A documentary on Taiwan’s medical achievements will be aired around the world early next year, says the Taiwan Department of Health (DOH). The 60-minute film will showcase the healthcare system and give insights into its potential for developing medical tourism. National Geographic Channel will broadcast the show. The film will be completed by Fox International Channels in December ready for showing next spring in more than 30 countries, drawing an expected viewership of 0.2 billion households. ’Taiwan’s Medical Miracles’ will discuss the nation’s moves to develop medical tourism. According to statistics, more than 15,000 foreigners, including people from China, visited Taiwan for health checks, cosmetic treatment and surgery in 2010, creating an output value of US$11,875,000. These figures are much lower than figures released in 2010 when the Taiwan Institute of Economic Research (TIER) Taiwan reported 40,000 medical tourists in 2009, and in early 2011 the Department of Health estimated that 2010 saw 85,000 medical tourists. Kaohsiung Medical University has signed a memorandum of understanding with a private medical center in Malaysia as a first step toward developing Kaohsiung into a hub for medical tourism in southern Taiwan. The cooperation can pave the way for the university to attract Southeast Asian clients to Kaohsiung. The Mahkota Medical Center (MMC) in Malacca is a medical tourism destination. The reason for the deal is that there is a shortfall of specialists in Malaysia, and the university will assist in the training of MMC paramedics and improve the center’s clinical research into acute and severe diseases. In return, the university hopes that MMC will set up an office in Kaohsiung to further help Kaohsiung’s medical sector tap the Southeast Asian market. Taiwan hopes to emulate Hong Kong and the Republic of Korea to become a medical service provider for wealthy mainlanders as cross-Straits individual travel has began. Many mainland residents have gone to Hong Kong or the Republic of Korea for medical and cosmetic treatment, but the cost of medical checks in Taiwan is half to two thirds of that in Hong Kong and Singapore. And they will not have a language problem in Taiwan as in Korea. Taiwan hospitals have often hoped to attract more clients from the mainland, but it was limited as mainlanders going for medical services in Taiwan could only travel in tour packages to the island. Shin Kong Medical Club, the health check division of Taipei-based Shin Kong Hospital, has received about 700 mainland clients since 2009. Many of them came to take the PET/CT examination, which checks for cancer. The three-and-half-hour examination is often part of their travel schedule. According to a survey by the hospital, 90 % of their mainland clients are satisfied with the service. The two governments lifted the ban on mainland tourists to Taiwan in June 2008, but they could only travel in tour packages. Individual travel began in June 2011, but the permit only covers residents in Beijing, Shanghai and Xiamen. As mainland travelers are free to design their own travel schedule in Taiwan, local hospitals expect more of them will come for medical purposes only. According to Taiwan’s health department, early indications are that one in ten mainland travelers will come for a health check or medical treatment. Medical treatment is limited as there is a 15-day legal stay limit. But Chao Yuen-chuan of the Taiwan External Trade Development Council (TAITRA) says the potential is limited by restrictions. He wants the government to revise medical visa screening laws and paperwork requirements, especially for Chinese nationals, so international tourists can come to Taiwan more easily, "A simplified document processing system is crucial, especially if we want to reach the Chinese market."

More foreigners are travelling to the Czech Republic for breast enlargements and facelifts as the economic crisis drives the search for cheaper cosmetic surgery, says Tomio Okamura of the Association of Czech Tourism Agencies, “We have witnessed a big increase in the number of medical tourists, from about 6,000 in 2008 to 9,000 last year in 2010. Foreigners now account for a fifth of the total number of cosmetic surgery clients in the country. The economic crisis helps us as people want cosmetic surgery that is less expensive but of a quality comparable to that in the West." Most of the clients are German, followed by Brits and Austrians, but Poles and Slovaks have also gone to the country for cosmetic surgery. Czech prices are about three or four times lower than in the West. Meanwhile, spa tourism is even more popular than medical tourism. Czech tourism highlights what is happening at top local spas - the top ten Prague spas- • Teplice is the oldest spa in the Czech Republic having opened its 857th spa season this year. People fancying luxurious amenities could visit a newly refurbished Imperial suite in the Emperor’s Spa. A new treat is the speciality spa coffee prepared exclusively for Teplice visitors who can enjoy the drink with traditional spa wafers.• The most famous spa in the Czech Republic is Karlovy Vary and there visitors can check the Elizabeth Bath named after the Austrian empress Sisi and celebrating its 105th anniversary this year. People can try Elizabeth’s bath with mineral water, an Indian anti-stress head massage or a Hawaiian relaxation massage. • Mariánské Lázně sees the reopening of a renovated spa house Nová Marie that offers comfortable accommodation and wide range of services and spa treatment including natural Mary’s gas CO2 and peat.• The spa hotel Royal Spa offers special spa and wellness packages and stays for high-end customers. The guests can enjoy wholesome baths at Balbín’s Spring or massages with herbal sachets.• The first radon spa in the world with a detoxication wellness package is in the Radium Palace hotel while Běhounek hotel organises fit weekends - two-day programmes full of physical activities.• Lázně Mšené is just under one hour from Prague and celebrates its 205th season this year with opening of a newly refurbished original interior of the spa restaurant Dvorana from 1905. Additionally the small family spa has diversified its treatment and wellness procedures and includes aerobic or zumba programmes as well as special physiotherapeutic packages for older guests.• *The Luhačovice spa offers a new traditional spa treatment package that includes various procedures of local mineral springs, traditional hydrotherapy and outdoor exercise signaling a return to a traditional type of wholesome exercise dating back to the beginning of the 20th century. Newly renovated luxurious four-star interwar-style Spa&Wellness Hotel Alexandria was opened at the end of the last year.• Mcely Spa is a chateau and English park as part of the spa. Private therapeutic suites offer a relaxing and inspiring environment. The English park also includes an outdoor jacuzzi, a small sauna building, natural swimming lake, multifunctional sports ground and a specially designed natural course for cardiovascular and muscular fitness.• The Spa at Mandarin Oriental, Prague is a former Renaissance chapel. Guests are greeted in a vast light-filled lobby, the former nave. The glass flooring encases illuminated remnants of a onetime Gothic church uncovered during the site’s reconstruction. Spread over two floors, the spa features seven treatment rooms including two couples’ suites. An underground passageway links it to the hotel.• Offering well-being massages for relaxation of the body and soul and luxury procedures, the spa in Le Palais Hotel offers an upmarket spa experience.

Romanian Health Minister Attila Cseke is planning a new law to grant spa resort status to ten localities, which have therapeutic springs, as Romania has the highest medical tourism potential in Europe and must take advantage of it by further developing resorts that provide therapeutic baths. The ten places that have therapeutic springs - Baile Olanesti, Covasna, Baile Felix, Sovata, Techirghiol, Amara, Baile Herculane, Baile Govora, Calimanesti-Caciulata and Ocna Sibiului - will be granted spa resort status. Romania’s 70 natural spas provide relief for many medical disorders and illnesses including rheumatism, endocrine, kidney, liver, respiratory, heart, stomach and nervous diseases as well as nutrition, metabolism and gynecological disorders. Romania is home to more than one third of Europe’s mineral and thermal springs. Natural factors are complemented under medical care by physiotherapy, acupuncture, electrotherapy and medicines produced from plants. The Tourism Ministry says medical tourism brought the country EUR 250 million in 2010, according to the association of tourism agencies in Romania. Around 3 % of the tourists who visited Romania last year went for medical services –60,000 people. Of these, 70% went for spa tourism, the rest being dental tourism, cosmetic surgery and anti-aging therapies. Although the country’s state medical care system has serious problems, private operators are opening clinics and hospitals, to fill the gaps in the domestic and international markets. The government believes that spa tourism has huge potential, much bigger than medical travel. Romania could generate up to EUR 500 million to the state budget by 2015 from medical tourism. Medical tourism has developed slowly in Romania. Three ministries in Romania, Tourism, Healthcare and Education have recently signed a partnership to collaborate in promoting medical tourism in Romania. Medical travel is also outbound, particularly to Turkey, Austria and Germany. Earlier this year, medical tourism agency Medical Insight launched the first Romanian website containing information about foreign hospitals. The website targets those who want to travel abroad for medical services. It now offers 17 countries and now plans to add information on spas in Romania for people wishing to visit the country. The number of foreign tourists to Romania could double in the next two to three years, according to the World Tourism Organization. 8 million people are crossing Romania’s borders each year, including 1.3 million tourists. The Romanian authorities are keen to increase the number of tourists, and get them to spend more money in the country by increasing their average stay in Romania. This is why spa and medical tourism is attractive as visitors both stay longer and spend more than the average tourist. The tourism ministry seeks to double tourist numbers by 2015. According to official statistics from the National Statistics Institute - 95% of foreign visitors come from European countries, while 56.4% come from EU member states. Hungary accounts for the highest number of tourists who entered Romania, with 32.2%, followed by Bulgaria with 15.9%, Poland - 10.2%, Germany - 9.7%, Italy - 7.4% and Austria - 3.8%.

Wellness Tourism Worldwide has issued the phase one report of the 4WR: Wellness for Whom, Where and What? project. The 4WR: Wellness Travel 2020 is a research project aimed at forecasting the state of wellness tourism by 2020 in three categories: • who (consumers• where (countries offering wellness tourism products)• what (types of wellness tourism products). 4WR collected information from 140 stakeholders from wellness, tourism, spa and healthcare industries in over 50 countries worldwide. The report is divided into two sections: Part one describes the current status of wellness tourism, and Part two offers industry perceptions and trends shaping wellness tourism by 2020 (Part two will be published in mid-August). The top 11 areas of wellness tourism are-• Beauty treatment• Sport and fitness• Leisure and recreational baths• Spa and wellness hotels• Yoga and meditation• Rituals• Nutrition and detox • Spiritual and wellness festivals• Occupational wellness• Spa cruises• New age Within wellness tourism are many cultural and geographic differences both of the people and destination countries. Traditions such as yoga and the availability of natural assets such as thermal water help determine who goes where. Services offered vary greatly from region to region. Natural healing is to the fore in Central and Eastern Europe, and the Middle East. In the USA and Canada the emphasis is on medical travel for treatment. Traditional and complementary treatment is the most important in the Far East while spiritual tourism dominates in Asia. There is a section of the report that offers pie charts for 12 regions. For each what it shows is what resources are available within very broad sections such as spa/ wellness and hospitals/hotels. Medical and wellness tourism has a tendency to exist in a vacuum, distancing itself from world events and normal tourism. Where the report does hit an important note is in stressing that both are just element of global tourism and that there is no simple division between medical/wellness tourism and other tourism as they are so inter-related that many elements are impossible to untangle. The World Tourism Organization’s latest UNWTO World Tourism Barometer says that international tourist arrivals grew by 4.5% in the first four months of 2011, with growth in all regions with the exception of the Middle East. Global tourism continues to consolidate the recovery of 2010 despite the impact of recent developments in the Middle East and North Africa, as well as the tragic events in Japan, which are temporarily affecting travel flows to these regions. Between January and April 2011 destinations worldwide recorded 268 million international tourist arrivals, some 12 million more compared to the 256 million registered in the same period in 2010. Europe exceeded expectations and posted the highest growth in the first four months of 2011. Destinations in Northern, Eastern and Southern Europe performed particularly well. Growth in Asia and the Pacific was in line with the world average, but slightly below previous prospects. Asia, and in particular North-East Asia, suffered the impact of the earthquake and tsunami in Japan which affected both its inbound and outbound travel as well as intra-regional travel from other markets. In the Americas, international tourist arrivals increased by 5%, driven by the strong results of South America, which contrasted with the below average growth of North and Central American destinations. The Middle East and North Africa have been considerably affected by recent developments. UNWTO maintains its forecast for an increase in international tourist arrivals in 2011 at between 4% and 5%, slightly above the long-term average and in line with previous assessments. The developments in the Middle East, North Africa and Japan are not expected to significantly alter the global forecast.

Wellness Tourism Worldwide (WTW), a new global trade body based in the USA and Hungary, has been launched. It was founded by health and wellness consultants Camille Holheb and Laszlo Puczko. WTW is an international trade alliance for wellness and tourism related businesses, organizations and institutions concerned with health, well being, leisure, tourism and sustainability. It argues that wellness tourism offers a larger market than medical tourism. The organization seeks to promote the importance of wellness tourism as an economic growth and social well-being generator, to encourage public-private partnerships, and to assist governments in developing policies that allow wellness tourism to thrive worldwide. It hopes to attract members across countries, regions and sectors that share the collective goal of accelerating wellness tourism growth. Wellness travel consumers have a wide range of needs and interests and WTW aims to attract and protect consumer interests by increasing awareness and acceptance of travel as a key activity for improving wellbeing and improving the delivery of wellness travel products through quality standards. Research shows the wellness industry will increase due to growing interest in staying healthy, the aging world population, fragmented healthcare systems, increased globalization and an increased interest in integrative health/complementary medicine. The wellness industry includes spas but also extends to organic, anti-aging and beauty, fitness, nutrition and supplements and human performance technology. Wellness motivated travel is a vague concept so the trade body seeks to include manufacturers, distributors, insurance companies, and others who service and support the operation of wellness service providers. It seeks as members-• Government agencies (ministries of tourism, ministries of economic development)• Tourism organizations and related businesses (destination management organizations, associations, travel agents, hotels, airlines, spas)• Corporate entities focused on employee wellbeing (corporations, insurance groups)• Healthy food and fitness related businesses,• Companies and organizations focused on sustainability,• Higher educational institutions offering wellness and wellbeing programmes. WTW aims to offer the usual range of services that the many existing medical/health/wellness organizations offer –• Webinars, workshops, and conferences.• Educational curriculum development.• Industry research.• A range of services to members and others. • Participation at industry events, trade shows, meeting and conferences.• Newsletter.• Familiarisation trips. There have been many global trade associations launched in the medical/health/wellness sector but most have folded or faded into obscurity. It mentions the need for quality standards in the wellness sector, which suggests that it ultimately seeks to offer accreditation; if so it will be entering an overcrowded market where most businesses that are not hospitals have yet to be convinced of the need for quality standards unless they are official government or medical authority requirements.

Mainland Chinese can now apply for solo visits to Taiwan under an agreement concluded by the Taipei-based Straits Exchange Foundation and its Beijing counterpart the Association for Relations Across the Taiwan Straits. The new free independent traveler scheme allows Chinese tourists to go to Taiwan independently instead of as part of group tours. The first stage will see up to 500 mainland Chinese enter Taiwan each day for trips of up to 15 days. Initially, it will only apply to residents of the three Chinese cities of Beijing, Shanghai and Xiamen while residents of the coastal province of Fujian, where Xiamen is located, will be allowed to travel individually to the Taiwan-controlled islands of Kinmen, Matsu and Penghu. Travellers may be accompanied by spouses, parents or dependents, must be at least 20, possess a verifiable yearly income of US$17,300 or have substantial savings in a bank. Those who overstay will be banned from entering Taiwan for three years. Students age 18 and over will be considered as long as they can provide proof of full-time enrolment in a recognized educational institution. Independent travel permits Mainland Chinese visitors to experience Taiwan. The initiative will benefit Taiwan’s tourism industries. The Taiwan government expects medical tourism to attract between 2000 and 9000 Chinese every year. Wang Chih-kang of the Institute for Biotechnology and Medicine Industry (IBMI) commented,” With Taiwan’s medical professionals, medical services on a par with those in Europe and the United States, and comparatively lower fees, medical tourism will become a major industry for the country. Taiwan can attract independent Chinese tourists for physical checkups or cosmetic surgery. Taiwan should relax the restrictions on the length of time Chinese tourists are allowed to stay in Taiwan to allow them time to convalesce after major surgery. According to Wang Chih-kang 3700 foreign nationals arrived in Taiwan for medical treatment over the past two years, most of who were Chinese. Language is Taiwan’s edge in developing medical tourism, Taiwanese medical professionals can communicate with overseas Chinese and they can also speak English well and can communicate with non-Mandarin speaking foreign patients." Taiwan’s tourism industry has performed well in 2011. Official statistics indicate that the island welcomed an all-time high of 5.57 million visitors in 2010 and is poised to exceed the goal of six million this year. Travel between the island and mainland stopped at the end of the civil war in 1949, and since 2008 Mainland Chinese travel to Taiwan was only allowed in groups due to official concerns they might otherwise overstay their visas and work illegally. Last year, more than 1.63 million Chinese visited Taiwan - most of them on organised group tours, the rest on business, family and study trips - a rise of 67 % from a year before, making China the biggest source of visitors to the island. Chen Hung-chi of the International Medical Service Center at China Medical University Hospital argues that Taiwan should first increase market presence in China’s medical industry in order to develop the island’s medical tourism. He argues that as China continues to lack medical services for the well off, it is best that Taiwan establishes a niche market as soon as possible to cater to this sector. Only after Taiwan builds up a comprehensive hospital chain and referral system in China can cross-strait medical resources be integrated, which in turn will boost medical tourism to Taiwan.

The future direction of outbound and domestic medical tourism for Americans is partly dependent on the effect of US healthcare reform; on who pays for insurance and whether or not the insurance will pay for medical tourism. Evidence given to politicians at an official hearing has to be read with care, as some of those offering views on what will happen in 2014 tend to spin information to bolster their own arguments. The Congressional Budget Office (CBO) estimates that only 7% of Americans now covered by employer-sponsored insurance will have to switch to federally subsidized policies through exchanges in 2014. But employee benefits consultant Lockton asserts that CBO has significantly underestimated a figure that may be closer to 20 million or 30 million of the 150 million Americans now with employer-sponsored coverage. The counter argument is put in a survey by the International Foundation of Employee Benefit Plans that finds that employers anticipate rising costs under reform, and many intend to increase employee cost sharing as a result, but few will cancel cover. According to consultants McKinsey, 30% of employers will definitely or probably stop offering health coverage in the years after 2014. 45% of employers say they will definitely or probably pursue alternatives in the years after 2014. Those alternatives include dropping coverage, offering it through a defined-contribution model, or in effect offering it only to certain employees. After criticism, McKinsey hastily backtracked with a long press release arguing, “The survey was not intended as a predictive economic analysis and was not an economic forecast, but a measure of attitudes of employers. It is an opinion survey so not comparable to the healthcare research and analysis conducted by others such as the Congressional Budget Office, RAND and the Urban Institute. Each of those studies employed economic modeling, not opinion surveys.” Putting the predictions in perspective, the number of Americans with health insurance through employers has already declined, due to millions losing their jobs. Most employees will continue to get coverage through their jobs after the new healthcare law takes full effect, says a new study sponsored by Robert Wood Johnson Foundation. It says that low and moderate-income families employed by small firms were the most likely to be affected by a loss of employer-sponsored coverage, as it may be cheaper for employers to help such individuals buy cover from the heavily regulated state health insurance. Another study by the Urban Institute said it expects the healthcare overhaul to help small businesses with 50 or fewer employees provide medical coverage to employees due to the tax incentives for small employers. Starting in 2014, the Affordable Care Act (ACA) will require mid- and large-sized companies to make payments to the federal government if they do not offer health insurance to their employees and dependents. Employers with at least 50 full-time employees will have to provide qualified health insurance coverage to their full-time employees and their dependents. Qualified coverage is defined as comprehensive (paying at least 60 % of health care expenses) and affordable (costing less than 9.5 % of employees’ household incomes). If they do not and if their employees purchase coverage instead through a new state insurance exchange with the assistance of federal subsidies, companies will have to make a tax payment of up to $2000 for every full-time employee beyond the first 30. The Affordable Care Act requires states and the federal government to review premium increases that appear excessive. The act provides for the operation of health insurance exchanges by states. Health insurance exchanges are organized marketplaces for the purpose of providing coordination and guidance to individuals and insurers. Individual policies can continue to be sold through the individual market outside the exchange. States will also establish exchanges for small-group health insurance coverage. States will have the option of merging their individual and small-group markets and may opt to have one exchange to serve both, while states can co-operate on joint exchanges. The varying estimates provoked an intense political and media debate, but it is a new situation for everyone, so asking business leaders to second guess now what will happen in three years time is a very poor predictor of what businesses will actually do in 2014.

Eight private healthcare companies, clinics and hospitals on the Costa Blanca have formed an alliance to try and attract more foreign patients. The Mediterranean Health Care Association says the objective is to make Alicante province a destination for European health tourism. The eight are: Vistahermosa Clinic, Medimar International Hospital, San Jaime USP Hospital in Torrevieja, Hospital Clínico in Benidorm, Vissum Ophthalmologist Corporación, Sha Wellness Clinic in El Albir, the Davó maxillofacial and the Casaverde neurological rehabilitation centre. Together they aim to internationalize their services through co-operation and a programme of marketing and joint promotion. €400,000 has been invested in the idea, and the plan is to find patients online, and via insurance companies, travel agents and public health bodies in other countries. The main target markets are Europe, United States, Russia and North Africa. President of the association, Alberto Giménez Artés explains, “Given the demographics of the health market it is hoped this Mediterranean part of Spain, with its sophisticated medical facilities, easy proximity to northern Europe and the other target areas, and its reasonable pricing, will prove a popular destination, for the older patient especially. The availability of cheap flights into El Altet’s expanded airport is also an essential factor in attracting health tourists. In addition to medical care the association also aims to provide accommodation and travel advice and arrange both for patients and accompanying friends and relatives as part of an all inclusive and holistic approach to this expanding service.” MajesticSpa Essential Moments, a boutique spa in the Hotel Majestic in Barcelona, Spain, part of the Catalan group Majestic Hotel Group, is the first spa in Europe to achieve SpaExcellenceSM certification. This certification is the culmination of months of organizing and documenting the spa’s quality system in accordance with the international standards of spa excellence from SpaQuality. The standards provide a framework for everything a spa does including planning, day-to-day operations, behind-the-scenes processes, leadership, teamwork, training, system evaluation, continual improvement and more. Spa director Eva Crespi says, "Implementing these standards have helped us to have a clear and concise management system. This translates into being able to be fully devoted to customer satisfaction. We developed protocols in order to improve our efficiency, which also makes it easy to train staff and incorporate changes and innovations.” Assessors conducted an assessment of the spa quality system for compliance The spa’s processes were assessed in several categories: intention and strategy, leadership, guest experience, operations support and improvement, as well as how well they worked together as a quality system. The spa can expect an unscheduled anonymous guest assessment to evaluate the spa from a guest’s perspective before the next annual assessment. MajesticSpa is on the 10th floor of Hotel Majestic and offers facial treatments, body treatments, massages, manicures, pedicures, waxing and make-up. The facilities include a reception area, four treatment rooms, two pedicure rooms, two manicure rooms, a make-up area, and a hydrotherapy circuit, which includes a dry sauna, an ice fountain, a steam room and a sensations shower with relaxing essential oils. SpaQuality is an independent organization specializing in evaluating quality systems in the spa industry. Julie Register and Linda Bankoski created it in 2003.

While other areas of the Philippines are still talking about developing medical tourism, Cebu is making rapid progress. Seeing Cebu’s potential for medical tourism, a group of dentists and entrepreneurs have set up Dentaland, a dental clinic within a local shopping complex, the Ayala Center Cebu.It will offer high quality dental services at a low cost to medical tourists. The company will be opening another clinic next year and is also working on its accreditation. Dentaland Inc. was formed by nine friends, seven of whom are dentists. The other two co-owners are Gino and Carmel de Pio-Salvador of Global Carrier Philippines, who handle the company’s marketing and management. The clinic is equipped with the latest state-of-the-art and modern hygienic facilities. It has created a room designed for children. The plan is to link up with hotels and with the wellness sector. Dentaland plans to work with the Cebu Health and Wellness Coalition as well as spas and other health and wellness destinations in Cebu. After working with four hospitals in the Philippines, Accreditation Canada International is also hoping to work with two Cebu hospitals to get them international accreditation that would give foreign patients more confidence in their services. In the Philippines, the Manila Doctors’ Hospital has achieved accreditation from Accreditation Canada International, and the organization is working with the Philippine Heart Center, Asian Eye Institute and Clinica Manila. Accreditation Canada works with hospitals in a step-by-step approach without overloading them with things that they need to do to get accredited. Hospitals believe that international accreditation will help them attract medical tourists. The accreditor does not have a fixed price, as it customises a programme to meet global health care standards to promote quality and safety in medical tourism. A well-prepared hospital can get accredited in 12 months, but the normal period is two years. Accreditation lasts for three years before it has to be renewed. Medical tourism is one of seven growing economic sectors in the country identified by the Joint Foreign Chambers (JFC) to help bring in foreign direct investments and create jobs. Among the core health care services identified by the Department of Tourism as in high demand among foreigners are executive checkups, cardiovascular care, cancer care, stem cell therapy, joint replacement surgery, weight management, eye care, dental care, cosmetic surgery, spa wellness treatments and long-term care and retirement. But for the country to attract more foreign patients, the JFC is recommending that the government promotes medical travel packages, and finally develop and implement the long promised national policy on wellness and medical travel.

The world’s first online portal dedicated to the medical evidence that exists for 22 spa and wellness therapies, Spaevidence.com, was launched at the Global Spa Summit in Bali, Indonesia. The new portal consolidates clinical evidence about 22 key spa therapies, including yoga, reflexology and aromatherapy, from four existing databases: Natural Standards, the Cochrane Library, Pub Med and the Trip Database. The portal has been developed with support from Dr. Ken Pelletier, Dr. Daniel Friedland, Dr. Marc Cohen and Nader Vasseghi. Among the therapies are lesser known ones such as ear candling, qi gong and music therapy. For each therapy it gives links to databases, research and ongoing trials. Under the 2011 banner of “Engage the Change: The Customer. The Money. The Future,” delegates attended dozens of presentations and panels exploring smart new ways to engage with consumers; enter new markets; embrace new technologies; implement new business, tourism and wellness concepts; and pursue new investments. There are at least 75,000 spas across the world, the number being difficult to determine as where a hotel with health leisure facilities ends and a spa/wellness centre begins is a matter of debate. Spas are seen as a leader in promoting both medical tourism and wellness tourism. The release of new industry research is a hallmark of every summit, and the ten research reports available online include:• GSS: “Wellness Tourism and Medical Tourism – Where Do Spas Fit?”• Coyle Hospitality Group: “Priorities of Today’s Spa Consumers” Each year a poll of the 500 plus attendees provides a window into current industry performance and the future. The 2011 delegate survey highlights include:• The economic turnaround is directly, positively impacting the spa and wellness industries: 82% predict an increase in gross revenues for 2011.• China ranks as the top country that spa groups would most like to expand their business, followed by other countries in Southeast Asia.• 57% report that social media campaigns are currently driving an improvement in customers/sales, but 26% still do not engage in any social media initiatives.• 37% report that group buying/online deal sites have driven an improvement in customers/sales, but 58% don’t participate in group buying/online deal sites, the fastest-growing online category. The spa industry in Indonesia has become the third fastest developing and third biggest in Asia after those in India and China, according to Indonesia’s tourism minister Jero Wacik, "in 2010 the spa industry in Indonesia grew 7% or almost as fast as that in China which grew 8% and that in India which developed 11 %. The spa industry cannot be separated from tourism and so it is contributing economically to Indonesia. We do not know the exact number of spas in the country, which is why we plan to make an inventory of spas. It is vital to improve the quality of the spa industry in this country so that it can attract more tourists. We will work with regional governments and produce an ethics code for the industry."

Taking advantage of the publicity that US domestic and overseas medical tourism is getting, an increasing number of agencies are promoting hospitals and clinics in South and Central America as cheaper than the USA, and with an eye on the ever increasing costs of air travel, a much shorter flight time than Asian destinations. Connecticut agency, Weltrek, is launching medical tourism and healthcare destination guides providing exclusive highlights of a destination, country or city with detailed information about the quality of healthcare found in that region. The agency only offers treatment at four locations in Ecuador and Costa Rica. Weltrek also offer Wel-pass for patients at a reduced cost for a limited period of time. Acquiring the Wel-pass allows patients to talk to their prospective surgeon via phone or web conference to answer any questions about their procedure. Patients can also transfer their medical transcripts to their chosen surgeon, safely and securely. Medical tourism agency, Gorgeous Getaways, has entered into a partnership with Costamed Hospital and Dental (CMC) to promote Cozumel in Mexico to Canadian and American patients seeking affordable high quality medical treatment in a safe and relaxing environment. US medical tourism agency, MedToGo International is helping an increasing number of Canadians get surgery in Mexico. US agency, Medical Tourism Company (MTC), is offering weight loss surgery in Mexico, 60-70% cheaper than in the USA. Mexico has emerged as a cost saving option even after considering travel, accommodation and other expenditures. MTC offers affordable weight loss surgery in Puerto Vallarta, Guadalajara, Tijuana, Hermosillo, Cuidad Juarez, Monterey, and Mexicali. MTC has also added cosmetic surgery in Costa Rica as Costa Rica is close to the United States and Canada and presents minimal problems in travel planning or budgeting. Costa Rica cosmetic surgery prices are very affordable. The Fundacion de Santa Fe de Bogota hospital in Colombia’s capital is one of few hospitals in Latin America that is able to treat advanced abdominal cancers. It offers specialist treatment that is only available in a very small number of places globally, and only three sites in Latin America. Currently, the outlook for people with these conditions treated with conventional therapy is poor; for patients with peritoneal carcinomatosis from colorectal cancer median survival time is six to eight months, with no five-year survivors. The HIPEC treatment shows promising results; research documents five-year survival rates varying from 25 to 70%. The treatment is helping the burgeoning Colombian medical tourism industry, attracting patients from other countries who would be unable to afford or otherwise access this life-saving treatment.

An EU funded project, ’The Role of Health Tourism in Improving the Competitive Strength of the Rural Areas in Hungary and Croatia’ is a trans-border project that aims to define factors necessary for the improvement of the competitive strength of the rural trans-border area through health tourism. The research results will be available soon. In cooperation with experts from the Institute for Tourism, REDEA is in charge of implementing the research that aims to present the situation and potential for the development of health tourism in Croatian and Hungarian regions near the border. On the Croatian side, the project relates to Medimurska, Viroviticko-Podravska and Koprivnicko-Krizevacka counties. In Hungary the three border counties are Zala, Somogy and Baranya. The Regional Development Agency (REDEA) aids the development of Međimurska County through activities related to small and medium-sized entrepreneurship. Health tourism is one of the oldest types of tourism in Croatia. It is the use of comparative natural and healing advantages arising out of the climate, with the purpose of maintaining and improving health and quality of life. The basis of health tourism is the use of natural healing factors that can come from the sea, spa, or climate. Geothermal sources are an extremely important resource in Hungary, so health tourism is also important there. The social impact of health tourism on the standard of living, employment and education will be determined. The general aim is to determine the importance of health tourism in the competitive strength of the rural areas in the border area, and to identify key success factors. Specific aims include- investigating investments, subsidies and support in the health tourism of the border area; evaluating the role of companies in health tourism and health institutions in the region. It also seeks to create an IT platform and trans-border network of Croatian and Hungarian health tourism institutions with an exchange of ideas, and a debate on development plans. Expected results include:• Research on the local authorities, companies, medical staff, tourists and the local population in health tourism.• Research on best practices.• IT platforms with presentations and interactive maps.• A new network of Croatian and Hungarian experts in health tourism on the border area.• Conferences and workshops.• Identification of success factors, needs and capacity of health tourism in the border area.• Impact of investments in the border area on the population.• Creation of a transborder network of health tourism.• Identifying investments into the development of health tourism; entrepreneurs, companies and institutions (hotels, spas, regional and local administration, hospitals) that are in some way connected to health tourism. As well as health tourism, the two countries are well established in dental tourism. Dental tourism is crucial for Hungary’s economy, generating 227million Euros in revenue each year according to Viktor Orban, Hungarian prime minister. Health tourism, especially spa and dental tourism is to receive special attention with the Hungarian government planning support worth 117 million Euros. Many dental surgeries across Hungary welcome the news of governmental support. Hungarian Dental Travel, a long-established UK based independent dental trip organiser only works with surgeries, which pass their on-going quality controls and live up to British dental patients long-term expectations. The company has just added Dr Salman, whose dental surgery is in the center of Budapest, and who speaks Arabic and English. The proprietor of Harley Street’s Milo Clinic, Dr Nick Milojevic, has opened a new surgery in his home country, Croatia, which will offer safe, expert cosmetic procedures at a fraction of the cost of equivalent treatment in the UK. Dr Milojevic is now offering a Harley Street standard service in Croatia, taking the worry out of seeking procedures outside Britain.

The outbound medical tourism industry has grown rapidly in recent years in Canada and two new reports throw some light on what is happening and why, but do little to solve the question asking how many Canadians go abroad for healthcare? An analysis of 12 phone interviews conducted with 10 Canadian medical agencies to understand Canadian patients’ involvement in medical tourism provides a snapshot. Questions in the research for the feature in BMC Public Health focused on the information provided, how medical tourists make decisions and what agencies do for their money. The ten agencies sent Canadians to 11 different countries. Estimates of the number of clients sent abroad annually varied due to demand factors. Most medical tourists are between 40 and 60, from a variety of socio-economic backgrounds. Potential customers were put off by fear of the unknown, and antagonism of most Canadian doctors to the concept of medical tourism. The report concludes that medical tourists are not similar to each other and have different reasons for going where they go; while those who consider it and fail to travel, all have different reasons too. The authors speculated that people with a historic family or ethnic link to a country considered as a medical tourism destination may not need an agency. Another conclusion was that the research provided no clues on how public healthcare could help, hinder or mesh with medical tourism. According to a report from Deloitte Canada - ’Medical Tourism in Canada – exploring a new frontier in healthcare’, 2% of the adult population travel between countries to receive treatment, and that figure is expected to grow each year. It suggests that 525,000 Canadians travel each year; a figure that is not supported by anecdotal evidence from hospitals and agencies - and previous Deloite estimates of travelling numbers have been much higher than reality. Over the past five years, Canadian governments have reduced the volume of insured medical services purchased out-of-country, but the costs of these services have more than doubled. At the same time, anecdotal reports suggest that Canadians are privately purchasing cosmetic and elective services at an increasing rate, though little data is available, admits the report. Many factors are influencing the growth and surrounding regulations of patients travelling for medical care:• Evolving medical tourism guidelines and international accreditation.• Expanding and increasing sophistication of foreign medical tourism operations.• Increasing provincial and local provider interest in supporting medical tourism through legislation and policy.• Increasing demand for outpatient surgery and a drive to reduce wait times.• Emerging consumer interest in medical tourism options.• Economic constraints and changing financial incentives. Adding to the emerging state of medical tourism in Canada is growing policy and public attention to waiting lists for key services, increasing consumer willingness to travel for health care services, and renewed direct-to-consumer marketing by medical tourism companies and foreign destinations. This growth presents opportunities for increased medical tourism in Canada – both for Canadians seeking care abroad and for establishing Canada as a medical tourism destination – and sets the stage for renewed focus on this health care trend by Canadian governments, providers and consumers. The Canadian Medical Association argues that there should be no need for a private medical-tourism industry and that policymakers should focus on improving Canada’s health-care system, so that there will be no need for a Canadian to go across any border to receive health care. It also argues that timely access and availability of treatments at home would entice Canadians to receive treatment at home rather than abroad. ArticleAuthors: Rory Johnston/Valorie Crooks/Krystyna AdamsJeremy Snyder and Paul KingsburyCredits/Source: BMC Public Health 2011, 11:416

In reply to a question in Parliament, Shri Ghulam Nabi Azad, Union Minister for Health and Family, released some previously unpublished figures and stated that no later figures are yet available. Total number of overseas visitors 2009 5,167,699 2010 5,775,6922011 6,309,222 Total number of overseas visitors who came for medical treatment 2009 113,6892010 155,9442011 138,803 These government figures put medical tourist arrivals at around 2% of total overseas visitors.

With many of the 50 countries that had already advised citizens to think twice before traveling to Thailand, upgrading advice to recommend that they either do not travel there at all or not to travel anywhere in or near the capital of Bangkok, medical tourism in Thailand is suffering as people cancel travel plans. Kuwait has recommended its citizens in Thailand to return home, and the UAE advised all to delay their planned travel to Thailand, while Oman has advised all to avoid Bangkok. This could affect Thailand’s medical tourism industry, as it is the period when people from the Middle East seek annual checkups at Thai hospitals. The Thai Government has imposed a 60-day state of emergency, which gives security forces the power to impose curfews, detain suspects without charge, censor media, ban political gatherings of more than five people and declare areas off-limits. The political situation in Thailand is unpredictable and sometimes volatile. Over recent years there have been instances of civil and political unrest resulting in large demonstrations and in some cases violence. The state of emergency applies to Bangkok and the neighbouring provinces of Nonthaburi, Pathum Thani and Samut Prakarn, and includes the Suvarnabhumi International Airport, one of the busiest in Asia. The Thai government has so far imposed no travel restrictions but this may change. Political demonstrations continue in and around Bangkok and elsewhere in Thailand. Some of these have been violent, including the use of firearms, and there have been casualties and deaths. The situation is unpredictable and further protests are expected. 800,000 Brits travel to Thailand every year and the Foreign and Commonwealth Office (FCO) advises against all but essential travel to Bangkok and neighboring areas and for most of the rest of the country- they advise checking with them before travelling. Malaysia, the Philippines, China and Australia have advised their citizens to avoid travelling to Bangkok and its surrounding areas and to monitor the situation closely. In countries that normally send high numbers of people to Thailand, airlines have cancelled flights, tour operators report bookings have fallen dramatically, and some insurers refuse to offer cover. Everybody is hoping that after elections in February, the situation will return to normal. Meanwhile the Tourism Authority of Thailand is trying hard to play down the crisis and says tourists have not been targeted in the ongoing demonstrations and that it is business as usual in most parts of Bangkok. On advice to customers from the medical tourism industry, there is a deafening silence.

International tourism grew 5% in 2013 with an extra 52 million arrivals, and similar growth is predicted for 2014.This is good news for medical, health and wellness tourism. It highlights the rise of China and Russia as leading outbound markets. International tourist arrivals reached a record 1,087 million arrivals, according to the 2014 UNWTO World Tourism Barometer. Despite global economic challenges, international tourism results were well above expectations, with an additional 52 million international tourists travelling the world in 2013. For 2014, UNWTO forecasts 4% to 4.5% growth, again, above the long-term projections. Demand for international tourism was strongest for destinations in Asia and the Pacific (+6%), Africa (+6%) and Europe (+5%). The leading sub-regions were South-East Asia (+10%), Central and Eastern Europe (+7%), Southern and Mediterranean Europe (+6%) and North Africa (+6%). Taleb Rifai of UNWTO says, “The tourism sector has shown a remarkable capacity to adjust to the changing market conditions, fuelling growth and job creation around the world, despite the lingering economic and geopolitical challenges.” UNWTO forecasts international arrivals to increase by 4% to 4.5% in 2014, again above its long-term forecast of +3.8% per year between 2010 and 2020. The UNWTO Confidence Index, based on the feedback from over 300 experts worldwide, confirms this outlook with prospects for 2014 higher than in previous years. 2014 regional prospects are strongest for Asia and the Pacific (+5% to +6%) and Africa (+4% to +6%), followed by Europe and the Americas (both +3% to +4%). In the Middle East (0% to +5%) prospects are positive yet volatile. Europe led growth in absolute terms, welcoming an additional 29 million international tourist arrivals in 2013, raising the total to 563 million. Growth (+5%) exceeded the forecast for 2013 and is double the region’s average for the period 2005-2012 (+2.5% a year). By sub-region, Central and Eastern Europe (+7%) and Southern Mediterranean Europe (+6%) experienced the best results. In relative terms, growth was strongest in Asia and the Pacific (+6%), where the number of international tourists grew by 14 million to reach 248 million. South-East Asia (+10%) was the best performing sub-region, while growth was comparatively more moderate in South Asia (+5%), Oceania and North-East Asia (+4% each). The Americas (+4%) saw an increase of six million arrivals, reaching a total of 169 million. Leading growth were destinations in North and Central America (+4% each), while South America (+2%) and the Caribbean (+1%) showed some slowdown as compared to 2012. Africa (+6%) attracted three million additional arrivals, reaching a new record of 56 million, reflecting the on-going rebound in North Africa (+6%) and the sustained growth of Sub-Saharan destinations (+5%). Results in the Middle East (+0% at 52 million) were rather mixed and volatile. Among the ten most important source markets in the world, Russia and China clearly stand out. China, which became the largest outbound market in 2012 with an expenditure of US$ 102 billion, saw an increase in expenditure of 28% in the first three quarters of 2013. The Russian Federation is the 5th largest outbound market. The performance of key advanced economy source markets was comparatively more modest. France (+6%) recovered from a weak 2012 and the United States, the United Kingdom, Canada and Australia all grew at 3%. In contrast, Germany, Japan and Italy reported declines in outbound expenditure. Other emerging markets with substantial growth in outbound expenditure were Turkey (+24%), Qatar (+18%), Philippines (+18%), Kuwait (+15%), Indonesia (+15%), Ukraine (+15%) and Brazil (+14%).

The number of infertile patients has been increasing worldwide. Responding to the associated rising demand for respective treatment the ideal would be fair access to fertility treatment at home for all patients. Since fertility treatment is not available or accessible in several countries, cross border reproductive care is a solution that enhances a patient’s autonomy and fits with the principles of freedom of movement of patients within Europe. Fertility patients seek assisted reproductive technologies abroad for a variety of reasons and the reasons for traveling might also be different between countries. The most common reason is law evasion when the technique is either forbidden per se or when a particular group is excluded from treatment. Other potential reasons to seek cross-border care include cost, perceived effectiveness, accessibility, and availability of donor gametes from a variety of ethnic groups. Crossing national borders to receive fertility treatment poses special challenges for the continuity, quality, and ethics of care. Temos has launched a new accreditation for the sector. ’Quality in International Reproductive Care’ takes into account good clinical treatment in assisted reproduction and good practice for cross-border reproductive care, both from the European Society of Human Reproduction and Embryology The new product covers the following treatments and techniques for reproductive care:• Intrauterine insemination• In vitro fertilization• Intracytoplasmatic sperm injection• Blastocyst transfer• Cryopreservation of oocytes, zygotes, and embryos• Gamete donation• Surrogacy• Egg donation The aim is to validate and optimize the facility’s medical and non-clinical services for medical tourists including the complete patients’ care cycle before travelling abroad, within the clinic and for the post-treatment and post-discharge procedures including the follow-up. Any health care organization may apply if it is operating as a licensed health care provider, accepts international patients, and is offering reproductive care services according to the national law. It must also be managing international patients and intending to continue or extend that in the future. And at least 5 % of the patients are regional and or international patients. 
There are other requirements. After the clinic has completed the self-evaluation form, the Temos team supports and accompanies the preparation phase until the onsite visit of the Temos assessors. Assessment is done by inspection onsite on the basis of professional judgement and clearly defined and standardized criteria. Further potential for improvement is discussed with staff and management onsite. In a detailed report all recommendations and demands are summarized. National norms, laws, different cultures, mentalities and quality approaches in different countries are taken into account for the overall assessment. Claudia Mika of Temos comments, “IVF centres have already applied for this and will start their preparation within the first half of 2014.”

Just Save Lives has expanded its range of services and business partners to provide organ transplant tourism packages for those in need of life saving surgery. Many people will experience partial to total organ failure in their lifetime as a result of bad lifestyle choices or genetic predispositions, but no one wishes to die from it. In the USA, as in many other countries, long organ transplant lists mean that people can take years to get to the front of the queue, leaving many seeking alternatives. Just Save Lives is a company providing legal guidance, document translation, insurance reimbursements together with professional guidance including locating hospitals and experts and recommending doctors. The company now offers medical tourism packages for Americans seeking major organ transplants in leading medical institutions in Israel. The company provides the full spectrum of services required to take care of every aspect of a medical transplant abroad including initial medical advice and medical summary, consultation regarding the most suitable hospital, medical staff and more to ensure every aspect of the procedure is to the client’s satisfaction. Just Save Lives offers liver transplant surgery, kidney transplant procedures and even heart transplants. The information on each procedure is presented as a package deal showing exactly what is included at every step of the process. Just Save Lives partners with Israeli medical tourism company Leshem Shamaim– which has proven knowledge and experience in the field of organ transplantation.

Polys Georgiades of the Medical Services Promotion Agency urges the Cyprus government to help and finance medical tourism, as it will bring economic benefits and without help the country will miss out on the sector. Polys Georgiades explains, "The state should meet its commitment and help the private sector both in the development of infrastructure and in boosting credibility for Cyprus internationally." Georgiades says that after the events of March 2013 with the impairment of insecure deposits and Cyprus’ banking restrictions, all designs and strategies for medical tourism were marginalized, since clinics, hospitals and all health service providers have given priority to ensuring their everyday viability. He stresses that in the current economic conditions there is a need for health providers to stop depending on the internal market, by attracting patients from abroad; "We must pay attention to alternatives to attract people, beyond the sun and the sea. Medical tourism is a good opportunity, because we have the infrastructure and can provide the service." Georgiades says that Cyprus will have to build its own identity as a medical tourist destination and will have to survive the tough competition from more than sixty countries where medical tourism is a national industry. He adds that Cyprus must meet international standards and introduce reforms to become a valuable destination for medical travelers. He argues that Cyprus has the necessary medical and health infrastructure, and a high level of service. Stressing that health tourists can combine their treatment with vacations in luxurious hotels, he adds that specialized surveys have shown that the country can develop phototherapeutic tourism, since the sun has special properties for the treatment of individuals who have symptoms of depression due to lack of adequate sunshine in their country.

German citizens are becoming more aware of the importance of staying healthy and energetic. Increasingly, they are taking health vacations to reduce everyday stress or to stay fit for their jobs. Over the past five years, holidays at wellness and spa resorts have risen by 30 %. By contrast, medical travel has declined, as according to the findings of the World Travel Monitor, commissioned by ITB Berlin, over the same period the number of cure, rehabilitation and hospital stays abroad has fallen by 18 %. At 3.3 million vacations, equivalent to 4.6 % of all trips abroad, Germans are more interested in foreign health and medical tourism than their European neighbours. Health and medical travel accounts for a total of 9.4 million trips or 2.4 % of all European travel abroad. Across Europe, over the past five years health vacations have increased by 38 %. Medical tourism has also risen by 24 %. Martin Buck of ITB Berlin comments, “Everywhere in Europe health vacations are becoming more popular. This is a big opportunity for organizers, hotels and destinations to expand and improve their services.’’ Germans and Russians are much keener to take health vacations than their European neighbours. The German market for health vacations abroad is approximately six times the size of Russia’s, but with German citizens medical tourism accounts for only 22 % more. The French market is the third largest for foreign health trips, while The Netherlands is the third largest for medical tourism abroad. Among German citizens the most popular foreign destination for health trips is Spain, followed by Italy and Austria. The countries most visited for medical reasons are Poland, the Czech Republic and Hungary. In Europe as a whole, the most popular countries for health trips are Spain, Italy and Austria, while Hungary, Germany and the Czech Republic are the leading destinations for medical tourism. According to the survey, socio-demographics also play a part. At an average age of 48, Europeans taking health vacations are younger than people travelling for medical reasons, who are 53. German travellers in both categories are older than the European average. People taking health vacations are 52 and those travelling for medical reasons are 61. Women prefer to travel for medical reasons rather than take health vacations. However they outnumber their male counterparts in both categories. Europeans say that when taking health vacations they prefer relaxing (50 %), followed by walking / hiking and swimming (43 % each). Among Germans, the most popular activities are walking / hiking (48 %), relaxing (47 %), followed by swimming (44 %). Germans are slightly keener on wellness programmes (30 %) than their European neighbours (26 %). By contrast, massages are less popular with Germans (15 %) than with Europeans as a whole (26 %). At growth rates of slightly under 100 % and 100 % plus respectively, at 0.4 million and 0.3 million trips each in 2010, at 3% each of the holiday market, Russia and China are developing into attractive markets for health vacations, particularly for their neighbouring countries.

Malaga has ambitious plans to become a healthcare destination. Malaga Health, set up by a group of local surgeons, will aim to attract patients to clinics, hospitals and treatment centres on the Costa del Sol. According to the group, the initiative could help boost Malaga’s tourism industry by €250 million annually in three years, as health tourism becomes increasingly popular. Co-founder Miguel Such explains,” We are sitting on an untapped goldmine and we do not even realise it. None of us are motivated by money. We are embarking on this project to help Malaga. Health tourism is not being fully taken advantage of in Malaga considering the resources we have. The average incoming patient will spend around €10,000.” Costa del Sol has many private clinics and hospitals. The Malaga Health project is also backed by the University of Malaga, Agencia Idea and Turismo Andalucia. Over 30 hospitals, clinics and other providers have already signed up including Xanit International hospital in Benalmadena, Hospital Parque San Antonio in Malaga, Marbella’s Clinica Ochoa, the Santa Elena Clinic in Torremolinos and several specialist hospitals in Malaga. Participating luxury hotels include the Villa Padierna (Benahavís and Carratraca), Vincci (Marbella) and the El Fuerte chain. To get the project off the ground the sum of €700,000 has already been raised. Consultants Deloitte have been hired to put together a business plan. As part of its tourism faculty, Malaga University is to create a new department of tourism, health and wellbeing. Whether it will be called Malaga Health, Costa de Sol Health, the current rather clumsy title of Tourism & Health Spain, or something a bit catchier, is yet to be decided. At launch it expects as many as 20,000 local health and tourism professionals to be involved in the campaign, which is likely to focus on European countries as that is where Spain gets almost all its tourists from. The region is already well known for health tourism as it has many spas, health centres, Arabic baths and spa hotels. Xanit International Hospital offers many services and has specialist units for cardiology and oncology. Hospital Parque San Antonio is a general hospital. Clinica Ochoa is a general clinic. Santa Elena Clinic specializes in helping tourists.

The chequered past of Satori Wold Medical’s CEO, Steven Lash, has resulted in the cancellation of Satori’s contract with the US city of Hartford to provide discounted surgery in Puerto Rico for city and board of education employees, before a single employee has gone abroad. In a July press release Satori claimed that Hartford was the first major city in the United States to offer this innovative medical travel benefit to their employees and dependents. Local newspaper, the Hartford Courant ran a feature on the Satori medical tourism scheme entitled ’City’s New Benefit: ’Medical Tourism’. The columnist, Kevin Rennie, a lawyer and a former Republican state legislator wrote: “It’s all in the hands of Satori, which won the competitive bid for the Hartford contract. Satori president Steven Lash has a wide array of experience. He was sentenced to 51 months in federal prison in 2004 and ordered to pay $36 million in restitution for his role in a $60 million fraud prosecution involving a physician network management company, according to newspaper reports. This is omitted from his extensive online company profile. After executing a pump and dump stock scheme, Lash will not fear employees’ Connecticut primary care physicians who cavil at patients flying to San Juan for sophisticated treatment” City spokeswoman Sarah Barr said, ”The city decided to cancel the contract because of fraudulent behavior that was brought to light in lawyer Kevin Rennie’s opinion column. When Satori World Medical Inc. was confronted about Steven Lash’s prior convictions, the city was not satisfied with the answers it received and the contract was terminated." The city has invoked a 90-day cancellation clause in the contract. There has been no criticism of the hospitals in Puerto Rico. The contract proposed that Hartford employees could go to Puerto Rico for hip, knee or shoulder replacement surgery, a coronary artery bypass, or other treatment at one of Satori’s network hospitals in Puerto Rico. Satori would provide airfare to Puerto Rico, ground transport, luxury hotel accommodation, and a $250 debit card to individuals willing to seek one of 70 approved operations outside the United States. The medical travel package also included airfare for the patient and a companion and several days of post-hospital rest at a luxury hotel. The Steven Lash conviction was originally reported by the San Diego Union Tribune in 2004: “A federal judge sentenced Steven Mark Lash, the former chief financial officer of FPA Medical Management, to 51 months in custody and ordered him to pay restitution of more than $36 million for his role in defrauding shareholders and lenders of the once-high-flying but now-bankrupt company. U.S. District Judge Marilyn Huff in San Diego further ordered Lash to undergo three years of supervised release ....... The jury found that Lash artificially inflated the San Diego company’s earnings and misrepresented that FPA had positive cash flow from operations. Positioned as a middleman between insurance companies and physicians, FPA promised doctors it could simplify practice management by coordinating the payments from multiple health insurers. The company’s revenue rocketed from $18 million in 1994 to more than $1 billion in 1997. Shortly after reporting its eighth consecutive quarter of record earnings in 1998, the company filed for bankruptcy. U.S. Attorney Carol Lam said she hoped the conviction would send a message - "Corporate officers who use their position to commit massive frauds are being held accountable and Steven Lash is no exception." The San Diego Reader has followed up with a blog post entitled “Local Ex-Medical Fraudster Loses Contract”. Whether the contract cancellation will affect any other existing or potential business for Satori remains to be seen. Nevertheless, the highlighting of the Satori CEO’s past and the cancellation of the contract will do little to advance the cause of Satori and the medical tourism industry in general.

Stem cell therapy companies in China and Germany, who were criticized by British experts warning of the dangers of stem cell tourism, have defended themselves by saying that their safety records are very good. British health experts said they are concerned about a growing level of international stem cell tourism where patients travel abroad to private clinics to have treatments that are not licensed by drugs regulators in Europe or the United States. The experts said they were particularly concerned about a firm in Germany called XCell-Center and about Beike Biotech in China, which offers stem cell treatments for a range of conditions including brain injury, cerebral palsy, multiple sclerosis, spinal cord injury and optic nerve damage. Beike Biotech, China’s leading stem cell research and regenerative medicine company, says that all its stem cells are administered by experienced physicians who work in and for leading hospitals in China, "Beike boasts an impeccable safety record, and it enjoys the support of various branches of the Chinese government and of leading Chinese universities and hospitals. Studies and peer-reviewed papers will show that Beike’s stem cell protocols are both effective and safe. In the West, stem cell treatment is treated like a drug, not a therapy. It requires phase II, III trials before Western doctors and scientists will accept its effectiveness. This has limited the availability and increased the cost of stem cell therapy in the West, causing considerable frustration for many patients who cannot afford to wait until the treatments are proven by Western standards." Germany based XCell adds that its stem cell preparations are made from bone marrow and intended for autologous use, or use by patients from whom they came, "These preparations are medicinal products for innovative new therapies. They are covered by European regulations on advanced therapy medicinal products and do not require a permit issued by the European Commission to be marketed." In a new peer-reviewed article published by the Journal of Translational Medicine, scientists from Beike Biotechnology and biotechnology company Medistem, reported positive safety data in 114 patients who were treated by doctors at Shenzhen Nanshan Hospital in Shenzhen using Beike’s proprietary cord blood stem cell transplantation protocol. It describes biochemical, hematological, immunological, and general safety profiles of patients with neurological diseases who were observed from between one month to four years after treatment. No serious treatment-associated adverse effects were observed. Dr. Wanzhang Yang, who led the study commented, "This important study, which is the largest of its kind, demonstrates the safety and efficacy of using cord-blood-derived stem cells to treat a variety of neurological conditions. However, it also suggests cord-blood-derived stem cells are a safe and viable treatment option for a much broader range of diseases and conditions than previously thought." The British experts led by Professor Peter Coffey of University College London, said they had been prompted to speak out about the risks of traveling abroad for stem cell treatment because of a flood of requests they are receiving from patients who read about apparently dramatic cures on websites and in the media. Clinics in Mexico, Thailand, Germany, Russia and China offer stem cell therapies with high price tags and little clinical evidence to back them up. The International Society for Stem Cell Research has previously warned of private stem cell clinics around the world seeking to exploit desperate patients oblivious to the risks. Several hundred private clinics have sprung up around the world claiming to have turned the dream of stem cell cures into reality. The centres offer treatments for conditions as varied as spinal cord injury, heart failure, Parkinson’s disease, diabetes, autism and eye disorders. Thousands of patients globally are believed to have had the therapies, which may cost in the region of £20,000 or more. Stem cells are immature cells from embryos, foetuses or adults that have the ability to transform into different kinds of tissue. They hold out the promise of potentially curative treatments for a host of conditions and diseases. However, rigorous testing of the therapies in clinical trials is still in its infancy. Some scientists believe it could be 15 to 20 years before trustworthy treatments are widely available, yet a large number of clinics claim to be offering them already. Currently, there are no stem cell clinics in the UK. The International Society for Stem Cell Research offers useful advice to anyone thinking of stem cell treatment.

The International Cellular Medicine Society (ICMS), a physician and researcher guided nonprofit organization for the advancement of adult stem therapy, has published its second Off Shore Stem Cell Clinic Survey Report. This study of 22 stem cell clinics in 13 countries is unique in that it is the only survey of the global stem cell market by an independent, medical organization. ICMS represents medical doctors and researchers from over 20 countries on six continents, and published this report as a follow up to the original 2009 survey. The 2010 edition has doubled the number of clinics reviewed and provides a new level of comparative analysis based on how stem cells are processed and implanted by specific clinics. David Audley of ICMS says, “ Stem cell clinics are everywhere. From Guatemala to Thailand, from Peru to Germany, clinics have responded to increased demand. While exact numbers are hard to verify, it is believed that there are between 100 and 200 clinics offering stem cell therapies. The issue is that clinics in Costa Rica and the Dominican Republic can both claim to treat congestive heart failure, but there has been no way to compare these clinics. As a patient, how are you supposed to make an informed health care decision with little or no information?” To build a model to compare clinics, patient volunteers for the ICMS contacted over 30 clinics worldwide and inquired about treatments for conditions ranging from congestive heart failure to Parkinson’s disease. The patients asked each of the clinics to furnish information about their treatment procedures. Out of the 30 clinics contacted by patients, 22 provided sufficient data to be analyzed and included in the report. Dr.Christopher Centeno of ICMS adds, “We recognize that medical tourism is growing, and that transparency about what is going on in these clinics is only way to separate out the wheat from the chaff. The combination of data provides significant insight into the landscape of the global stem cell treatment market to help patients and physicians make more informed healthcare decisions.” The report seeks to inform patients by providing multiple levels of comparison from cell type (adult versus embryonic) to procedure price to conditions treated. Additionally, the report provides an analysis of clinics based on the complexity of their cell processing and implantation procedures. ICMS plans to publish the report annually as a guide for patients and physicians to compare the treatment options available by stem cell clinics worldwide. ICMS is dedicated to the advancement of safe and effective adult stem cell therapies through research, education and oversight by peers. The report concludes that the stem cell landscape remains problematic for patients. While new clinics have appeared across the globe to offer treatment, it remains nearly impossible to accurately compare and contrast treatment, much less make an informed decision about which procedure may be best for a patient’s condition. With 22 reporting clinics, 88% of procedures utilize autologous stem cells. There appears to be a growing level of procedural complexity about the method by which stem cells are processed and injected.

Vanity Cosmetic Surgery is the first cosmetic surgery group in the world to accept payment by new currency Bitcoin. Vanity Cosmetic Surgery is the biggest cosmetic surgery centre group in Florida .It recently announced that it would accept Bitcoin from all their patients to cover up to 100% of the total cost of their services. Initially discounted as a marketing gimmick, many people have inquired about this new addition and quite a few have already used this currency. Carlos Yela of Vanity Cosmetic Surgery says,” With this change it will be easier for people to pay with Bitcoin .We want to give our patients all the convenience possible. People will be able to pay with Bitcoin in full for any cosmetic surgery or any other service in our centres for breast implants, rhinoplasty or nose jobs, tummy tuck, liposuction, botox or even a facelift.” Yela explains why Bitcoin is important,“ It is about globalization, as with the Internet people have access to options they did not have before and Bitcoin helps reduce financial barriers. It offers big savings in currency exchange fees.” Vanity believes that it is important to go the extra mile to appeal to patients outside their local market, and the implementation of Bitcoin is only part of this in their three clinics in Florida. The clinics offer a recovery programme “Home Away Vanity”, that includes seven days accommodation and all the necessary transportation, medicines and in-house care from registered nurses in a luxury home with all the amenities a high-end hotel can offer. This approach has been in part the reason for their success attracting foreign patients.

A recent study reveals that the number of Chinese tourists has overtaken the number of Japanese tourists, becoming the number one tourist country visiting South Korea. In 2013, the number of Chinese tourists increased by 53% on 2012, a total of 4.05 million among the 12 million tourists that visited Korea. Software development firm 3rdpot has launched a medical recommendation service app targeting these Chinese tourists with the support of the South Korean government. The launch comes in the heels of a growing number of single visitors for medical tourism. Although group tourism still makes up the majority of the tourists, there are a growing number of young single Chinese tourists visiting Korea for cosmetic procedures. Unlike group tourists, single Chinese tourists have to take care of their own reservations for flight tickets and accommodation during their medical stay in Korea. The app simplifies the process of reservation for these single tourists, making it possible for tourists to purchase single deals, compared to package deals, including flight, accommodations, SIM cards and mobile phone rentals. The app also includes a map service with GPS tracking solution, with location-relevant travel information, allowing people to travel around easily without any guide. The app can be used on all mobile devices and computers.

January has seen more EU countries pass laws and set up national contact points, in line with European Directive 2011/24 on EU cross-border healthcare. Italy has approved the Legislative Decree, implementing the directive and setting up contacts point for Italian patients considering going to another country and Europeans considering going to Italy .The new law is effective from March 2014 and by then there will be a national contact point and regional contact points in Veneto, Liguria, Trento and Valle d’Aosta. Spain has passed all the laws needed by Royal Decree and set up a national contact point within the Ministry of Health. Poland has passed a law and set up a national contact point within the National Health Fund. Polish patients will be able to travel to other EU countries to receive planned medical treatment .The treatment will be refunded by the National Health Fund (NFZ). The government is worried that if thousands of patients who currently have to wait for months to see a specialist head abroad for care, the NFZ budget will be quickly spent .So the Ministry of Health has restrictions to discourage Poles from seeking healthcare abroad including a compulsory foreign treatment referral from a Polish doctor and restricting refunds to only treatments and drugs reimbursed by the NFZ. Romania has transposed into national law the Directive on cross-border patients’ rights but has not yet set up a national contact point. Cyprus has passed a law implementing the directive and a national contact point is being set up soon with a new website. Speaking at a recent seminar, health minister Petros Petrides praised the benefits of implementing the EU directive on cross-border health care, hailing it as truly reformist, “The adoption of the directive will contribute to improving the quality and safety of health care across Europe and ultimately benefit health care systems in EU countries. As a country aspiring to develop a high-quality medical tourism industry, we satisfy all the required criteria, combining a beautiful Mediterranean environment with natural wealth, climate that is ideal for patient treatment and rehabilitation, tradition in healthy nutrition, historical and cultural heritage and internationally renowned medical professionals. Implementing the directive poses a unique opportunity to modernise our healthcare systems.” At a recent European Patients Federation cross-border healthcare conference Nathalie Chaze from DG SANCO, an organization for patients showed concern that national contact points may not give the right help: “The Directive covers all providers and gives patients the reimbursement as if they were in their own member state. The ideal national contact points should be accessible, accurate, available and customer-friendly. There should be an emergency hotline available to allow for a rapid response as well as information campaigns organised raising awareness about this legislation.”

In an agreement with the Norway Health Authority, UF Proton Therapy Institute in Florida will treat both children and adults who have rare tumors in the nasal and sinus cavity, skull, and brain. There are no medical centres in Norway that offer proton therapy, and for cancers in highly sensitive areas, proton therapy provides patients a superior treatment that also minimizes risk of damage to vision, hearing and brain function. UF Proton Therapy Institute has a similar arrangement with the United Kingdom’s National Health Service, which has referred 200 children and adults for proton therapy in Jacksonville, Florida since 2010. Nancy Mendenhall of UF Proton Therapy Institute explains, “It is significant for both the advancement of proton therapy and our institution to be selected by our colleagues in Norway to care for their patients. It signifies acceptance of proton therapy as the gold standard of care for many kinds of cancer and it recognizes our medical expertise caring for patients who have cancers that in some cases are one in a million.” Since opening in August 2006, UF Proton Therapy Institute has achieved international recognition for excellence in delivering proton therapy. The pediatric program is the largest proton therapy practice in the world, with an average of 25 children on treatment daily. Hundreds of people travel great distances to Jacksonville each year to have proton therapy that can give patients the best hope for cure and to go on to live a normal, healthy life.

The Latvian Health Tourism Cluster has launched a new promotion for 2014. In cooperation with Latvia’s resorts association the cluster has created a marketing brochure to promote the area, treatment, clinics, hospitals, spas, hotels and tour operators. It explains the specialities of each health destination. Two targeted groups are English speaking Western Europeans and Russian speakers from Russia and the other CIS states, So, the brochure has been published in Russian and English languages, and will be distributed at foreign medical tourism fairs, professional exhibitions, workshops and conferences. The print run of the brochure is 6,000 copies and it was created with the support of the Latvian Tourism Development Agency. Latvia believes it has advantages in both medical and health tourism with high product and service quality, professional medical staff, modern technological equipment to ensure services, and much lower prices than most European countries. Most destinations have both English and Russian speaking medical staff, so there is no language barrier. The problem Latvia has to overcome is that it is a little known tourist destination, and many people may be unsure as to where exactly it is. Jurmala is the first city in Latvia to receive resort status. The government recently granted the status of a resort city to a part of Jurmala’s administrative territory, but not parts in Brazciems, Priedaine and Varnukrogs. The idea is that the new status will help attract local and foreign investment in the infrastructure and will promote the health tourism services of Jurmala in domestic and foreign markets. To obtain resort status, a number of conditions must be met - within the resort there are natural healing resources, at least one resort’s clinic is operating in a territory of a resort, and natural healing resources are used in the operation of the clinic. Environmental quality indicators must meet the statutory requirements; it must have an appropriate tourism infrastructure. Jūrmala has a range of natural healing resources to improve health and prevent diseases, as well as for rehabilitation and healing. Jurmala is the largest resort city in the Baltic States and well known for its mild climate, sea, healthy air, curative mud and mineral water. The attractions of Jurmala include a 33 km long white sand beach, a large pine forest and the natural border of the city – the river Lielupe. People go there to recover and strengthen their health by enjoying the healing effect of mud bathing and mineral waters.

Dialysis patients looking to escape the cold or take advantage of snow-related recreation can choose from destinations that include a variety of popular US vacation spots, where they can take in the sights while still receiving regular dialysis treatments. Fresenius Medical Care North America (FMCNA), the nation’s leading network of dialysis facilities, has added more than 200 dialysis clinics to its nationwide network, largely through its 2012 purchase of Liberty Dialysis Holdings which included more than 70 dialysis facilities in Hawaii, California, Colorado, Nevada, Texas, and Utah. Patients who receive blood-filtering dialysis treatments in a clinical setting need to visit a dialysis facility three times per week to remove waste products and excess fluids from their bodies after their kidneys have failed. Patients can schedule treatments at any of the company’s 2150 facilities through FMCNA’s Patient Travel Service. Available to all US dialysis patients at no cost, regardless of who is their primary dialysis provider, the service locates and schedules dialysis treatment for any patient traveling in the United States, Puerto Rico and abroad. The FMCNA network allows patients to receive their life-sustaining treatments at or near popular tourism destinations such as:- Haleakala National Park, on Hawaii’s Maui island- The Golden Gate Bridge, in San Francisco- The Rio Grande River at Laredo, Texas- Pikes Peak and the U.S. Air Force Academy, at Colorado Springs, Colo.- Zion National Park, at St. George, Utah- Lake Tahoe, at Carson City, Nev. Shalita Simmons of FMCNA explains that the Patient Travel Service is helping US dialysis patients better understand their travel options, “Our patient education efforts have made both the staff and patients more aware of what we provide. We have made dialysis travel options easier, which results in an improved quality of life for patients.” The travel service also can help home dialysis patients arrange for dialysis supplies during their trip. For patients travelling by air, a letter of medical necessity may also be required to authorize them to carry their own treatment supplies. FMCNA’s Patient Travel Service arranges tens of thousands of treatments each year for patients traveling in all parts of the USA. It processed 40,000 travel requests during 2013, with the most popular destinations being New York City and the New Jersey Shore; Las Vegas; Myrtle Beach, South California and Florida.

Romania aims to develop health and wellness tourism. The problem is that the government is short of cash and there are not enough big investors in the country willing to part with substantial sums and wait a long time for a return. So when President Traian Basescu travels to other countries, he takes the opportunity to promote the benefits of Romanian health tourism and seek private investors. He does have an unusual style. His latest attempt was in Turkey where he openly asked Turkish businessmen at a Turkish-Romanian business forum to invest in Romanian balneal tourism, “Tourism is a field in which major investments can be made, but maybe it is not the best signal to tell Turkish investors to come and invest in our tourism when in Turkey there is a boom of investments in tourism. So I ask you to do something you cannot do in Turkey: invest in balneal tourism. Romania has excellent natural conditions, resources for balneal tourism. In Romania, health springs from the earth. We have waters with out-of-the-ordinary therapeutic qualities and you may remember Romania’s capacity when it comes to treating third age ladies, the famous geriatric programmes. We have an extraordinary potential. Investments in balneal tourism ensure a guaranteed profit. I am inviting you to invest here as investing here is guaranteed profitability as there is no seasonal problem with health tourism. The natural resources we have make it possible to exploit such health programmes both in summer and in winter.” Basescu continued by also asking them to invest in infrastructure, in energy, and in the food industry, as all are priorities for development. To ensure he covered all possibilities, the President concluded by seeking investment in healthcare, hospitals and clinics, “Romania is extremely interested in private investments in health. The country has major drawbacks here and investments in health are welcome.” Romania has been trying for years to undertake a profound reform of its health system, which is in very poor condition. This has been postponed several times. New draft legislation was prepared but has not yet been adopted. Part of the problem is endemic corruption. Many doctors and hospitals often expect immediate cash payment for health services. The lack of investment, high level of bureaucracy, lack of income and the underdeveloped private system are the main issues behind the current dire situation of the national health system. During 2013 the Romanian government and the IMF were at loggerheads. With the IMF encouraging the Romanian government to rethink its plans to scrap the financing of private hospitals. The IMF, which gives loans and aid to the country, opposed these measures, as spending on private healthcare only amounts to 2.7% of the total healthcare budget .The almost broke government decided that private hospitals would no longer receive funding from the National Health Insurance Fund. Whether Romania will succeed in getting investors is an interesting question. Potential investors will worry that the former Communist state is still very much a centrally controlled country that has many problems. But there are now few EU countries that offer the chance to develop private healthcare, plus health and wellness tourism facilities from an almost clean slate.

Despite near demonisation in parts of the US and Israeli media, Iran is a peaceful country that is successfully attracting local medical tourists away from rivals with political and civil strife, and away from countries that have a tendency to interchangeably use the two quite different words of Muslim and terrorist. This is probably the clearest example in the world of how politics and the global media both affect where medical tourists go for treatment. Thanks to its geographical position, the conditions in neighbouring countries, reasonable prices and advanced medical facilities, Iran is becoming a destination for Islamic and regional medical tourists. An increasing number of hospitals in Iranian cities offer medical and health care services for foreign medical tourists. Iran offers very advanced healthcare. Geographical closeness and cultural and religious similarities have turned Iran into one of the favourite destinations for the Islamic world, as well as Muslim and other denominations from nearby countries. Iran has a highly educated workforce and is a local leader in scientific and health development. It is one of the top five countries in the world in biotech and nine out of 15 high usage biotech molecules are produced in Iran. There are two strands to the demand, medical tourism and health/wellness tourism. The existence of mineral fountains in many parts of the country, targets the latter market. Other markets include fertility treatment, stem cell treatment, dialysis, heart surgery, cosmetic surgery, and eye surgery. Latest figures suggest that 30,000 medical tourists enter Iran annually; plus 200,000 health, wellness and spa tourists. It has a Health Tourism Committee that has produced rules and regulations for tourist healthcare service centres so that hospitals and clinics that want to offer health tourism services to foreign citizens need to acquire licenses from both the Ministry of Health and the Iranian Tourism Organisation. It also offers health service training to employees of tourism agencies and encourages hospitals to open international patients’ wards. Iranian hospitals that hold a medical tourism license from the Ministry of Health arrange airport transfers as well as accommodation. In addition, a nurse can be assigned to each patient. The key target market is the Gulf region, taking people who used to go to Europe or troubled local rivals such as Jordan. An increasing number of patients come from Azerbaijan, Turkey, Iraq, Pakistan and even India. Some come as the prices are lower than at home, some come for specialist care, and many come simply because they feel more culturally comfortable in Iran than in Europe or Asia. Iran offers services in ophthalmology, cardiology, kidney transplants, dentistry, urology and general surgery. Based on studies conducted by Iran tourism organisation ICHHTO-Iraq, Afghanistan, Persian Gulf states, Central Asian nations and Iranians residing abroad are the main targets. ICHHTO provides travel agencies active in health tourism with special facilities such as a pavilion for them in overseas fairs. ICHHTO has also specified certain provinces for health tourism with the co-operation of the Ministry of Health:• Tehran province for treating tuberculosis and lung disorders.• Khorasan Razavi for ophthalmology, skin care, heart surgery and orthopedics.• Fars for liver, kidney and marrow transplants.• Yazd for treating infertility.• Qom for its sun and desert potential.• Hamedan, Ilam and Zanjan as centres of herbal medicine. What began as a development to stop Iranians from travelling abroad to get medical treatment has turned into success in attracting health and medical tourists. Iran is quietly taking business from established competitors, and ignoring the global media frenzy that surrounds it.

The second edition of “Health, Tourism and Hospitality: Spas, Wellness and Medical Travel" takes an in-depth and comprehensive look at the growing health, wellness and medical tourism sectors in a global context. The book analyses the history and development of the industries, the way in which they are managed and organised, the expanding range of new and innovative products and trends, and the marketing of destinations, products and services. The 2nd Edition has been updated to include:• Expanded coverage of the hospitality sector with a focus on spa management.• New content on medical tourism.• Updated content to reflect recent issues and trends including: ageing population, governments encouraging preventative health, consumer use of contemporary and alternative therapies, self-help market, impacts of economic recession, spa management and customer loyalty.• New case studies taken from a range of different countries and contexts, and focusing on established or new destinations, products and services such as: conventional medicine, complementary and alternative therapies, lifestyle-based wellness, beauty and cosmetics, healthy nutrition, longevity and anti –ageing. Each chapter is written by one or a group of authors. Although some chapters began as academic papers they are all written in a user-friendly style, as the editors have been ruthless in cutting out jargon and academic speak. At over 500 pages long it is an essential read and as it is readily available from Amazon and bookshops it should be on the bookshelves of anybody involved in medical, health or wellness tourism. It is written for the business by the business, so avoids the hype and simplification common to consumer guidebooks on the sector. Health, Tourism and Hospitality- Spas, wellness and medical travelSecond editionPaperback £ 34.99Hardback £ 95Routledge imprint of Taylor & Francis Editors Melanie Smith and Laszlo PuczkoISBN 978-0-415-63865-4

Richard Sealy, minister of tourism, wants a more focused fusion of medicine and tourism to benefit Barbados. He stresses that the fusion is important, not only for tourism, but also for the medical profession and for the development of Barbados. At a recent conference Sealy explained his logic; “We have to see this fusion as providing some exciting opportunities and not purely as an economic argument. It is not just a case of earning foreign exchange because in broadening your horizon, staying on the cutting edge and offering your services to a wider pool of persons, you are taking it to the ultimate extreme in terms of being a better practitioner by having a larger pool. So it is not just good for tourism, it is good for medicine, and it is being a good doctor. It is good for the development of Barbados so medical tourism is extremely important as having significant spin-offs.” He added, “We have not properly analysed the extent to which the Queen Elizabeth Hospital as a regional centre, has been doing medical tourism over the years. As several departments in the QEH have catered to people from other countries in the region, that is a tourism product. Tourism is any money earned outside of the jurisdiction being spent within the jurisdiction, and if you follow that simplistic definition, we have had medical tourism in Barbados for years.” Sealy then explained what the government planned; “We need to see how we can properly develop the fusion between medicine and tourism in a more structured way given the fertile ground we have already. If we are going to see ourselves offering our medical services to the world, we will have to be at the cutting edge. Telemedicine offers new scope for medical tourism and provides professionals with the capacity to offer those services to people abroad.”

Accelerating numbers of Chinese visitors to the islands of Hawaii represent a refreshed and unprecedented opportunity for health tourism. A few years ago, on contract with the Hawaii Tourism Authority, consultants Global Advisory Services worked with the healthcare and hospitality industries and developed a business plan: "Healing in Paradise: A Strategy for Cultivating Health and Wellness Tourism in Hawaii." The consensus was that success depends on gaining an intimate understanding of the unique intentions of visitors. The economic crisis saw tourist numbers fall so it was all forgotten about. Previous attempts at formal medical tourism on Oahu were unsuccessful. They focused on modern medicine and executive wellness, targeting visitors from Japan. Hawaii is too expensive to compete with Thailand, Malaysia and India for discounted modern services such as dental implants, cosmetic surgery or elective joint replacements. Hawaii also has difficulty competing with world-renowned brands on the mainland such as Mayo Clinic or Cleveland Clinic for rare or complicated conditions. The islands are seeing a revival in tourism, led by well off Chinese visitors seeking to enjoy the sun and surf. Whether they can be persuaded to buy healthcare is an open question. A better possibility may be health and wellness offerings from up market spas and similar modern health offerings.

The official support plan to boost Polish medical tourism is reported to have been a great success, and efforts will be increased in 2014. The programme of transforming medical tourism into one of Poland’s export specialties was first implemented by the Ministry of Economy in March 2012. By the end of 2013 the three-year project reached its halfway mark. The first half focused on creating marketing and promotional materials rather than visits abroad. This was accompanied by adverts in the foreign press and visits of potential business partners and journalists to Poland. 2014 will be quite different with more inbound and outbound trips. Over 40 clinics and hospitals will participate in fairs and trade missions in seven target countries- Germany, Russia, Scandinavian countries, UK and USA- as well as trade fairs in Dubai. Trade missions organized for 2014 in Germany, UK, Denmark, Sweden and Norway provide for meetings with the companies from that country interested in establishing business relations with the Polish medical tourism industry. 2014 will also see adverts in trade publications of those seven target countries, promoting Poland as an excellent place for treatment, rehabilitation and rest. In 2014 Poland will also fund visits of foreign guests, interested in Poland’s medical facilities. A group of journalists from the seven countries will visit Poland in May. All this has been arranged by the European Center for Enterprise.

Official South Korean tourist organization KTO expects medical tourist numbers to reach 598,000 in 2015 and 998,000 in 2020.With such a surge in numbers, the revenue from medical tourism is expected to jump to 3.5 trillion won in 2020 from 1.01 trillion won in 2013. The KTO expects the amount of average per capita spending in Korea by medical tourists to grow from 2.53 million won in 2013 to 3.56 million won in 2020. It predicts that the number of medical tourists from foreign countries could reach about 1 million and generate revenue of 3.5 trillion won (US$3.2 billion) by 2020. Since the country launched a promotional campaign to promote medical tourism in 2009, the number of people visiting Korea for treatment has increased by 38.4 % annually. The number of hospitals and clinics involved in the industry has grown to 3800 this year. In 2012 159,000 people from 188 countries visited Korea for medical treatment. The Korea Tourism Organization claims that this rose to 399,000 in 2013 and will reach 998,000 in 2020. While there is general agreement that medical tourism is growing, not everybody believes the KTO figures as if true they would mean a huge increase from 2012 to 2013 of an additional 140%. Soon after the KTO figures had spread globally, the Health Ministry said that just over 200,000 foreigners visited Korea for medical treatment in 2013, but it will take a while for exact numbers to be known. That the KTO managed to announce the 2013 figures two months before the end of 2013, speaks for itself. The key reason for the increasing numbers and bullish predictions is the growing popularity of Korea’s medical services in foreign countries, particularly China. The China Daily reported that 62% of 31,000 Chinese people who went in South Korea on 15-day medical tourism visas in 2012 had cosmetic surgery. South Korea saw its surplus in its health tourism account top US$100 million in 2013, largely thanks to increased spending by overseas travellers seeking healthcare and medical services in the country. According to data compiled by the Bank of Korea, the country’s income from medical tourism reached $187 million in the first 11 months of 2013, up 35.3 % from $138 million a year earlier, marking the biggest tally since the central bank began to keep related data in 2006.The income outpaced local residents’ overseas spending on medical travel, which amounted to $86.4 million during the same period, down 11.2 % from a year earlier. So the country logged a surplus of $101 million in health tourism in the January-November period, compared with a surplus of $41 million a year earlier. South Korea’s medical travel income came in at $59 million in 2006 but has increased steadily on the back of the advancement of medical technology and regional governments’ efforts to attract overseas patients. The income gained steadily from $69.8 million in 2007 to $89.5 million in 2010. The comparable figures for 2011 and 2012 were $131 million and $149 million. South Korean residents’ overseas expenditures on health-related services reached a peak in 2007 at $137 million and then fell to $96 million in 2009 before rebounding to $109 million in 2010.They spent $78.5 million and $105 million, respectively, in 2011 and 2012. The country logged its first surplus in medical tourism in 2011 at $52.2 million. In 2012, the surplus fell to $43.8 million. 2014 saw a head of state go to South Korea for medical treatment. Armenian president Serzh Sargsyan had rejuvenation treatment at Chaum Center in Gangnam. Chaum has drawn many rich people from around the world who go to Seoul in their private jets. Among them have been Chinese and Canadian business tycoons, the prime minister of Kazakhstan and Saudi and UAE royalty.

Europeans have a low awareness of the right to cross-border medical care while the gap is widening on health provision between richer and poorer EU countries. The Euro Health Consumer Index 2013 is the seventh study made on European healthcare systems. The report from Health Consumer Powerhouse takes a consumer and patient perspective. Across Europe there is still very low awareness of the right to search for medical options outside of people’s own country. Not even among the better-informed populations of Western Europe the mobility right is common knowledge. In large parts of the EU it is hard to find any patient advocate – and few patients – aware of this important opportunity. Since EHCI started measuring outcomes, the average performance level of national healthcare has risen significantly. General improvement is evident, in the shadow of austerity. Even under financial restrictions treatment outcomes keep improving and generally, the range and reach of the healthcare systems is kept up. There is a growing awareness of the need for prevention. Long waiting for appointments seems to be a cultural phenomenon in some countries rather than a financial one, a pattern that is hard to change. In the UK the NHS urgently needs further reform if it is to match the services offered by Western Europe’s leading health systems. Both English and Scottish healthcare provision lags behind the performance of most Western European countries. The financial crisis has led to increasing inequity in healthcare services across Europe. The results show that there is now a two-speed delivery of healthcare, depending on the consumers’ country. The quality of care that consumers can expect is discernibly higher in richer countries than in poorer. In addition, the gap is widening. Arne Bjornberg of Health Consumer Powerhouse says: “Healthcare decision makers are concerned by the impact of the economic crisis. Our 2013 ranking indicates that wealthier countries are clustered towards the top of the Index, and this is more marked than in previous years.” There are also concerns for healthcare companies and patients over access to new therapies and treatments. Financial restraints have encouraged growing numbers of countries to increase the delay between the approval of new medicines and therapies and their gaining reimbursement. Because newer treatments are often more expensive, slowing their introduction is a way of containing costs. For the first time since the first EHCI was launched in 2005, there is now a clear gap in healthcare provision between the affluent, financially strong parts of Europe and the less affluent, crisis-struck countries. Although treatment results such as cancer and infant survival keep improving all over Europe, there are almost no medium-income countries in the top half of the Index in 2013. The researchers assessed and rated health care systems in 35 countries. Netherlands scores 870 points of the maximum of 1,000, surpassing Switzerland (851), Iceland (818), Denmark (815), and Norway (813). Serbia, Romania, Latvia, and Poland scored lowest. The study praises the Dutch system, partly because of the high number of independent insurers and health care providers that compete for the patient. The high patient involvement and limited political interference characterizes the Dutch system.

A long waiting time to get treatment from state or private healthcare at home is a key reason why people become medical tourists. A new report shows that waiting times are growing across Europe and elsewhere. "Measuring and Comparing Health Care Waiting Times in OECD Countries" is a new OECD report by Valerie Moran, Luigi Siciliani and Michael Borowitz. Waiting times for elective (non-emergency) treatments are a key health policy concern in several OECD countries. This study describes common measures on waiting times across OECD countries from administrative data. It focuses on common elective procedures, like hip and knee replacement, and cataract surgery, where waiting times are notoriously long. It provides comparative data on waiting times across twelve OECD countries and presents trends in waiting times in the last decade. Waiting times appear to be low in the Netherlands and Denmark. In the last decade the United Kingdom (in particular England), Finland and the Netherlands have witnessed large reductions in waiting times which can be attributed to a range of policy initiatives, including higher spending, waiting-times target schemes, and incentive mechanisms which reward higher levels of activity. The negative trend in these countries has halted in recent years and in some cases reverted. The analysis also emphasizes systematic differences across different waiting-time measures, in particular between the distributions of waiting times of patients treated versus the one of patients on the list.

Hungarian dentists who target foreign patients have so far received 12.4 million Euros in European Union and state funding available under a scheme that supports the development of dental tourism in Hungary. The targeted funding from the National Development Agency’s Economic Development Operative Programme and the Central Hungary Operative Programme has so far supported 136 dental practices, and up to 20 requests are pending. The Central Hungary Operative Programme is co-funded by The European Regional Development Fund. In 2013, dental clinics participating in the government’s Dental Tourism Development programme reported an overall increase of more than 19% in turnover. Many of the clinics are in Budapest. The opposition party Democratic Coalition has attacked the dental tourism development programme’s funding process as unfair. It claims that access to grants is only given to those enterprises which pay HUF 1.5 million in annual membership fees to Orvosi Turizmus Iroda Zrt, a private company run by Laszlo Szűcs and Bela Batorfi. Some leading clinics have refused to take part due to this restriction. Being a registered member of the Hungarian Dental Tourism Development Programme is a condition for any application for innovation funds – as this is the only way national targets can be achieved due to their complexity. The programme aims to triple the number of patients visiting Hungary in five years, to stop the exodus of Hungarian dentists, and to make Hungary the worldwide leader of dental tourism by the end of 2015.

Residents of the northern Greek city of Xanthi are increasingly crossing the border into Bulgaria in search of cheap dental services. The average price for dental fillings in Bulgaria ranges between 15 and 20 Euros. Most Greeks are patients without covered health insurance. Greek dental tourism is so popular that clinics in Petrich have already started writing their working hours in both Bulgarian and Greek. It is mainly working class Greeks who go there; some of them also speak Bulgarian. Bulgaria is a preferred destination due to the low-cost, high-quality dental care for British citizens as well.

New figures show that while Australia may have a smaller inbound than outbound medical tourism industry, inbound medical tourism is often driven by better off tourists, while outbound is driven by less well off people seeking to save money, mostly on dental and cosmetic surgery. More than 10,000 medical tourists flew into Australia in 2012/2013 for procedures, pumping more than $26 million into the national economy, new figures show. While an increasing number of Australians are travelling to Asian countries such as Thailand and Singapore for cheap care, Australian doctors and hospital chiefs say a small but increasing number of wealthy people from the Asia-Pacific region are going to Australia for treatments such as orthopedic and heart surgery, cancer services and IVF. Data from Tourism Research Australia, the federal government’s agency in charge of tracking trends, shows 10,739 people went to Australia for medical reasons in the year to September 2013 - double the number in 2006. The data, which models information from surveys of 40,000 people in Australian airports each year, found medical tourists spent about $26 million in 2013, up from $12.7 million in 2006. This figure did not include their airfares and packages they had already purchased. While there is no precise data on who is coming to Australia and why, from the government survey, there is local evidence. Epworth Group hospitals care for 600 international patients a year from 31 countries, including the Pacific Rim, USA, New Zealand, Singapore and Indonesia. This includes medical tourists and people who fall unexpectedly ill while visiting Australia. The Monash IVF centre gets 50 medical tourists a year paying a premium price for reproductive treatment. A 2010 Victorian government report on export opportunities recommended that Victorian hospitals set up assistance centres in Indonesian cities to guide people wanting to travel to Australia for medical treatment. The report suggested that the service would include transportation, medical referrals and appointments, hotel accommodation, assistance before, during and after hospitalisation, and customer service assistance for billing and financial inquiries. Neither hospitals nor government have followed up on the recommendation. Government in the state of Victoria is working on a strategy to increase health and medical exports including medical tourism. Weight-loss surgery, robotic surgery, orthopedic surgery and IVF are key areas under consideration. One opportunity under discussion is Melbourne’s Parkville Precinct that by late 2015 will include a new major cancer centre. The federal and state governments in a public-private partnership fund the Peter MacCallum Cancer Centre. One proposal under consideration is to include 50 private beds on a separate private floor and to use medical tourism to help generate revenue for public services. The argument is that as long as international and privately insured Australian patients do not cut into the provision of healthcare for public patients in the hospital, it could generate income to boost public services the way overseas students have done for the education sector. Some local politicians and doctors are against having any private patients there. An increase in inbound medical tourism would require hospitals and government to work together. At present medical tourists are being treated on an ad hoc basis at public hospitals without proper co-ordination. There is a recognition that it needs to get better organised to make it simpler for people to come in on short-term visas and to pay the money, and link in with local hotels.

In recent years, Wellness Tourism Worldwide, has been forecasting wellness travel trends. Camille Hoheb of Wellness Tourism Worldwide argues that there are many revenue-generating opportunities in wellness tourism, but success depends on delivering services in the right niche. Among the top wellness trends predicted for 2014 are: • Matters of the mind Consumers are increasingly interested in vacations that offer mental restoration such as yoga and meditation. • A growing niche for wellness travel agents Given the growing interest and demand for holistic vacations that promote health and well being, there is an increasing demand for wellness travel agents. • Living the local life There is a deeper appreciation by consumers for the indigenous culture and lifestyle of the host destination. Getting to know the locals in a meaningful way improves the traveller’s experience. •The fusion of food and wellness tourism Destinations have capitalized on the goodwill of their exotic cuisine by fusing culinary tourism with wellness tourism in a package. This is a fast rising niche as food and drink tourism is increasingly popular and generates much revenue. • Holidays offering relief from stress Holidays are a way of dealing with the stress of modern life. This is also linked to dealing with problems of obesity and the nagging physical ailments of an ageing society. • The desire for personal enrichment Personal well-being is a more holistic concept than just adhering to healthy food and regular exercise. So, weekend getaways, vacations and retreats all contribute to personal enrichment. • A slower pace of travel Advocates of “slow travel” encourage travellers to reduce the pressure of checking off the sites to see and things to do • The growth of the affluent and altruistic traveller Many better off travellers, who have been enlightened by personal discovery and valuable life experiences, tend to contribute more altruistically to charities and local communities. Combining a holiday with volunteering is becoming more popular. • Secondary wellness Many people may not travel for wellness, but when they are at a hotel may spend money on spas and other wellness facilities at the hotel, or even choose a hotel because it has these options. • Spas in pursuit of wellness tourism Spas are rebranding and repackaging their offering to attract a bigger share of the wellness market

The Costa del Sol is promoting health tourism to encourage people to go to the area for treatment in private clinics, of which the province has plenty. The target is to bring in 40,000 health tourists by 2017. The Costa del Sol Tourism Board is working with the national ministries of health and ministry of foreign affairs to create a health visa. Spaincares is the marketing brand that is the result of health and tourism ministries joining together at national level to collaborate and attract health tourists. The Tourism & Health Spain group has been set up and membership includes several clinics in Malaga province, as well as spas, hotels, travel agencies and other companies in related sectors. The aim is to promote the Costa del Sol as an ideal area for health, as well as beating seasonality by attracting visitors all year round. Although some medical tourism is expected, the bulk of the business is the spa and health and wellness business that ties in easily with existing tourism. The biggest target market is the UK, as British tourists account for 24% of the 60 million Spanish tourists every year, as well as there being 250,000 expatriates living there. The other key markets are also the main sources of Spanish tourism-Germany, France, the Netherlands and Scandinavia, countries that already know the Costa del Sol. Costa del Sol is competing with Madrid, Barcelona, Pamplona and the Balearic Islands as a key destination for health tourists. The region has excellent connections by rail and air. Health tourists are expected to spend more than those that just go to Spain on holiday.

The SFU Medical Tourism Research Group in Canada has released details of a study on medical tourism in Chennai, India; ’ An Overview of the Medical Tourism Industry in Chennai, India’. Chennai, once known as Madras, is the largest city in the southern region of India and the capital of Tamil Nadu state At the Apollo Specialty Hospital, orthopaedic patients come from the US, Canada, Australia, Italy and the Middle East. They get 100 medical tourists a year for orthopaedic procedures. International and local patients pay the same fees, although locals are less likely to utilize the more costly deluxe and platinum wards. Billroth Hospitals has been actively marketing its services to medical tourists for six years and has seen a growth in medical tourism patients. The majority of its international patients are from the Middle East, Nigeria, Tanzania, and Oman. 50 to 60 foreign patients attend the hospital each year, primarily for cardiology and oncology services. Frontier Lifeline Hospital is very active, with 50% of their patients being medical tourists. The hospital specializes in pediatrics. Iraq is the main source of medical tourists. They also get many patients from Oman and other Middle Eastern countries, as well as Africa (particularly Nigeria), Bangladesh, and Sri Lanka, many of who are non-resident Indians. Global Health City actively recruits foreign patients by sending doctors to work in medical camps in source countries. From these visits they receive get 200 queries a month, many relating to pediatric surgeries and transplantations. They receive the majority of their patients from Iraq, along with East Africa, the Middle East, Sri Lanka, Bangladesh, Pakistan, and Nepal. While costs for medical tourists are slightly higher than for locals, 30 to 40% of their patients are international and the numbers are increasing. Chennai has been particularly effective at increasing its medical tourism industry. Some claim it has 40% of all medical tourists in India, with 200 international patients each day. Half of all patients receiving treatment in Chennai come from outside of the state of Tamil Nadu. The main countries of origin are Nigeria, Kenya, Burundi, Congo, Bangladesh, Oman, and Iraq; with others from Sri Lanka, Myanmar, Tanzania, Oman, and Iraq. Chennai has done deals with foreign countries including Tanzania, Uganda, and Kenya, so their citizens are sent to Chennai on government-sponsored medical tourism. Tourism is important to Chennai, and medical tourism includes substantial numbers from other parts of India.

Phase two of Dubai Healthcare City (DHCC) will add destinations for medical tourism as well as spa resorts, sports medicine facilities, waterfront residences and nutrition centres all aimed at health and wellness tourists. Phase one has two hospitals and also offers orthopedics, dentistry, ophthalmology, diabetes management and cosmetic surgery. It now has more than 90 specialties and 4000 licensed health professionals with 17 complementary and alternative medicine providers. DHCC has appointed two specialist medical travel businesses to promote the city. They will connect patients to doctors and arrange for their travel, accommodation and transportation requirements from pre to post-treatment. Salamatak Healthcare Management was appointed at the end of 2013 and Meditour will open soon.

Barbados is seeking to develop medical tourism and hopes that the opening of a new laser eye clinic can help. The Lion’s Eye Care Centre is equipped with ultra-modern state-of-the-art ophthalmology equipment and will open soon. At first it will just have one operating theatre, but there are plans to open the other two by 2015. The aim is to target not just Barbados, but other islands as few other islands have modern laser eye clinics. The clinic is part of the state owned Queen Elizabeth Hospital.

Florida state senator Aaron Bean wants to bring more medical tourists to Florida through an advertising campaign that requires at least $3.5 million in state spending a year for four years. Bean has proposed SB 1150, a medical tourism bill that would force the local development agency Enterprise Florida to market the state as a health care destination with substantial spending on marketing and advertising for the next four years. In 2013, Florida had 92 million visitors from overseas and other US states, with 100 million expected for 2014. Bean’s logic is that medical tourists spend more money than regular tourists. So the bill aims to be a vehicle for local hospitals, clinics and hotels to ask to be included in a state sponsored promotion. Attempts to attract medical tourists to Florida have been rather hit and miss with as many failures as successes. The Greater Miami Convention and Tourism Bureau has partnered successfully with seven hospitals and has attracted patients from South and Central America, as well as other US states. One failure was when a group of Sarasota hospitals targeted Canadians seeking hip and knee surgery. Although a website still exists, the hospitals admit that it has attracted few patients, cannot justify spending any more money promoting the idea, and probably cost ten times the actual revenue it generated. Bean’s bill also calls for matching grants to local economic development groups, which would coordinate businesses to respond to medical tourists’ needs. But opponents argue that the money should come from hospitals and clinics, not the state or local tourism budgets. South Lake Hospital in Clermont has partnered with urology centre PUR Clinic, to attract international medical tourists. Numbers so far are small at 20 a month. But it has had patients from Australia, Belgium, Cyprus, Norway, and East Africa for this highly-specialized urology treatment Whether the cost of promoting a hospital or region can be recovered in extra revenue is the debate that will determine the success or failure of Bean’s medical tourism bill. But it might sneak though on the basis that in a state getting 100 million visitors, even a few thousand medical tourists is hardly more than a drop in the Atlantic Ocean.

The Nigerian government and the national medical association have joined forces on in a direct attack on outbound medical tourism. The Nigerian Medical Association (NMA) has applauded the new National Health Act, as it will help to substantially reverse the trend of frequent and sometimes unnecessary foreign medical trips, and could even make Nigeria a destination for medical tourism. The new law has provisions that directly tackle outbound medical tourism and the resultant negative impact for Nigeria with substantial sums flowing out of the country. It seeks to stop the use of tax payers’ money where politicians, government officials and their families go free on foreign medical trips, for medical conditions that can effectively be treated in Nigeria. Dr Osahon Enabulele of NMA explains, “Lots of Nigerians, including top political office holders travel frequently to other countries in search of medical care even for medical conditions that can be satisfactorily managed in Nigeria. Available evidence suggests that over 5,000 Nigerians visit India and other countries every month for medical tourism with lots of these Nigerians faced with various risks and challenges including misdiagnosis, legal and ethical issues, exposure to infectious diseases, as well as other complications, particularly post-surgical complications. On average, over $800 million dollars is lost annually by Nigeria on account of foreign medical trips.” The new law provides a minimum package of basic healthcare services (including the provision of free medical care for children under 5 years of age, pregnant mothers, the elderly and people with disabilities), as well as improved funding for primary health care through the setting up of a National Primary Healthcare Development Fund to be mostly funded by national taxes. The aim is to offer Nigerians greatly improved access to quality healthcare services, so that deaths amongst Nigerians, particularly the rural poor, as a result of inability to pay for healthcare services (including medical care for emergencies) are drastically reduced. The new federal minister of health, Dr Khaliru Alhassan is an opponent of medical tourism and seeks to get the Federal Ministry of Health to improve healthcare in the country: “There has been a lot of accusing fingers towards us that federal politicians are responsible for medical tourism. The Federal Government of Nigeria is losing billions of dollars because of us; a lot of people are looking at us that we are responsible for people going out of the country. I have a lot of work to do to change this perception.” Although politicians have attacked medical tourism in recent years, many were at the same time benefiting from free state paid medical care outside of Nigeria. The difference now is that those wanting change have a new law and renewed vigour to tackle the problem, which will be good news for many Nigerians but bad news for a struggling Indian medical tourism sector. The federal government now has a clear mandate to ensure that Nigerians are healthy by working with the states, local government and the private sector to deliver the promise of transforming Nigeria’s healthcare as laid down by the National Health Development Strategic Plan; and the cabinet has warned national and local politicians that it will come down heavily on anybody causing problems by setting one ministry against another, or otherwise allowing local politics to delay the national plan.

As Malta’s tourism industry recovers from recent woes, the government plans to promote niche tourism areas. One of these is medical and health tourism, where previous campaigns failed due to lack of co-ordination and lack of focus. The biggest reason for previous failures was that the government made encouraging noises but was reluctant to spend money or energy in positive help for local businesses. Malta could attract a considerable amount of medical tourism ­ but not without government help, according to a German surgeon who has set up practice in Malta. Ulrik Rebers and his wife Xenia Lorenz Rebers have opened the International Knee and Hip Centre – Malta at the Prince of Wales complex in Sliema, offering knee and hip replacements at Saint James Hospital. The surgeon has operated in Malta on thousands of people in recent years, but almost all of these have been residents of Malta, local and foreign, rather than people who went to Malta for treatment. He argues that it is now a good time to target other EU countries, “I was involved in marketing medical tourism from the Netherlands to our former base north of Dusseldorf but Malta is not branded overseas for medical tourism. If we tried it alone it would take four to five years to even get a foothold. To be effective it needs a coordinated thrust by the government Rebers’ latest centre opened a few weeks ago, and uses computers to create 3D images to ensure the most accurate surgery available, aligning the new joint across various axes such as left and right, leg-length and rotation. He explains, “Research showed that almost a third of replacements did not achieve alignment for length and right/left tilt. And even a tiny difference can cause problems for life.” He uses new Swiss-made titanium and ceramic implants, and custom-made joints are also available to ensure as perfect a match with the original joint as possible. One of problems of medical tourism is that most patients want the work done in one trip, but historically this type of surgery often requires several trips. With the latest materials and computer input, it can all be done within two weeks. -with a consultation two days prior to the operation, five days as an inpatient, and seven in a hotel recuperating under the scrutiny of the centre. The surgeon sees the key target market as the UK and the Netherlands, not because it saves money, as such operations are free in both countries, but because both have long and lengthening waiting lists. The third market is Russia as it is cheaper to have the work done in Malta than at home. He argues that while Malta may be more expensive than Asia, Europeans feel more comfortable in a European jurisdiction. And it is a tourist destination that many British, Dutch and Russian visitors are already familiar that has good flight connections with no more than a few hours’ flight.

A new global advertising campaign called “Thailand Extreme Makeover” from the Tourism Authority of Thailand aims to attract medical tourists via the internet. The campaign is part of the government’s aim to promote Thailand as the leading medical tourism country in Asia, particularly after recent political turmoil meant fewer travellers went to the country than had been hoped. Thailand Extreme Makeover accepts online applications and three people will win a trip to Thailand to get beauty treatment and travel around the country. Winners have to agree to be filmed and have video clips of all activities uploaded to social media in a follow up campaign called “Happiness You Can Share”. For the campaign the key target region is the Middle East, followed by Asia and then Europe. The contest is a form of reality TV where selected contestants undergo makeovers including various cosmetic surgery procedures. There is a $5,000 cash prize too. Thawatchai Aranyik of TAT explains, “The campaign is a reality competition that will not only create awareness about Thailand as a destination for medical tourism and the excellence of our medical facilities, but also promote the kingdom as a travel destination with something for everyone. Thailand already has a great reputation for its excellence in medical care and people come here for operations of all kinds.” Potential candidates send photos showing their face from all angles – straight on; at the left and right profile; from the back and from above. Candidates also need to include their personal health profile and reasons for wanting a makeover. The judging committee, made up of medical experts and beauty surgeons, will then select three candidates who will be invited to Thailand for their life – and face-changing trip. During their stay in Thailand, each of the contestants will be videoed and clips uploaded to the special Thailand Extreme Makeover website. This will allow their friends and relatives to watch and follow the progress of the makeover as well as allow members of the public to vote for their favourite contestants. In the end, the contestant with the highest number of votes will win the cash prize and a luxury tour in Thailand. The two runners-up will also be treated to their own luxury tour packages.The audience who follows their progress and votes for their favourites also get the chance to win various beauty rewards and prizes.

2013 saw an increase in medical tourism to the Czech Republic, almost all from Europe. Although exact numbers are not known, most clinics report a substantial increase in business. Most customers come from Germany, Russia, Austria and the UK. The main treatment is cosmetic surgery. Breast augmentation accounts for half the business, the rest being liposuction, abdominal work and eye surgery. Also popular is a range of fertility treatment, with customers mostly from Germany. Local clinics estimate that 2013 saw 4,000 to 5,000 fertility treatment customers. The popularity of IVF treatment is that laws in the country are less strict than other EU countries, but strict enough to ensure more protection for customers than they have in Asia. Although fertility centres, cosmetic surgeons and dentists all offer lower prices than many EU countries, they use the same quality of materials, are trained to the same standards, and offer surgeries of equal quality. There is nothing that the medical tourist cannot get at home, so the low price of treatment, accommodation and travel are the key factors. Whether medical tourism purely based on price is sustainable in the long run depends very much on what happens in the countries where medical tourists come from. In the UK, with several price and treatment comparison sites starting to drive down local prices for dental care and cosmetic surgery, the potential savings from going to Europe may vanish. But as yet the same is not true for fertility treatment. At present comparison sites have not gained enough foothold in Europe to affect local markets, so with local prices stable or increasing, the Czech Republic can expect more business from Austria, Germany and Russia in 2014. For the German and Austrian markets the country has an added bonus that parts of the country are German speaking as they used to be part of Germany. This attracts medical, health and wellness tourists. Franzensbad, which for most of its life was German rather than Czech, has been a spa town for six centuries. The resort has expanded significantly to create a successful, bioclimatic spa. The carbonated water and hot mud are still available as appealing cures and sources of pain relief but now the spa offers even more specialized treatments to keep up with the demands of visitors. In addition to the anti-inflammatory mud baths and drinking cures, Franzensbad now offers to treat everything from cardiovascular and digestive issues to musculoskeletal conditions and skin diseases via therapies including dry, volcanic carbon dioxide baths, electrotherapy, reflexology and oxygen therapy. Franzensbad is two hours from Prague and offers numerous experimental treatments, twenty-six springs and many therapies. The waters, which reach an average temperature of 52 degrees, have been used for their healing properties for centuries as an aid for circulation, cardiovascular health, rheumatics and inflammation. Franzensbad is typical of a historic spa town that has been expanded and restored to attract domestic and international health tourists. As well as the development of the Aqua Forum water center, there are new areas for cycling and hiking and a restored four-star Imperial Spa hotel.

Total health spending has fallen in one in three OECD countries between 2009 and 2011, with those hardest hit by the financial crisis most affected. This is a sharp reversal from the strong growth in the years prior to the crisis. This makes it all the more important that countries make their healthcare systems more productive, efficient and affordable, says the OECD. The seventh edition of Health at a Glance provides the latest comparable data on different aspects of the performance of health systems in OECD countries. It provides striking evidence of large variations across countries in the costs, activities and results of health systems. Key indicators provide information on health status, the determinants of health, health care activities and health expenditure and financing in OECD countries. Each indicator is presented in a user-friendly format, consisting of charts illustrating variations across countries and over time, brief descriptive analyses highlighting the major findings conveyed by the data, and a methodological box on the definition of the indicator and any limitations in data comparability. This publication takes as its main basis OECD Health Statistics 2013, the most comprehensive set of statistics and indicators for comparing health systems across the 34 OECD member countries. Spending per capita fell in 11 of 33 OECD countries between 2009 and 2011, notably by 11.1% in Greece and 6.6% in Ireland. Growth also slowed significantly in others, including Canada (0.8%) and the United States (1.3%). Only Israel and Japan saw the rate of health spending growth accelerate since 2009 compared with the previous decade. Health spending in Korea has continued to grow at more than 6% per year since 2009 but more slowly than in previous years. Governments have worked to lower spending through cutting prices of medical goods, especially pharmaceuticals, and by budget restrictions and wage cuts in hospitals. More than three-quarters of OECD countries reported a cut in real-term spending on prevention programmes in 2011 over 2010, and half spent less than in 2008. Cuts to spending on cost-effective prevention programmes on obesity, harmful use of alcohol and smoking are a cause for concern. Any short-term benefits to budgets are likely to be greatly outweighed by the long-term impact on health and spending. Reductions in the supply of health services and changes in their financing through increases in direct out-of-pocket payments for patients are also affecting access to care. After years of improvement, waiting times for some operations in Portugal, Spain, England and Ireland show some increase. Across the OECD, low-income groups are worst affected and may be foregoing needed care such as medicines or check-ups for chronic conditions. This may have long-term health and economic consequences on the most vulnerable in society. For the first time, average life expectancy exceeded 80 years across OECD countries in 2011, an increase of ten years since 1970. This trend shows no sign of slowing down. Those born in Switzerland, Japan and Italy can expect to live the longest among OECD countries. Chronic diseases such as diabetes and dementia are increasingly prevalent. In 2011, close to 7% of 20-79 year-olds in OECD countries, or over 85 million people, had diabetes. This number is likely to increase in the years ahead, given the high and often growing rates of obesity across the developed world. The burden of out-of-pocket spending creates barriers to health care access in some countries. On average in the OECD, 20% of health spending is paid directly by patients; this ranges from less than 10% in the Netherlands and France to over 35% in Chile, Korea and Mexico.

Medical travel to and between Gulf countries is a topical subject and some local doctors are trying to move the debate to practical matters. Multiple factors play a role in the continuity of care in the GCC such as the location of the hospital, the availability of virtual consultation and follow up, as well as factors related to the patient’s age, medical condition and possibility for travel. All of these factors dictate the current climate for medical travel, and medical facilities and health authorities need to address these issues in order to facilitate medical tourism across GCC borders. Dr Bariah Dardari of Al Zahra Hospital, Dubai offers insight into the solutions and obstacles, "The continuity of care across GCC is available currently on a small scale, especially for patients seeking medical attention and travelling between Saudi Arabia and the UAE, or Oman and the UAE. However, more can be done to encourage patients to use the proximity of the GCC countries for their continuous medical care." Dr Dardari believes that any difficulty in the efficiency in the flow of crucial information and the continuity of care in a cross-border setting must be overcome, in order to further facilitate the process of medical travel, "I believe one can overcome any deficiency in continuity of care across borders by establishing a system that includes pre-and post-consultation communication. This can be attained via e mail, Skype or telephone. The risk of data misuse is minimal if certain patient privacy rules are established, for instance, test results should only be given directly to the patient via a secure email." The main reason why parents sent their children abroad for treatment in the past was because centres in the UAE providing pediatric healthcare facilities were non-existent. In the past decade the UAE has made progress in areas such as neonatal medicine, pediatric orthopedic, and pediatric neurodevelopment. The opening of pediatric hospitals in the future, such as Al Jalila, will allow the much needed pediatric medical attention within the UAE instead of the need to find it abroad, and perhaps even encourage medical travel to the UAE.

In an attempt, partly to react to the problems of medical tourists, but mostly to stem the low tourism numbers for 2013, India’s government has extended the country’s limited visa-on-arrival scheme to tourists from 180 countries. The new scheme, which the government plans to implement by October, would allow foreigners traveling to India from approved countries to apply for a visa online and pick it up upon arrival at 26 of the country’s airports. The current system, which has tourists in all but 11 countries wait several weeks after submitting visa applications to learn whether they have been approved, has long been seen as a major deterrent for potential visitors to the country. Internal resistance by various governmental ministries, most notably the Home Ministry (which has had objections to the issuing of visas to Chinese citizens in particular, due to a border dispute between India and China) has made progress on the initiative slow. But the currently dismal state of India’s tourism industry, which accounted for 6.6% of the country’s GDP in 2012, has proven to be a powerful motivator. Travellers’ concerns over security, especially in the wake of several high-profile attacks against women, are widely credited for the hit the industry has taken. While it is sure to provide a short-term boost, the government’s goal of drawing 12.6 million international tourists by 2016 looks far-fetched as the underlying problems deterring travelers remain. The Indian government has allowed free medical visas for Maldivian nationals for 90 days. The restriction on 60-days’ gap between two entries has also been lifted. It is also agreed that medical visa holders will be no longer required to report to the Foreign Regional Registration Office (FRRO) if their visa is for less than 180 days. Medical visas last for a year, or the period of treatment, whichever is less. They allow up to 3 trips to India in one year. As well as the patient, they cover up to 2 accompanying relatives. India’s Ministry of Tourism has extended the Marketing Development Assistance (MDA) Scheme to include medical tourism. Under the scheme the ministry provides financial support to approved medical tourism service providers, subject to availability of funds.

Most medical tourism models take the patient to the hospital, while some take doctors to patients in another country. A Canadian version is to take the doctor and the patient from their home country to a remote island. Two surgeons in Calgary, Alberta, regularly fly to the Turks and Caicos to perform operations on Canadian patients. The service is coordinated by Global MedChoices, a company based in Memphis, Tennessee. The company also offers the service to Americans and has two surgeons from the United States. With just a one-hour flight from Miami, the Turks and Caicos Islands is an English speaking British protectorate that is part of the British West Indies in the Caribbean. The two main hospitals on the Turks and Caicos are run by Canadian group InterHealth, and the one used was built in 2010 and has Accreditation Canada International status. According to Global MedChoice, this is a niche market. The limited numbers and Canadian connection means that can be confident they are receiving high-quality care from an experienced surgeon from their own country. So the common medical tourism worries about the competency of a foreign doctor and the conditions of an overseas hospital, both vanish. Having a Canadian surgeon also helps with post-operative care after the return to Canada. The Calgary physicians who operate in Turks and Caicos sometimes perform on their own patients, and can therefore provide follow-up care themselves when back in Alberta. The Canadian surgeons and their patients benefit by jumping local waiting lists. And for the surgeons, having a few days break from a Canadian winter in a warm and sunny place (350 days of sun a year) with great beaches and diving is hardly a hardship. Most Global MedChoices clients are Canadian or American. In the 18 months that Global MedChoices has been operating, it has provided more than 50 procedures and has reported no complications. It is not major surgery but the more routine, although often painful knee, hip or shoulder surgery. So the motivation is more on being able to get on with their lives that saving money. While recovering, patients stay at exclusive personal condominiums or hotels that are minutes from the hospital and very close to Grace Bay Beach.

Leading US airline Southwest Airlines has selected 73 US nonprofit hospitals and medical organizations, with 99 locations, for the Southwest Airlines 2014 Medical Transportation Grant Programme. These organizations can offer free roundtrip airline tickets to families who are facing serious illness and need to travel for specialized medical care. Being able to fly for free to receive the best medical treatment available eases the financial burden on families, giving those who are already facing so much one less thing to worry about. In 2014, Southwest will provide more than $2.8 million in free transportation to caregivers and patients seeking medical treatment. Linda Rutherford of Southwest Airlines explains the logic, "Partnering with these hospitals and organizations to provide hope for those dealing with serious illness is an honour for us. It has touched our hearts to be able to connect our flights with the hospitals’ care, and see the amazing difference this unique programme is making to families in our communities." The project began seven years ago, and since then more than 33,000 tickets, totaling $13.2 million in free transportation, have been distributed to organizations in 26 states, making a positive difference in the lives of more than 26,000 patients. One grateful patient is Toby Shaw. Toby battles arthrogryposis, which affects the joints in his arms and wrists. With this free air travel he is able to travel from his home in Ohio to Shriners Hospital for Children in Philadelphia to receive the best treatment available for his condition. Dr. Dan Zlotolow, at Shriners Hospital for Children comments, ”I am grateful our hospital is able to partner with the airline to provide Toby and so many other patients like him the best treatment for their conditions, Together, we are able to offer our patients a long-term treatment plan without worrying about the burden of travel costs." Southwest is the USA’s largest carrier in terms of originating domestic passengers boarded, and including wholly owned subsidiary, AirTran Airways, operates the largest fleet of Boeing aircraft in the world to serve 96 destinations.

A trip to the doctor costs six times more in the UAE than Oman, while a dental visit is four times as much in the UAE than Oman. Health insurance is most expensive in Bahrain due to the sky-high local cost of healthcare. The latest Cost of Living Reports Middle East (CLR) says a mid-level GP visit costs $78.50 on average in the UAE. The second-most expensive country is Qatar at $54 per consultation at an internationally certified hospital, followed by Bahrain and Saudi Arabia ($27) and Kuwait ($26.50). In Oman, a trip to the doctor costs on average only $13. Dental care is also the most expensive in the UAE, at an average $108 for a routine check-up, while the same consultation costs $80 in Bahrain, $71 in Qatar and Kuwait, $41 in Saudi and $26 in Oman. While the UAE is by far the most expensive country for healthcare it does have the biggest range of care in terms of international hospitals and clinics in the Gulf. In a separate report on the UAE, CLR notes that UAE public spending on healthcare had increased to above the world average at about 75 % of total spending in the sector. Over the next three years spending there on the healthcare sector is expected to grow by 16 % annually The CLR’s GCC report finds that in a like-for-like comparison of seven measures, Qatar came out the most expensive overall, followed by the UAE, Saudi, Bahrain, Oman and Kuwait.

Medical tourism is often touted as the cure for Asian countries with economic problems, but new research from Jeremy Snyder’s team at The Simon Fraser University Medical Tourism Research Group suggests this is far from a guaranteed success. The team reports that the East Asian region is a dynamic and evolving destination for medical tourists, home to many of the most visible and well-known hospitals serving medical tourists from across the world. The remarkable success of established East Asian medical tourism providers in marketing their services to international patients has spurred interest among other countries in the region that aim to join these larger players. The enthusiastic embrace of medical tourism by East Asian hospitals and governments is, in theory, well justified. Health services exports could potentially diversify regional economies. Industry promoters say it can increase foreign direct investment into the private health sector, help countries retain their existing health workforce, increase training opportunities for health workers, and ensure that the local health sector has access to the latest technological advances. Taken together, these benefits can provide local populations with the opportunity to access cutting-edge and high-quality health services at home. But medical tourism also creates social and health risks for countries investing in the sector. Investment in medical tourism can drain resources from the public health sector and divert attention away from the less profitable health needs of the local population. High paying jobs in the medical tourism sector can increase the flow of workers from the public to private sector and from rural to urban areas, as has been the case in Thailand and Malaysia. New, high-tech equipment and highly trained health workers will certainly be a boon to wealthy patients within these countries. But there is little reason to think that these services, targeted at privileged locals and foreign patients, will be accessible or relevant to the vast majority of the local population. Medical tourism may actively worsen health inequities in these countries. Increased investment in the private health sector in India has been accompanied with decreased public sector investment and promised public access to private facilities through public-private partnerships have generally not been realized. The promised economic benefits of medical tourism are far from guaranteed. Growth in the sector has come through the lowering of trade barriers in the health services industry. Large regional players in this industry have the power to play governments in the East Asian region off one another, seeking the regulatory and tax environments most favourable to their bottom lines. This competitive environment is favourable to those investing in the medical tourism industry, but it is less clear whether the host countries will experience similar economic benefits if tax concessions and other benefits are not matched by economic returns or if medical tourism developments fail to materialise. Countries considering marketing their private health sector internationally should be cautious and aware that industry stakeholders have an incentive to inflate numbers about the market’s potential and exaggerate the potential benefits of this industry. As East Asia already hosts some of the most developed and high profile destinations for medical tourists, it is unclear if new markets in the region can successfully compete for the limited number of medical tourists, especially those from outside East Asia. If countries do wish to pursue medical tourism development, they should focus on developing the necessary regulatory and healthcare financing conditions domestically that will encourage medical tourism to emerge and prosper. In its worst form, medical tourism is the result of poorly regulated healthcare markets with insufficient domestic healthcare cover. So, medical tourism is primarily a symptom rather than a cause of inequitable health systems. East Asian nations should focus on strengthening hospital quality and safety regulations while extending domestic healthcare cover universally and comprehensively. By focusing on affordability and quality of care, a well-functioning health system oriented to the needs of the local population first and the international market second can develop. Developing the medical tourism sector in a way that provides sustainable social and economic benefits is a difficult task. Countries in East Asia looking to advance or grow their own medical tourism sectors should be cautious, given that it does not offer a sure prescription for providing economic benefits or addressing health sector ills. Focusing on strengthening core health system elements, such as financing and regulation to improve the quality, affordability, and accessibility of health services locally, may encourage international patients to visit while ensuring that the system is fair and accessible for locals.

Another Caribbean island has taken the next step into developing medical tourism. Early in 2014 the governor, Peter Beckingham, announced the British overseas territory’s plans to develop a medical tourism policy as part of wider tourism campaign to extend the types of tourism on offer. The Turks and Caicos Islands consist of 40 islands and cays, eight of which are inhabited. The islands are 550 miles southeast of Miami, Florida, just below the Bahamas chain and just to the east of Cuba and the island of Hispaniola (Dominican Republic and Haiti.) The islands are home to 31,000 full time residents, and welcome more than 200,000 tourists annually. Upmarket tourism is centred on Providenciales. Coral reefs and 200 miles of beaches draw holidaymakers and divers, mostly from the US and Canada. Wealthy retirees are among the more recent settlers. At the other end of the economic scale, migrants come from impoverished Haiti and the Dominican Republic. In turn, thousands of Turks and Caicos citizens take advantage of job prospects in the neighbouring Bahamas. There is a modern hospital system comprising two state-of-the-art medical centres, managed by InterHealth Canada; Cheshire Hall Medical Centre on Providenciales and Cockburn Town Medical Centre on Grand Turk. For major surgery or specialist care, locals go to the Bahamas or Miami. Recently, two surgeons in Calgary, Canada, have occasionally been flying to the Turks and Caicos to perform joint procedures on Canadian patients. The service is coordinated by Global MedChoices, a company based in Memphis, Tennessee. The territory’s cabinet has approved the setting up and membership of a medical tourism steering committee. But it gave it a short deadline of 12 months to develop clear policies for the operation of medical tourism activities in the hospitals in Providenciales and Grand Turk.

Germany reports the treatment of 224,000 foreign patients in 2012. But with over 30 million tourists, how many of these “overseas patients” may have been injured or sick holidaymakers? Jens Juszczak at Bonn-Rhein-Sieg University estimates that 45% of the total (100,000) went to Germany explicitly for treatment. He also suggests that the number reflects a survey of hospitals, plus data from the statistics office and from different ministries. So, the actual number could be an under-reporting of up to 10% due to under registration. Allowing for increased numbers in 2013, this would give current numbers at around 125,000. But the error margin is wide; actual numbers could be anywhere between 100,000 and 150,000. The quoted figures for 2012 were 8.6% higher than 2011, with the biggest growth from Russia and the CIS countries. With an estimated 8,300 inpatients and 12,400 outpatients, Russia is now the largest source market. Where they come from can be skewed by including tourists. For example,. many tourists come from France and the Netherlands. Both countries also provide some medical tourists but the second largest medical tourist market is from the Middle East, particularly the UAE and Saudi Arabia. Juszczak says that Germany gets twice as many patients from the CIS and the Baltic States as from the Middle East, and that the number from the area has grown seven fold over recent years. But the mixing of tourists and medical tourists in the numbers makes it hard to know which countries are the main providers of medical tourists rather than tourists who needed treatment while in Germany. Juszczak says 80-90% of treatment is in public hospitals, typically university hospital centres of excellence. Helios, Asklepios and Mediclin are the most active private health groups. This public sector bias reflects that many patients go to Germany for the sort of complex procedure that only university hospitals can deliver. There may be arguments on actual numbers but there is no doubt that Germany is one of Europe’s leading medical tourism destinations with numbers increasing, particularly from Russia.

More and more foreigners seek paid health care services, mostly cosmetic surgery, surgical treatment of obesity and assisted reproduction, in the Czech Republic. Local health centres attract medical tourists from the UK, Germany, Austria and Russia as local clinics claim to charge half what the customers would pay at home for comparable treatment. Unofficial estimates from clinics put numbers up in 2013 compared to 2012, with the number of foreign clients attending Czech clinics more than doubling in the past few years. František Lambert of ISCARE clinic told local newspaper Pravo, “In 2013, we provided care for over 1.000 clients from Germany, mostly for cosmetic surgery and assisted reproduction, with some obesity surgery." One draw for couples seeking help to have children is that local legislation is less rigorous than other EU countries; allowing anonymous sperm and egg donation. Jaroslav Hulvert of ISCARE estimates that the total for local clinics was 4,000 to 5,000 couples seeking fertility treatment.

ISQua, the global organisation that accredits the accreditors, has awarded four-year accreditation to the regulator of Dubai Healthcare City for patient safety and service quality standards Dubai Healthcare City only accepts hospitals and clinics with certain recognized international accreditations. Early in 2014, the state of Dubai agreed with the other UAE states that this logic would apply to all private clinics and hospitals across Dubai and all other member states by 2020. The new seven-year UAE National Agenda announced accreditation in the health sector as one of the main objectives of the Agenda. The Centre for Healthcare Planning and Quality (CPQ), part of the Dubai Healthcare City Authority (DHCA), has had its second ISQua accreditation for Outpatient Clinic Quality Standards.CPQ is responsible for the regulation and licensure of all healthcare facilities and practitioners within Dubai Healthcare City ( DHCC). At present most hospitals and clinics in DHCC have international accreditation from JCI. JCI also accredits in other UAE states, while other international groups accredit a few hospitals and clinics. Under discussion is whether the requirement for all hospitals and clinics to be accredited, will be allowed to use any ISQua accredited accreditor, or whether the long term aim is for all to be regulated by CPQ. If the latter option is chosen, then CPQ would need to get itself and the standards approved by ISQua for inpatient treatment too. There is a precedent for a local regulator to take over. When certain UAE states began introducing compulsory health insurance for all citizens, residents and expatriate workers, part of the new legislation was that only insurers and brokers authorised by a local insurance regulator could offer cover. Offshore international insurance was not a legally allowed substitute. ISQua’s accreditation gives confidence and credibility through formal worldwide recognition. Maintenance of this award depends on the submission to ISQua of two progress reports, one at 12 months post survey and the second at 30 months post survey. Dr Ayesha Abdullah of CPQ commented, "Achieving accreditation for the second time by ISQua’s International Accreditation Programme is testament to our commitment of placing quality and patient safety at the forefront. It demonstrates to our stakeholders that the standards applied to outpatient clinic and ambulatory surgery centres in DHCC meet international best practice. Our standards have undergone a rigorous and credible development process in keeping with ISQua’s comprehensive criteria that included many of DHCC ’s healthcare facilities." The DHCC is home to two hospitals, plus 120 outpatient medical centres and diagnostic laboratories. CPQ is an independent regulatory body responsible for licensing healthcare providers and professionals, and setting and maintaining international best practice in healthcare delivery and patient care within DHCC.

Blogging on new UK cosmetic dentistry cost and clinic comparison site Teethwise, founder Eoin Holohan claims that the number of people travelling for dental treatment from the UK has dropped significantly over the past decade. According to Eoin, cheaper dental implants and other cosmetic treatments are now available in the UK, so fewer patients need to travel. Eoin Holohan explains, “The market has matured and many dentists are now travelling to see patients. The only foreign dentists who still have patients travelling for treatment are those who can offer consultations and other parts of the treatment in the UK.” “2005 was a great year for dentists in Hungary. Their country had recently joined the European Union attracting lots of European tourists including 250,000 UK nationals. Austrian dentist Alexander Schreiner opened up a clinic on the ground floor of a hotel in central Budapest to take advantage of the patient rush. At the time he was travelling to UK where he and a colleague would meet with up to a hundred patients over a couple of days in conference rooms, all interested in finding out about dental treatment in Budapest. Almost a decade later and Dr Schreiner sits in his clinic wondering where his UK patients have gone. The number of UK nationals travelling to Hungary has fallen by 38%. Whilst partly due to the economic climate, Hungarian dentists and dental tour operators have confirmed a significant fall in the number of medical tourists.” Holohan explains the reasons for falling numbers; “The two factors causing a drop in the number of people travelling for restorative and cosmetic dentistry are the economic climate and price pressures on restorative dentistry in the UK. Restorative dentistry or dental implants can be an expensive procedure for people and quite often it is not an expense they have planned for. Patients can expect to pay in the thousands whether at home or in cheaper locations. A full jaw replacement with 6 implants will cost from £9,900 in the UK and £6,000 in Hungary. Implants are rarely available on the NHS.” He explains why competition has led to falling prices in the UK; “Increased competition in the UK has driven down the price of dental implants, which are now available from as little as £995. Agnes Tuba of London Dental Implants, who place implants in London and Hungary, has confirmed that it only makes sense for patients to travel if they require 4 or more implants. LDI can carry out parts of the procedure and any aftercare in London, which makes travelling for the main part of the procedure a more attractive option for patients.” Holohan adds another reason for lower prices; “The cost price of dental implants has fallen. Low cost manufacturers have driven down the prices of implants as more and more dentists are offering a low cost alternative along with a premium implant brand. This has forced the established manufacturers to cut prices.” He adds, "Some dentists have spotted the opportunity to establish specialised dental implant clinics. These clinics operate on a high volume basis. They attract patients by offering cheap implants and balance the books by fitting lots of them. This allows them to spread their investment in training and equipment over significantly more treatments thus increasing their margins.” Holohan goes on, “Some Hungarian dentists and businessmen realised that patients are reluctant to travel for medical treatment, especially if they had not yet met their dentist. Rather than waiting for patients to come to them they decided to go to the patients and set up clinics in the UK. Vital Europe were one of the first clinics to offer treatment in the UK and Hungary and have told us that people are a lot more likely to travel if they can have a consultation carried out at home. These clinics that give patients the option to have treatment in the UK, in Hungary or a combination of both are the only type of Hungarian clinics attracting UK patients today.” Hungarian dentists are still very busy, “Although the number of patients travelling from the UK has fallen, Hungarian clinics still get patients from countries with easier access or where dental implants are still expensive. London Dental Implants see many patients from Germany and Scandinavia at their Budapest based clinic and have recently opened a second clinic due to increased demand.”

Hoping to improve on the increasing number of medical tourists, Baja has appointed Dr. Jorge Tagle as the first director of the department of medical tourism. The region gets the majority of medical tourists from the USA and the rest from Canada. Most go to border cities like Tijuana and Mexicali (the state capital). The new department seeks to increase the number of patients’ and their relatives’ staying in local cities while receiving treatment. The department of medical tourism seeks to unify efforts by public and private hospitals, hotels, restaurants, government agencies and related businesses and entities to attract patients, rather than them wasting money and energy competing with each other. Dr. Alberto Aceves, a leading bariatric surgeon in Mexico, is optimistic, "We are hoping for government health agencies to regulate and provide proper validation and certification for every service related to medical tourism, so creating a trustworthy atmosphere among patients visiting us.” Millions of tourists go to Baja each year and the second most important reason to travel to the state is to get health services. The state claims it had 800,000 medical visitors traveled during winter 2012-13, although this includes many who just go for a medical check up, and probably includes large numbers who are just travelling companions. As there is no collecting body, there are concerns that this figure is also exaggerated as clinics and hotels are both counting the same person, and that figures are based on numbers of nights and procedures, not the number of people. The state government suggests that some visitors stay in Mexico for more than one night if they undergo any kind of treatment or surgical procedure (adding up to 66% of their traveling budget spent on medical attention); patients bring along relatives and/or other companionship (at least in over 70% of the cases); so they all need services such as hotels, restaurants, entertainment and other activities. Baja is groundbreaking among Mexico’s states by creating this department of medical tourism. One of the key tasks will be to get a better handle on how many medical tourists actually go there.

After three poor years for Lebanon’s tourism industry due to regional and local turmoil, a new tourism minister is looking to expand beyond the traditional Gulf tourists. Michel Pharaon has several plans to give a needed boost to a sector that makes up 20% of the Lebanese economy. One key area is to focus on attracting more medical tourists, “In Lebanon, we have professionals in the health care industry that can bring in tourists from Yemen, Iraq, Libya and Algeria. We have a committee working hard on the project. An increasing number of Iraqis come to Lebanon for medical reasons. Health tourism has good potential for the country.” The need to attract tourists from beyond the traditional Gulf markets is especially important as GCC states maintain their travel warnings on Lebanon over possible abductions and other security threats that have kept many Gulf tourists away since 2012, with the United Arab Emirates and Kuwait governments warning their citizens not to travel to the region. The main problem that Lebanon has is convincing potential medical and other tourists that the government and their security forces and the Army are in control. Last year there was a series of bombings related to the ongoing conflict in neighboring Syria, but Pharaon seeks to convince people of the relative safety throughout much of Lebanon, “70% of Lebanon has not witnessed a gunshot for the past 20 years.” The number of tourists to Lebanon dropped by 6.69% in 2013 compared with 2012, while European visitors topped the list ahead of Arabs for the first time in years. While the number tourists from the Gulf dropped, Pharaon says that other Arab markets are ripe with potential, “We are currently targeting Jordanians, Iranians, Egyptians and Iraqi tourists.”

Hair transplants are becoming more popular in Ireland with an increasing number of celebrities admitting to having them to make themselves look and feel younger than they are. An increasing number of clinics in Ireland are offering the procedure as a way of compensating for the falls in the number of locals having cosmetic surgery. For some in Ireland the cost is just far too expensive. Economic troubles have seen a reduction in the number of Irish people flying to Budapest for dental work and cosmetic surgery at low prices, but the previous success in attracting local patients to Hungary sees clinics there now offering low price hair transplant procedures for foreign patients in Budapest. Hair transplants in Ireland range from €3.95 per follicular unit extraction graft up to €10 per FUE graft in Dublin clinics. People can have the same procedure done in Budapest for as little as €1.70 per FUE graft. Thomas Dunleavy has launched a new Irish company. Growhair.eu has partnered with Sikos Clinic in Budapest, a cosmetic surgery and hair transplant clinic run by Dr Gèza Sikos who has 22 years experience in hair transplants. Dunleavy has worked in dental tourism in Budapest and saw the need for the same service for hair transplant treatments. Thomas Dunleavy says, “With low cost airline fares on offer to Budapest and hotel prices very cheap it is a win-win for anyone wanting to have the procedure done but who simply cannot afford it in Ireland.” Potential customers have a free online consultation in Ireland where they speak with Dr Gèza Sikos. Growhair.eu then takes care of the rest; flights, hotel and transfers. For most it is just a one-day procedure where Dr Sikos uses a technique with minimal to zero scaring, transplanting up to 2,800 FUE grafts in one day. This means it is just a two-day visit to Budapest to have treatment carried out. The agency claims that within 7 to 10 days the procedure is unnoticeable and within 9 to 12 months customers will have achieved full re growth of their hair. For an average balding person needing 2,500 FUE grafts the cost in Ireland ranges from €9,875 up to €25,000 depending on which Irish clinic they use. The same treatment in Budapest costs €5,400 with a 10% discount via Growhair reducing it to €4,860.

The SFU Medical Tourism Research Group in Canada has released details of a study on medical tourism in Bangalore, India; ’An Overview of the Medical Tourism Industry in Bangalore, India’. Bangalore is the capital city of the state of Karnataka, one of the four southern states of India. Bangalore has 15 major hospitals that cater to international medical travel. Some have specialty services like orthopedics, oncology, or reproductive health, but most are multi-specialty hospitals. Apollo Hospitals Bangalore serves both national and international patients, but a separate wing has an exclusive international patient focus. The hospital has in-house translators for Arabic, and other languages are outsourced to translation agencies. It provides guesthouses within the hospital premises for patients and their carers, with additional housing nearby. Medical tourists do not form a major part of its revenues, although the number of patients is increasing each year, with 1,000 patients in 2013, primarily from the Middle East and Africa, particularly, Central Africa. Columbia Asia has two hospitals in Bangalore. International patients primarily receive orthopedic, cardiac and ear, nose and throat services. It does not focus exclusively on medical tourism. Although there is no separation between the local and the international wards, it charges higher prices for foreign patients. The majority of patients come from Kenya, Nigeria, and Ethiopia, but it also gets patients from Oman, Iraq, Bahrain, Sri Lanka, Bangladesh, Maldives, and Myanmar. Medical tourists comprise 10 to 12% of the total, and it treats between 25 and 300 foreign patients per month. It offers specific concierge services to patients to help them with their visas and registration. Fortis Healthcare has five hospitals in Bangalore. Patients come from 55 countries, with 50% from Africa, 6 to 7% from the United Arab Emirates, and 3 to 4% from the UK, US, and Australia. The group has in-house Arabic translators, and gets 40 to 50 medical tourists per month, comprising 22% of all patients and 20% of all revenues. For Mallya hospital most of the non-resident Indian patients come from the Middle East. The patients generally come with English speaking attenders, but the hospital sometimes experiences problems with Arabic patients who come without such attenders and who are unable to communicate in English. It does not provide any tourism related services. Manipal hospital is one of the leading hospitals in Bangalore catering to international medical travel. It has in-house translators for Arabic and Swahili. For other languages it hires the services of an outside agency. The hospital offers concierge services to medical tourists and provides accommodation for caregivers. It does not have a separate wing for medical tourists, but an exclusive international wing is being planned. It has a different price structure for domestic and international patients, so international patients pay 30% more. There has been an increase in the number of international patients, mainly from Africa, the Middle East, and the Maldives. It has also had a few patients from Canada, USA and the UK. Narayana Hrudayalaya gets medical tourists, primarily from Bangladesh, the Middle East, Africa, and Malaysia. 15 to 20% of patients are medical tourists, 500 patients per month. Medical tourism has seen an increase of 30% in the last year. In-house translation services are available for French and Arabic, all other languages require outside agencies to be hired. The hospital has an in-house travel agency, provides concierge services, and has its own accommodation; in addition to this it has ties with hotels and airlines.

The US is regarded by many as a source of medical travelers, but a new website reminds us that inbound medical tourism is at least equally important, and information from across the USA suggests it is again on the rise. Doctor For Cash, a Las Vegas based company, seeks to increase inbound US medical tourism, so has launched a new website to offer American doctors the means to directly advertise their practices to prospective foreign patients. Using DrforCash.com, medical professionals are able to clearly indicate the range of services they offer, as well as give accurate pricing information for their procedures. This process is quick and easy, and offers prospective clients — no matter their country of origin — to easily gather the information they need in order to make an informed decision about which doctors they are interested in contacting. The website is solely targeted at offering the USA as a destination for international patients by helping them find the right. The site allows patients to share their experiences with each other. These client reviews serve to help guide new patients to a doctor who will be the right fit for them.

The latest plan seeking to make Dubai a major medical tourism destination is more detailed than earlier attempts. The plan up until 2016 includes a dedicated portal for medical tourism as well as special medical tourism packages to be promoted in international markets. A second phase to 2020 will aim to further develop facilities and branding to reinforce Dubai as a global medical tourism destination. Essa Al Maidoor of the Dubai Health Authority explains, "We are focusing on developing Dubai’s medical tourism initiatives. The medical tourism strategy has been designed over two phases, the first one until 2016 and the second until 2020.The aim is to ensure Dubai features among the top medical tourism destinations around the world. We have carefully selected health services to be promoted taking quality and prices into consideration to attract tourists to the emirate." Dr Ramadan Ibrahim of the health regulation department says that Dubai has 2,500 health facilities and that the number of medical tourists who visited Dubai in 2012 was 107,000. The targets are to get 170,000 by 2016 and 500,000 by 2020. A five fold increase to 500,000 by 2020 is an major challenge that will require Dubai to take business away from other Gulf states, most of which have an extensive hospital building programme; and from leading Asian competitors that are also targeting Russia and CIS countries. For a country with a population of only 4.7 million, 500,000 medical tourists would mean one medical tourist for every ten men, women and children in the state. The sectors that DHA will promote include orthopedic and sports medicine, cosmetic surgery, eye surgery, dental treatment, dermatology, preventive health check-ups, plus wellness and skincare services. Target countries will be Russia and other CIS countries including Belarus, Uzbekistan and Kazakhstan; South Asia; and other Gulf states, as these regions are where the majority of medical tourists who visit Dubai come from. It has been attracting an increasing number of patients for cosmetic surgery, and has also seen increased numbers from Kuwait, Saudi Arabia and Qatar. The medical tourism strategy aims to provide high-quality health services at acceptable prices, so price benchmarks will be set up. 18 private and four public hospitals will be built in the next few years. Medical tourists will be issued with new visas and a choice of travel and accommodation packages. The packages will include visa, hotel stay and activities in Dubai, to be launched later in 2014. The DHA plans to rate hospitals from one to five stars, depending on the quality of their services, within the next two years. The aim is to a clear-cut ranking system to enable medical tourists to discern what type of facility they want based on the price and location. There are many challenges in achieving the goals, with many people from the UAE still choosing to travel overseas for treatment, and the medical tourism market seeing supply rise faster than demand. Dubai has a shortage of doctors and nurses, while the vast majority of medical staff are expatriates on short-term contracts who return home after a few years.

A new survey has asked Canadian doctors for their opinions of cross-border healthcare between Canada and the USA, and of overseas medical travel. The report, “Methods: A Cross Border Health Care Survey” was recently published in Globalisation and Health. The four authors used research with Canadian doctors via the Canadian Medical Association’s e-panel. The purpose of the survey was to gain an understanding of their experiences and views of their patients acquiring health care out of country, either as medical tourists paying out-of-pocket for their care or out-of-country care patients funded by provincial/territorial public health insurance plans. Quantitative and qualitative results of the survey were analyzed. 631 doctors replied. Diagnostic procedures are the main reason for patients becoming medical tourists. The main reason why patients seek care abroad is because waiting times in Canada are too long. Some doctors are frustrated with the lack of information about out-of-country procedures and post return complications upon their patients’ return to Canada. The majority agrees that it is their responsibility to provide follow-up care to medical travellers, although a substantial minority argues that they have no such responsibility. The report concludes that cross-border health care, whether government-sanctioned or patient-initiated is increasing in Canada. Such flows are thought likely to increase with aging populations. Government-sanctioned outbound flows are less problematic than patient-initiated flows but are constrained by low approval rates, which may increase the number paying for their own overseas treatment. The authors argue that further research on both types of flows (government-sanctioned and patient-initiated), and how they affect the Canadian health system, can contribute to a more informed debate about the role of cross-border health care in the future, and how it might be organized and regulated.

South Korea aims to attract 350,000 tourists a year from Russia by 2017 by developing tourism programmes including medical services tailored to Russian customers. This will mean more work for medical and other translators, plus some hospitals may hire Russian-speaking doctors. The number of Russians visiting Korea has been steadily rising. In 2013, the number of Russian travelers reached 175,000, up 5% from 2012; but it is not known how many of these travelled for health or medical reasons. South Korea is just one of many countries all seeking to target the increasing numbers of medical tourists from Russia. The competition is fierce, and many places struggle with language capability. The regional government in Incheon, which has a modern international airport and is scheduled to host the Asian Games this year, sees medical tourism as a major potential earner. The Incheon Medical Tourism Foundation (IMTF) was founded in 2011 with the ambition of making Incheon Northeast Asia’s leading medical tourism city. It has been accredited by the Ministry of Health and Welfare as an approved regional medical tourism association. According to IMTF, the number of medical tourists in the region rose from 2,898 in 2010 to 4,400 in 2011, and from 6,317 in 2012 to over 10,000 in 2013.The target for 2014 is 14,000 medical tourists. The IMTF is targeting patients from Khabarovsk and Vladivostok, after a deal in January 2014 between Korea and Russia that allows travellers to visit in either direction for up to 60 days without a visa. New plans for 2014 include a one-hour medical service at Incheon Airport, targeting transfer passengers so that they can receive fast and accurate medical checkups, skin care, and teeth cleaning, while waiting for their plane. The service will ensure that patients get to the hospital within one hour after their arrival at the airport; targeting 500,000 passengers with more than a four-hour layover at the airport, out of 6.5 million Incheon airport transfer passengers. A medical information centre will be set up within Incheon Airport’s Customs, Immigration, and Quarantine area and transfer desk areas so people can experience medical services, get medical tourism information, and meet potential doctors. Incheon sees the main target areas as China, Russia, Central Asia, Vietnam, Canada and US military personnel based in the region. In 2012, international patients (not necessarily medical tourists) were: 28 % Chinese, 8.9 % Americans, 7.6 % Russians, and 4.0 % Mongolians. Russia is showing a high annual growth rate of 88.1 % in the last four years. To take advantage of Incheon airport, the aim is to create the image of “Incheon Healthcare City” by naming Incheon Airport as the “Medical Hub Airport.” Within this, is a new group, the Incheon Cerebral & Cardiovascular Cluster (ICC). Within the ICC are Incheon City, Incheon Medical Tourism Foundation, Catholic University, Gacheon Gil Hospital, Inha University Hospital, and other smaller hospitals and clinics. The point of ICC is to jointly target cerebral and cardiovascular disease medical tourists as a group.

The number of medical tourists visiting Tunisia is increasing every year. The majority come from Libya because of the better level of care available in Tunisia and the wrecked state of Libyan healthcare. Even before the 2011 revolution, many Libyans would visit private Tunisian hospitals for a regular check-up, with their government footing the bill. Even now, many have their medical care paid for by the state as long as they can provide evidence from a Libyan doctor that they are unwell. Tunisia seeks to become a major regional destination for medical and health tourism.155,000 foreign patients went to Tunisia in 2013 according to health minister Mohamed Salah Ben Ammar. European patients also visit Tunisia, mostly for health tourism and holidays at hotels providing spas and medical centres in their facilities. Cosmetic surgery and dental treatment are other reasons the country attracts many patients from Europe, the Gulf and Asia, with the number increasing year by year. Within Tunisia the main locations are on the coast including Tunis, Bizerte, Tabarka, Sousse, Sfax, Gabes, and Jerba. Tunisia is also famous for its hot water springs in Tunis, Hammam-Lif, Korbous, Jebel Oust, Ezzeriba, Zaghouan, Hammam Ejjedidi, Nafta, and Hamma Gabes. The temperature of these hot water springs can reach 65 degrees celsius and are believed to be a good remedy for rheumatism and other diseases. The Ministry of Tourism is reluctant to promote these as attractive tourist destinations, as they are concerned that the quality of care and accommodation is not yet acceptable to modern tourists.

The Diplomatic Council medical program, a Netherlands based membership group is certifying the “best hospitals of the world” for international patients and medical tourists. The fees for this certification process depend on the size of the facility. They usually range from €25,000 to €40,000 plus an annual renewal fee. The certification process is carried out by Temos, the German based international hospital certifiers, who evaluate the hospital after a month-long preparation phase and review process, examining quality criteria relevant to the delivery of services to the international patient. A second certification, "Approved for International Patients’ is conducted on a self-evaluation basis and can be obtained online. Hospitals again pay an annual fee. But there is no visit or external audit. The fees for the certificate are €1,600 per year plus 19 % VAT. The Diplomatic Council is a membership organisation, based in The Hague “founded as a non-governmental organisation (NGO) with the purpose of developing friendly relations among nations”. membership is not restricted to members of the Diplomatic Corps, and is open to “distinguished personalities from politics, economy, society, culture and sports.” According to their web site: ’All members of the Diplomatic Council are reviewed by the “Council of Ambassadors” and being classified as “honourable”’ It does not have official status with any government or other body.

The perception that Indonesians go to Malaysia just for the cheapest price deal is too simplistic, says a fascinating and detailed research report on Indonesian medical travel. ’More than medical tourism; lessons from Indonesia and Malaysia on South to South intra-regional travel’ by Meghann Ormond and Dian Sulianto’ looks at medical travel flows between Indonesia and Malaysia. The study concentrates on motivations, preparation and practices. Using 35 detailed interviews of Indonesians going to Malaysia for healthcare, it fleshes out how things work beyond the basics. The authors asked about treatment, accommodation and transport, as well as length of stay. One key point it highlights is that the idea of medical tourists traveling across the world for the cheapest care is out of date as most medical travel is regional, often between easy to reach nearby countries. The ease of travel determines where in the country medical tourists go, as does how comfortable they are with the final destination. The report also highlights that people from Laos go to Thailand mainly because it is a short trip across the border and they go there even for basic healthcare, as the Laos system is very poor. Rather than being welcomed, this cross-border trade is causing problems for some hospitals as many Laotians do not have the means to pay and hospitals are being over-burdened. Regional medical travellers vary in terms of socio-economic group, medical condition, ability to travel, distance travelled, destination, length of stay, number of people with them and type of hospital they go to. While cost is a factor for some, other drivers are availability of healthcare, quality of equipment and doctors, and recommendations. With a dearth of quality healthcare in Indonesia, the growth of a prosperous middle-class, increased affordable cross-border transport and ease of border crossing- an increasing number of Indonesians (maybe as many as a million) go to Thailand every year for healthcare, but they tend to stay for a shorter time and spend less than other nationalities, partly as much of this is outpatient care. Two out of three travel to the state of Penang, a quarter to Melaka and the rest to Sarawak. The case studies were only of people going from Indonesian Borneo to hospitals in the Sarawak capital, Kurching. They can get there by air, sea or land. In deciding where to go, many use a medical travel agent. Each of the three private hospitals in Kuching has official local representatives with offices in Pontianak that register customers, schedule their consultations and testing, and provide the hospitals with customers’ records and medical conditions. They may also provide payment options (allowing patients and their families to settle Malaysian hospital bills in Indonesian currency or transfer additional funds) and transport to and from Kuching (transport ticket purchase, own transport services, etc.). This type may receive a combination of base salary and commission from the hospitals for each customer served. Numerous commission-based agents arrange not only transport and accommodation but although they do not have medical training may conduct the investigation of customers’ ailments, identifying what they deem to be the appropriate specialist for their ailments, registering them and accompanying them to the consultations, even interpreting for doctors and their patients. Those not using an agent tended to be seasoned medical travellers; had friends and family in Kuching on whom they could rely; wished to avoid the extra fees charged; or desired greater independence in selecting facilities, doctors, transport and accommodation. Diagnostic, treatment and medication costs were widely regarded by medical travellers as similar across Indonesia and Malaysia. Care in Kuching entails the additional burden of transport and accommodation costs as well as sometimes temporarily closing their businesses or taking leave from work or care responsibilities to go abroad. Yet all travellers found the additional financial burden to be worth it: as it was better healthcare than they get at home. Before travelling, they budgeted for consultations, treatment and medication as well as transport, lodging and food. As credit cards are rare and since only some hospital linked agents offer facilitated payment and money transfer options, cash payments are predominant. Travellers require time to amass the estimated amount and exchange currency before leaving Indonesia. Numerous hotels, guesthouses and private homes are available for rent by day, week or month, for travellers on tight budgets are near the private Kuching hospitals. Many low cost cross-border coach services compete with one another and as do freelance medical travel agents for patient custom. Indonesian and Malaysian low-cost airlines have even added new routes and additional flights to respond to medical travel demand. To minimise costs, most travellers opt for land transport (cross-border economy coach services, shared vans and taxis.). Most stay in low-budget accommodation of economical hotels, privately rented homes or guesthouses owned and run by Indonesian agents or at family and friends’ homes. It is common to secure accommodation in Kuching only after learning from their doctors how long they need to stay for testing and treatment. Travelling with family and friends to Kuching allows patients to get logistical, physical and emotional support, The study concludes that by focusing marketing efforts on further away patients, the development of promotional campaigns, travel infrastructure and attractions that interest and engage higher-spending medical tourists are all ignoring the lower spending but far more numerous nearby medical tourists that are the basic customer base of most hospitals. Campaigns focusing on low –cost may miss the point that it costs many of these people more to get treatment in Malaysia than it would in Indonesia, so price is not the main driver. The authors argue that by concentrating attention on higher-status tourists that stay longer and spend more than conventional leisure tourists that authorities and hospitals miss that international medical travel is mostly intra-regional in character, and driven by local economic and political conditions in both their source and receiving locations. The study suggests that much promotion and research into medical travel ignores the importance of unpaid care-giving travel companions, and how the ability of friends and relatives providing free accommodation influences where people go. It points out the flourishing informal economy of unlicensed agents, the purchase of prescription medication in Malaysia for family and friends in Indonesia, and local travel enterprises are mostly ignored. The study argues that proximity, cross-border support networks, and confidence in the quality of diagnoses, treatment and medication are much more important than price. Intra-regional medical travel becomes a feasible way to manage chronic health needs, with people commuting on a routine basis for treatments, check-ups and refills. But research and promotion on international medical travel is focused on long-haul journeys for expensive treatments and surgeries. The frequent, short-distance and typically outpatient medical commuting is a much bigger component of medical tourism than the vision promoted by national bodies of long-distance travel for cheap care. Politics, socio-economic factors and diverse geography are mostly ignored and make medical travel look much simpler than the reality is.

An Irish dental practice is slashing prices to attract new clients and prevent patients from the Republic of Ireland travelling overseas for treatment. MyDental, based in Ballsbridge, Dublin, has drastically reduced prices to attract new patients. The practice promises to match lower fees charged in Northern Ireland to discourage patients from the South crossing the border or going to European countries to take advantage of lower costs. The clinic found that prices it charged were not competitive when compared to clinics over the border or in Europe. But by lowering prices it is encouraging Irish patients to stay at home for treatment. The clinic insists that quality of products used is not reduced but that the lower prices increase numbers so lowers overheads. It points out that comparing treatment prices alone is not accurate as customers also need to take into account time off work, costs of travel and accommodation. MyDental in Dublin’s Ballsbridge maintains it can match any price offered in Northern Ireland for treatment as it keeps outgoings to a minimum. Gerard Egan, clinical director argues that when all costs are taken into account then the practice can usually come in cheaper than travelling to Europe .In good economic times there was a flood of Irish dental patients going to Europe but numbers have fallen to a trickle Egan stresses that the quality of work and materials used are the same as any other clinic, but argues he can save a patient about a third by buying in bulk from suppliers and laboratories.Growing numbers of patients are now visiting them from Northern Ireland and a large number of clients are Europeans working in Ireland, particularly Latvians and Lithuanians. The clinic has seen the new low-cost model work so well that it plans to open two new clinics, a second in south Dublin and one in Munster, next year.

Government backed and EU funded marketing is promoting low-cost medical tourism to Poland. The key target regions include Scandinavia, Germany, and the UK. Poland points out the easy availability of low-cost flights, cheap accommodation, and attractive tourist cities such as Krakow. Scandinavians mostly seek cosmetic surgery. According to Magdalena Rutkowska of Poland’s medical tourism development programme, which is 75% funded by EU money, 320,000 medical tourists went to Poland in 2012. 42% had cosmetic surgery, mostly breast implants. 33% had dental and 9% had obesity-related treatments such as gastric bands. Fertility treatment is now getting business too. To make it easier for customers, an increasing number pf clinics and hospitals are offering packages that include transport to and from the airport, and accommodation in apartments or hotels. One target of the promotional body is UK health insurers. It hopes to persuade them to send customers to Poland, but with the recent failure of medical insurance tourism insurance plan Passport2health, that is going to be an uphill struggle.

The number of foreign patients treated in Korea rose 32.5 % to more than 211,000 in 2013, according to the Ministry of Health and Welfare. Exactly how many of these are medical tourists is not revealed. A conservative assumption that three out of four are medical tourists would mean around 150,000 medical tourists in 2013. Korean hospitals and clinics revenue from treating foreign patients rose 47 % to 3.93 trillion won in 2013 from 2.67 trillion won in 2012. Each patient spent 1.86 million won on average ? up 10.7 % from 2012. This reflects the growing popularity of Korean clinics among foreign patients, partly thanks to the government’s active medical tourism programme. The ministry counted patients who received medical treatment without national health insurance. They include patients who went to Korea for medical treatment and cosmetic surgery, travellers who needed treatment and residents who have no national medical insurance- including some Koreans, expatriates, foreign workers and US military personnel and their families. Nearly 10 % were hospitalized for 12.3 days on average while 8.7 % just had health checkups. Dermatology and cosmetic surgery were the most common areas for foreign patients. 9% visited dermatologists and 8.6 % saw cosmetic surgeons. Internal medicine topped the chart, accounting for 24.4 % of patients. Chinese patients were the biggest foreign spenders as they accounted for 26.5 % of the total number and spent a combined 1.02 trillion won in 2013. The number of Russian patients increased 46.2 % to 24,000, replacing the Japanese as the third-largest group after the USA. Russian patients spent more than Americans at 87.9 billion won .The US figures include a large number of US military, expatriates and travellers. Chinese patients tend to visit cosmetic surgeons and dermatologists while Russians have health check-ups and get treated by gynaecologists and dermatologists. Patients from the United Arab Emirates spent the most per person on average at 17.71 million won, followed by an average of 4.56 million won paid by patients from Kazakhstan. The number of patients from the Middle East rose 237 % to 1151. 350 were sent to Korea by the Dubai government under an agreement between the two countries. Korea aims to get up to 1000 from Dubai via the government this year, having already treated 290 between January and April. With Dubai spending millions heavily promoting medical tourism it seems very strange that the Dubai government is increasing the numbers of patients it sends overseas. The number of Russian tourists travelling to South Korea is expected to double to 350,000 this year after the introduction of a visa-free regime in January and this will increase medical tourism numbers from Russia. Half of all Russian tourists go to Seoul. Park In-seok of the Health Industry Bureau comments,” We expect the number of international patients to continue increasing with the visa waiver programme for Chinese people, and an increasing number of Russian medical tourists as Korean hospitals have pursued marketing activities in different regions of Russia.” The health ministry forecasts 250,000 foreigners will receive medical services in Korea without national health insurance in 2014. The long-term goal is to get a million foreign patients per year by 2020. One of the busiest medical tourist locations in Korea is Gangnam District in Seoul, which specializes in cosmetic surgery. The number of medical tourists who visited Gangnam was 19,135 in 2010, 24,535 in 2011, 34,156 in 2012 and 43,000 in 2013, more than a 25 % growth each year. Busan plans to attract medical tourists to the big hospitals in the city. The hospitals in Western Busan including Donga University Hospital, Kosin University Hospital, Busan Adventist Hospital and Kang Dong Hospital have formed a medical tourism group. Busan University Hospital is expected to join the group as it seeks more medical tourism business. Gangwon Province in the East has set up a medical tourism promotion group that goes to China, Russia and other countries to promote medical tourism in their province. Daegu, Korea’s fourth largest city has an advertising brand of Medi-city Daegu and Jeju Island is promoting medical tourism.

Whether patients are prepared to travel to another country for treatment under the EU cross-border directive, and whether the sending country is prepared to implement the rules, is being tested. If British patients from Kent are not prepared to make the short hop across the channel to Calais, and if the NHS puts up administrative barriers, then all those hospitals expecting a substantial increase in business will be disappointed. Brits channel hop to buy antiques, drink and cigarettes, but whether they trust French doctors with their health, nobody yet knows. Centre Hospitalier de Calais is advertising for business from the nearby English county of Kent in the hope that patients will opt to have their operations done in France, under the EU rules on patient rights for cross-border healthcare. Kent patients need approval beforehand from their local NHS hospital for some 144 treatments, have to pay the bills and then seek to claim the costs back. Under the NHS they do not pay anything. The NHS has made it clear that it may consider travel costs, but no patient has the right to get these paid. The NHS also makes it clear that it will not pay for any costs of traveling companions and patients must pay all hospital and hotel bills for accommodation, but cannot reclaim these from the NHS. Calais hospital has 502 beds, parking for 350 cars, and mostly private, en suite rooms with the latest technology for MRI and CT scans. It offers a range of treatment including cosmetic and reconstructive surgery and vascular surgery. The NHS does not pay for cosmetic surgery. The Centre Hospitalier de Calais is targeting residents of the Calais region and also for European neighbours. The site at Virval is south east of Calais, and offers easy access from the city centre and the ring road surrounding the city. Kent residents seeking treatment in France are limited to what the cost of treatment is in their home county. How this is interpreted is going to be of interest to NHS hospitals across the UK. One key problem is that NHS hospitals do not publish a price list so patients will not know in advance how much they can claim. If the price in France is higher than the UK, then the patient pays the extra. If the price in France is lower than in the UK, the patient does not keep the difference, but still has to pay travel and accommodation and food costs- as these are not offset against any medical savings. Significantly, local NHS hospitals have refused to comment to Kent papers running stories on the Calais bid. Although regulations from the Department of Health are detailed, and the theory is understood, how they are interpreted at local NHS level is still a mystery to both hospitals and patients. How a hospital calculates the cost of an operation where the patient is charged nothing has yet to be solved, as it is unclear whether the costs should or should not include pre- treatment costs and aftercare.

FindMeHealth is a new independent comparison website for private healthcare, offering free consumer information on healthcare services’ quality and price. The aim is to make it easy for patients to find the right healthcare specialist and surgery treatment, compare prices, and book treatment online. It uses a hotel like five star system to rate surgeons and consultants that allows potential patients to see the records, experience and qualifications of different surgeons and how much they charge. The aim is to make private healthcare more accessible and affordable to customers through the use of information to transform the relationship between patients and health professionals by providing trusted and comparable information on quality and price to help people book private outpatient consultations with consultants online in a quick, easy and convenient way. Important to the service is making it easy for potential patients to compare like for like treatments across a range of providers, based on reliable health outcomes information and customer feedback, so they can make an informed decision and ultimately choose the right treatment and provider. Similar to how hotel and travel websites work, key to the site is the use of featured reviews from patients. Dr Mark Ratnarajah, co-founder of FindMeHealth says that to solve the problem of bogus and malicious reviews, all comments will be carefully scrutinised and vetted. It expects to have 4000 to 5000 UK surgeons on, each with a free listing. They are not charged for that listing but can advertise on the site. The website follows the model of other new competitors by only charging them a fee if a booking is made by a patient. The prices quoted are the actual prices charged for that patient, not indications or average procedure prices. It does not direct patients only to those who pay to advertise. Patients do not need a GP referral as long as they are paying for the outpatient consultation themselves. Future plans include adding in-patient treatment and other healthcare. Although the UK has seen other small sites launch in recent months this one has massive financial backing from Ed Wray and fourteen other professional investors. It is already planning the next stage of investment. Ed Wray explains: “FindMeHealth can help put consumers back in control and to make better choices.” Ed Wray helped found the world’s largest online betting exchange Betfair in 2011 that has five million bets a day, and is a director of leading UK peer to peer online lender Funding Circle. The initial target market is the estimated quarter of a million self-pay private patients, a market worth £500 million-plus a year or 15 % of the total UK private healthcare market. Ratnarajah plans to expand the service to cover the rest of the private healthcare market in due course. The launch has no public intention of yet including treatment outside of the UK, but for anybody targeting UK medical tourists with outpatient treatment such as hip or knee surgery, cosmetic surgery, or fertility treatment, it means that these customers now have an easy way to compare UK prices against anything overseas hospitals and clinics offer. Dental care is not yet included.

One of the biggest problems facing US domestic medical tourism is that comparing prices is very difficult. When hospitals, clinics or agencies seek to promote medical travel from other states, convincing patients that the price is competitive is an uphill struggle. But a new portal will change that. Three of the biggest American health insurers have joined to create a price comparison site, and others are expected to join the initiative as several have expressed interest. It is good news for domestic US medical tourism, and a wake up call to overseas hospitals and agencies that quote sky high US prices, in comparison with their own, that continuing to use the highest prices, when customers can check US prices for themselves will just take away any credibility they have. Aetna, Humana, and UnitedHealthcare– have teamed up with non-profit Health Care Cost Institute (HCCI) to launch an online portal in early 2015 where they will publish information on healthcare prices; the price of treatment, not the price of insurance. Price transparency is a serious cause for concern within US healthcare as a lack of price transparency means that customers cannot easily tell if they are getting a good deal from their hospital. People expect to pay more in a big city than in a remote town, but prices vary hugely between almost identical hospitals. Insurers are not doing this out of the goodness of their heart, as they see it as a way of pressurizing hospitals to reduce costs and obtaining US wide price information. It is also to their benefit that consumers can make a more informed decision when obtaining medical care .More comparison tools will be added over time. The simplest explanation of the start point of the HCCI online is that it will upload price information that insurers have internally. So the more health insurers join in, the better the data will be. It will take time to build as pricing data will come from commercial health insurance schemes, plus Medicare Advantage and Medicaid health plans. US healthcare reform encourages the publishing of government-funded healthcare cost data but states that like to be awkward could refuse to take part just to make a political point. HCCI accepts that pricing information alone is unfair, so cost data will be supplemented with quality and other information to provide consumers a transparent and comprehensive destination to make more informed decisions about health care. “Consumers, employers and regulatory agencies will have a single source of consistent, transparent health care information based on the most reliable data available, including actual costs, which only insurers currently have,” says David Newman of HCCI. For hospitals and clinics this will offer new and accurate information about costs and quality that allows them to see information on competitors.

Romania is promoting health tourism, while medical tourism is bringing a much-needed boost to the economy. The Spa Tourism Employers Association (OPTBR), backed by the National Tourism Association (ANT), has in partnership with the National Institute of Gerontology and Geriatrics and the Ana Aslan Foundation a pilot programme to promote health treatment and to revitalize the famous Romanian brand Ana Aslan. The Romanian Medical Tourism Association (ARTM) and is another partner promoting the project. The aim is to repromote the power of the Ana Aslan brand, which concentrates on spa treatment for older customers. Part of the pilot is finding ways to use modern phrases rather than off putting promotion terms such as geriatric treatment. This is aimed not just at foreign tourists, but at the large internal Romanian spa tourism market that is expected to grow as the economy recovers. The pilot has two programmes ’Live Young’ and ’Relaxation. Rebalancing. Revitalization’ at the O3Zone Hotel, in the Central Romanian resort of Baile Tusnad resort. Customers will have free access to the swimming pool, jacuzzi, dry and wet sauna and to the gym at the spa centre. Ana Aslan therapy includes preventive or curative treatment with products personalized to the patient. Treatment is or a wide range of problems associated with the degenerative process specific to women: rheumatism, peripheral circulatory disorders, depression, hypertension, and atherosclerosis. On medical tourism, Dragos Raducan of the Federation of Employers from Romanian Tourism (FPTR) explains,” There are no official statistics, but from local medical tourism sources we estimate that 2013 saw over 20,000 medical tourists in Romania.” This is mostly for cosmetic surgery and dental treatment, with some medical treatment. The association estimates that they spend over EUR 60 million on health services, accommodation and food. According to the National Association of Travel Agencies (ANAT), a medical tourist spends, on average, between EUR 1500 and EUR 2000 for treatment plus EUR 1500 on accommodation and food. Most come from the UK, Germany, France, Italy and Israel and are aged between 40 and 60, according to ANAT.

On the morning of 20 May, the chief of the Royal Thai Army declared martial law across the whole of Thailand. There is an increased military presence and soldiers have taken over TV and radio stations, and blocked off roads in the capital, Bangkok, and in neighbouring provinces. The army insists that its assumption of responsibility for national security was not a coup, but as government has not been consulted about the army’s decision, it is effectively a military coup. The situation is evolving and any company sending people to Thailand should monitor local news and social media for developments. Tourists have been warned to allow extra time for journeys, including to the Bangkok airports. Any agency sending medical tourists to Thailand must consider what would happen if a medical tourist gets innocently caught up in the situation. Several governments have warned their citizens to think again before travelling to Thailand. The UAE has warned citizens not to travel to Thailand, which may affect the established medical tourism flow from the region. Insurance organizations have warned that because the intervention is a military one, many travel insurances could no longer be valid nor provide full cover. Martial law supersedes the Internal Security Act, which had previously been imposed by the government. Martial law provides an enabling framework for the Royal Thai Army to take action it deems necessary to enforce law and order, and instructions can change rapidly. Political demonstrations continue in and around Bangkok and elsewhere in Thailand, including Phuket. There have been indiscriminate attacks involving weapons and explosives at protest sites and at protest marches causing casualties and deaths. Attacks have taken place during the daytime and at night. Protest action has caused significant disruption to roads in affected areas, with knock-on effects across the city. The situation is unpredictable and further protests are expected. By law tourists must carry a passport with them at all times. Tourists have been arrested because they were unable to produce their passport. There is a nationwide curfew for all residents and visitors; all need to be indoors between 10pm and 5am. The military measure caught the Tourism Authority of Thailand (TAT) by surprise as they were about to launch a range of tactical campaigns aimed at Europe and the Middle East to retain tourists confidence and ensure the growth of the country’s tourism industry .The campaign is on hold. While many areas in the country are unaffected, many medical travelers either go to Bangkok, which is at the centre of the troubles, or go through airports that are being affected by political demonstrators. Airlines are taking decisions by the hour. With an increasing number of countries warning citizens to be cautious about traveling to Thailand, it is inevitable that the numbers of tourists and medical tourists to Thailand will fall in 2014. Mario Hardy at the Pacific Asia Travel Association in Bangkok predicts that visitor numbers will fall by at least 5% this year, “Tourism is a huge income for the country, so this military intervention is not helping. It is not good for Bangkok and not good for tourism in Thailand.” The Tourism Authority of Thailand insists that international visitors can continue to travel in the destination as usual, “All public transport and tourist attractions, including airports, tourist sites and shopping malls, are currently open and operating as normal.” With tourism accounting for 10% of the country’s gross domestic product, keeping hotels and shopping malls open and busy is key for South-east Asia’s second-largest economy. Because of the troubles, even before the military action, in the first four months of the year, foreign arrivals dropped 5 % — about 400,000 —compared to 2013, figures from the Thai Department of Tourism show. Bangkok hospitals report lower medical tourism numbers for 2014. Bangkok Dusit has seen a drop of more than 30 % in patients from the Middle East this year. Bangkok is suffering from a dramatic drop in visitors, a trend that is indicative of a much great problem in Thailand’s tourism industry. Those reliant on tourism in the city are noting the especially clear absence of Chinese visitors. Even before the military intervention, the first 4 months of 2014 has become a disaster for Bangkok tourism. Tourism arrivals at airports fell 38% on 2013 and Chinese numbers are down 48.1%, Russian numbers are down 40% and Indian, Japanese and South Korean arrivals at least 30% down. Many tourists are staying away because of the state of the economy and a lack of spending confidence and some are calling this the worst tourism crisis in a long time. Thailand is now also in danger of losing its crown as the world’s top destination for medical tourism if foreigners looking for low-cost, quality healthcare are frightened away by the political unrest.

The Tourism Observatory has carried out a conceptual study on the possibilities and directions of a joint health tourism strategy for the three Baltic countries (Lithuania, Latvia and Estonia) The report provides a summary of research undertaken on health tourism in the Baltic States identifying which resources and products are common to the region as a whole and which are unique to each country. The Baltic States have had a fairly successful collaboration in tourism (especially promotion) for several years. Collaborations and clusters are seen as being useful tools for sharing good practice, improving quality and branding. A Baltic Health Tourism Cluster was established in 2013. Following attendance at the launch of the Cluster, Laszlo Puczkó undertook a study involving several respondents from each of the Baltic countries from the health, wellness, spas, medical and/or tourism business sectors. This analysis sought to help the countries identify what is specific in their health tourism resources, attractions and products at the same time as working towards collaboration and a common regional brand for health tourism. The results of this study, which is available for purchase, will form the basis of a joint Baltic Health Tourism Strategy. Lithuania has seen a boom in medical tourism. Body Bureau, a London-based agent and pre-assessment clinic that specialises in infertility treatment, health screening and dentistry, says that healthcare visitors from the UK to Lithuania have increased by 19.5% over the last two years. It says that within this timeframe the total number of patients visiting Lithuania from abroad was up by 42.3%, although it does not say where these figures come from. One Vilnius-based infertility clinic, Northway, reports a doubling of patient numbers in the past year. Aaron Zukauskas of Body Bureau explains, “Vilnius is one of the most affordable, capitals in Europe and has a lot to offer, including a beautiful old town. Lithuania is rated one of the top countries in the world for the quality of its health and hygiene. This helps make the country very attractive for people who want to improve their health, or get quality healthcare services.”

In an effort to expand the local niche market of medical tourism, The Palace and The Victoria hotels have teamed up with private hospitals, Prestige Cabs and UK medical tourism agency Linda Briggs. Linda Briggs will arrange for British medical tourists seeking medical treatment in Malta to stay at The Palace and the Victoria hotels for pre-surgery and post surgery recovery. For certain treatments, Linda Briggs will also fly in leading surgeons from France and other European countries. Together with its local partners, Linda Briggs is promoting Malta as a five-star medical destination, offering a complete service to patients needing surgery. As part of an added service to customers, Linda Briggs is offering insurance cover underwritten at Lloyds of London that will cover travel and some costs related to surgery, as well as any emergency treatment needed in Malta during recovery. Linda Briggs comments “For this venture to succeed, we needed partners who are committed and who will leave no stone unturned to provide the high level of service that is now expected in this sector.” Discovery Channel recently filmed a programme showing the positive side of cosmetic surgery, and featuring a Botox® party at the Limes Bar at the Fortina Spa Resort in Malta. The event was organised by Linda Briggs. There have been many historic links between Malta and the UK, and a long standing link between Malta and Italy. A more recent link is the Malta/France one with more French people traveling, retiring or even setting up businesses in Malta. Malta is still working out how to best take advantage of these links in developing cosmetic and medical tourism.

PlacidWay has published ’2014 Medical Tourism Global Consumer Demand Survey Analysis’. The research based on a global sample of potential and actual medical tourists, analyzes the consumer’s behavior when making medical tourism decisions and the consumer specific needs, perceptions, and desires. Pramod Goel of PlacidWay explains,” It is important that medical providers, medical tourism groups and governments trying to promote medical travel, align their healthcare solutions by understanding the nature of demand and developing a specific message as well as the specific programme, closely mapped to consumer demand," The purpose of the new report is to identify how medical consumers think, what are their needs, how will they buy, where do they seek information, what is important for them when considering traveling abroad for medical care, what are their income levels, why would they go abroad for healthcare, and who is the medical consumer or medical tourist. The research gathered information from those who have already traveled abroad for medical care, and from people who are considering going overseas for healthcare, and analyzed the what, how, where, when, who and which of the perceived medical travellers. The objective of this research is to understand consumers buying behavior, their needs, and their perception of the medical tourism. The study also identifies how factors such as age, gender, and geographical region have an impact on medical travel. The analysis sheds some light on medical tourism industry from consumers’ perspective and answers questions: o Who is the consumer?o What is the consumer’s demographic composition?o Which treatments would the consumer consider important to buy globally?o Why would the consumer travel abroad to receive medical services?o Where would the consumer go to get such treatments? o Where would the consumer go to find useful information? o How much is the consumer willing to pay for medical services abroad? o When is the consumer ready to make medical travel decisions? Pramod Goel concludes, "As the medical tourism industry matures, by understanding consumers we may bring equilibrium to the supply and demand equation of medical travel. We will be able to institute appropriate educational elements to propel the demand. We can customize medical travel products and services to meet and expand consumers’ expectations from this industry."

Israeli police are investigating doctors from Tel Aviv Sourasky Medical Center suspected of using public hospital facilities for private surgery on medical tourists to Israel. The issue was uncovered in December of last year by the Channel 2 investigative programme Uvda. Following the televised programme, the health ministry said that medical tourism was going to be investigated to strengthen the public health system. But so far nothing has happened; it seems that the authorities and politicians are waiting for the police to act. The Uvda programme showed hidden camera footage of senior brain surgeons from the hospital agreeing to bypass waiting lists to fit in patients from the former Soviet Union who were willing to pay them tens of thousands of Euros. In the two cases shown on the programme, doctors were caught on film speaking to a female producer posing as an agent representing fictional patients in the former USSR looking to fly to Israel for treatment. It was thought that the programme had been forgotten and the accusations not proven. But the Israeli police have spent six months collecting evidence. The basic accusation is that doctors have, with or without agreement from local hospitals, been using hospital facilities to treat overseas medical tourists and that these substantial payments have been in cash, and are illegal. The police are not widening the net at this stage, nor getting involved in political arguments on medical tourism or the prices charged. What the police have accused the three very senior doctors from Ichilov Hospital in Tel Aviv of is failing to declare income and failing to pay tax on cash payments. The police are trying to determine how many patients were brought to Israel for the unapproved treatments, and how many doctors took part. The doctors questioned could face charges of fraud, tax evasion and bribery. Medical tourism is a major income earner for Israel’s hospitals, with tens of thousands of patients traveling to the country each year. That the police made a highly visible and public swoop on all three doctors suggests that they have fairly solid information. By concentrating on the tax angle it becomes easier to establish innocence or guilt, and for a jury to understand the charges. What the police will now do is to follow the money, follow the information and see who they can charge with what, and leave the health authorities and politicians to deal with the wider debate on the legality of medical tourism in public hospitals, and the problem of medical tourists being charged double what locals pay. The outcome could have a significant impact on medical tourism in Israel.

The Florida Legislature ended its regular election session with legislators unable to pass a bill to promote medical tourism. The House and Senate bill would have allowed Florida tourism bodies to create a five million dollar marketing plan to entice tourists around the globe to think of Florida as a medical destination. The proposal designated $3.5 million to Visit Florida, the state’s main tourism driver, to set up a four-year plan to promote healthcare options, providers, services and specialties. An additional $1.5 million in state funding would have been allocated to establish a matching grant program to support local and regional economic development organizations with medical tourism. The Florida House of Representatives has passed its budget that included $71.3 million to Visit Florida, the state’s tourism marketing agency. The medical tourism bill will now have to wait until late in 2014 to get reconsidered. The knock back means that it will be harder for the state to achieve the target of 100 million tourists in 2014, as the politicians allowed a budget of less than three-fourths of the money that the state governor said was needed to reach that goal. Visit Florida, the state’s tourism arm, estimates that Florida attracted 26.7 million visitors in the first quarter of 2014, a 2 %increase from 2013. For all of 2013, the state welcomed 94.7 million tourists, a 3.5 % increase over 2012. The state governor had asked lawmakers to increase funding for Visit Florida, the state’s tourist marketing arm, by more than $36 million, to $100 million. Instead, as part of the proposed $77.1 billion spending plan for the budget year that begins July 1, legislators included $74 million for Visit Florida. The funding level approved by lawmakers does represent a $10.3 million increase from the current year. The requested funding for Visit Florida included $5 million for medical tourism. The new medical tourism bill sought to give Visit Florida $3.5 million to craft a marketing plan aimed at people seeking medical treatment, from specialized surgery to routine procedures or cosmetic surgeries, and another $1.5 million to provide matching grants to local and regional economic-development organizations that have medical tourism marketing programmes. The state governor and Visit Florida could still seek to promote medical tourism by using general funds, but the organization appears understandably reluctant to get in the middle of a wider battle for control between the governor and state politicians.

The Sovereign Investment Authority of Nigeria recently told the World Economic Forum that 30,000 Nigerians spend $1 billion annually on medical tourism. 60% is spent in four major areas of healthcare: cardiology, orthopedic, renal dialysis issues and cancer. This is a much lower figure than has appeared previously in the international media. The plan now is to get overseas hospital groups to build new hospitals in Nigeria, and while this could benefit Indian hospital groups who have overseas building plans, it is not such good news for the Indian hospitals that Nigerians go to. Recent high profile terrorist events may make overseas investors wary of long term investment in a country that despite being the richest in Africa, seems reluctant to spend that money on healthcare. The biggest problem is that Nigeria is not one cohesive place but a mix of rival tribes, rival states, rival policies and rival interests. While it makes long-term sense for Nigeria to build new hospitals to stop better off locals spending healthcare cash overseas, expecting that development to come from overseas investors when the national government clearly has many problems in controlling what happens within the country, is perhaps a hope to far. Even if Nigeria can alter the direction of medical tourism in the long run it now seems clear that outbound medical tourism for the rest of the decade is going to stay high and perhaps even grow. Any suggestions that Nigeria could become a major medical tourism destination anytime soon are require a significant leap of faith.

The Dubai Health Authority has met with private hospitals to discuss the rollout of the medical tourism strategy later this year. Hospitals were told what they must do to be included in the new promotion. The government is ensuring that all relevant organisations including the immigration department, airline industry, hospitality sector, public and private hospitals will work together to ensure medical tourists receive excellent treatment and hospitality. All hospitals and clinics interested in being part of the medical tourism initiative will have to fill out a detailed medical tourism eligibility form and submit all documents to the Dubai medical tourism department within DHA.The documents will then be evaluated by the medical tourism committee and hospitals will receive platinum, gold or silver membership based on their score. The committee will look into detailed aspects of each applicant including the specialities they would like to promote, details of the doctors who provide those specialties, and the number of procedures they have conducted. This information will be verified with the DHA health regulation office as part of the secondary verification check. In addition to medical facilities, DHA will also evaluate hospitals on the basis of the comfort and ease they provide patients. This includes checking whether they have translators, chauffeur services, hospital transport, and other services that would all be part of the medical tourism package. Hospitals must agree to offer pre-priced all-inclusive medical tourism packages that will include treatment, visa, travel costs, hotel accommodation and recreational activities for families who accompany the patient. Only successfully approved hospitals and clinics will be part of a new Medical Tourism Club; and the DHA will only promote club members. It will be interesting to see what happens if hospitals and clinics, most of whom have spent substantial amounts of money investing in Dubai Healthcare City, either decide not to apply join, not to offer packages, or are turned down by the DHA committee, or are unhappy at the star rating they get. The first packages will be launched in September and will be and wellness and preventive services package. This includes medical check ups. These packages will be promoted on a new DHA run medical tourism website that will include all details and hyperlinks of approved clinics and hospitals. There is some confusion as the latest information from the DHA says that the website will not be ready until between October and December 2014. The medical tourism packages will target patients living outside the UAE and the Middle East region in general. Dubai’s goal is to attract large numbers of medical tourists. This very tight control over product, service and pricing is an approach that no other country has attempted. Many of the authorities and organizations are effectively, as is DHA, state controlled; so it will be interesting to see how, or indeed if, private hospitals and clinics, particularly those owned by overseas investors, are happy to work in this state controlled way.

Both Kuwait and Saudi Arabia are seriously considering making health insurance compulsory for all visitors. It will almost certainly be required that travelers buy their cover from companies authorized within each state, as this is how they have arranged other compulsory health insurance schemes. Details and timing are awaited. The plan, to stop visitors using local hospitals for free except in real emergencies, may restrict hopes of inbound medical tourism. Saudi Arabia has decided to implement mandatory health insurance that must include cover for medical assistance and evacuation in emergencies for foreigners intending to visit the Kingdom. Hajj and Umrah pilgrims are exempted from this requirement. The Council of Cooperative Health Insurance has yet to confirm the date from which the new requirement apply. It is also not yet confirmed whether insurance can be arranged by any travel or health insurer in the country the visitor is travelling from, or whether it has to be arranged by a health or travel insurer licenced within Saudi Arabia. Once the new rule is implemented, only those foreign visitors who have taken out proper health insurance policies will be eligible to apply for visit visas in Saudi diplomatic missions abroad. Many visitors entering the Kingdom on visit visas are parents of expatriates who are aged or suffering from chronic diseases, and their medical expenses are high. Many women join their husbands on visit visas and deliver babies, which is expensive for Saudi hospitals. Visitors who are insured will be protected from medical costs arising out of treatment for sudden unexpected sicknesses, infections and accidental injuries. Only a handful of Saudi insurers can handle this type of cover and if insurance has to be bought locally it is likely that there will be an increase in premiums. What has to be sorted out is what insurers refuse to cover people for because of age or existing illnesses. They could be banned from refusing cover, or visitors deemed to old or ill may simply be refused entry to the country; the local insurance market suggests that the latter is the most likely. While making travel insurance compulsory for all visitors may seem easy in theory, in practice it is far from the case and any country has to balance whether the money it saves on healthcare, is worth the money lost from reductions in visitor numbers. KuwaitVisitors to Kuwait could soon be forced to buy health insurance for the duration of their stay after the Kuwaiti parliament’s legislative committee accepted the proposal put forward by MP Khalil Al Saleh that also stated visitors could only be treated in private hospitals. Access to health services is controversial in Kuwait, where two-thirds of the population are expatriates and the country has not built a new hospital for some time. The health ministry intends to build nine new hospitals, although it made a similar pledge more than a decade ago which has not been fulfilled. Last year, it segregated access to hospitals, banning expatriates from attending public facilities in the morning, except in an emergency. Kuwait provides free medical services to all citizens, while expatriates pay an annual health insurance fee of $175 plus partially subsidised charges for certain procedures. If Kuwait follows other countries, the traveler does not get a free choice of insurance, as they have to choose one or selected insurers within the country itself, which is likely to be the route that Kuwait takes as it ties in with how they regulate health insurance Other Gulf states are considering similar restrictions but are waiting to see what Kuwait and Saudi Arabia do If they both implement the rule without damage to trade or tourism, the others will copy an idea that seeks to restrict access to hospitals. Cuba has had a similar rule for years, with no problems for the country but a headache for US insurer AIG who have been prosecuted for breaking US sanctions by offering travel health insurance to Canadians. The UK is seeking to apply new compulsory health insurance rules to certain classes of visitors.

Australian health insurer, nib, is considering becoming a medical tourism agent for its customers, but not offering insurance cover for medical tourism as the main reason that Australians go overseas for treatment is cosmetic surgery, something that health insurers do not cover. The insurer has 18 branches across the country and if it cannot increase income in a very competitive market for health insurance, then it will have to close some. This is why ideas for producing extra income, such as becoming an agency for Australians seeking cosmetic surgery overseas, are being considered. Mark Fitzgibbon of nib explains, ’’If you’re going to go overseas for surgery you want to deal with a company you trust. Australians are spending a lot of money on cosmetic surgery by going overseas. Everyone is making money out of it: the airline, the travel agent, the credit card and loan companies, as well as the clinics overseas. So we are exploring the prospect of having a role in assisting people making those decisions, because they know our brand.’’ While globally, insurers are not keen on insuring medical tourism, there are other insurers around the globe that have dabbled in helping customers go to another country for treatment such as cosmetic surgery that they do not insure; as there are then no conflicts of interest. A new dental tourism venture is targeting Australians. Dental Abroad, based in Auckland, New Zealand is seeking to take Australians to New Zealand for dental care. A weakening New Zealand dollar and cheap airfares have helped make the venture viable. It has been set up by a dentist and a technician who makes dental implants. It offers Australians a net saving of 20% to 30% on the dental cost in Australia. The company promises that work done in Auckland will be of a higher standard than in other countries where dental tourism is popular, such as Thailand. The company specializes in the larger complex restorative cases involving 3 or more teeth requiring crowns, bridges or cosmetic veneers. Implants are made in house to high quality controls and standards, with a 3-year guarantee. Only internationally recognised brands of implants and fixtures are placed.

A special edition of the UK journal, Clinical Risk published by the Royal Society of Medicine, looks at how the combination of an under-regulated market, increased marketing and overwhelming media hype have created a perfect storm that threatens patients and practitioners alike. The journal’s editor argues that cosmetic surgery patients are at more risk than ever before. Dr Harvey Marcovitch, who commissioned leading experts in the field to write for this special issue says, “Patient safety is this journal’s main aim and there can be no area of medicine where patients in the UK are more in need of protection. We need tight control of advertising of cosmetic surgery, including internet advertising. We need proper regulation of the industry and we need both surgeons and GPs to manage patient expectation.” In ’Clinical Risk in Aesthetic Surgery’, Nigel Mercer of the British Association of Aesthetic Plastic Surgeons (BAAPS) calls for tighter regulation in the UK, “There has been a massive increase in marketing, including discount vouchers, 2-for-1 offers and holidays with surgery. In no other area of medicine is there such an unregulated mess. What is worse is that national governments would not allow it to happen in other areas of medicine. Imagine a ’2-for-1’ advert for general surgery? If we have to sell anything, we should sell our advice, not procedures. If we cannot self-regulate then regulation will eventually be imposed. All cosmetic treatments are medical interventions, and every medical intervention has a complication and failure rate.” .He also suggests that there should be a Europe-wide ban on advertising all cosmetic surgical procedures, including on internet search engines. In ’France Sets Standards for Practice of Aesthetic Surgery’: French surgeon, Alain Fogli describes the strictly defined guidelines for cosmetic surgery in France which include: - surgical procedures can only be undertaken by surgeons who are registered specialists and deemed competent; neither possession of a general medical degree nor that the practitioner is experienced are sufficient qualifications; a ban on all forms and methods of publicity and advertising, direct or indirect, in whatever form, including the Internet” In ’Minimizing Risk in Aesthetic Surgery’ Foad Nahai of the International Society of Aesthetic Plastic Surgeons (ISAPS) says, ” Regulations governing the training of all cosmetic surgeons are sorely needed. Governments are reluctant to become involved, as they see this issue as a dispute between various physician groups and not a public safety or patient safety issue. Since by law any physician is allowed to practice cosmetic surgery, attempts by individual physicians or plastic surgery organisations to restrict those who are not qualified is viewed as a restraint of trade.” In ’Improving the Safety of Aesthetic Surgery’ Rajiv Grover recommends careful pre-operative counselling, thorough documentation and exploring with the patient what degree of correction and scarring is realistic, and not being falsely optimistic about the likely outcome. In the UK, although there are measures and standards to help regulate the industry, some cosmetic surgeons operate outside these regulations. Some treatments and procedures are unlicensed for cosmetic use, but can be given at the discretion of doctors, or by some clinics. Invasive cosmetic surgery and laser treatments are regulated.Some cosmetic surgical procedures are not covered by current regulations, such as botox injections and injections of aesthetic fillers. Surveys by the International Society of Aesthetic Plastic Surgery show that England has one of the poorest controls of cosmetic surgery in the world, says Dai Davies from Plastic Surgery Partners. He believes that the UK is one of the worst regulated countries in the world and says, “practically anyone can perform risky treatments (such as injectables) that should only be performed by qualified doctors. The industry is out of control.”

A Toronto hospital piloting medical tourism has run into a media storm of protest that could kill the project, as it had been trying to pilot quietly without publicity. Despite targeting a very small number of patients (ten in 2014) it has sparked a debate about the costs of Canadian healthcare, access to healthcare for Canadians and how healthcare in Canada is and should be financed. Critics range from those decrying all medical tourism to those who say Canadian hospitals should only be for Canadians. There have been very few supportive messages. The reason for the pilot is that Canadian hospitals are working to ever more restrictive budgets, and need to either find ways of substantially reducing costs or new revenue streams. As health insurance is not legal in most Canadian provinces, hospitals have to rely on state funding or self-paying Canadians. All Canadian hospitals treat foreign patients in emergencies, and a handful, including Toronto’s University Health Network; raise millions treating international patients on a referral basis. Sunnybrook Hospital’s board has approved a one-year international patient programme and so far it has had two patients; a Barbadian woman who paid $60,000 for radiation treatment for breast cancer, and a Jamaican man who paid $20,000 for radiotherapy for prostate cancer. Sunnybrook is planning to treat fewer than 10 international patients in a one-year pilot phase so is not openly soliciting medical tourists. Michael Young of Sunnybrook explains, “This is part of a number of initiatives from our new department of business development. Through our website we are beginning to advertise that we are open for business. The profitability of this could be as high as $1-million annually. It could be much more than that, but the limiting factor will be our spare capacity.” Critics argue that patients from abroad could displace tax-paying locals or pave the way for rich Canadians to buy their way to the front of the queue. In 2013 McGill University Health Centre in Quebec performed cardiac surgery on a Kuwaiti woman whose government paid the $200,000 cost, and the province’s health minister called it “unacceptable” and vowed not to let it happen again, except on compassionate grounds. Sunnybrook has vowed not to displace Ontario patients. The hospital plans to treat foreigners only where it has extra capacity or staff on standby, as it does on its burn unit. The profits could be used, for example, to prevent closing operating rooms. Budgets for Ontario’s hospitals have been frozen for three years, while the running costs keep rising. Ontario has no plans to stop hospitals attracting medical tourists but Quebec plans to do all it can to prevent local hospitals targeting foreign patients. The Canadian healthcare system is under pressure, with rising waiting lists and insufficient finds. Province controlled regulation means that in some provinces health insurance is legal, in others it is not, while in some provinces private healthcare in hospitals is allowed, while in others it is not allowed or strongly discouraged. Some provinces have even made noises about banning medical tourism, although it is doubtful that they have the legal powers to do this. As evidence of what local hospitals are doing on medical tourism slowly emerges, it has provoked another debate with some evidence that hospitals are, or are being encouraged, to charge foreign patients double what they do for Canadians. Canada is a microcosm of the global debate on medical tourism. There are only a finite number of doctors, nurses and hospital beds so a surgeon performing surgery on well-to-do foreigners is not available at that moment to treat locals; so is the hospital using spare capacity, or using local capacity for foreign patients to boost revenue? Should foreigners be charged much more than locals? Can money from medical tourism allow hospitals to keep operating rooms open longer and thus reduce wait times for locals; or is this using resources that increase waiting times? In Canada there is an underlying problem for the healthcare system — as governments, both federal and provincial, have cut funds. This triggers another debate as to whether throwing money at any health-care system will fix it, or whether ways of changing how hospitals work and where people are treated is a better long term solution; as is happening in the excellent Scandinavian systems. For Canada, the only certainty for hospitals and medical tourism is that if they do not seek new revenue they get criticized for not having enough resources to treat locals, and if they do embrace medical tourism they get criticized for treating foreigners rather than locals. So whether any individual hospital administration will promote medical tourism may depend very much on how far they can tolerate sustained criticism in the media, from patients, and from politicians who are ultimately responsible for signing off what state provincial funding they get.

Leading Australian and New Zealand health insurer nib has launched a domestic and overseas cosmetic surgery and dental offer, nib Options for Australian consumers only, offering treatment in accredited facilities. The launch was supported by a marketing campaign, fronted by leading GP and television personality Dr Ginni Mansberg. nib Options is a fee-for-service product which will provide safe and reliable choices for consumers wishing to undertake cosmetic and major dental procedures in Australia or overseas. It is not in any way linked to the health insurance offering. Customers have a choice during the early assessment stage about where they would like to seek treatment, with nib Options accessing leading Australian cosmetic surgeons as well as fully qualified cosmetic surgeons and dentists in overseas facilities. The insurer refuses to name the clinics, but according to the website it appears that at present all it has is one cosmetic surgery/ dental clinic in Phuket, Thailand, and one or two clinics in Australia. Mark Fitzgibbon of nib explains, “This is all about helping Australians to choose from a borderless network of surgical excellence as well as providing safety assurance. While receiving cost-effective treatment is also a factor for consumers, we know that the most powerful attraction is providing safety assurances that only high quality hospitals, surgeons and dentists will be involved. Such safety assurances cannot be made lightly, so we have devoted a lot of time and effort to ensuring nib Options will successfully deliver what it promises based on our brand reputation and capability. The hospitals and dental facilities we are dealing with are internationally accredited.” Fitzgibbon adds, “Over time, I am confident that more and more Australian and overseas surgeons and doctors will want to partner with us once they see the benefits it will bring to their practices. This fits very neatly with our commitment to helping people finance their health care. We are helping the customer at every stage starting from the initial consultation through to travel arrangements, accommodation, the actual surgery and afterwards. Some people will have neither appetite nor ability to travel overseas for a procedure while others will take the travel option so they can also recuperate quietly. For those Australians who do travel overseas for medical treatment, we want to give them peace of mind by making the experience safer and more reliable.” All the costs involved in undertaking surgery, both before and in the post-operative phase, as well as the aftercare promise are bundled into one overall package price. The Australian and overseas packages also include an after care promise to assure customers that nib Options will be there to help them through a process for any further follow-up treatment and care, for up to 12 months after the surgery, should they need it. nib Options is a fee-for-service product, it is not health insurance. It is a bundled, one-stop service from the initial medical consultation assessment, actual surgery and post-surgery care, as well as travel arrangements, accommodation, concierge services for consumers who go overseas. The use will have no impact on nib health insurance premiums or products. Customers can choose treatment in Australia or overseas; they have a choice during the early assessment stage about where they would like to seek treatment. At launch the service is limited to dental treatment and cosmetic surgery in Australia and Thailand. Cosmetic surgeons in Australia have to be members of the Australian Society of Plastic Surgeons. ACHSI, the International arm of the leading Australian accreditation body Australian Council on Healthcare Standards will conduct the audit on potential international clinics. As to be expected from their previous track record on seeking to defend high Australian medical prices, the service has been roundly attacked in the media by the Australian medical establishment. The onslaught rather backfired when Australian Medical Association president Steve Hambleton went too far, and was widely ridiculed across the Australian media for his “When you travel overseas and eat lettuce or a salad you could return home with a multi-drug resistant bug in your bowel. That could start to hurt you if you have complications from surgery and end up in intensive care and we might not be able to treat the infection.” cartoons depicting dangerous foreign lettuce quickly followed. More than 3,000 people visited the nib Options website in the first three days of its operation and nib had to put on additional call centre capacity. 30 % were interested in overseas cosmetic surgery, 50% in overseas dental care and 20% in Australian cosmetic surgery.

A consumer survey on potential medical tourists visiting a medical tourism show is never going to be representative of Russian consumers, but it does bring insights into what Russian medical tourists want. Many countries are targeting Russia as a source of business, but often know little about how healthcare works in Russia, or that many so-called Russian customers are Russian speaking but come from other states that used to be part of the USSR. The object of the survey was to find out who are these Russian medical tourists, what do they want, and what do they spend? The 3,524 visitors attending the Moscow Medshow in March provided an opportunity to conduct a major survey into the requirements and tendencies of the Russian client/patient. 422 people answered questions. How much would you be prepared to spend on medical treatment abroad?11% are prepared to spend more than 25,000 euro on their treatment abroad, 36% say that the cost of their treatment could be between 10,000 to 25,000 euro, and 53% say that their budgets for treatments are at a maximum of 10,000 euro. When are you looking to have medical treatment?42% planned for treatment within 2-6 months. 22% have chronic conditions and are looking to travel at the earliest opportunity. What specific treatments are you looking for overseas?63% are looking for diagnosis and subsequent treatment, 9% are looking for surgery abroad, and 6% are interested in cosmetic surgery, while 7% are looking for dental treatment. 15% express interest in spa and preventative medicine. What countries are of most interest for your treatment abroad?Two countries, both with long involvement in the market, lead the list: Germany recorded 32% followed by Israel with 22%. Others are Hungary at 6%, Spain at 5%, Switzerland at 5%, and Czech Republic at 4%. Bulgaria, Austria, Turkey, and China each scored 3%. 36 countries were indicated as medical tourism destinations of interest .The results may suggest that Russians from this region prefer to go to European countries, but those thousands of miles away in Eastern Russia may prefer Asia, and Arab states, or they too may prefer Europe. It may be something countries should research before targeting the Russian market. What is your primary reason for visiting the Moscow MedShow?41% were visiting the exhibition to gather first-hand information on what medical treatments are available abroad, their costs, and conditions. 17% have a specific condition that required treatment and are looking for direct meetings/contacts with hospitals/clinics. 9% are looking for information and details on preventative medicine, while 33% are there out of professional interest. Age and genderThe age of Russian looking for treatment abroad revealed some interesting statistics, as 46% are 30 to 50, 40% over 50 and 14% under 30.58% are female and 42% male.

It has been many years coming, but the government’s medical tourism initiative is finally happening, with a more realistic approach. Originally it promised thousands of new jobs, and thousands of new tourists. The latest target, although still based on little more than guesswork, promises up to 3,000 jobs in the next four years, during this four-year term, about 50% less than what some officials had hoped. Puerto Rico is a self-governing territory of the USA, with a population of 3.7 million. Tourism is an important money-earner; the island receives up to three million visitors each year and is a port-of-call for cruise liners. Being a United States territory, no passport is required for travel for US citizens, and the cost of treatment is less than half of that on the mainland. It has a few medical centres offering cosmetic surgery, cancer treatment and a full range of medical treatment. But the public healthcare system is overstretched and there is little investment in private healthcare. American medical travellers have the same legal recourse as they do in the U.S. The administration is hoping to do deals with US health insurance plans and target markets where there are significant Latino populations. It is not exactly a sophisticated strategy. And the politicians have not even agreed to spend money to set up a medical tourism promotion board, so a strategy based on a new body to promote the region could again fall at the first hurdle. There is a significant US military contingent at bases in Puerto Rico, but the US Military health system (TriCare) sends its troops and dependents home to the mainland for medical care of any significance - even maternity care because basic obstetrical care is insufficient to meet TriCare standards.

For 15 years, Malaysia has steadily worked towards building a strong healthcare tourism sector. In the last 10 years, revenue from healthcare tourism increased tenfold. This makes it one of the fastest growing sectors in the country. In 2012, growth was 16.2% and in 2013 this was 15.8% .The Malaysian government is optimistically targeting 10 % annual revenue growth in both 2014 and 2015. The biggest source of business is nearby Indonesia partly due to the lack of health care in Indonesia, partly due to price, and partly due to the comfort that Indonesians have in going to a fellow Muslim country with halal food. Another key source of business is Singapore, due to the overcrowding in Singapore hospitals and the much higher medical costs in Singapore.Just over half of Malaysia’s business is in the state of Penang. The state recorded revenue of RM370 million in 2013, a 20% increase on 2012. Dr. Mary Wong Lai Lin of the Malaysian Healthcare Travel Council (MHTC) comments,” Malaysia is the only country in the region where healthcare tourism is promoted by the government.” The ministry of health plays an important role in ensuring that private health facilities country adhere to all the necessary safety and quality requirements by regulating them through the Private Healthcare Facilities and Services Act 1998 and Regulations 2006.”

Construction of China’s first special zone for medical travel will begin later this year. The Boao Lecheng International Medical Travel Zone is at Boao Town in Qionghai city and covers an area of about 20 square kilometers. The areas in the plans include the Dale area and Xiaole Islet area. The Xiaole Area will consist of three projects: the Bole Zero-carbon Pavilion, a healthcare centre and a redevelopment project. Projects in the Dale Area include an advanced cancer treatment center, an international conference center and a healthcare infrastructure facility. As the first healthcare project in the zone, construction on the advanced cancer treatment center will begin this December and will be in use within 3 years. Construction cost of the zone is estimated to reach US $ 16 million, and most of the projects are expected to be ready by 2016.Hainan province is constructing China’s first special zone for medical travel, in order to attract domestic and international medical tourists. Traditionally in China, people prefer to stay where they are and seldom travel, but an increasing number of people are breaking with tradition. Particularly for older retired Chinese, when winter comes, they pack up and go to Hainan, China’s tropical island province, to avoid the cold in the north. At present Hainan is a good place for winter retirees, but there are few local medical services and amenities. Included in the new development will be traditional Chinese medicine and many wellness options. Lu Zhiyuan of the Hainan Tourism Development Committee says Hainan Island has a unique advantage for developing medical tourism,” The island has very good air quality, very pure water, blue sky and ocean." There is some confusion as to whether it is mainly a health and wellness destination and whether it really will have any potential to target overseas visitors. As with any Chinese state development, all statements are super optimistic and any criticism or awkward questions are promptly crushed. In many ways it is all an experiment. The government is allowing several privileges and policies in the trial zone. Overseas medical institutions are allowed to set up business within the zone. Other preferential policies include lower taxes for imported medical instruments and medicines.

The Colorado Senate is waiting for the state governor to regulate the travel insurance industry in the state for the first time. House Bill 1185 requires the Division of Insurance to issue licenses for limited-lines travel insurance, typically purchased by tourists wanting to hedge against a last-minute trip cancellation or seeking coverage if they need to be evacuated from a vacation for medical reasons. This would include policies bought by Americans in the state going to another US state or another country for medical treatment. The Senate was moved to act after getting complaints from people who had bought travel policies from unregulated companies, only to find that they did not cover everything they expected. The bill is expected to become law sometime later this year. This is part of a general trend where an increasing number of US states are either producing regulations that are wider then US federal regulation, or where the Federal government is slow to act; this year there has been a flurry of state based regulation on various consumer issues including peer to peer lending and equity crowd funding. There is a common theme, on areas where consumers are being asked to pay relatively substantial sums of money to businesses offering services where the business has specialist knowledge that the consumer lacks. The question now is, which will be the first state to regulate medical tourism agencies?

Arizona-based company American World Clinics (AWC) has had agreement to build a private clinic in Costa Rica that will mainly offer health care services to foreign retirees and medical tourists. AWC is investing $150 million in the construction of a 12,000-square-metre clinic scheduled to open in 2016 in San Rafael de Alajuela on the main road connecting San José with the Pacific province of Puntarenas. It will offer general surgery plus specialty care in orthopaedics, cardiology, urology, oncology, and cosmetic surgery. AWC estimates the hospital will have the capacity to perform up to 18,000 surgeries annually. The project also includes construction of a five-star, 100-room hotel operated by California company K-Hotels, and a retirement community for 400 people. It is being funded by New York financier National Standard Finance. AWC plans to locate in highly desirable locations throughout the world. The first location in development is Barbados, with other potential locations including the Bahamas, Canary Islands, the Dominican Republic, Uruguay and Spain. Gran Canaria in Spain is a possible location for a new clinic, while Madrid is another option.

The Expatriate Health Coverage Clarification Act of 2014 has been passed by the U.S. House of Representatives. The bill clarifies that the Affordable Care Act does not apply to expatriate health insurance plans, such as those plans offered by major US insurers to US expatriates working overseas. The bill had previously been defeated but success was due to changing the wording to clarify that the definition of an expatriate is someone who spends at least six months outside of the USA. The measure is aimed at helping U.S. insurance companies that are at a competitive disadvantage with foreign firms that do not have to comply with ACA requirements such as free preventive care and a ban on lifetime coverage limits. Expatriate health insurance plans offer high-end, very wide cover to executives and others working outside their home country, giving them access to a global network of health care providers. But if ACA rules were to apply to U.S. insurance companies offering these plans, those rules raise costs and put non-U.S. insurance companies at a competitive advantage. Members of both parties agree that these plans should therefore be exempt. There was widespread agreement on the need for a fix under the health law for US - written expatriate plans that can be sold to Americans working overseas and foreigners working in the USA or elsewhere. But senior Democrats and the White House opposed the bill on the grounds that legal permanent US residents could be sold expatriate plans that do not meet the basic requirements of the health law. Further changes are expected as it moves through the Senate, to fill these legal loopholes. The relevance for medical tourism is that in the past several attempts have been made to sell insurance plans, often written outside the USA, that include elements of medical tourism- with these plans being targeted at people from a particular country who work and live in the USA but may consider treatment elsewhere. The new law makes it clear that plans underwritten in the USA or elsewhere targeted at US expatriates working anywhere in the world, are legal under the Affordable Care Act. It also makes it clear that specialist plans aimed at expatriates of any nationality working in the USA are also legal. Medical tourism agencies thinking that this offers a new opportunity to target the Diaspora of a particular country are going to be disappointed. The new law does not change the basics that the Affordable Care Act rules apply to people living and working in the USA; they do not have to be US citizens. The tax authorities run certain aspects of the ACA and their ruling is simple; a temporary expatriate working for a few months in the USA does not have to comply with the ACA. But even if they are an expatriate of another country who settles in the USA, without becoming a US citizen, they must comply with the ACA. Only the tax officials of the IRS can rule when a temporary expatriate becomes a US resident, but tax lawyers advise that the maximum term is 12 months, and if it clear that the person is becoming a permanent resident then effectively the IRS will allow them a few months to settle in and then treat them as a US resident; the IRS does not have to wait 12 months to do this. And the new law now rules that expatriates can only work for 6 months in a year in the USA before ACA rules apply. So if a medical tourism agency or insurance broker wants to link overseas treatment to an insurance plan, as the expatriate may prefer treatment in their home country, then they can now do this without breaking the ACA. But they cannot also offer that plan to people from that country who are resident in the USA, unless it complies fully with all the rules and regulations on cover and pricing as required under the ACA. Even then it may not be legal, because insurance in the US is regulated on a state by state basis and it is up to the commissioners in each and every state that the plan is marketed in to decide whether or not that plan and the offering agency and the insurer, are doing so legally. Even cross- border plans between the USA and Canada, and USA and Mexico, have problems, as while California accepts their legality, Texas does not. For any other insurance plan offered from outside the US targeting citizens of a particular country, the chances of it complying with the requirements of the ACA, IRS and state insurance commissioners is very slim. The big US insurers of expatriate insurance plans are very relieved at this new law, but even then, just because it is legal in the USA, does not make it legal in the country the US expatriate is working and living in; as an increasing number of countries are tightening the rules on what insurers can offer from both within their country and as offshore insurances targeted at people in that country. All the big US insurers have looked at, researched and even piloted combining domestic or international health insurance with medical tourism, and without exception they have walked away from the concept, other than for Mexican cross border plans.

The National Conference in Abuja discussed Nigeria’s future and how oil money can be used in a fairer way. In a bid to reduce the current negative impact of medical tourism on Nigeria and its healthcare system, it suggested strict procedures that must be observed by public officers seeking medical treatment outside Nigeria. The 500 politicians at Conference argued that seeking medical treatment abroad has resulted in unaffordable capital flight and a drain on Nigeria’s economy. More specifically it cited evidence that regular abuse of existing processes for screening of referrals for foreign medical treatment as one of the reasons. The recommendation is that there should be restriction of government sponsorship of public officers for foreign medical care; and that unless for exceptional cases that require referral abroad, all public officers must use local clinics and hospitals. A medical board made up of medical and healthcare professionals must screen these exceptional cases. In addition, the recommendations of the board should be subject to the approval of the Minister of Health, who is the chief medical adviser to the Federal Government, except where such exceptional cases are serious emergencies, in which instant approval may be given. The Conference admitted that there is an urgent need for improvement in the quality of healthcare services in the country. Despite its vast resources, Nigeria ranks among the most unequal countries in the world. The poverty in the North is in stark contrast to the more developed Southern states. Even in the oil-rich South-East, the residents of Delta and Akwa Ibom complain that all the wealth generated flows up the pipeline to Abuja and Lagos. The oil is located in Southern Nigeria and delegates from oil-producing areas want local communities to keep more of the revenue it generates. However, poverty levels are far higher in the North and delegates from non-oil-producing resist such moves. Oil states keep 25% of the oil revenue they earn and hand the rest to the federal government. Nigeria is one of the world’s biggest oil producers but most of its 170 million people live in poverty. Some Nigerians want more powers to be delegated to the country’s 36 states. Agreed at the Conference was that free healthcare be established for children aged 0-5; senior citizens from the age of 65; people living with disability; plus free maternal services and free school health programmes. Nigeria loses huge sums in capital flight to medical tourism, as most of the nation’s hospitals lack the modern equipment needed for effective diagnosis and treatment. N80 billion annually on medical treatments abroad goes to India, Germany, UK, Israel and the Middle East. While efforts are being made to transform healthcare in Nigeria by equipping the hospitals with modern equipment, the investment needed to do this and build many new hospitals is huge. President Goodluck Jonathan recently expressed his determination to involve local and international private investors in the health sector reforms, “A lot of Nigerians go to seek medical help abroad and almost all the hospitals that attend to them outside this country are privately owned. If we encourage the private sector to take the lead; that would save the amount of money Nigerians pay outside. The determination of our government is to ensure that our citizens have access to quality and affordable healthcare services. The role of the private sector in complementing government efforts is crucial.” Dr Osahon Enabulele of the Nigerian Medical Association (NMA) wants the speedy passage of the National Health Bill by the National Assembly to curb medical tourism. “On medical tourism, one way to tackle it is to support the National Health Bill. The bill has a provision for the constitution of a body of medical experts, which would assess the requests of those, especially top political office holders, who want to go abroad in the name of attending to some health conditions. The National Health Bill could mean medical tourism will be wiped away sooner than later.’’