surgery. The trend is exploding in Asia. Macau has recently surpassed Las Vegas in terms of annual gambling revenue, and its gargantuan Venetian Macao Resort Hotel not only features the impressive V SPA, but also will soon see a MaloClinicSPA, the largest integrative wellness centre of its kind in the world. The centre will offer the most comprehensive array of world-class medical treatments, spa services and wellness programmes in the region. Owned and managed by Lisbon-based MALO CLINIC Health & Wellness Group, the MaloClinicSPA’s aims to offer an integrative, all-inclusive approach to complete wellness, covering seven professional areas - oral rehabilitation and dental cosmetic, preventive and curative medical care, spa, total beauty, cosmetic anti-ageing, leisure & fitness, and life long wellness. Treatments will be developed and delivered by a team of the highest trained doctors and healthcare professionals in a first class, healthy and comfortable environment. Dr Paulo Malo explained: It is a brand new concept in Asia Pacific, marking the future of health and wellness by merging diagnostic and clinical services with spa treatments and wellness care all under one roof. We aim to provide guests the highest quality wellness service to address their individual needs in a trusted, relaxing spa environment." The new centre will consist of four key areas; clinic, spa, beauty salon and a leisure and fitness area. A multi-disciplinary team of 50 medical doctors and licensed healthcare professionals will include dentists, clinical and traditional medical doctors, pharmacists, lab specialists, spa therapists, physiotherapists, public health specialists, psychologists, nutritionists, and sports and fitness specialists. It will be opened in two stages, with the entire facility scheduled to be in full operation by late summer 2009. The MaloClinicSPA is Malo’s first foray into Asia and represents a foothold into this dynamic market. Placing a spa in a casino hotel was a gamble when first done in the USA in the 1980s. Now casino spas include the largest and most expensive spas ever built. Singapore recently legalized gambling; Sentosa Resort & Spa is adding a casino, Banyan Tree plans a casino-spa resort, and the Marina Bay Sands project is in the pipeline. Casinos that gambled with luxury spa facilities have seen huge profits from them, so there will be more in-casino luxury spas in 2009.

The annual Cyprus Medical Tourism Conference at the Marriott Hotel in London will be a one- day trade event on February 5, 2009. The free conference is organised by three Cyprus government bodies. The conference aims to put medical professionals, travel companies and insurance providers from the UK in touch with medical professionals based in Cyprus working in fertility, obesity, orthopaedics, reconstruction, dentistry, cardiology and optometry. For the first time, the conference will also showcase spa and well-being services with the participation of Cyprus Spa Association. Participants include: Cyprus Dental Association, Ygia Polyclinic, Iasis Hospital, Picture Perfect Medical Coordinators, Blue Cross Polyclinic, American Heart Institute, St Raphael Private Hospital, Vorka Polyclinic, Nicosia Dental Polyclinic, Pedieos IVF Centre, M.D. Medical Centre, Apollonion Private Hospital and Chrysovalatou Clinic. The conference will include presentations, meetings, exhibitions and networking. Presentations include Dr Nicos Maroudias on the health system in Cyprus; Keith Pollard of Treatment Abroad on health tourism in Cyprus and the Cyprus Tourism Organisation on Cyprus as a medical tourism destination. The Cyprus Chamber of Commerce & Industry has a tight control on medical tourism providers in the country. Being a former British colony, the main market is the UK. Most Cyprus-based doctors and consultants have been trained in the UK, US, Switzerland, Sweden or Germany. The dental and medical personnel involved in health tourism speak good English.The small island has six public hospitals, more than 80 private hospitals and clinics, 2,500 beds, 2,250 doctors and 720 dentists. Some private clinics get half their business from medical tourists. The main source markets are the UK, Germany, the Netherlands, Russia, Greece and the Middle East. Cyprus is looking to further develop medical tourism by promotion of the medical, dental and spa services available. The Cyprus Health Service Promotion Board had been created to promote medical tourism. The number of people travelling to Cyprus for cosmetic, general surgery, IVF, Ophthalmic and dental treatment is said to increase year on year. This is mainly due to prices being significantly lower than at home, treatment can be received without delay, and alternative treatments are extensively accessible. Ironically, the only hospital or clinic with any form of international accreditation, The Princess Mary’s Hospital in Akrotiri, with CHSK accreditation, does not seek medical tourists as it is mainly for British service personnel and their families. This means that Cyprus has very little chance of selling itself to markets such as the US. But British and  European medical tourists have an almost total lack of interest in whether or not a hospital or clinic is accredited by JCI or any of the other essential accreditors, the question being nowhere on the list of things to check when deciding where to go.

The launch of yet another new American medical tourism agency, with a world network of hospitals, targeting companies who could be interested in medical tourism, is no longer news. There are scores of them, often using the same JCI-approved hospitals, the same countries and the same sales patter. Hidden away among the predictability is the launch of Satori World Medical’s new global hospital network offering high-quality healthcare and dramatic cost savings.  It has a genuinely innovative idea. Whether is works will be the acid test. Based in San Diego, Satori World Medical is concentrating on employer-sponsored medical tourism whether it is insured or self-insured, fully or partly paid for by the employer, or just an employee paid for service sponsored by the employer. It also targets insurance companies. The innovation is that the money saved will be shared between the employer, insurer and employee. The Health & Shared Wealth Program stipulates how the share is split for each company or insurer. For example, an employer could choose 20 percent as the level of sharing, so if a procedure cost US$20,000 using Satori, and the average cost for that procedure in the US is US$60,000, then the employee would receive US$8,000 (20 percent of the US$40,000 savings) deposit in the employee’s HRA. The contribution to the employee is tax-free and is tax deductible to the employer. An HRA is an employer-funded arrangement that reimburses employees for certain medical care expenses incurred by the employees. Unused amounts can be carried forward to future years. Satori ’s pricing model includes airfare (for the patient and a companion), hotel, doctor and hospital fees, personal accident insurance and all administrative services that delivers up to 50 percent of savings when compared to the same procedure performed domestically. The company also offers coordinated concierge medical travel services for all patients from a team of trained nurses. Satori’s network of JCI-accredited hospitals offers treatment in Costa Rica, India, Malaysia, Mexico, Panama, Philippines, Singapore, South Korea, Thailand, and Turkey. Not all details are finalized, but those already signed up are: Costa Rica Hospital Clinica Biblica India Asian Heart Institute Indraprastha Apollo Hospital Wockhardt Hospital Mexico Christus Muguerza Hospital San José Tec de Monterrey The Philippines The Medical City Singapore National University Hospital ParkwayHealth-Gleneagles Hospital ParkwayHealth-Mount Elizabeth Hospital Thailand Bangkok Hospital Medical Center Bumrungrad International Hospital Turkey Acibadem Healthcare Group Anadolu Medical Centre

Every week, we see an announcement of a new deal between medical tourism agencies, hospitals, businesses and insurers, offering overseas treatment to Americans. Persuading American employers and their insurers to send employees overseas has been a much more difficult struggle than many ever imagined. Terrorist attacks in India, Hamas rockets in Israel, kidnappings in Mexico these are not headlines that help sell employers on the idea of sending employees abroad for medical care, despite the potential for substantial costs savings. While the patient’s main concern is to save money, employers and their liability insurers are more concerned about safety, and the risk of being sued if an employee sent overseas is injured or killed in an accident or incident, kidnapped, or the treatment goes wrong. Agencies and others promoting medical tourism may play down these concerns, but with the US insurance industry in crisis, no employer can afford to run the risk of alienating their health and liability insurers. Agencies have often concentrated on selling on cost, and not understood the importance of getting risk managers and a company’s insurance brokers on board too. Medical tourism agency Planet Hospital has signed up five employers. But after the November terrorist attacks in Mumbai, Planet Hospital’s employer clients said they wanted to cross India off their list. Los Angeles-based clothing retailer American Apparel recently signed up for the service. But the company is restricting its options to Mexico. While an employer may be hesitant, employees are less so. As individuals, they often have a huge cost incentive. But unless employees are uninsured or underinsured, there is no financial incentive steering them overseas for care. Indus Health, a medical tourism agency specialising in India, is reported as having a corporate customer that has sent 15 employees overseas for care and during the terrorist attacks in Mumbai in November, had four clients in India, who were unaffected by events. Subsequent trips to India were not cancelled. Most employers now know what medical tourism is and most healthcare insurers and larger employers have looked at it. The cost saving is appealing, but no employee can be forced to travel overseas. Employees and their families must have incentives and perhaps even get a share of the savings.

Destination programmes is the new and more accurate term for domestic US medical tourism. Destination programmes are cropping up at more large medical centres and hospitals as evidence of further specialisation of healthcare delivery at the hospital level and also of an in-country variant of medical tourism. The basic idea behind these programmes is for hospitals to market themselves as being particularly skilled at treating certain conditions. There are two variants, one driven by quality and specialisation, the other driven by cost. As medical tourism is usually sold on a mixture of quality and cost, this makes for an interesting alternative that could alter forecasts for outbound US medical tourism, or skew it in the direction of cosmetic and dental, rather than surgical. Much may depend on what reforms to the health and insurance system the new US president drives through, and how far he cools down the climate of fear that makes many Americans cautious of travelling to foreign countries for care. Until now, most US hospitals have been quiet on seeking business from outside their local community. But this is slowly changing. This is how the University of Michigan Health System (UMHS) describes its new offering:  This is a way of attracting more patients from around the region, the country and the world to UMHS for advanced specialty care in specific areas. The first one, in skin cancer, launched late in 2008 attracted dozens of new patients from Michigan, around the country and even Japan. The six new ones deal with aortic diseases, congenital heart, endocrine oncology and three on cancer. One of the keys to developing destination programmes is the patient scheduling challenge, compressing care into the small number of days that the patient from afar will have allocated for the visit. This is no small feat for a hospital where departments tend to operate autonomously. The ability of hospitals to solve this problem is vital. Furthermore, hospitals must look into providing concierge services for patients and their families especially when they have to travel great distances for treatment. Concierge services involve attending to the lodging and transportation of family members as well as other services for extended stays. Hospitals still have much to learn from the hotel industry. Meanwhile, a number of locations in the US have created a competitive advantage in specialised healthcare for decades which draw patients from not only all over the US but from around the world. The Mayo Clinic is but one of many examples. Medical tourism agencies such as North American Surgery are connecting patients with US hospitals willing to compete on price with providers overseas and across town. Some US hospitals are giving big discounts to patients who pay up front in order to fill unused capacity. The North American Surgery network of US healthcare providers offers access to high-quality surgical procedures at prices that are often 50 percent below US hospital averages.

The Singapore government wants to grow its share of health tourists from the Gulf States as the Lion City’s Ministry of Health recently signed an agreement with Dubai’s Department of Health and Medical Services (DOHMS).   Our vision is to provide a complementary offering to healthcare systems across the Middle East, with a focus on advanced and innovative areas of medicine within Singapore, said Ke-Wei Peh, area director for the Middle East and Africa at the Singapore Tourism Board (STB). Singapore hosts an average of 200 patients from the Gulf every month. It hopes to draw one million foreign patients to the country by 2012. However, Health Minister Khaw Boon Wan has been quoted saying that it will be a challenge to meet this target under the current economic conditions. He pointed out that hospitals will have to work harder to attract medical travellers and that it may take longer for this target to be realised. While the numbers for 2008 are not available yet, latest but contested figures from the STB suggest that the number of medical tourists fell some 15 percent between 2006 and 2007. Based on exit surveys of international travellers at Changi airport, 348,000 medical tourists came to Singapore in 2007, compared with 410,000 in 2006.This drop came as a surprise as all Singapore hospitals registered higher patient admissions and patient days in 2007, compared with 2006. The figures clash with earlier STB numbers that said the city state attracted 571,000 medical tourists in 2007, up from 410,000 in 2006. The STB is urgently analysing the figures and survey methodology, as both sets cannot be correct. Industry professionals have predicted a 10 percent drop in 2008 because of the worsening global economy. Others in the industry have argued that the 2008  figures will be about the same as 2007. Singapore is confident that it will increase numbers in 2009. There is a debate between those who want to focus on Asia and the Gulf states, and those who also think that Europe and the US have potential. Singapore’s Parkway Health Group has three representative offices in North America but 17 in Indonesia. National Healthcare Group director Tyrone Goh said: "Jakarta is a one-hour flight to Singapore versus 20 hours from the US. Some in the trade feel that the potential of business from the US, particularly paid for by employers and insurers has been over-hyped. A case in point is when US company Hannaford and insurer Aetna allowed employees to go to Singapore for treatment. By the end of 2008, not a single employee had gone to Singapore. Early indications for 2009 show a slight flattening to no impact on the numbers of foreign patients coming to the city-state, depending on who you talk to. Singapore Medical Group, where up to 60 percent of patients hail from abroad, expects those from Germany, Japan and Australia to increase this year. ParkwayHealth has seen a short term 5 to 7 percent dip in medical tourists, particularly for elective or simple surgeries; but also reports a rising number of patients from non-traditional markets like Vietnam, Cambodia, the Middle East and Russia, and other less developed countries, where state-of-the-art medical facilities are hard to come by.

Specialist American travel insurance intermediary Seven Corners has signed US medical tourism agency Healthbase as the first preferred partner for the bordercross worldwide policy underwritten at Lloyds’ of London. The insurance is for any nationality, but the patient must be travelling outside the country they live in. Saroja Mohanasundaram, chief executive of Healthbase, said: "We are the only medical travel facilitator to provide a custom insurance programme to our clients as a further commitment to providing high-quality medical travel services at an affordable cost." The insurance plan provides Healthbase patients coverage for the treatment of common surgical complications such as adverse reactions to anesthesia, stroke, myocardial infarction, deep vein thrombosis and infections. Jim Krampen of Seven Corners said: "The medical complication benefits we designed for Healthbase clients will provide peace of mind and cover the cost to treat medical complications abroad and when they return home." Healthbase has a large number of internationally accredited hospitals in 14 countries, including India, Mexico, Costa Rica, Singapore, Thailand, Panama, Turkey, Belgium, South Korea, Malaysia, the Philippines, Hungary, Brazil and the US. Healthbase customers do not all live in the US. There are plans to add more destination countries soon - Canada, the UK, Jordan, Taiwan, New Zealand, Australia, El Salvador and Guatemala. Seven Corners originally planned to only sell via medical tourism agencies, but progress on this has been so slow that they are now also offering to quote direct to medical tourists.

A recently released research paper shows that US$14 billion is being spent across the Gulf on new hospital and healthcare facilities. Healthcare builds are continuing across Gulf countries with a mixture of public, private and joint-venture initiatives. The aim is to address the needs of patients, both local nationals and expatriates, and reduce the number of people who are going outside the region for medical treatment. With most states developing many new hospitals and clinics, the long-term aim is to promote medical tourism between Gulf States rather than overseas, and to also attract patients around the world. Figures show that Saudi Arabia is leading the way with a total spend on healthcare construction projects of more than US$6.6 billion, while the UAE and Qatar are closely matched at US$2.9 billion and US$2.8 billion respectively. Saudi Arabia has a total of 83 projects ranging from the US$400-million King Saud University Medical City in Riyadh to the US$5-million Qatif Central Hospital expansion. Kuwait has one major hospital project under construction the US$1.2 billion Jaber Al Ahmed Al Sabah Hospital. Bahrain is spending US$130 million on the 312-bed King Hamad General Hospital, which is running two years behind schedule. In the UAE, the biggest project is the US$1.9 billion first phase of the Cleveland Clinic Al Suwwa Island development in Abu Dhabi and the second is the Mohammed Bin Rashid Al Maktoum Academic Medical Centre in Dubai Healthcare City budgeted at US$572 million. Also in Dubai Healthcare City, the 400-bed University Hospital is under construction and will be completed in 2011. The UAE has a state-backed fund investing in healthcare. Mubadala Healthcare buys in global quality to overhaul the local healthcare system, encouraging Abu Dhabi residents to spend their healthcare dollars at home. The fund has only one shareholder, the government. Government figures show an estimated US$2 billion is spent annually ferrying UAE nationals abroad for treatment. Mubadala Healthcare ’s first two ventures,  the Imperial College London Diabetes Centre (ICLDC) in Abu Dhabi and the Abu Dhabi Knee & Sports Medicine Centre have been a success. The fund is a partner in Cleveland Clinic Abu Dhabi, a 360-bed hospital, scheduled to open for business in 2011. Cleveland Clinic Abu Dhabi will be an integrated clinic-hospital design that will serve local and international patients in an environment that combines excellent amenities with world-class medical care. One of the objectives is to address the needs of patients currently travelling abroad for treatment. Also in the pipeline is a spinal injury facility, on course to open in 2010, with a reference laboratory and a wellness and diagnostic centre planned for the same year. Once completed, the Abu Dhabi Spine Centre will be the first national unit of its kind. Parkway Health recently signed a deal to manage the upcoming Danat Al Emarat Women and Children’s Hospital in Abu Dhabi. Two of the government’s key partners, Johns Hopkins and Cleveland Clinic, also run the two largest UAE public hospitals.

Although health tourism is still new to Vietnam, it sees plenty of potential. Vietnam has an abundance of natural resources to provide natural health remedies to the health tourism industry, particularly hot springs and mineral springs. The Vietnam National Institute and Hospital of Acupuncture, alongside travel companies, are implementing a programme on combining travelling with acupuncture and acupressure. To date, thousands of people have joined the programme. Some of Vietnam’s most popular tourist sites offer added health benefits. Thap Ba Hot Springs in the central coastal city of Nha Trang, the Kim Boi Mineral Waters in the north-western province of Hoa Binh and the Vietnam National Institute and Hospital of Acupuncture are all places where visitors can enjoy traditional therapies. Also, the Vung Tau Medicoast in Ba Ria-Vung Tau province and Hoan My Dalat hospital in Da Lat provide health tourists with high-quality medical services. An increasing number of foreigners are arriving in Vietnam to embark on health tours, as the country is known worldwide for its traditional herbal medicine. The Vietnam National Institute and Hospital of Acupuncture is internationally recognised and more affordable than similar institutions in countries such as Thailand and Singapore. The Vietnam National Administration of Tourism (VNAT)’s development strategy aims to turn the country into one of the world’s top destinations by 2010. VNAT plans to advertise Vietnam on international television networks, as well as in newspapers in Singapore, Malaysia, Thailand and Cambodia.

During the campaign, US President Barack Obama promised Cuban Americans unlimited travel to their native land. Although this pledge does not apply to other American citizens, who are currently banned from or seriously restricted in travelling to Cuba, many in the US expect the country to be an emerging destination for medical travel. According to the US travel trade, two out of three Americans want an end to travel restrictions to Cuba. If President Obama grants general licenses that do not have to be applied for and does away with the cumbersome registration process of travel service providers, American travel agents and tour operators will receive an immediate business opportunity. Cuba has boasted a medical tourism programme for the past 40 years. Most people come from Caribbean and Central American countries. An increasing minority source of overseas-based patients is Canada, which unlike the US, has travel ban to Cuba. A handful of Canadian medical tourism agencies send Canadians to Cuba. One of these is Choice Self Directed Healthcare, which has launched a medical check-up service aimed at those already on or planning a vacation in Cuba. The agency also offers Canadian and American patients the option of going to Cuba for dental treatment, orthopaedics, cosmetic procedures, eye care and diagnostic services all at a significant cost savings. A hip replacement costs US$60,000 in the US, but in Cuba the cost is US$8,000, a savings of 86 percent. It even offers drug and alcohol rehabilitation treatment in Cuba. In Cuba, the public Cira Garcia Clinic in Havana provides the health check. It includes both an initial assessment and follow-up appointment with a specialist in internal medicine, laboratory investigations, electrocardiogram and simple radiography of the thorax. It costs international patients US$284, including a copy of all test results and recommendations. Daren Jorgenson, founder of Choice, said: Cira Garcia Clinic is a state-of-the-art facility staffed by fully licensed and well trained physicians, nurses and support staff, providing international patients with an outstanding quality of care comparable to that at leading Canadian healthcare facilities. According to Cubanacan Tourism and Health, the umbrella organisation charged with promoting Cuba’s health tourism facilities, the island attracts 3,500 health tourists a year. Cira Garcia Clinic claims 1,300 in-patient health tourists a year. However, both figures have been constant for at least three years, so their accuracy is doubtful.

When the UK’s most renowned medical journal, The Lancet, offers a thoughtful paper on health tourism, it shows that the medical profession takes the business of medical tourism very seriously. What is fascinating is that Dr Richard Smith of the London School of Hygiene and Tropical Medicine, and colleagues who helped him, have no connection with medical tourism. Unlike others, they are neither trying to promote medical tourism, nor protecting healthcare organisations from a threat to their income, nor promoting a medical tourism service or book. Much of what is written on medical tourism gives the impression that the vast majority of potential business comes from the US or the UK. As totally unbiased observers, they show that although these are important markets, they are far from being core to worldwide medical tourism. The paper pointed out: Social, cultural, and linguistic factors generate a strong regional dimension, with substantial intra-regional movement of patients, especially in bordering countries. For example, 70 percent of patients going to Singapore and Malaysia are from their neighbouring Asean member countries, while medical travellers going to Cuba are mainly from the Caribbean and Central America, and those going to Jordan are mostly from Yemen, Bahrain, Sudan, Syria, Libya, Palestine, and Saudi Arabia. The diaspora population is also an important source for foreign patients for countries such as India, The Lancet paper noted. This is a view that contradicts many writings on medical tourism, which do not view citizens living abroad are potential medical travellers. Diaspora is more then just expatriates living outside their own country, it extends to the second, third and subsequent generations. To those in the medical tourism business, the paper offers little that is new. But the analysis of the business is still interesting. Some of the findings are:     Health tourism accounts for an estimated four million patients a year     The market is worth US$20 billion to US$40 billion now     It could be worth US$100 billion by 2012.     Asia is the leader in attracting such patients. Thailand attracts one million a year, with India, Singapore, and Malaysia expected to reach that number by 2012.     The demand for services abroad is driven by domestic non-availability, often in specialised and niche or alternative treatment areas.     Low labour costs combined with high-quality medical professionals (many of whom are trained in the US or the UK) give many developing countries a huge cost advantage. The paper’s view is that active assistance from governments is what makes certain countries more successful than others. Many countries also engage in active policies, aggressive marketing and targeted initiatives to promote themselves as regional hubs for medical tourism. Governments offer special facilities and incentives for medical tourists, such as investing or helping with investment in multispecialty world-class hospitals; expedited visa procedures, including specific medical visas; integration of healthcare and tourist facilities; and funding higher medical education overseas to strengthen human resources, it said. It also illustrated why some hospital groups do better than others. Corporate hospital groups in India, such as Apollo Hospitals, Fortis Healthcare, and Wockhardt, have partnered international insurance and tourism companies and hospitals and practitioners abroad. Private healthcare groups in Singapore such as Raffles Hospital and Parkway Group Healthcare, have established marketing offices in China, south Asia, the Middle East, Indochina, and Russia. The paper also observed that while medical tourism is only one part of global healthcare, other factors are inextricably entwined within it, ie: the movement of health professionals and services across country boundaries, and the internationalisation of investment in and by hospitals and clinics. So increasingly, it is the hospital going to the patient rather than conventional medical tourism. The paper’s outsider view noted that while some governments and hospitals are extremely active and professional, those who passively support the business, and somehow expect customers to flock to them, are always going to be disappointed. One area seen as a constraint for the industry is the lack of portability of national and private health insurance. But they appear to suggest that even if all insurers were to pay for medical tourism, this would only result in a marginal increase in patient numbers travelling overseas.

Thailand’s leading private hospitals are gearing up for rapid growth in the medical tourism sector over the next three to five years. Two of the country’s biggest hospital operators Bangkok Hospital Medical Services (BHMS) and Piyavate Hospital have begun adding rooms and upgrading medical facilities to prepare for an expected increase in the number of foreigners in search of affordable medical treatment. BHMS is the largest hospital group in Thailand and the second biggest in Asia. It has 19 hospitals in the group. The flagship hospital, the 600-bed Bangkok Hospital Medical Center (BMC) in Bangkok, is actually comprised of four facilities: Wattanosoth Cancer Hospital, Bangkok International Hospital, Bangkok Heart Hospital and Bangkok Hospital (formerly Bangkok General Hospital). All of them have JCI status. Sixty percent of BMC’s patients are Thai nationals and the other forty percent are from other countries, foreign patients who are either visitors or expatriates living in Thai capital. BHMS has been preparing for the medical tourism boom for a couple of years. It has already increased the number of beds at Bangkok Hospital Pattaya, Bangkok Hospital Samui and International Clinic Koh Chang. The group is also renovating and adding beds at Bangkok Hospital Phuket. Furthermore, several hospitals in the group are gradually upgrading their operations to qualify for JCI accreditation. Specifically, Bangkok Hospital Pattaya and Bangkok Hospital Phuket are reported to be waiting for their accreditation to be formally announced. Bangkok Hospital Pattaya has 110,000 international patients annually from 136 countries. In another development, Piyavate Hospital, which is being renovated and expanding, said that 20 to 25 percent of its patients last year were foreigners, accounting for half or 50 percent of the hospital’s revenues in 2008. Foreign patients’ contribution to revenue is expected to reach 60 percent over the next five years. Piyavate Hospital chief executive Tanatip Supparit estimated that some 1.4 million foreigners received medical care in Thailand in 2008, with 800,000 receiving complicated treatment. The hospital plans to establish a medical centre in Oman, which supplies most of the hospital’s foreign clients, and is looking for locations for other overseas centres. "Southern and Eastern African countries are interesting targets for us, as some patients in those areas have begun seeking medical treatment in Asian countries like India and Thailand," said the hospital’s chief executive. Meanwhile, the Tourism Authority of Thailand (TAT) has said there are over 30 Thai hospitals ready for foreign patients. TAT expects two million visitors to take advantage of medical treatment services and facilities in Thailand in 2009. Majority of medical tourists come from the Islamic countries in the Persian Gulf: the United Arab Emirates, Oman, Qatar and Kuwait. Governments of these countries have contractual relationships with several hospitals. As a result of this, several thousand patients from the Middle East come to Thailand each year for care. Another large source of foreign patients are neighbouring Asia countries such as Cambodia, Laos, Vietnam, Myanmar and Bangladesh, where the quality of medical care is not as advanced as in Thailand. Also in recent years, patients from Europe, Australia and New Zealand, North Americans and, more recently, East Africans have been flying into the country for medical treatment.

A proposed EU directive would allow European citizens to have a procedure anywhere in the EU and be reimbursed in their home country, even if the treatment can be had at home. European citizens can already use medical services while on holiday or business using the European Health Insurance Card, and planned surgeries in other EU member states can be arranged if there is agreement between a patient’s own doctor and the doctor abroad who will treat the patient. This is commonly done in cases where a procedure is not available in the patient’s home country. However, the new plan would place power in the hands of patients who now have the option to seek treatment elsewhere in Europe, even if that procedure is available at home. For inpatient procedures, prior agreement may still be required but day-case patients could soon have the power to refer themselves to clinics anywhere in the EU and claim the costs back from their local health authority. The fine details of the plan are being thrashed out in Brussels this month. The move follows several rulings by the European Court of Justice, which supported patients’ rights to travel for medical procedures.   The new directive will guarantee entitlement to medical and dental care across the EU, and reduce waiting lists. There has been some concern that patients will have to pay upfront and cover their own travel expenses. It is also expected that patients will only be refunded the amount the operation would cost in their own country, rather than the fees they will actually pay out. For example, an Irish patient undergoing surgery in Sweden would only be reimbursed the cost of that procedure in Ireland, even if the price were higher in Swedish hospitals. If the price was lower, the patient could not pocket the difference, In a submission to the Department of Health, the Irish Patients’ Association warned against diluting the package of care currently available under the National Treatment Purchase Fund (NTPF). The NTPF pays for Irish patients who are waiting more than three months for an operation to be treated in private hospitals in Ireland and Britain. This can include travel expenses for the patient and a companion. Patient mobility between the Republic of Ireland and Northern Ireland is currently less than one percent of total treatments. The Department of Health said Ireland is not opposed in principle to the directive in this area, but acknowledged it was difficult to estimate how many Irish patients would travel overseas for treatment, and how many European citizens would seek medical care in the Irish system, which is quite expensive compared to other countries. Professor Charles Normand of Trinity College, Dublin, believes the numbers going for treatment outside their own countries will be small and will mostly be restricted to patients travelling for particular elective operations where there are long waiting lists. His view is contradicted by European Commission research that said 79 percent of Irish people would be willing to travel elsewhere in the EU for specialist care or to be treated more quickly. The European Commission has submitted the proposed directive to the Council and European Parliament.MEPs discussed the issue at committee level on January 21 and are expected to vote at the end of April. However, while the debate remains vigorous in Brussels, it is unlikely that the directive will come into effect until member states have been given time to prepare for its impact.

Medical tourism will remain robust and resilient despite the economic slowdown, according to the Malaysian investment and research group OSK Research. The majority of medical tourists to Malaysia seek curative medical treatment instead of aesthetic purposes, it said in its research note. Based on this fact, we believe demand for medical tourism in Malaysia will remain resilient as patients with a medical condition will seek treatment regardless of whether there is a recession or not, although those considering treatment for aesthetic reasons may defer their decision, the OSK study said. OSK Research predicted Malaysia could gain from the slowdown given the competitive advantage over the main competitors, namely Singapore and Thailand. Since Indonesians formed the biggest number of medical tourists to Singapore and Malaysia, the slowdown might result in some Indonesian patients seeking treatment in Malaysia rather than in Singapore because of the former has cheaper cost. We believe Malaysia will always have a price advantage over Singapore unless Singaporean players adjust their pricing drastically - which we believe is highly unlikely, due to the higher labour and operating costs, it noted. Also, it noted that the recent turmoils in Thailand provided an opening for Malaysia to raise its profile as an alternative destination for medical travel. Our discussions with the major players in Bangkok indicate that they have not seen any sign of recovery in the sector as a large number of its foreign markets such as the United Kingdom, the United States, Canada, New Zealand and Australia are still warning their citizens against travelling to Thailand due to high political risk, OSK Research said. Nevertheless, Thailand expects the recovery to come in the second half of 2009 once the political landscapestabilises, it added. This situation offers great opportunities for Malaysia to capture some of Thailand’s market share in medical tourism given that Malaysia offers comparable services at competitive prices," the OSK study stated. Malaysia is also eager to woo medical tourists from the Gulf.  Apart from the low cost of procedures in Malaysia, the government offers discounted tickets to family members of patients travelling to the country.   Syed Muhadzir Jamallulil, head of Tourism Malaysia in Dubai said: "There are a lot of facilities in Malaysia that can take care of the medical needs of travellers from the Middle East. They are much cheaper than the Gulf." Malaysia is fast emerging as a value-for-money destination for medical tourism, thanks to its world-class health and medical facilities, said Frost & Sullivan Asia-Pacific healthcare practice consultant Tham Lin Hui. The growing awareness about medical tourism in Malaysia will attract more foreign patients to seek treatment in the country, she added.

India’s growing medical tourism industry will be adversely impacted in the short-term as a result of the Mumbai terror attacks, a leading healthcare industry official has said. Vishal Bali, chief executive of Wockhardt Hospitals, said: "While foreigners still fear to visit the country there will be a short-term impact on medical tourism. A day after the terrorists attacks in Mumbai, we got calls from US patients asking whether it was safe to travel to Bangalore. We assured them of safety and many came in. Though there is some fear in the minds of foreigners, they also have a lot of confidence in our country. I expect only a short-term impact." The terrorist carnage began on November 26 and lasted for over three days resulting in nearly 200 dead and massive damages to two of the city’s leading five-star hotels. Wockhardt Hospitals, a leading player in medical tourism, is considering raising funds through the private equity route after scrapping plans to raise funds from the capital market for expansion because of a poor response. But world recession has made investors including private equity funds to think twice before investing. Wockhardt want to invest substantially in the next three years by expanding its healthcare infrastructure. The company has 15 hospitals in the country with a combined capacity of 1,500 beds and the plan is to increase it to 4,000 beds in the next three years. Another leading Indian medical tourism player, Fortis Healthcare has earmarked a fund of around $500 million for acquisitions, is in talks with more than two players in southern and western India. Fortis currently has 2,600 beds in 22 hospitals, mostly in northern India. It will add 150 beds in Mumbai and another 400 through acquisitions by March. Ideally, it seeks those with 150 to 200 beds, with a target of 40 hospitals by 2012. Delhi-based Panacea Biotec is to set up a super-specialty hospital in Gurgaon. The company has entered into collaboration with Dr Umesh Gupta of Umkal Group to set-up a multi super-specialty hospital.

Spa Resources International (SRI), the Dubai-based specialised spa management and consultancy company, has entered into a new agreement with United Eastern Medical (UEM), one of Abu Dhabi’s leading healthcare development and investment companies. The joint venture aims to address the acute increase in interest for integrative health, beauty and wellness services in and around the UAE. Both parties will bring their unique strengths and leadership positions in the medical and spa industries to facilitate the creation of a holistic healthcare environment in the region, which integrates spa and wellness services. Daniella Russell, director of Wafi Health & Leisure Group, the parent company of SRI, said: "UEM has a focused and strong vision for the future of the medical sector in the region, and as a home-grown company Spa Resources International is very happy to be an integral part of that vision. Our extensive experience in the development, management and operation of spa, leisure and wellness facilities in the region will stand us in good stead in our joint venture with UEM, with whom we share common ideals, values and goals as to where we want to take the healthcare industry."" UEM aims to develop and manage an integrated health delivery system that comprises world-class specialty hospitals and premium healthcare facilities throughout the Middle East. Mohammed Ali Al Shorafa, managing director of United Eastern Medical commented: "Our partnership with Spa Resources International, forming Spa Resources United Eastern LLC (SRUE), is very exciting for UEM as it perfectly mirrors our strong ambitions and vision to transform the regional healthcare system. The new centres that we will develop together will create an ideal synergy offering a combination of spa treatments alongside unique health and medical programs, and will bridge the large gap between healthcare and wellness." Among the upcoming projects in this joint venture is the expansive spa and wellness centre that will be located within UEM’s flagship project, Danat Al Emarat Hospital, a 300-bed women and children’s hospital currently being developed in Abu Dhabi and due to open in 2011. It targets both the UAE and nearby states.

Tuanku Fauziah Hospital (TFH) has received accreditation from the Malaysian Society for Quality in Health (MSQH) for its healthcare services. It was presented by Perlis Health director Dr Mahani Yusof to TFH director Datuk Dr Faiz Ahmad Khan. "The accreditation is indeed our proudest achievement as it is like the accreditation given to hospitals in developed countries. It also proves that we are able to be on par with the best hospitals, not only in Malaysia but also in the world," said Dr Faiz. The hospital also announced a major project to build a block of multi-discipline wards for TFH with the state-of-the-art facilities and equipment. THF is 100 years old and the new area is expected to be ready by November 2011. The new building will include an obstetrics and gynaecology patient evaluation centre and ward, a paediatrics ward and a royal ward for royalty. The Health Ministry is considering linking Malaysian Society for Quality in Health (MSQH) accreditation as a criterion for renewal of hospital licenses. The ministry’s deputy director-general Datuk Dr Noor Hisham Abdullah said the move would help steer the country toward creating a safer Malaysian healthcare system and provide better outcome for facilities and services. He said the ministry had set a 2010 deadline for all public hospitals to be MSQH surveyed, with some 64 per cent having been assessed and accredited by MSQH. "I advise all private hospitals to do the same to embark on the process of MSQH accreditation. The accreditation will provide a competitive edge, particularly to hospitals keen on health tourism," said Dr Noor Hisham. There are now 77 MSQH accredited hospitals.

New Malaysian medical tourism agency Perfect Enhancement expects to capture 10 per cent of the cosmetic surgery market share within five years, and two to three percent by the end of 2008. Aside from having confidence in its marketing strategy and services, the firm attributes its optimism to the industry’s rapid but stable growth. "We are geared towards penetrating the cosmetic surgery market by offering our services to international and local patients. We are proud to be the only agency that has a visiting medical consultant who is a qualified doctor, performing screening interviews and post-procedure care," said PESB managing director Lenny Irana Zahari. PESB believes its strict business practice of working only with the best surgeons, private hospitals and hotels in the country will make them the preferred medical tourism agency in three years. The business has tied up with four major private hospitals and clinics and is looking at the possibility of expanding into other medical tourism services in the future. While not promoting cosmetic surgery alone, the firm feels that it is part of its responsibility to educate the public about the proper channels and the importance of understanding the procedures and its risks as well as knowing the best people to do the job. The four local hospitals and clinics used are: The Prince Court Medical Center (PCMC), a prestige new five star 330-bed international hospital in Kuala Lumpur. It is one of the largest private hospitals. Owned by Petronas, it is managed by The Medical University of Vienna in cooperation with Vamed. The Columbia Asia Hospital in Puchong, Selangor is one of the 21st century "model hospitals", run by the Columbia Asia company which is the result of a ten-year development effort that combines best care with best technology practices all under one roof. Nicanor Clinic is a modern, sophisticated and fully accredited Day-Surgery centre, using state-of-the-art technology. Imperial Medical Centre (IMC) is a one-stop personalised cosmetic medical centre that provides total solutions in the field of plastic & cosmetic surgery, cosmetic dermatology and laser treatments. Being the first aesthetic and cosmetic surgery medical centre in Malaysia to obtain a license from The Ministry of Health of Malaysia, IMC started operation in May 2008, and is owned by a group of cosmetic surgeons.

Anantara Hotels, Resorts & Spas, a leading developer and operator of luxury resorts and spas has signed a new management contract for its first Anantara Resort in the Sultanate of Oman. Anantara will partner with Blue City Company 1 (BCC1) to develop the 100-room luxury resort and spa that will be located on a natural peninsula some 60 minutes from the historical city of Muscat. Guests staying at the resort can also indulge in a rejuvenating and relaxing spa experience at the Anantara Spa. Roger Kacou, vice-president of hotels and leisure, BCC1 said: "The alliance combines the strength of Anantara’s experience in designing, developing and managing luxury hotel developments with Al Madina A’Zarqa’s commitment to building a city of the future and placing Oman on the map as a premier tourist and business destination in the Middle East." The group is set to open Anantara Qasr Al Sarab in late 2009 in the Liwa desert in Arabia’s Rub Al-Khali. In October, it opened Desert Islands Resort & Spa as the centrepiece of the unique Sir Bani Yas island experience in the UAE. The exclusive resort offers 64 luxuriously designed rooms. Safaa Spa has four treatment rooms offering an array of natural treatments Äì Thai massage, aromatherapy, and Ayurvedic therapies. Prior to Desert Islands Resort & Spa, Anantara had planted its presence in the region with standalone spas located in the Emirates Palace, Abu Dhabi and the 10,0000 sq foot Anantara Spa at Kempinski Hotel Ishtar Dead Sea in Jordan.

Singapore’s first mediplex and a new alliance with a US company to send employees to Singapore for medical treatment, have positioned Singapore as an industry innovator and a top destination for medical travel. Singapore’s first fully integrated mediplex, Connections at Farrer Park will open in 2010 to patients both foreign and local. The 19-storey Farrer Park mediplex will be one of the largest and most advanced of its kind in Asia and will feature a hospital, private medical suites and a full-service hotel for. The mediplex will offer a full spectrum of patient-oriented facilities and services, with some of the region’s best physicians. PlanetHospital, a US-based health tourism agency, arranged a learning trip to Singapore in November for key executives of California-based corporation, Snow Summit Ski Resorts. Snow Summit is looking to offer high quality, reliable and affordable care in Singapore for its employees. Darla Hanft of Snow Summit, said: "Safety, cleanliness and food remain obstacles for many when presented with alternative healthcare destinations. This is where Singapore has a clear advantage over other destinations." Earlier this year, supermarket chain Hannaford Bros., with Aetna’s help, offered its 27,000 employees a deal where employees can receive a hip replacement in Singapore’s National University Hospital, with the entire US$8,000 tab covered, including travel for the patient and spouse. American agency, Companion Global Healthcare, included Singapore’s ParkwayHealth as part of its global provider network where patients have access to pre-negotiated, in-network rates at ParkwayHealth’s facilities, with dramatically lower costs than those typically charged in the US. The World Health Organization currently ranks Singapore the best country in Asia, and sixth in the world. Singapore’s hospitals and medical centres have achieved high marks in clinical indicators that equal and even surpass most in the developed West. Singapore is proving to be an attractive medical destination, especially because medical treatments such as a heart bypass could cost upward of US$130,000 in the US but would only cost US$18,500 in Singapore. In 2007, over 500,000 patients travelled to Singapore specifically for health care, and this number will be higher in 2008.

Medical tourism in Israel will total NIS 160 million in 2008, compared with NIS 100-110 million in 2007, according to a study by The Center for Academic Studies at Or Yehuda. The survey claims that 48 percent of the patients came from Eastern Europe, mostly Russia and Ukraine; 37 percent came from Jordan, Cyprus, Turkey, the Palestinian Authority, and other neighbouring countries; and, 14 percent came from the United States and Western Europe. Sixty-five percent of the patients came to Israel for complex or risky surgical treatments and 35 percent came for various cosmetic treatments. This contradicts long-standing figures from the country’s tourist board that the main market is Germany. The economic crisis is expected to reduce the number of cosmetic surgical treatments of foreign patients in 2009. Recent attacks on Gaza will make Westerners wary of planning trips in a country at war. Widely circulated press reports on the study omitted certain crucial information that throws serious doubt on the study’s accuracy. Although there are over forty medical tourism and travel agencies promoting medical and health tourism, and scores of hospitals and clinics seeking business, the study only interviewed 100 patients in three centres;  Hadassah Medical Organization in Jerusalem, Tel Aviv Sourasky Medical Center (Ichilov Hospital), and Tel Hashomer Medical Center.This very unscientific sampling technique shows yet again why you have to be very wary of widely circulated reports on country statistics. Russia is increasingly becoming the major source of tourists to Israel. Tourism from Russia has grown steadily since September, when Israel waived its visa requirement under a reciprocity agreement with Moscow. The two countries launched direct charter flights from Eilat to Moscow and St Petersburg just last month. To date, the Israeli government has taken no action to promote or to curb medical tourism and has allowed the industry to develop undeterred and unregulated. According to government spokespeople, 15,000 foreigners came to Israel’s hospitals for treatment in 2006. The number of foreign patients grew to 20,000 in 2007. The figure for 2008 is expected to be 30,000.

Treatment Abroad, the leading information portal for medical tourism, has launched a Perfect English copywriting and editing service for healthcare providers who want to improve the quality of the English used on their websites. The company’s team of native English-speaking copywriters will review the English language version of an overseas website and re-write its content in grammatically correct, properly translated and easy to understand. A well-written site is an important factor in patient choice and most English-speaking medical tourists expect and want potential healthcare providers to be able to communicate in good English.   This new service is a particularly valuable tool for clinics, doctors and hospitals targeting medical tourists from the US, the UK and other English-language speakers whose first impression of a provider is often formed by the standard of English used on its website.   A site that has been badly written or translated can give a poor impression or inaccurate view of the services offered and an incorrect view of the capabilities of the medical staff to understand its patients. This can discourage potential patients from making further enquiries, while a well written website, with clear and correctly worded information, instils confidence in potential medical travellers when researching treatment options. The introduction of this service is part of Treatment Abroad’s commitment to supporting its clients and it is part of a wider service of providing clients with a range of sales and marketing tools to help them reach as many potential medical tourists as possible. Keith Pollard, Treatment Abroad managing director said: We know from our survey of 650 medical tourists that a well written website is an important marketing tool and plays an essential role in attracting patients. A poorly worded site can reflect badly on a clinic or hospital and good communication between healthcare providers and potential patients is a crucial part of attracting English speaking medical tourists.  This new copywriting service is part our commitment to providing a comprehensive after-sales support service to our clients.

Despite the global economic downturn, Malaysia expects to see a 28 percent rise in foreign patients seeking medical treatment in the country. Among the reasons cited is the establishment of a one-stop medical and tourism online portal that facilitate all needs of overseas-based patients be it consultation, treatment, accommodation or tours. MalaysiaHealthCare.com (MHC) chief executive officer Suresh Ponnudurai said the country would continue to attract health tourists from countries such as Indonesia, Singapore, Bangladesh and Japan and those from the Middle East and Europe. Malaysia is one of the region’s centres of medical excellence owing to its quality and affordable facilities and services. About 360,000 health tourists visited Malaysia in 2007, a 20 percent increase from 2006. The use of technology and the internet has positioned the healthcare industry as one of the best in the region. Malacca received more than 64,000 medical tourists last year, mostly Indonesians, and was ahead of Penang, Federal Territory, Johor and Selangor. The numbers are expected to increase after the upgraded Batu Berendam Airport opens to bring in tourists from neighbouring countries. Also, a 300-bed private hospital Straits of Melaka Specialist Centre will be developed in Klebang within the next two years. MHC acts as a channel to network, integrate, facilitate and manage all aspects of health and medical tourism for health tourists and service providers such as hospitals, travel and insurance agents, airlines and hotels. Medical tourists can schedule their treatment and holidays by making online bookings for services. The country’s Health Ministry will be launching a special website on health tourism next month to disseminate information worldwide on the Malaysia’s medical tourism industry. Health minister Datuk Liow Tiong Lai said the website will include information on the medical facilities and specialist services available, as well as the payment rates, to make it easy for those interested to seek treatment in Malaysia. He added the ministry will indirectly help private hospitals in the country attract tourists who wanted quality medical treatment and healthcare. In line with the government’s aim of developing the medical and health-based tourism sector, the ministry held a promotion drive and briefing in Indonesia and Vietnam last year. These promotional efforts will be extended in 2009 to several other countries including Australia.

The Associated Chambers of Commerce and Industry of India (ASSOCHAM) has predicted that medical tourism will grow between 22 and 25 percent in 2009 and will start to have an annual growth rate of 30 percent from 2010 to reach the size valued at about Rs95 billion by 2015. Currently, the size of medical tourism in India is measured at Rs15bn. ASSOCHAM estimates that India is poised to become an epicentre for medical tourism from throughout the world. ASSOCHAM says that at least a six -fold increase is anticipated in the size of medical tourism by 2015, and worldwide patients will make India as a preferred choice for medical treatment because of cost. Projected market value for the Indian medical tourism market is as follows: Rs15 billion in 2008, Rs19.5 billion in 2009, Rs25.35 billion in 2010, Rs32.95 billion in 2011, Rs42.84 billion in 2012, Rs55.69 billion in 2013, Rs72.40 billion in 2014 and Rs94.12 billion in 2010. ASSOCHAM estimates that the cost of surgery in India can be one tenth of what it is in the US and Western Europe and sometimes even less. A heart-valve replacement that would cost US$200,000 or more in the US for example, goes for US$10,000 in India and that includes round-trip air travel. Similarly, a metal-free dental bridge worth US$5,500 in the US costs US$500 in India. The Chamber has estimated that 180,000 foreigners visited India for treatment from various parts of the world in the eight and half months since April 2008. It expects the number will increase between 22 to 25 percent this year. If ASSOCHAM is correct, this would put the current number of medical tourists to India at 270,000 a year from now, 670,000 by 2012, and 1.3 million by 2015.

The US healthcare market does not work like other markets.  Because health care costs are usually paid for by a third party either by the insurance provider or by the government, patients are not price-sensitive and providers don’t feel the need to compete for their business.  Lack of competition results in a highly artificial market plagued by problems of high costs, inconsistent quality and poor access, said Devon Herrick, senior fellow with the National Center for Policy Analysis (NCPA). Herrick is the author of the report entitled Health Care Entrepreneurs: The Changing Nature of Providers published by the NCPA last month. But in healthcare markets where patients pay directly for all or most of their care, providers almost always compete on the basis of price and quality. Herrick cited the following:     Cosmetic surgery: Since it is rarely covered by insurance, patients pay out of pocket and are sensitive to prices. They typically compare prices before surgery and pay a price that has been falling over time in real terms.     Laser eye surgery: Competition is holding prices in check and improving quality in vision correction surgery, including accurate correction, faster healing, fewer side effects and an expanded range of conditions that can be treated.     Medical tourism provides cash-paying patients healthcare outside of the US in high-quality facilities that rival domestic facilities. Patients can save 30 to 50 percent by going abroad. What lessons can be learned from these examples of entrepreneurship in healthcare?  The most important is that entrepreneurs can solve many of the healthcare problems that critics condemn, said Herrick, adding that   Public policy should encourage, not discourage, these efforts. NCPA is a non-profit, non-partisan public policy research organization established in 1983. The NCPA’s goal is to develop and promote private alternatives to government regulation and control, solving problems by relying on the strength of the competitive, entrepreneurial private sector. According to the latest official statistics, 7 million Americans have their own annual individual health insurance, four million more buy short-term cover, 83 million are covered by government schemes and 45.7 million have no health insurance at all. The figures for employer health insurance are confusing as they integrate policies paid fully by the employer with policies paid for only by the employee under a group offering.

The USAID Jordan Economic Development Program SABEQ, a five-year development initiative aiming to build the private sector in Jordan, recently conducted two workshops on Joint Commission International (JCI) standards for hospitals. The workshops were held in cooperation with the Private Hospitals Association (PHA). The first workshop provided a JCI overview, targeted at an audience from the Royal Scientific Society, University of Jordan Hospital and others. It detailed JCI standards and conducted a general discussion of the process of preparing for an international accreditation. The longer second workshop targeted Jordan’s private hospitals, enabling private hospital representatives to discuss actual JCI accreditation standards and how they can be applied in Jordan. Discussions covered each chapter of the JCI accreditation manual separately. Methods towards hospitals’ compliance with JCI standardisations were also freely discussed in interactive sessions between presenter and audience. USAID’s Economic Development Program SABEQ involvement aims to enhance productivity and revenues by achieving international hospital standards and creating jobs for Jordanians. The medical services sector in Jordan is an important and vibrant sector. Medical tourism derives upon the Kingdom’s reputable performance in health services and the latest PHA estimates say that foreign patients generating around $650 to $700 million in revenue to more than 120,000 incoming patients per year. This figure is much less than estimates made in 2008 of 250,000 foreign patients; the lower figure does not mean less people coming to Jordan, but by taking out resident expatriates and making other adjustments, the figure is now much nearer reality. One of the main objectives of the national strategy for the medical services sector in Jordan is to target and increase the number of incoming patients and revenues generated from their treatment and stay in Jordan. By ensuring the standards of Jordanian hospitals through accreditation programmes, Jordan can become more competitive on an international level, in the medical tourism sector. Dr Fawzi Al-Hammouri, chairman of PHA, commented: Four Jordanian hospitals have now acquired JCI accreditation. Highly qualified Jordanian physicians have secured an outstanding reputation for Jordan in the region and beyond. Jordan has a total of 101 hospitals, of which 58 are privately run. Forty-eight are PHA members including the four, all in Amman, who have JCI accreditation Al-Essra Hospital, Jordan Hospital & Medical Center, King Hussein Cancer Center (KHCC) and The Specialty Hospital.

In the looks-conscious, affluent society of South Korea, cosmetic surgery is the way to go. Imperfections in appearance are corrected through cosmetic surgery to achieve the wider eyes, whiter skin and high nose bridges that many South Koreans deem as beautiful. The financial meltdown has, however, affected cosmetic surgery business, forcing some among those in search of beautiful looks to say no to the knife. Clinics report the number of patient visits each month has been down 40 percent since September last year. But plastic surgeons have been quoted saying that the country’s economic decline has brought a silver lining. A cheap Korean won has encouraged more and more Japanese, Chinese and Korean-Americans to come to Seoul for cosmetic procedures. Some clinics report that by the end of 2008, 20 to 30 percent of patients were foreigners, up from 10 percent a year earlier. A few larger clinics are capitalising on the downturn at home to open branches in China, seen as the industry’s next big growth market. A recent survey of medical tourists by the Korea Tourism Organization (KTO) shows that beauty care and cosmetic surgery, along with oriental medicine and general health check-ups, are the most popular reasons to come to Korea. The number of foreign visitors coming to Korea for medical purposes has been steadfastly growing, from 16,000 in 2007 to over 40,000 in 2008, according to the Korea Health Industry Development Institute. The Council for Korea Medicine Overseas Promotion reported that 37,000 foreigners visited the country in 2008 to receive medical treatment, more than double the 15,000 who came in 2007. Korea’s key target markets are Japan, China, the United States and the Russian Far East. The KTO believes that for Japan, marketing activities should focus on beauty care, cosmetic surgery and oriental treatment, while China shows the most potential for inbound travellers. Other markets as the US, Thailand, Singapore and India show relatively low interest toward Korea than other popular medical travel destinations, so the KTO wants to concentrate on promoting Korea’s price competitiveness, rather than on quality. As for Russia, KTO suggests that the marketing should revolve around improving Korea’s overall recognition in the region, and developing total tourism packages linked to medical treatment. KTO is building a one-stop information centre, to open this year, with the aim of attracting 100,000 medical tourists by 2012 .The KTO also plans to use its 27 overseas offices and to participate as many exhibitions and shows abroad as possible. Until now, it had been illegal for hospitals, clinics or agencies in Korea to recommend the services of a hospital or mediate between a patient and a medical institution for profit. Lawmakers passed a bill in early January that allows Korean hospitals and other medical institutions to market their services to foreigners. Korea’s medical industry is racing to meet the demand. Hospitals are hiring interpreters, while some are planning to place ads on newspapers catering to Korean communities overseas. The Ministry for Health, Welfare and Family Affairs projects 80,000 people will visit Korea for medical treatment this year.

A health tourism complex will soon be built in the El Khabayat region near Gabes, a coastal town located some 400km south of the capital. The 140-hectare complex will comprise several health cure centres using essentially thermal waters for which the area is known. Hotels, leisure facilities, a golf course and a conference centre will also be part of the development. Work is expected to start during the second part of 2009. Tunisia is increasingly becoming a hub for medical tourism, having treated some 102,000 patients in various cosmetic clinics. The Tunisian Central Bank’s latest figures show that health tourism revenues reached 60 million dinars (US$43.14 million) in 2007. Most of the revenues are generated by cosmetic surgery, orthopaedic interventions, eye surgery, heart surgery and dentistry. Tunisia is also the world’s second largest destination for thalasso therapy. In 2007, 151,000 visitors, mostly from France and Switzerland, stayed in Tunisia’s 41 thalasso therapy units authorised by the Public Health Ministry.

Thailand expects to welcome about two million medical tourists this year, according to the Tourism Authority of Thailand and the Department of Export Promotion. A 38 percent increase from the 2006 figures of 1.45 million was recorded. The combined revenue from the foreign patients of THB40 billion (US$1.15 billion) in 2006 is expected to rise to THB45 billion (US$1.3 billion). Figures have been rising in recent years. In 2002, there were 630,000 medical travellers with a combined spending of THB18 billion (US$519.7 million). In 2003, the number was 973,532 with a spending of THB26 billion (US$750.68 million). In 2004, the number rose to 1.1 million with THB30 billion (US$866.17 million) in revenue. In 2005, the number reached 1.25 million with over THB30 billion (US$866.17 million) in revenue. The figures may be correct, but critics argue that the practice of some Thai hospitals of counting one patient staying in the country going to hospital on three days, as three medical tourists, and including non-Thai outpatients (and there is a large population of resident expatriates as well a huge numbers of visitors) who only go to hospitals for prescription drugs, as medical tourists, hugely inflate the figure to as much as three times the real numbers. The political problems of late 2008 caused a temporary hiccup. Curiously, the figures above ignore the loss of medical travellers due to political unrest. No one knows how many medical travellers were lost, but the Bank of Thailand estimates that it deterred 3.4 million tourists from visiting the country. Assuming the political problems are solved, the trend will be year-on-year increases in medical tourists going to Thailand - the disagreement is about how many. Hospitals involved in medical tourism report some slowdown. But, despite a triple hit of political unrest, increased airfares and recession, they claim to suffer less than expected. Phyathai Hospital weathered the rough times through its focus on Persian Gulf customers. Currently, Westerners account for 5 percent of overseas patients at Samitivej Hospital, but sees more potential in the East than the West. Some Bangkok hospitals have contracts with Gulf state governments.

You would not dream of going to or sending customers to Iraq or Afghanistan for medical treatment. As much as hospitals, clinics and agencies protest that politics and war is not their concern, customers watch television and read newspapers. If a country seems at war or in crisis, then it is human nature to think twice and consider an alternative destination. Thailand and India found that political unrest and terrorism did affect medical tourism numbers, and that business as usual only returns months after the end of the problem. Other countries with unstable governments or lawless areas, suffer, despite their denials, from visitors being scared away. With hundreds of countries now to choose from, and many thousands of hospitals,clinics, spas and centres actively seeking medical tourists, it is easy to find an alternative to a troubled country. Tourism crisis expert David Beirman, reported in eTurboNews, made some very interesting points on the Gaza crisis, which apply to tourism and medical tourism: In 2008, Israel, the Palestinian territories, Jordan and Egypt all enjoyed record year for tourism arrivals. One of the key reasons that these four destinations enjoyed such strong tourism inflows was because there was a general perception that they all experienced relative stability during 2008. However, the picture for 2009 is far less optimistic, at least for the short to medium term. In 2008, the interplay of tourism between Israel, Jordan and the Palestinian territories and Egypt was positively influenced by the relatively benign security environment. Israel, the Palestinian Authority, Jordan and Egypt face a challenging 2009. The eruption in Gaza has created a whole range of perceptual and security concerns about the safety of travelling to Israel and these concerns will also apply to Palestine, Jordan and Egypt. To add further intensity to the challenges the global economic downturn will mean that the four destinations will switch from being the highly affordable destinations they were in mid 2008 to relatively expensive destinations. The fact that many hoteliers in the four destinations have significantly increased their prices in recent months has exacerbated this problem. A recession usually means that travel does not stop but tourists tend to gravitate to destinations closer to home or those that are very affordable. Israel, Egypt, Jordan and Palestine have all enjoyed positive growth from the discretionary travel market and will find that their longer haul markets may look elsewhere on both security and economic grounds. Haifa University’s Dr Yoel Mansfeld wrote some years ago that surges of conflict and terrorism had a negative impact on tourism to Israel and the immediate region. And in his analysis, peaks and troughs in international tourism arrivals to Israel were heavily influenced by the perceived security environment. Many agencies and hospitals promote their services as medical treatment with a cheap holiday. So when the holiday trade gets hit, so will the medical tourism trade. Hospitals and agencies in regions hit by war, terrorism and political unrest have mostly failed to connect with consumers on their concerns. Websites remain unchanged. In a period when medical tourists are less certain of their ability to pay for treatment, political problems can be the tipping point that makes them change destinations or even stay at home. Medical tourism needs to find ways of satisfying real or imagined customer concerns. Your hospital may be hundreds of kilometres away from troubled areas, but customers’ geography is very hazy.

Washington-based The Icon Group is actively seeking medical tourism providers from around the world, who want American venture capital. Philip Slaton of Icon speaks to IMTJ Q: Is it your money? A: We are agents of venture capital companies. We are not the actual venture capitalists. What we do is find the medical tourism company, have it prepare submission documents, and submit them to the VC investor company. We bring the parties together.    Venture capital is not lending money. It is making equity investment in the infrastructure of a business with the idea of making it a huge financial success. Q: What areas are you targeting? A: Central and South America, the Caribbean, Southeast and Southwest Asia, South and North Africa and Eastern Europe. Q: What types of business? A: Of primary interest are hospitals, clinics and medical tourism agencies. Q: What level of finance? A: Our VC investors are only interested in investment projects requiring a minimum of US$3 million invested per year for a minimum of three years. Q: What do you look for in a prospect? A: Business stability, proper accounts and good standing with governments. True sustainable growth opportunities that need investor capital. Q: Who are the venture capitalists? A: Venture capital is funded from private investors that place money with hedge fund managers. Investors are usually formed into limited partnership investor pools or limited liability corporations with the hedge fund manager as the managing officer or partner. This partnership invests in the company and takes a very substantial ownership position in the company including voting seats on the board of directors. Venture capitalist are owners of the company along with the original owners, according to an owners’ agreement that all parties agree to before money is funded. There is no investment to be returned and this is not a loan. It is an equity investment, in return for ownership in the business. Q: Can you expand on your role? A: The level of scrutiny of the VC investors is breathtaking. The challenge that I face daily is getting books of companies cleaned up enough so that standard accounting methods are implemented and an independent audit is done. Q: What interest have you had so far? A: I have interest from 35 medical tourism providers. I expect four to six at the most to pass muster for VC investment consideration.Venture capital is not long-term money. It is an investment in a business to help it reach sufficient size that it can be sold or floated on a stock market. Medical tourism is a new business that banks are often wary of, so entrepreneurs need to turn to private markets for capital. Venture capitalists as co-owners will fire owners or managers who fail to perform; they keep a tight rein on their investment and ensure it is not used for personal gain.

The managements of Israel’s hospitals see medical tourism as a source of income, but the sector is its infancy, although efforts are being made to encourage it. The Israeli government has begun to understand the potential. Tourism bodies are starting to promote the country. Last year, Israel received 35,000 medical tourists, bringing hospitals revenue of $100 million. Most of the patients are from Eastern Europe, Russia and the former Soviet states, as well as the Balkans. Like many other countries, Israel wants the American medical tourists. There are strong links between the US and Israel. But, in the short-term, the chances of getting much US business are remote. Most Americans regard Israel as being an integral part of the Middle East. The simple fact is that Americans do not want to go to places regarded as politically unstable. Much depends on whether President Obama can help restore peace in the Middle East. There are other problems as well prices are higher than Thailand. Singapore or India, few websites are in English, and marketing leaves a lot to be desired. A leading local business, Israel Scientific Instruments (ISI), has recently set up a medical tourism agency. It wants to promote Israel a destination of choice for American medical tourists, but is concerned that all agencies and hospitals are going their own way, and that without coordinated marketing, it will be an uphill struggle. The other problem for Israel is that the US medical tourism industry has spent the last three years educating Americans that they should only go to JCI-accredited hospitals. Many US medical tourism agencies, employers and insurers have got themselves into a situation that they disregard other reputable accreditation agencies, and will only send people to JCI hospitals. Almost every other country is more flexible and international, seeing JCI as just one of many factors to consider when seeking treatment. The big drawback to getting American business is that only three hospitals have JCI status. Three others are in the two-year process of getting that status, but many hospitals see no point in spending money on JCI, as, compared to Europe, they see little potential from US sources. All three hospitals with JCI status are part of Clalit Health Services. These are the Ha EMEK Medical Center in Afula, Meir Medical Center  inKefar-Saba and Soroka University Medical Center in Beer Sheva, Three more hospitals are in the process of obtaining accreditation:   Kaplan Medical Center in Rehovot, and two owned by Clalit; Carmel Medical Center in Haifa and Beilinson Medical Center in Petah Tikve.

A Jones Lang LaSalle Hotels research study entitled FocusOn Medical Travel said the medical travel sector has the potential to develop into a lucrative niche market for hotel operators and investors. Thailand, Singapore, Malaysia and India are developing first-class facilities. International tourists are attracted by the high-quality and relatively low-cost healthcare offered. With destinations such as Eastern Europe, Turkey and Dubai getting in on the act, this market is poised for rapid expansion in the future. As travellers become more discriminating, they will continue to seek out hotels and resorts that offer a complete array of amenities. Medical spas, medical travel and rehabilitation at desirable destinations will play a large role in the new generation of spa resorts. In Dubai alone, there are at least 120 spas, health clubs and clinics offering wellness services. By 2015, the United Arab Emirates could be amongst the top spa destinations in the world with an estimated 200 hotels offering world-class facilities, said Mark Wynne Smith at Jones Lang LaSalle Hotels. The report emphasised that all involved must ensure that the medical travel industry offers accessible, affordable and high-quality care to cement the reputation of this fledgling sector and allow the travelling public to make informed choices about their medical care. There is enormous potential for partnerships between hotel chains, property developers, airlines, insurance companies and financial institutions. These partnerships are vital as medical travellers need the security and peace of mind provided by purchasing an all-inclusive package for their trip. Medical Tourism has the potential to become a significant tourism segment with investment opportunities ranging from large scale hotel developments adjacent to city hospitals or specialist offerings with some minor modifications to existing product. In either scenario, the amount of incremental capital expenditure will depend on the size and opportunity within the market and should be a key consideration for any investor, added Smith.

An increasing number of visitors to Vietnam are combining tourism with the advantages of natural medicine. Vietnam has abundant natural resources to provide natural medicine for the health tourism industry, especially hot springs and mineral water sites. Naturopathy tourism is still a new industry in Vietnam. The country’s health facilities and services are as not as modern as other countries, but it is known worldwide for its traditional herbal medicine. Some of Vietnam’s most popular tourist sites offer added health benefits. The Thap Ba Hot Springs in the central coastal city of Nha Trang, the Kim Boi Mineral Waters in the north-western province of Hoa Binh and the National Institute of Acupuncture in Hanoi are all places where visitors can enjoy traditional therapies. Nha Trang offers a mud bath at the Thap Ba Hot Spring Centre. The director of the Thap Ba Hot Spring Centre, Hoang Quang, said that despite the fact that natural medicinal tourism is new to the country, his centre has received 400,000 travellers this year, including 31,000 foreign tourists. Meanwhile, the National Institute of Acupuncture in Hanoi is world-renowned for its technique of using acupuncture anaesthetic instead of general or local anaesthetic for surgery. Hanoi is a centre for health tourism for herbal treatments, particularly acupuncture. Vietnam’s tourism sector is anticipating an average of 7 to 8 million foreign visitors a year for the next 10 years, but is still struggling to create an image that will increase those figures. One solution is to enhance advertising in key markets and give priority to building a brand name for national tourism. Vietnam is in need of a clear message to convey its attractions to potential tourists. The development strategy of the Vietnam National Administration of Tourism (VNAT) aims to turn the country into one of the world’s top destinations by 2010. VNAT plans to advertise on international television networks as well as in newspapers in Singapore, Malaysia, Thailand and Cambodia. But it has yet to identify strategic tourism products in its advertising campaigns. The cultural and eco-tourism aspects of current advertising campaign have appeared vague and are not memorable to visitors.

Market Image, a team of healthcare professionals and internet-savvy marketers, is extending its marketing services to medical tourism facilities around the world. Founded a decade ago, it originally just worked with Canadian healthcare providers. It has developed websites for the international pharmaceutical industry, medical clinics, and pharmacies. The company restricts its clients to those in the global healthcare industry. It offers a variety of marketing services including web site design, internet marketing, search engine optimization, PR services and a Canadian based call centre service. The company now wants to expand to provide services for hospitals, surgeries and agencies worldwide. Medical tourism is big business. The patients are there. The doctors and hospitals are there. We use our real-world marketing experience and knowledge of the healthcare industry to inform patients, insurance companies, employers and government market segments about these international facilities. We make sure prospects know that these medical professionals understand the unique needs of foreign patients and they are open for business, says Market Image marketing manager Victor Tiongco. The company offers packaged services like its Seahorse service, which includes 12 press releases per year, call centre services, 1-800-number on website for North American patients, and two blog entries per month.

South Africa can accommodate up a million medical tourists every year and is ideally placed to the become a destination of choice for medical and cosmetic surgical procedures, says Cawe Mahlati, organiser of the inaugural South African Health Tourism Congress (SAHTC) in Gauteng. Mahlati says a strong health sector could bring down the cost of healthcare in the country, at a time the country is seriously considering restructuring what the public and private healthcare sectors offer internally. More than 300 delegates representing medical tourism agencies, hospitals and healthcare providers, dentists and doctors, government representatives and insurers attended the congress. The aim is to create a health tourism cluster, getting all parties to work together to market South Africa as a cost-effective, quality provider of medical and cosmetic procedures. In the last few years politicians and government bodies have offered no support or shown any intent to assist medical tourism. This will change as the congress has received the support of the government with both Deputy Health Minister Thokozile Xasa and Deputy Tourism Minister Molefi Sefularo speaking at the event. Xasa said that the government aims to complete a national strategy and implementation plan by the end of this year to develop the country as a destination for international medical tourism. He also said that out of 9.5 million foreign tourist arrivals in the country last year, 410 000 were medical tourists, but organiser Mahlati is wary of trusting those figures. Trade estimates in recent years have consistently used a figure of only 20,000. She suggests that the creation of a health visa would make it easier to calculate real numbers. Xasa admitted that the country’s service offering in medical tourism is sporadic, The industry in its innate state is fragmented and consequently inefficient."A pioneer in medical tourism, South Africa has long established itself as a destination for health tourists, with thousands of foreign patients electing to have cosmetic or medical procedures in local hospitals. But more organized rivals have overtaken it as marketing has mainly been left to agencies, with few hospitals prepared to promote their services. The congress aims to stimulate the inbound health tourism market in South Africa. Deputy Minister of Health Molefi Sefularo said, Although the private sector is the main beneficiary of health tourism, there is a slow stream of patients who are price sensitive and have seen the opportunity of using the public sector hospitals. There is much scope for collaboration between the medical, tourism, hospital and travel industries. It is therefore important for the public sector to utilize this opportunity in a co-ordinated manner, without negatively affecting access to the South African patients.South Africa has to position itself therefore as a destination of choice for medical healthcare ahead the 2010 FIFA World Cup." South African Medical Association regulations prohibit commercial brokers from recommending patients to doctors, and restrict doctors from marketing their services directly or indirectly to the public. The authorities sudden interest in medical tourism is due to an acceptance that leisure tourism in South Africa has reached saturation point, giving an impetus to new strategies that target medical and health tourism for high spending visitors.

South Florida is becoming an international destination for health care, and various new initiatives, often led by the medical tourism programme for the Greater Miami Chamber of Commerce, are increasing the inbound flow. But substantial unpaid fees mean that Miami hospitals will no longer accept patients from Turks and Caicos. Bahamas based The Bank of the Bahamas, with a branch in Florida, has a new Visa card that allows Bahamians discounts of between 30 % and 60% at seven South Florida hospitals. South Florida facilities accepting the card are Mercy Hospital, Baptist Hospital, Cleveland Clinic Florida, Jackson Memorial, Broward General, Miami Children’s and UM Health Systems. The bank argues that it is not promoting medical tourism, simply accepting the fact that as Bahamian residents do travel to Florida for healthcare, they are helping them afford treatment. Many hospitals offer international patients discounts off the gross charges, but foreigners generally still pay more than Americans with private insurance, which generally negotiates rates of discounts of 50 percent to 70 percent off gross rates. Four Miami-Dade hospitals have enlisted in a joint-marketing program through the Greater Miami Convention and Visitors Bureau to market the region. One issue is whether hospitals are getting paid for international patients. Several South Florida hospitals are owed $20 million for treating patients, but there are differing accounts as to whether the money is owed by medical tourism agency Southern Health Network, or the government of the Turks and Caicos Islands. In April, the Turks and Caicos Islands Government decided not to renew its contract with Southern Health Network, the third party company that had been handling the country’s overseas medical referrals for the past two years. The Turks and Caicos, eight inhabited islands, has been in financial and political turmoil for months. A premier known for extravagant spending resigned in March after a commission of enquiry proved corruption accusations, and a commissioner appointed by the United Kingdom has been trying to sort things out. The UK government has taken over responsibility for the country, as it is a British Overseas Territory. According to documents filed with the Miami-Dade County Circuit Court, two Miami businesses are suing Southern Health Network for failing to pay for services provided to Turks and Caicos residents who travelled to the US for care. Several other hospitals claim they have not been reimbursed for money owing back to 2006. Baptist Health is owed money, as is Miami Children’s Hospital. The two providers suing Southern Health Network are plastic surgeon John Grossman, owed $50000, and SkyeMed Pharmacy and Infusion Services, owed $76,000. Southern Health Network has filed a lawsuit against the Turks and Caicos government for fees of $16 million. What complicates matters is that according to a transcript from a Turks and Caicos government corruption inquiry held earlier this year, in 2006 island officials contracted with Southern Health Network to secure and coordinate U.S.-based healthcare for residents who needed treatment beyond what they could obtain through the islands’ healthcare system. But several years into the contract, investigators said that the medical travel program grew from $4 million a year to tens of millions of dollars annually under Southern Health Network’s management. Investigators found that Southern Health Network is owned Delroy Howell, a business associate of former Turks and Caicos finance minister Floyd Hall. According to Hall’s inquiry testimony, the agreement called for Southern Health Network to negotiate the provider contracts and pay for the provided treatment upfront. They would then receive reimbursement, which would include a fee based upon a previously negotiated discount-rate formula, from the Turks and Caicos government. But government officials cancelled the programme in April largely because of costs and questions over the contract-award process. In 2006 Hall brought a proposal to the Cabinet that Southern Health Network, a Miami company set up for the purpose, be awarded the health care management contract at 50 percent of the savings they achieved. Prior to April 2006, a Canadian company, Canadian Medical Network (CMN), had been providing overseas health care management to the Turks and Caicos Islands government and in CMN’s last year of operation they had dealt with health care provision totaling $4.2 million and received fees of some $443,519, calculated on the basis of 25 percent of the discounts on real or inflated prices for medical services that they were able to negotiate on behalf of the TCI government.

Although the Kingdom of Saudi Arabia has an expanding and up to date health system with world-class hospitals containing state-of-the-art facilities, it has yet to make its mark in the booming medical tourism industry. Many of its own citizens look overseas for medical help and treatment. Dr. Sami Badawood of Jeddah Health Affairs says that fewer Saudis are going overseas, while there is an increase in the number of medical tourists from Gulf countries. The number of people going abroad for medical treatment has decreased by around 20 to 30 percent over the last three years. This is because of two reasons, the global economic downturn, and that better medical services are now available in the Kingdom itself. Dr. Badawood admits that there has not been enough marketing overseas for the Kingdom’s heath sector, but there are strategic plans afoot and that special attention is being given to build a brand for medical tourism in Jeddah, The strategic five-year plans seek to develop medical cities in Jeddah that will have concentrated medical services, similar to those in other countries, and this will attract people, but more private sector investment and cooperation with specialized companies is required.  Jeddah’s summer festivals also attract tourists from different regions, and medical tourism is at a peak at this time of the year with a dramatic increase in the number of patients seeking appointments. Jeddah has 40 hospitals and an increasing number of private clinics. The Ministry of Health and the Jeddah Governorate are to hold a workshop on how best to develop the plans to boost medical tourism in Jeddah. Formal conclusions from this will be sent to the Saudi Commission for Tourism and Antiquities (SCTA). SCTA is responsible for promoting tourism, and is working with private and public sectors on implementing marketing programmes to attract medical tourists and boost the capacity and resources of private hospitals. Saudi Arabia does have competition from other Middle Eastern countries; particularly Jordan and the UAE.Korea, Malaysia, Thailand, India, the Philippines and Eastern European countries are attracting substantial numbers of medical tourists from the Middle East. Dr. Badawood admits that tourism and medical tourism work separately, and says that the most popular medical services for which people come to the Kingdom are paediatric and obesity treatments and eye surgery. Cosmetic surgery is increasingly popular but cosmetic treatment is much more expensive than in India, Egypt and Lebanon. Surgery costs are lower than the US, but higher than many Asian countries. The kingdom has expertise in stem-cell treatment and infertility treatment. The government and private sectors are not yet working in unison. Where to position itself on cost and expertise, is an unsolved puzzle. The bottom line is that while thousands of Saudis go overseas, it is difficult to get substantial numbers of inbound medical tourists.

Japan plans to attract Asian and Russian medical tourists as a way of boosting healthcare income to help the country cope with rising costs of its aging society, says a report from the Ministry of Economy, Trade and Industry. Japan plans to begin a pilot project in September with ten of the country’s biggest hospitals, including the National Cancer Center and Keio University Hospital in Tokyo, while travel and translation companies will help coordinate tour packages. As healthcare in Japan is not cheap, it cannot promote cost savings. The plan is to offer added value that is not widely available elsewhere, such as gene diagnosis and regenerative therapies to restore lost or damaged cells and tissues. The project includes package tours combining medical checkups with sightseeing at cultural, historical and sports venues. Promoting Japan to medical tourists could make hospitals less dependent on patients’ payments to cover their costs, but the volume of visitors needed to make any real impact is huge. As Singapore has found, promoting quality over cost saving is not an easy path, and prices in Japan are a lot higher than Asian medical tourist destinations. The ministry project is a one to two year pilot to get feedback on the feasibility of medical tourism for the longer term, and the ministry is reluctant to give away any detail of how it will attract travelers. For months, a panel of experts has been meeting at the Ministry of Economy, Trade and Industry (METI) behind closed doors to discuss the merits of attracting wealthy patients from Asia and Russia to Japan for top of the range medical treatment. Countries such as India, Singapore and Thailand are a popular destination for Asians, Russians, Americans, Europeans and even Japanese who don’t want to pay the high costs at home. Japan cannot compete on price, e.g. a heart procedure costs $100,000 in the USA or Japan, but as little as $20,000 at top private hospitals in Asia. The cost of drugs in Japan is one of the highest in the world. The ministry is hoping the idea will boost the finances of the nation’s hospitals. Many hospitals that rely on national health insurance payouts from the government are struggling to make ends meet. Currently about 80% of Japan’s annual medical costs are paid for by the state. Japan’s national insurance system is hard up for money too. With the population graying, the number of workers paying for insurance has dwindled, to the point where the payments no longer cover the annual costs. There are problems, even with the pilot. The country has few doctors who are bilingual. No hospitals in Japan have JCI or similarly accepted international accreditation. Japanese hospitals are not allowed to advertise and are not interested in international accreditation, partly due to accreditors refusing to translate essential documents into Japanese. Japan even has a shortage of doctors with fewer doctors per head than most other major countries. The only good news is that the quality of care in the 8000 private hospitals is excellent. The pilot is well intentioned, but achieving results will be an uphill struggle.

Indian research group Koncept Analytics has published a new short 49-page report on medical tourism, Medical Tourism Report 2009. This report gives an overview of the medical tourism industry with a focus on Asia. It discusses the major medical tourist destinations of Singapore, Thailand, Malaysia, India, Philippines, Taiwan and South Korea and their respective competitive advantages. The major healthcare organizations in Asia are also profiled. Author Vikas Gupta argues that, More than thirty countries in Asia, Africa and Eastern Europe are serving millions of medical tourists annually. Thailand, Singapore, Malaysia, India and Philippines are the major destinations in the Asian medical tourism market. Thailand is more popular among Western European medical tourists for cosmetic surgery. Singapore and India specialize in complex procedures with India having a cost advantage and Singapore a technology advantage. Global economic downturn has resulted in decline in visitor numbers in Singapore and the same holds true for medical tourists also. The decline is most among Indonesian patients, but is being compensated by patients from other places such as Vietnam and the Middle East. The private healthcare market in Singapore could witness a period of slower growth due to declining medical tourists. The healthcare industry in Thailand has seen rapid growth in recent years, ahead of the country’s GDP. In Thailand, medical costs are lower than in Singapore and also, it is a much more popular tourist destination. The cost of healthcare in Thailand is about five times lesser than it is in the US. The Malaysian government is aggressively promoting medical tourism. It has extended the visa period for health tourists from one month to six months. Major hospitals in Malaysia are targeting new markets such as Vietnam and Cambodia. India is one of the lowest cost and highest quality of all medical tourism destinations. It offers low-cost cardiovascular and orthopedic procedures, at about one-tenth the cost of similar surgeries in the US. Taiwan provides high-quality healthcare at very competitive prices but is a slow starter. A liver transplant costs half as much in Taiwan as in Singapore. China is a key target market for Taiwanese hospitals. The Korean government is promoting the nation’s growing medical tourism industry and has set a target of 100,000 foreign patients by 2012. However, Korea is considered to be a latecomer in medical tourism. The report includes: 1. Medical tourism overview2. Market overview2.1 Singapore2.2 Thailand2.3 Malaysia2.4 India2.5 Philippines2.6 Taiwan2.7 South Korea3. US - outbound medical tourism4. Rise of medical tourism in Africa & Middle-East4.1 Uganda4.2 Tunisia4.3 Jordan4.4 UAE5. Profiles of hospitals5.1 Bumrungrad Hospital5.2 Parkway5.3 Bangkok Dusit Medical Services5.4 Raffles Medical Group5.5 Thomson Medical5.6 KPJ Healthcare5.7 Apollo Hospitals There are many tables including- Patient demand US Outbound Tourism (2007-12E) Comparative cost of major medical procedures by country Worldwide medical tourism market (2006/12E)

Russia and medical tourism are often linked, with Russians seen as key target markets for South Korea, Taiwan, The Philippines, Japan and small Eastern European countries. But there are signs that inbound trade is developing, and, remembering the size of the country, internal domestic dental tourism. Medical tourists leave Russia because it is problematic to receive some kinds of treatment back home. But for those seeking specialist medical attention or medical spas, Russia is becoming a popular destination, particularly for Germans, at a fraction of the cost of many Western hospitals or medical spas. Russia offers competitive competence and quality to patients, in addition to luxurious and therapeutic accommodations.  For those traveling to Russia, especially to St. Petersburg, for medical treatment or procedures, many facilities have the same quality, integrity and credentials as Western doctors and hospitals, often offering services for 40-80% less. Cardiology, neurosurgery, and ophthalmology are some of the areas where Russian doctors are highly qualified professionals. Russia offers numerous benefits to medical tourists, including rehabilitation at the Rehabilitation Clinic of Dr. Vorobiev in Moscow, for people suffering from every addiction imaginable, from drugs, to alcohol, to gambling, benzodiazepines and barbiturates. Patients can also be treated for neuroses, depression and sexual disorder. The AVA-Peter Clinic in St.Petersburg, is a specialist fertility clinic Although they have the facilities, hospitals and clinics are mostly poor at promotion. A handful of medical tourism agencies are emerging. Russian Medical Tourism (RMT) is one of the first medical tourism agencies in Russia. It can suggest medical institutions and doctors. RMT cooperates only with a select few Russian clinics and hospitals Dental tourism grows more and more popular in Moscow due to the economic crisis. It is twice as cheap to have your teeth fixed in the regions and countries near to Moscow, than in Moscow. Dentistry went up 40-50% in price at the beginning of the summer in Russia. In Moscow one filling can cost 4,500 rubles ($145), while in a province it costs about 2,000 rubles ($64). The number of people willing to go outside Moscow to enjoy healthy teeth has been growing recently. Travel companies, which organize such tours, have had a tenfold increase in their clientele. Medical tourism agency Health Vacations Inc. of St. Petersburg, targets Americans and Canadians by offering high- quality, low-cost medical care in St. Petersburg at 40-80% lower than the cost of the same procedures in the United States. It also offers new technology that has not yet been approved in the US, including hyperthermia treatment for cancer and the prosthetic disc nucleus for degenerative disc disease.

Beacon Dermatology is the latest clinic in Ireland to get JCI accreditation. Michael Cullen, chief executive of Beacon Medical Group, explained why a group, that has treated a few medical tourists to date, bothered with the expense of obtaining a JCI Accreditation: Beacon seeks to achieve JCI Accreditation to show the clinic’s commitment to providing excellence in safety standards and quality care. He added: We feel this accreditation is testament to Beacon Dermatology’s commitment to safety and hygiene standards. We are the first private dermatology clinic in Ireland to achieve this award. Since obtaining JCI, we have become more aware of patient safety and aim to improve the quality of care at all times. Beacon Dermatology is a dermatology clinic offering an extensive range of medical, surgical and cosmetic dermatological treatments as part of the Beacon Hospital health system in Sandyford, Dublin.  The system is managed through a partnership with University of Pittsburgh Medical Centre (UPMC). The other recent subsidiary with JCI status is Beacon Renal, a state-of-the-art therapy centre offering haemodialysis and peritoneal dialysis for the treatment of patients with chronic renal failure.  It currently treats over 100 patients thrice weekly and has capacity to treat over 200. Professor J Mark Redmond, Michael Cullen and Paddy Shovlin founded Beacon Medical Group in 2002 to advance Professor Redmond’s philosophy and vision of healthcare excellence in Ireland. Its first major initiative was the Beacon Medical Campus. This encompasses Beacon Hospital, Beacon Renal, Beacon Dermatology, Beacon Consultants Clinic and Beacon Consultants Concourse. Meanwhile, the Beacon Medical Mall houses specialist centres in eye laser treatment, dentistry and weight-loss as well as The Irish Maternal Foetal Foundation and a pharmacy. A Women’s and Children’s Hospital is planned for development adjacent to the Hospital.

As more patients are looking to Israel as a destination for quality, cost-effective care, International Medical Services (IMS) is expanding its operations to 12 offices worldwide, with new offices in Mongolia and Nigeria. IMS Israel is the leading medical tourism agency in Israel. IMS offers patients the chance to have a procedure done in one of 18 medical centres in Israel. Doctors and specialists offer a range of services including cosmetic surgery, oncology, urology, orthopaedics, in-vitro fertilisation and neurosurgery. Austine Agbaje of IMS Nigeria, pointed out: It is not easy for patients in Nigeria to obtain the medical care they need. This partnership with IMS Israel makes first-rate care more accessible to patients, and at a lower cost. Urjgee Duuya of IMS Mongolia concurred: Israel represents a highly attractive destination for residents of Mongolia to access exceptional medical care that is simply not available here. Meanwhile, the company has also forged partnerships in Moscow to add to its offices in the Ukraine and Kazakhstan, where there is little medical infrastructure for better healthcare. Ira Nissel, founder of IMS, said: Russia and Israel have abolished the need for visas, making it very appealing for IMS to establish a new office and partnership in Moscow. Our offices are now focused in regions where patients can afford to access top quality medical care but find that it is not available in their home countries. By establishing a local entity in each of these countries, IMS increases its market reach and expands its capabilities to channel many more patients to Israel. Most local citizens in these countries are more comfortable and confident with medical travel when their medical travel coordinator has roots within the community.

India-based hospital chain Narayana Hrudayalaya plans to set up a health city in Mexico that will also cater to patients from the United States. Devi Shetty, chairman of the Narayana Hrudayalaya group of hospitals, said: Our next project will be a health city in Mexico. We may tie up with some American hospitals for this project. The health city in Mexico will be a 3,000- to 5,000-bed facility and we are looking for joint ventures. We foresee healthcare delivery problems in the US. They also have problems in undertaking a 20-hour journey to India for heart and other surgeries. As Mexico is closer to America, they will find it easy to undergo treatment there." The government of Mexico has asked the group to set up a large health facility. The health city will be built either in the capital Mexico City or in Guadalajara, the country’s second largest city. The proposed health city will cater to the requirements of patients from the US. The group is reportedly in talks with the US-based Sutter Health for the project. The chain of hospitals has already built one of the world’s biggest cardiac hospitals in Bangalore. It currently has the Asia Heart Foundation in Kolkata, R C Agarwal Memorial Hospital in Tinsukia, and the Sparsh Hospital in Bangalore. Over the next five years, it is expanding its operations to six other Indian cities, including a multispecialty hospital with research facilities in Hyderabad.

Whenever the medical tourism industry begins to appear professional, a scandal comes along that gives more ammunition to people who are against local patients going overseas for treatment medical tourists coming to their country. Patients from Gulf states, forced to travel abroad because of a lack of available organs, are having documents falsified by Egyptian hospitals in a bid to cover up illegal kidney transplants. The Egyptian Ministry of Health and a number of leading nephrologists have confirmed that transplant patients from the region are returning home with false documents showing information including fake hospitals and surgeons. Dr Abdel-Rahman Shahin of the Egyptian Ministry of Health said: They play with the papers. We have detected several cases of violations." Dr Sadiq Abdulla, a consultant vascular and renal transplant surgeon at Salmaniya Medical Complex in Bahrain added: Reports are ’templated’. There is no name of the hospital, doctor or the institute. It does not even mention the name of the patient, just that he or she had a kidney transplant. Even the date has been changed. Egypt has become a hot spot for wealthy citizens from the Gulf seeking to buy kidneys and undergo transplant surgery as diabetes rates in the region have soared. The Unite Arab Emirates has the highest percentage of adult diabetes sufferers in the region. In Bahrain, it is estimated that a quarter of the country suffer from type 2 or adult onset diabetes while 11,000 people in Saudi are on dialysis, almost a quarter of them have diabetes-related illnesses. Regional specialists estimate as many as 150 patients from the Gulf states travel to Egypt to undergo illegal transplant surgery every year. This number has increased since Pakistan, Taiwan and the Philippines stopped the treatment of foreign patients seeking transplant surgery in early 2008 in response to international pressure. The Middle East Society for Organ Transplantation reported that 13 patients from Kuwait had travelled to Egypt for illegal kidney transplants since the beginning of the year. One died following complications after surgery. In Bahrain, at least eight patients have returned from Egypt following surgery since May, and three of these had to be hospitalised in Bahrain following complications after operations in Egypt. It is illegal in Egypt to operate on foreign transplant patients and for patients to receive organs from unrelated donors, but loose regulation and poor enforcement have allowed the country to become a popular place for illegal transplant surgery. However, the illegal transplants are also causing deaths and medical complications. The Egyptian Ministry of Health is currently investigating six cases of malpractice following a series of illegal transplant operations that included five patients from Saudi Arabia and one from Palestine. Four doctors have so far lost jobs. In June, a private hospital in the Giza region was shut down after authorities discovered a 26-year old Egyptian man trying to sell his kidney to a 75-year old Saudi man for US$2,000. The government has the right intention, but lack of resources means it is only able to pursue a few cases and it seems powerless to stop the trade. Unless the illegal trade of human organs is stopped, Egypt’s hopes of becoming a medical tourism destination will lie in pieces.

According to the European Spas Association (ESPA) in Brussels, wellness travel accounts for 60 percent of all trips taken primarily for health reasons. Trips to spas and rehabilitation centres comprise the remainder. More than any other age group, 35- to 50-year-olds, are part of the boom in wellness travel, which is both healthy and fashionable. The healthy properties of water is ancient knowledge that goes back at least to the Romans. Vestiges of their thermal baths can be found all over Europe, and people today are rediscovering the meaning health through water. Basic wellness travel is for those with a good salary and little free time. They go to a hotel with a large selection of wellness services, sleep late, eat substantial meals and go to the sauna a lot. The health conscious, on the other hand, have a more structured concept of how the time should be spent. They want to rectify specific feelings of malaise, are interested in regeneration and desire good advice and medical care. This category of wellness travel is on the rise. Spa visits, health tourism, wellness, beauty and fitness programmes, regenerative, reconditioning and relaxation stays, are all dynamically growing products that are offered within tourist packages. Besides classical and traditional European therapeutic procedures, these key European centres continue to welcome new, alternative and modern trends, including Indian, Chinese and oriental treatment methods, while natural cures are enjoying a revival. Spa centres also now often include modern aqua parks, cosmetic centres and similar services. The type of client at spas ranges from guests in search of a rest to the truly ill, including all forms of prevention (primary, secondary and tertiary) up to rehabilitation and the treatment of chronic diseases. As far as medical treatment facilities, guests can choose outpatient centres located within and outside the centre of town, in-patient treatment performed totally or partially in a health centre, or in the case of acute illness, in a fully equipped clinic. The European Spas Association (ESPA) represents 25 member federations from 22 European nations, together representing over 1,200 of the estimated 1,500 spas and health resorts in Europe. Similar terms are used to describe spas and medical wellness throughout the international health tourism sector. The regulations and standards in force regarding aspects such as infrastructure, hygiene, safety and comfort vary considerably from one country to the next. And this makes competition unfair: with different quality standards reflected in prices, it’s hard for top-quality resorts to distinguish themselves from their cheaper competitors. ESPA has developed the EUROPESPA Seal of approval that means the holder meets the exacting standards of ESPA in terms of general therapy infrastructure, hygiene and safety. The EUROPESPA seal of approval is designed for spas and health resorts in the classical healthcare segment as well as centres specialising in medical wellness whose services include treatment and cures. Only 27 spa centres hold this quality standard.

International Medical Insurance Group, a new US based insurance intermediary specialising in medical tourism, has launched MedTour,  a package that combines medical complications insurance and medical travel insurance, on the www.medicaltripinsurance.com website. It is a combined package not available separately. It is arranged via Dallas insurance broker US Risk, and underwritten in the US by international insurance group AIG. Each policy is individually underwritten, there is no set price. Managing director of International Medical Insurance Group, Doctor Samir Kulkarni, a practising anaesthesiologist in Miami, explained: The product is a combination of Travel Medical Insurance and Medical Complications Insurance. The complications coverage is for post-surgical issues that may arise such as infections, heart problems, pulmonary embolisation that may result in hospitalization or surgery. There is a limit of up to $150,000 total coverage. The patient after returning to the US, can go to any doctor or hospital they choose and do not have to go to a network doctor. The product is only for Americans travelling abroad. Our goal is to be able to sell to agencies, individuals, employers, and insurers in the US. We would also like to have the providers offer this to the patients as well. All hospitals, clinics, and surgeries need to be accredited by a well-respected accreditation agency. Medical Complications Insurance: Cover up to $150,000 after surgery Benefit period up to six months from the date of the initial treatment Travel Insurance: Accidental death and dismemberment Baggage delay Collision damage Credit card loss Emergency evacuation and repatriation of remains Emergency medical expenses Trip cancellation Trip interruption Trip delay It is currently only available for sale in following US states: Alabama, Arkansas, California, Delaware, District of Columbia, Hawaii, Idaho, Iowa, Kansas, Kentucky, Nebraska, New Jersey, New Mexico, Ohio, Tennessee and Wyoming.

The increase in international recognition of Korea’s medical skills is essential to the attraction of more medical tourists, according to a survey published by Korea Tourism Organization (KTO) and Korea Health Industry Development Institute (KHIDI) on medical travel in Asia. The research was conducted on overseas visitors who had visited or planned to visit Korea or other Asian nations as medical tourists. The survey shows visitors put more weight on the quality of hospital staff, reliability of institutions and cost savings than the condition of facilities and equipment. The surveyed show 75.8 percent of medical tourists in Asia mainly came for cosmetic surgery, followed by Oriental medicine and health checkups. Among visitors to Korea, 80.3 percent were satisfied with the healthcare, with cosmetic surgery showing the highest satisfaction level of 87 percent, while Oriental medicine showed a relatively low level at 72.2 percent. Ohm Kyong-sop of KTO, comments: Besides Japan, no country in Asia showed dominance in terms of recognition level of medical tourism, indicating that Korea can become a major player in healthcare tourism if it becomes competitive on service, but it is also possible for the country to fall behind if it fails to do so. Satisfaction levels were higher than expectation levels, meaning people visit Korea without high expectations but are satisfied after receiving treatment. Personal recommendation from visitors will be essential to promotion. Despite its high quality, Korea’s medical tourism has low recognition. We will improve service. Lee Shin-ho of KHIDI said the number of foreign patients has increased to 40,000 as of this November from 16,000 last year, The government seeks to revise the Medical Law to facilitate medical tours, such as allowing hospitals to promote themselves. Korea’s medical tourism will be competitive when such systems are prepared, Lee said.

Tourism officials in Turkey want to expand the offering to focus more on the health and wellness offerings. Turkish health tourism offerings include laser-eye surgery, dentistry, cosmetic surgery and fertility treatment. Twenty three institutions will jointly hold Turkey’s first health tourism fair in Antalya from February 26 to March 1, 2009. The Hetex Health Tourism Fair is being arranged at the Antalya Expo Center by Anfas Antalya Fair and Exhibition. The target market is agencies and others from 105 countries. Numbers of health tourists are estimates rather than hard figures. Although 200,000 a year is a regularly used figure this includes large numbers coming to spas and wellness centres in hotels, so the true medical tourist figure is probably nearer 20,000. What further complicates the figures is that they include elderly people from nursing homes sent by Scandinavian governments in groups for long-stay holidays. For example, Aspendos Hospital will get 200 elderly people paid for by the Norwegian state, from January to May 2009. The health tourism fair may become more targeted, but at present organisers and advisors have been quoted as primarily seeking the somewhat mythical vague target of 46 million uninsured Americans. Recession, terror attacks in India, political problems in Thailand and Turkey, and a new US President promising affordable health insurance for all, will make it increasingly difficult for countries to persuade more than small numbers of Americans to go overseas for treatment. Turkey is also targeting Europe. Organisers quote a normal EU price of 3,000 to 5,000 euros for laser eye surgery; compared to 1,500 euros in Turkey inclusive of hotels for three nights and airfares. What Turkey has to do is to convince potential EU customers that the cheap prices do not mean poor quality. For a country such as Turkey to have 23 JCI accredited hospitals and clinics is quite incredible, Convincing agencies and customers that those regulated by the Ministry of Health which regulates the clinics and hospitals in Turkey, offer acceptable standards is not so simple as there is no international standard to measure them against. This is why so many places seeking overseas business have or are seeking JCI status.

Recognising that professional liability is one of biggest concern of the medical travel industry, US-based Clements International has developed a new insurance product that is geared for medical travel agencies. Working closely with medical tourism operators in Asia and India, the company has designed liability, accident and trip cancellation insurance products to meet the needs of the industry. These insurance products are for the protection of medical travel agents against potential liabilities. As new partnerships are created, it is important for participants to understand the risks involved with the medical tourism industry. If a medical travel agency were sued for unintentional misrepresentation of information or a negligent act, the new insurance product would cover the amount to be paid by the facilitator and the defence costs. Policies can include claims arising from the acts of consultants, sub-contractors and agents; libel and slander; loss of documents; intellectual property; joint venture liability and breach of confidential information. The personal accident cover pays a pre-agreed upon amount if the medical tourist is permanently disabled or dies during the trip. This immediate compensation may also dissuade the beneficiaries from engaging in a tedious and costly litigation process. Policies can include accidental death, permanent disablement or dismemberment as a result of a medical procedure. Meanwhile, the trip cancellation insurance reimburses a medical tourist for prepaid non-refundable expenses such as airline tickets and accommodation if a trip is cancelled due to an unforeseen emergency. Dan Tuman of Clements International explained: Our target market includes Asian agencies, but we have the capabilities and markets to underwrite (insurance coverage) almost anywhere in the world. If outside the US, the choice of law may not be the US as we do use Asian and European insurers. He added: Agencies should insure their operations to protect their balance sheet and increasingly hospitals, self-funded plans, travel agents, and insurance companies, will want partners to have insurance. This new industry is fighting for credibility and insurance protection is an important component. There is no guarantee the underwriters will offer a policy to every proposer. A proper and complete application with a well-defined business plan is essential.

Companion Global Healthcare has selected Global Protective Solutions, administered by Custom Assurance Placements, and underwritten by underwriters at Lloyd’s of London, to provide affordable specialty travel insurance with defined benefits for medical travellers. The policy also includes liability options for employers. Companion Global is the first deal for the new insurance range. Policies are only available via specific wholesale deals and are not sold direct to consumers from the insurance intermediary. Companion Global offers healthcare choices to US patients only in a network of JCI-accredited international medical facilities. We selected GPS based on the company’s experience in handling international travel insurance and its reputation for service excellence, says David Boucher of Companion Global Healthcare. Tracy Simons of Custom Assurance adds: These insurance plans address the unintended consequences of medical travel, with benefits that can be tailored to each individual or group-specific need. They include accidental death and dismemberment, medical expenses, disability, emergency evacuation, repatriation of mortal remains, additional travel expenses, meals and accommodations, family coordination, residence modification, loss of reproductive function, and more. Benefits tailored to each individual or group specific needs and can include the following options: Accidental death and dismemberment Medical expenses Disability Emergency evacuation Repatriation of mortal remains Additional medical or surgical treatment benefit Additional expenses for travel, meals and accommodations Family coordination Residence modification Loss of reproductive function Custom Assurance Placements is a wholesale broker that chooses specific agencies as partners and develop custom programmes needed for a selected risk or exposure group. Coverage can be on an individual trip basis or included in an employer group benefit for a nominal per member per month charge.

The recent terror attacks in India and political unrest in Thailand has affected medical tourism agencies and international patient centres, Healthyworld Travel went so far as to warn people that for the foreseeable future healthcare consumers should consider going to another Asian location besides Thailand for health care. Thailand is now at a very volatile point in its capital Bangkok due to anti-government demonstrations. Violence is being constantly threatened and acted upon between opposing sides of politics. Violence could break out anywhere at anytime between different political elements thus endangering tourists. Unless travel to Thailand is absolutely necessary then holidaying in Thailand should be suspended until further notice. Asia has very many choices for obtaining affordable health care, the company stated. For travellers from the UK, the Foreign and Commonwealth Office stopped short of advising against holiday travel to Thailand, but advised those planning trips to consider the present situation when making your decision. It also advised against all but essential travel to Mumbai until further notice. Sir Richard Stagg, British High Commissioner to India, counseled caution in all areas. India is a very big country, and it would wrong to draw the conclusion that those travelling to other parts of the country should not go ahead with their plans. But everyone coming to India needs to be aware that it has a history of terrorism. The real message is not on temporary problems for travellers or temporary setbacks to either country’s medical tourism ambitions, it is that all agencies and patient centres should have contingency plans The international trade bodies and organisations promoting travel and medical tourism in their own countries should have policies for these and other contingencies. On India and Thailand, with the exception of a belated response from a Thailand travel body, everyone has been struck dumb. It has been left to foreign governments to issue warnings and advice. If medical travel wants more people to take it seriously and not  be seen as just a passing fad, then international and national organisations, national bodies and individual agencies/ hospitals need to take their responsibilities more seriously. We looked at 20 sites promoting medical tourism to India and Thailand- and at the time of writing, not a single one mentioned current problems. Travellers are not stupid, keeping your head down and staying silent is not an option.

The Australian Tourism Export Council (ATEC) will host a health and wellbeing conference in Cairns next month to look at ways of making Australia a medical tourism destination. Not on the agenda is a topic that will affect those countries attracting Australians for dental tourism, and those working out how to position Australia as a destination. The topic is wholesale reform of the Australian health system. The Rudd Labor government has embarked on a massive transformation of the failing health system in Australia that will turn Medicare on its head and firmly embed the private health insurers as managers of a US-style health system. The reforms will effectively hand over the Medical Benefits Scheme (Medicare), the Pharmaceutical Benefits Scheme (PBS), a new dental scheme, and public and private hospital cover to the private health insurance industry. The aim is to create a health industry where health care becomes a commodity and public and private providers compete for patients seen as customers in a market. The key elements of the government’s program are outlined in the final report of the National Health and Hospitals Reform Commission (NHHRC) entitled A Healthier Future for All Australians. The commission wants the federal government to fund and control all primary health care services and establish primary health care centres, taking control from individual states, with the new system up and running by 2015. Every Australian will automatically belong to a government operated health and hospital plan under a voucher system. They can then select to move to a not-for-profit or private health insurance fund of their own choosing. The insurance fund would receive a risk-adjusted allocation of funds for each member the amount would vary depending on the age, medical history, and other possible risk factors of the individual. The payment is attached to the individual hence the term voucher. It is the government’s contribution towards payment of medical and hospital services. This voucher covers a very basic level of cover, referred to as universal service entitlement. The new Medicare Select means that will be able to select what medical services their health insurance covers them for, their choice only limited by their ability to pay. Those who can afford it, may buy additional coverage for services not included in the universal service entitlement or to cover the gap between the rebate from the fund and what the medical practitioner charges. The health funds will shop around on the health market and purchase services from competing public and private providers for their members. A fund may buy places in public or private hospitals for its members. The belated recognition that dental care should be a universal entitlement is a huge step forward. Denticare would be established to provide access to basic dental services. The government has embarked on a program of consultation with the key participants in the health sector to thrash out more detail and hopes to gain agreement for its health agenda from the states and territories at a meeting of health ministers in late 2009. If it fails to gain their cooperation Rudd has vowed to take it to a referendum at the next federal elections.

As part of efforts to develop medical tourism in Cross River, Nigeria, the state government and a consortium of US-based hospital development experts, led by OMMA Healthcare, have agreed to build a world class state-of-the-art hospital in Calabar. Cross River State governor Liyel Imoke says that this is part of the state’s vision of providing an affordable health care delivery service to its citizens. The state intends to remodel its health facilities and services including full compliance with international standards. The Governor explained that the state took time to identify competent partners that share its vision based on its competence and capacity, stating that they intend to provide services that are now being provided outside Nigeria. The aim is to stop Nigerians travelling outside the country for medical treatment .The hospital would be for Cross Riverians, other Nigerians, and people from other countries across the West African Sub region where healthcare availability is poor. Colorado, USA, based OMMA Healthcare, will develop a modern, state of the art hospital in Calabar. The company has wide experience of developing healthcare projects in the Middle East, Africa, Mexico, Latin America, Central Europe, and Asia. Rees Associates has over 30 years experience in hospital design and is a regular partner of OMMA.The aim is to plan, programme and design a highly efficient and functional US standard hospital. Construction work will begin soon on a site near to Calabar Energy City, and will take three years And in Ghana, Dr. Felix Anyaa of Holy Trinity Medical Centre (HTMC) in Accra wants the government to consider health tourism as Ghana has expertise in heart operations and spinal surgery. He says that while it costs$100,000 in the USA for cardio surgery, it cost just $10,000 in Ghana to have the same surgery. HTMC is a private 60-bed hospital, dental clinic and spa. Anyya argues that if medical business is well promoted as a tourism product, the country would benefit tremendously and earn much-needed foreign exchange.

Last year, despite being well-known for cosmetic surgery ,South Korea could not take advantage internationally due to the Medical Service Act that banned the introduction of patients to medical practitioners. 2009 shows a completely different story. Following the enactment of the revised Medical Service Act on May 1, hospitals can promote medical services to foreign patients. A medical tourist visa was introduced on May 11, and foreign patients who make reservations at Korean hospitals can now easily enter Korea. As a result of this changing environment, the number of foreign patients at six leading Korean hospitals jumped 41 percent year-on-year in May, higher than the 32-percent gain between January and April. Korean hospitals are radically changing what services they offer foreign medical tourists after the Korean government singled out medical tourism for growth. South Korea’s Health Ministry hopes to attract 100,000 medical tourists by 2011. The Seoul Metropolitan City recently held a familiarization tour for ten leading Japanese tour operators. Gyeonggi Province sent representatives from seven hospitals in the province to Kazakhstan’s largest city of Almaty to hold a medical services promotional session there. A call center will soon be launched in Tokyo to connect Korean hospitals and clinics with Japanese patients. A new website is providing foreigners with counselling on medical tourism in Korea via translators. Indicative of the change is that the country’s first profit-making hospital backed by foreign corporate capital will be set up in Jeju. Previously, only doctors and non-profit corporations were allowed to open and operate medical institutions. Wooridul Hospital in Korea, and the Tasly Group, a large Chinese pharmaceutical company, have agreed investment for the project. Wooridul International Hospital will have 100 beds and aims to be open by 2011 in Seogwipo, Jeju.It will include a spinal clinic and cutting-edge medical examination facilities. The US$100 million project is the first large-scale joint investment of domestic and foreign capital in the medical industry. With a revised law, hospitals can now hire agencies to help attract medical tourists. In the past, although advertisements targeting the general public were allowed, medical institutions could not hire agencies to seek patients for them or directly target marketing efforts at specific groups. South Korea continues to be a popular destination for Asian women seeking cosmetic surgery and the government now hopes to get patients from all over the world, including America and Europe. Many rivals suffer from doctor shortages, but here over 3000 new doctors start practice every year, and they need overseas patients as the domestic market is at capacity. New jobs as medical coordinators and medical agents are also being created. A new educational company has been set up to teach South Koreans how to pursue a career in this industry. Hospitals and medical agencies that want to carry out marketing activities to attract foreign patients have to register with the government. The health ministry says that since May, 388 medical institutions and agencies have registered.

According to the Medical Tourism Report 2009 from UK based medical tourism information website YourSurgeryAbroad.com, four out of 10 Britons going abroad for surgery do so to avoid NHS waiting lists at home. This was the top reason for seeking treatment, including dentistry and eye laser surgery, while 30% went overseas because it was cheaper. Most people (28%) had dentistry work done while 10% opted for cosmetic operations like liposuction or breast surgery. Of this figure, 8% had had surgery abroad at least once, and men were almost twice as likely to have had surgery abroad. Older people were far more likely to go abroad for treatment, with 16% of those aged over 65 years seeking treatment abroad, and 12% doing so on more than one occasion. In comparison, 7% of those aged 18 to 24 and 8% of those aged 25 to 35 sought treatment abroad. The poll found that 34% of people went abroad because they were uninsured for particular treatments or surgery in the UK, while 32% wanted a treatment or surgery not available at home. More than one in four (27%) wanted to combine treatment with a holiday and 9% wanted to go abroad to get away from family or work while they recuperated. The most popular treatment was dentistry, 10% had cosmetic surgery, 7% had eye surgery and 6% had blood and dialysis treatment. Thailand (7%), Malaysia (8%) and Singapore (7%) are the most visited destinations, with Spain (7%) and Italy (5%) revealed as Europe’s medical tourism destinations of choice for UK medical tourists. Adam Nethersole comments: "Our research shows that people are willing to travel to get the treatment they need, rather than endure a protracted waiting process with the NHS. 71% of Britons in our survey are using the internet to research their international medical treatment options. The survey was carried out online by independent market research agencies, Global Market Insite in the USA and 72 Point (One Poll) in the UK. The sample size of 8003 had 7000 from the UK and 1003 from the USA. Key findings:* Only 10% of most recent surgery abroad was cosmetic, contradicting a commonly held viewpoint that healthcare abroad is primarily for cosmetic and plastic surgery.* The US market predominately considers cost of treatment to be the most important motivations when deciding to go abroad for treatment. * The UK market generally goes abroad for procedures to beat NHS waiting times.* The most common fear with surgery abroad is the medical standards in destination countries, highlighting a need to publish more information about international accreditation and healthcare standards abroad.* The global financial crisis has increased the likelihood people will participate in medical tourism. There are two separate reports available for purchase; The Medical Consumer Report: UK and The Medical Consumer Report: USA. You can order a copy of the individual reports for £160, or both the USA and UK reports for £300.

Taiwan is a relative newcomer to medical tourism, but while others in Asia look for American and European business that may or may not exist in sufficient quantities, Taiwan is concentrating efforts on visitors from Japan and China. These countries are the two main sources for tourists, as each year 2.2 million Japanese and Chinese tourists go to Taiwan. While in American and Europe, economists argue about whether there is a deepening recession, slump, downtown, or slow recovery, the latest predictions from China are very encouraging. China’s economy is expected to expand 8.5 percent in 2009, and its growth will accelerate to 9.8 percent next year, as a strong growth in domestic demand has offset the drop in external demand. Japanese industrial output plunged last year, but analysts say the worst appears to be over, with production and spending recovering quickly. Taiwan is also particularly well positioned to attract medical tourists from China, given the cultural proximity, common language and popularity of its tourist attractions. There is no universal free healthcare in China and few have insurance. China is going to be switching to a new Universal Health Care Insurance plan by the year 2110. It will be a great deal different from the Chinese health insurance plans that are currently available. For the average Chinese person the out-of-pocket expense for medical treatment is astronomical. Shin Kong Hospital has signed an agreement with Shin Kong and HNA Life Insurance Co  a 50-50 joint venture between China’s Hainan Airlines Co and Taiwan’s Shin Kong Life Insurance Co, for Beijing-based MJ Health Screening and SweetMe Hotspring Resort to arrange for policyholders and members of these companies to visit for medical tourism. The business is still in its trial period, Beijing MJ Health Screening president Jack Tai reports that three more medical tourist groups from Beijing will travel to Taiwan in the next three months, In future, we hope there will be a group of more than 30 members visiting Taiwan each month. A 32-member tour group from Beijing recently went to Taiwan for six days of health checks, spa treatments and sightseeing, making it the second Chinese group to visit Taiwan for medical tourism this year. Shin Kong Wu Ho-Su Memorial Hospital, which launched the special tourism packages, reports that in addition to the health checks offered last month, more services were on offer this time around. In addition to PET and other health checks, Taiwan is offering micro cosmetic surgery, liver transplants, heart surgery and artificial joint replacements. Jen Chi Hospital has a dialysis centre that is attracting overseas patients. In the case of Japanese tourists, dental implant surgery or Chinese medicine packaged with hot-spring treatments for a reasonable price is proving attractive. But not everything is rosy. Local hospitals are lagging behind in terms of international marketing and resources to develop the industry. Tight regulations limit the services they can offer. As the medical services sector is considered non-profit, government regulations bar hospitals from advertising their prices to attract foreign clients. Being unable to compare prices is a huge drawback for potential medical tourists. Taiwan also has a long and complex visa application process for medical tourists.

Cruise ship operators often point out the health benefits of a relaxing cruise, but an American company plans cruises with a difference. SurgiCruise, based in Los Altos, California, is a new business set up to put American patients on purpose-fitted healthcare cruise ships. Using doctors on ships, it seeks to offer a wide range of medical procedures at prices far lower than in US hospitals. SurgiCruise seeks to wed medicine and travel by offering surgical procedures on cruise ships. Originally, the business planned to focus on cosmetic procedures such as liposuction, facial peels and breast augmentation, but the recession has driven down prices in the US. So it will now begin with orthopaedic treatment, as it is difficult for these patients to travel many hours in a plane and to stay in an unfamiliar country. The number of orthopaedic procedures increased in the US by nearly 25% between 1997 and 2005, with knee and hip surgeries topping the list. But with rising healthcare costs, many people are finding it difficult to afford the surgery they need. Most people needing this are retired, so have the time to recuperate with a cruise, while younger people wanting cosmetic surgery do not. The doctors will be US-trained, with nurses and other staff from overseas. SurgiCruise will charge a fee for the procedures and post-surgical care, and the patient will pay for the normal cost of the cruise. Co-founder Jeff Winner has an IT and engineering background, while partners Dr. Terry Knapp is a plastic surgeon, and Dr. Martin Polanco founded a specialized treatment centre focusing on treatment-resistant depression. The company is self-funding and using angel investors, but still has to raise the rest of the $2 million it needs for a start-up. As it cannot afford to buy a ship, is in advanced negations with several cruise lines to introduce on-board surgery centres, to begin in 2010. The cruise ships will be specially retrofitted to provide a state-of-the-art facility to deliver medical care close to the United States, probably off the coast of San Diego. This could be in US waters, as the US doesn’t interfere with economic activity on cruise ships, or may take advantage of the lower regulatory costs of using ships in near-offshore waters, about 12-miles offshore. The company’s mission is to deliver excellent medical treatment at a reasonable price.  It believes that as a service provider it should do everything possible to reduce the fear, pain, anxiety, and frustration of customers. By linking surgery and cruising, it aims to aid recovery by a totally relaxing environment. Whether the business even begins is not yet certain, it may depend on funding. Cruise companies are wary of expensive refits of ships unless they are certain of being paid.

Singapore is quite successful at attracting medical tourists, but healthcare providers accept that potential is limited. It is a small island selling on quality rather than price. Several businesses have thought that rather than getting people to come to them, why not take their offering to them. Local hospital groups are very efficient, understand marketing and are able to deliver high quality care at a reasonable price. By taking care overseas, they benefit from lower costs, while customers benefit from savings on airfare and accommodation. Having an overseas presence also raises the profile in local regional markets. Many Singapore-based companies have or plan hospitals or clinics in overseas countries. Parkway Holdings, Singapore’s largest healthcare provider, is one of the region’s leading healthcare service providers, with a network of 16 hospitals and medical centres with more than 3300 beds throughout Asia, including Singapore, Malaysia, Brunei, India and China. Last December, the company made its first foray into the Middle East when it won the bid to manage the Danat-Al-Emarat Women and Children’s Hospital in Abu Dhabi. Overseas operations now account for a third of revenue, with international revenue growing faster than domestic revenue. Future plans include five new Pantai hospitals in Malaysia over the next five years. Raffles Medical Group is the largest private group practice in Singapore. It operates a network of 65 multi-disciplinary clinics across Singapore and three clinics in Hong Kong. The group also manages the airport clinics in Singapore’s Changi International Airport and Hong Kong’s Chek Lap Kok International Airport. Currently the largest non-hospital based healthcare provider of specialist medical, dental and wellness services in Singapore, Pacific Healthcare has operations in China (Shanghai, Shenzhen), Hong Kong and India (Mumbai) as well as representative offices in Jakarta, Bangkok and Ho Chi Minh City. It has investments in cardiac centres in Goa and Bangalore, a cardiology and imaging facility in Shanghai and wellness facilities in Shenzhen. Later this year it is opening a medical centre in downtown Jakarta in a joint venture with PT Plaza Indonesia Realty. Another Singapore-based healthcare company, Thomson Medical Centre, runs Hanh Phuc International Women and Children Hospital in Binh Duong Province. When other similar hospitals open elsewhere in Vietnam, it will run those too. International Enterprise Singapore is a government agency promoting the overseas growth of Singapore-based enterprises. It sees great opportunity in building or operating hospitals and clinics, particularly in China, UAE, India, Vietnam, Russia, Ukraine and Indonesia. China and the Middle East are seen as offering the best long-term potential on health care. Singapore is in a strong position to compete for a slice of the healthcare business in the emerging markets. It has a great reputation and track record for clinical excellence that cuts across the full spectrum of healthcare services. Singapore also has high healthcare management standards. It is in the forefront of medical science and technology and is a multi-faceted medical hub in the region.

A few months after the launch of two specialist travel insurances aimed at UK-based medical tourists, comes the launch of the first of two covers, ironically both using UK insurers based at Lloyds’ of London, primarily targeting US-based travellers. Both are offered on a wholesale basis rather than being aimed directly at consumers. This week, we cover the offering from Seven Corners. Next week, we will be able to reveal details of Custom Assurance Placements and their link up with Companion Global Healthcare. Seven Corners’ Medical Tourism Insurance includes: Trip cancellation/ interruption Medical treatment to remedy treatment complications Emergency medical coverage for acute illness and injuries Emergency evacuation due to acute illness and injuries Emergency evacuation due to treatment complications Repatriation of remains Lost baggage/personal effects and baggage delay Trip delay / missed connection Global assistance 24/7 It does not guarantee the treatment or pay any of the bills of the treatment or travel or accommodation, or cover travel or treatment within the US. Jim Krampen, co-Founder of Seven Corners, said: "It addresses the specific needs and concerns of the medical tourist. Distribution will only be through medical tourism agencies, hospitals and clinics that directly market their services to individuals and have been approved by us. They will be evaluated on how many years they have been providing medical travel and tourism services, the volume of patients, the hospitals and clinics they utilize, their E&O coverage for medical tourism.  If they would like to receive a small commission for selling the plan they have to have an applicable and valid license in their jurisdiction and complete insurance agent contracting with us. We offer them customised branding of the online quote and purchase [internet] engine link we provide for the plan. We also provide a voluntary delivery of the plan for individual purchase via a customised quote and purchase link we can provide to medical tourism providers.  The main target will be Americans travelling from the US. The medical tourism providers can be based anywhere in the world.  The hospital or clinic providing the treatment must be outside the US. Krampfen added: Many of the medical tour providers I have spoken with are not insurance professionals and just want to offer the plan as link on their site as a service to their clients and assist them in providing more medical tours.  In which case, we are the licensed agents.  We will not pay commissions to anyone without a valid insurance license.  If they don’t have a valid license they will just have to offer the link as a service. We have launched our first live purchase engine link with an agency in the US at the beginning of this month.  We have 15 others, mostly in the US, in line, as we are reviewing their criteria to become approved.  We expect at least 20 providers with live links on their site by the end of the year.’ The company expects a take up rate of 50 percent primarily for the high-end treatments.  The experience of those already offering cover is that this is incredibly optimistic and that they will be very lucky to achieve a tenth of that, particularly as there is an age limit of 64 on it, which rules out many older travellers. Depending on the country where the agency or hospital is based, if the insurance is offered on voluntary basis, the provider must comply with local insurance laws if they want a fee. Offering it as a package is more complex as the Lloyds’ rules are very strict, if the agency or hospital has customers from certain countries then they have tough rules on laws on offshore insurance, and some providers will have to be licensed to sell insurance in their own country.

PlanetHospital, an established California-based medical tourism agency, has opened an office in Jeddah, Saudi Arabia to serve inbound and outbound medical tourists from the Gulf region. "The Gulf has the potential to drive growth in medical tourism. It is not only a place where medical travellers come from, but it is also becoming a medical tourism destination itself thanks to major hospital development throughout the region," said Mohammed Alarifi, managing director of PlanetHospital in Jeddah. In the past few years, the company has helped patients from the Middle East to secure advanced medical treatment abroad. With PlanetHospital Middle East, the company now will be aggressively promoting its ability to inbound medical tourists to the Gulf region hospitals. It will work with local new insurance providers to create a medical tourism based benefit, and eventually attract Middle Eastern expatriates in the US to come to the region for medical treatment, rather than going elsewhere. PlanetHospital has been working to expand its business by teaming up with insurers interested in providing an overseas option for members. Company founder Rudy Rupak said they have been negotiating with a major US insurer but those plans are delayed until at least 2010, after the insurer became a prominent victim of the financial crisis. PlanetHospital does already offer a range of insured plans for specific countries and ethnic groups. Since 2002,PlanetHospital has sent more than 2,000 patients to overseas hospitals.

China’s Ministry of Health is targeting illegal organ transplants, after reports surfaced that some hospitals were illegally doing organ surgeries for foreigners. The ministry says that any medical institutions could have their licenses revoked if they cannot pass the ongoing qualification re-examination. At present, 164 medical institutions on the Chinese mainland are licensed to carry out organ transplants nationwide. The ministry has named 16 hospitals that have failed to comply with regulations on organ transplants. Under the National Organ Transplantation Committee and the ministry, an expert team will further evaluate other organ transplant practitioners. Organ transplants in China are covered by the 2007 regulations that establish national oversight and credentials for Chinese transplant officials. The regulations ban organ trade, organ trafficking and transplant tourism for foreigners and establish a national organ donation system that includes deceased and living donors. Official estimates indicate that 2 million Chinese need organ transplants each year, but only 20,000 operations are performed because of a severe shortage of donors. But still some hospitals sell organs to foreigners as a lucrative business. Three hospitals were penalized for illegally selling human organs to foreigners in 2008. In February, the ministry launched an investigation into a report that 17 Japanese tourists each spent about $87,000 for liver or kidney transplant operations at an unidentified hospital in Guangzhou. There is a regular stream of reports from within hospitals, that some hospitals are totally ignoring the regulations, faking identities to fool authorities and still performing organ transplants on foreigners who were willing to pay. There is a gap between current regulations that insist on the informed consent of donors and regulate recipients, and reality. Organ brokers advertise on the internet and some medical staff at hospitals advise patients to find their own source of organs to avoid lengthy waits. In the UK, from October, medical tourists from abroad will be banned from coming to the UK to receive donor organs as part of a new crackdown on medical tourism following cases of foreigners paying for organ donations from NHS donors. An official investigation revealed that earlier this year private patients from China, Libya and the United Arab Emirates were among 50 foreigners who were given new livers in the UK. A report issued by the World Health Organisation (WHO) in 2007 named five international hotspots for organ transplants tourism as China, Pakistan, the Philippines, Egypt and Colombia. In Egypt, inadequate legislation regulating human organ transplants has made Egypt the international hotspot for kidney trafficking. Up to 95 % of the 3000 legal kidney transplants per year, and hundreds of illegal ones, involve a commercial transaction. A nationwide ban on organ transplants from cadavers means all kidneys must be harvested from live donors. Most are sourced by organ brokers from destitute young Egyptians, who are coerced into selling their kidney to pay off debts or meet rising living costs. The organs are sold to clients, often wealthy Gulf Arabs, who use forged documents to circumvent a ban on transplants to unrelated or non-Egyptian recipients. Official periodic crackdowns on hospitals and clinics performing transplants for foreign clientele have done little to deter transplant tourism. A draft law to regulate organ transplants was recently rejected by Egypt’s parliament. The bill had proposed to ban the sale of organs, prohibit transplants to foreigners, and impose sentences of up to 15 years in prison and 180,000 dollars fines for violations. It also sanctioned cadaveric organ transplants, which would have alleviated the pressure on live donors. Proponents expect the bill to pass when the legislature convenes in the fall. In Colombia, all transplants, including those on foreigners, must be approved by Colombia’s national health agency, and a 2004 law calls for available organs to be offered to Colombians first. However, several websites offer new livers and kidneys in Colombia within 90 days, and it is increasingly becoming a medical transplant tourism for Americans, where there are thousands more in need of a transplant than can get one.

In a blow to Dubai’s hopes of becoming a major medical tourism destination, a new survey of UAE residents by leading newspaper, The National, says that more than 70 % would seek medical treatment overseas if they fell seriously ill. The survey reveals a widespread lack of confidence in the nation’s healthcare system. The survey was both of international expatriates, and Emiratis, with 57 % of the latter saying they would seek treatment abroad. That the vast majority of expatriates, who are mostly covered by health insurance, would prefer to go elsewhere for treatment is a body blow. Only 21 % of all respondents would put their faith in UAE healthcare if they became seriously ill, says the survey, carried out from July 24 to 28 for The National by YouGov, an international research organisation. More than half (53 %) of the 876 people asked said they would prefer to return to their home countries for treatment, while 18 % said they would seek treatment in other countries. Analysis of responses by national groups suggests that this lack of confidence might be based on more than mere perceptions or prejudices; although a high proportion of Asians (71 per cent), Westerners (57 per cent) and Arab expatriates (42 per cent) opted for leaving for treatment in their home countries. Although this option is not open to Emiratis only 26 % of UAE nationals said they would be happy receiving treatment there. A similar proportion of Arabs (27 %) and Westerners (24 %) expatriates said they would elect to be treated in the UAE for serious illnesses, but only 15 % of Asian expatriates said the same. Dr Fatma Abdulla of the Dubai School of Government argues that the healthcare sector has only itself to blame for the lack of confidence. She says that internationally, health care has become a consumer industry focusing more on giving patients the best possible personal care, but local hospitals have little concept of this and give patients what doctors and hospitals think they want. Although this attitude may be less unfriendly in the new clinics and hospitals of Dubai, there is a residual worry that the local hospital industry has concentrated so much on shiny new hospitals and equipment, that they have failed to grasp the importance of consumer care. A high proportion of respondents (45%) said that either their friends or family in the UAE or they themselves (13%) had travelled abroad for medical care, including surgery. The main proportion of respondents who had travelled for treatment were Westerners, 27%, piling more misery on for the country’s medical tourism industry that wants to attract people from Europe and the USA. Destinations for medical tourism varied, largely according to nationality. India was the most popular, with 57 % of those who had gone abroad for treatment, or whose friends of family had done so. Thailand was the top destination for Emiratis (64 %). For western expatriates, the UK was the top choice for 61 %, while Thailand and the US attracted 17 % each. In November2008, the Ministry of Health announced that a ratings system for doctors and hospitals would be introduced as part of a drive to make the UAE a destination for medical tourism. The National survey shows a disbelief in both the plan and the logic behind it. Respondents were asked how well equipped they felt the UAE was to tap into the medical tourism market now or in the near future. Less than a third believed it was well equipped to do so, 28 % thought it was not well equipped and 19 % felt it was not at all ready. With prices far higher than Asia, this survey may finally force the UAE to accept that it only has limited medical tourism potential.

The Czech Republic is well known for its dentistry and spas, but it does not fully capitalize on its high quality health care for cosmetic surgery or medical treatment. Last year, more than 6,000 people went to the Czech Republic for cosmetic surgery, 20% of the total. Patients come from the nearby countries such as Germany, Austria or Slovakia and from the UK. Women use the services of the cosmetic surgery far more often than men, 87 % of the foreign patients are female. This fact also influences the most popular operations chart breast augmentation liposuction and rhinoplasty are on the top. Men are discovering the advantages of artificial body improvements, they prefer liposuction and rhinoplasty. Except for cosmetic surgery, medical tourists come mostly for dental, orthopaedic or infertility treatments. An average client from abroad spends 3 to 10 days in the Czech Republic, much longer than an average sightseeing tourist. It is rare for visitors to combine their medical stay with sightseeing or post-op spa treatment. The Association of Czech Travel Agents feels there is a gap in the market that offers new business possibilities for travel agents as well as spas, of offering post-operative relaxation at spas. Czech destinations such as Prague where many go for cosmetic surgery have an advantage over their rivals, but the well-known Czech spa cities could attract more foreign cosmetic surgery clients. The number of foreign patients using Czech spas is growing with one in five spa patients being a foreigner. Spas in Karlovy Vary mainly see Russians and people from the countries of the former Soviet Union, plus Spaniards, Germans, Chinese and people from Asia. Many of them visit the spas for one-day treatment. In Teplice spa, 30 % of clients are from overseas, with the number of clients from Arab countries growing this year. They mainly use the services of the spa as outpatients. The Arab spa clients who annually make up about two-thirds of all foreign clients of the Teplice spa usually rent flats in the town for a couple of weeks from where they visit spa facilities. They usually come with their whole families and they spend most of their leisure time in the local park. While Arab numbers are up, the number of Germans visiting the Teplice spa has fallen this year. Foreigners make about 15 % of clients of the largest Moravian spa  in Luhacovice. They are mainly from Israel, but also from Austria and other EU countries. The state-run spa Karlova Studanka, Moravia, says Poles are the main visitors, but Germans have also started visiting the spa this year. The country has 30 spa towns across the country, several hundred natural springs and large deposits of mineral-rich mud. The Czech Republic is known for its high standard of medical care and low costs in comparison to other countries. Highly qualified staff take good care of guests at spa facilities, and in combination with the unique affects of the water and mud, guests can expect top quality procedures.

St. Luke’s Medical Center plans to open its second hospital facility in the Metro Manila right at the heart of the country’s newest business district - Fort Bonifacio Global City, by the end of the year. The opening will now be some time in 2010.The new St. Luke’s Hospital will have two towers: a 14-storey, 600-bed hospital building; and a Medical Arts Building that will house 375 doctors’ offices. The hospital will be built on a 1.6-hectare lot with a gross floor area of 154,000 square meters and will be one of the biggest hospitals in Metro Manila in terms of total floor space. The new St. Luke’s Medical Center at Fort Bonifacio Global City is expected to generate 2,700 new jobs for non-medical staff and will bring in about 1,000 doctors, partly from the original facility in Quezon City. The 650-bed St. Luke’s Medical Center in Quezon City is the most advanced hospital in the country in terms of equipment and technology, professional expertise, range of services, quality of patient care, medical research, and customer service. It receives patients from around Asia, Micronesia, the Middle East, Europe and the United States. St. Luke’s at the Fort has successfully been registered with the Philippine Economic Zone Authority as a medical tourism park. It is only the second hospital to do so. PEZA registered medical tourism parks enjoy a host of incentives, including the payment of a special 5-percent tax on gross income, in lieu of all national and local taxes. Additionally, they enjoy four years of income tax holiday on profits solely derived from servicing foreign patients. After the four-year ITH or income tax holiday, the medical tourism parks will just pay a 5-percent gross income tax on income solely derived from servicing foreign patients, in lieu of all national and local taxes. As a PEZA firm, St. Luke’s can also import medical equipment, including spare parts and equipment supplies, duty-free. As a medical tourism centre, it will be allowed to employ foreign nationals subject to existing laws. The first registered medical tourism park was the St. Frances Cabrini Medical Tourism Park in Batangas City, where the St. Frances Cabrini Medical Center is a clinic for cancer patients and for the Japanese market. In 2007 St. Frances Cabrini Medical Center became the country’s first Medical Tourism Special Economic Zone. This was later confirmed by Philippines Economic Zone Authority (PEZA)- naming St. Cabrini as developer and operator of the country’s first Medical Tourism Park. Initially conceived to service the health care needs of the more than 8,000 employees of its affiliate company Yazaki-Torres Manufacturing Incorporated and other industrial clientele in the vicinity, the need for a modern hospital and the pace of development of the region created a bigger demand and quickly expanded the client base for the medical centre. St. Frances Cabrini Medical Center is owned by the Torres half of the Yazaki-Torres group. Feliciano Torres, president of Yazaki-Torres Manufacturing Incorporated (YTMI) is the chairman and CEO.

Malaysia has the potential to become a medical tourism hub, says Frost & Sullivan’s Dr Pawel Suwinski: The recent promotion of medical tourism by the government and the Association of Private Hospitals of Malaysia is excellent. Health tourism is one of the brightest points in the growth of the healthcare sector in Malaysia. The latest figures on medical tourism in Malaysia support Suwinski’s claim. The compounded annual growth rate of foreign tourists to Malaysia seeking medical care is 25.3% from 1998 to 2008.Revenue per patient grew from US$92 in 1998 to US$241 in 2008. While most foreign patients came from neighbouring countries with less developed medical infrastructure such as Indonesia, there is a growing market in developed countries. Simranjit Singh,also of Frost & Sullivan says Cost and relative political stability lends Malaysia a distinct comparative advantage in the field of medical tourism. There is no denying that Malaysia has an edge over Singapore and even Thailand in this respect. The recession had led to rising healthcare costs in the West, making the Asian region a cheaper alternative for medical treatment. According to a survey carried out by Frost & Sullivan, potential medical tourists are concerned primarily with accredited doctors and nurses, accessibility to hospitals and leisure at their place of stay. Malaysia fared well in all three areas. The report adds that healthcare expenditure in Malaysia is increasingly driven by increased privatisation within the healthcare service provision and upgrading of existing healthcare infrastructure within the public sector. The market for healthcare services has also received positive impetus from growing promotion of health tourism and development activities. The Malaysian healthcare system is dominated by private hospitals accounting for an average of 62 percent of total number of hospitals annually from 2002-2008.As at the end of 2008; there were 144 public hospitals and 224 private hospitals in Malaysia.The Malaysia Healthcare Travel Council (MHTC) is being set up within the Health Ministry to promote and develop the country’s health tourism industry. It will report to an advisory committee chaired by the health minister. Members of this council are representatives from the government and the private sector involved in health tourism. The Consumers’ Association of Penang (CAP) argues that there should be a very clear separation between the public and private sectors when it comes to healthcare because the government is responsible for regulating the private healthcare sector and carrying out enforcement duties.CAP says, There is bound to be a major conflict of interest. How can the ministry regulate and enforce laws when it is, at the same time, involved in promotional activities for this very same industry? There will be the tendency to favour the industry. Seeing the way the top people in the ministry are going all out to publicly support health tourism, it appears that the ministry is letting the public know that its priority is turning more towards business. Government hospitals are still critically understaffed. Key specialists are serving instead in the private sector. Faced with long waiting times, patients sometimes resort to seeking treatment at private healthcare facilities. This is often in spite of the charges at these facilities being something they can ill afford. As patient load and services at private healthcare facilities increase due to aggressive promotion of services, charges for treatment go up. CAP calls on the ministry to halt this alarming trend towards being totally involved in encouraging health tourism. The ministry should remain independent and play its role to regulate the private healthcare sector. There should not be a travel agency housed in the Health Ministry.