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Medical tourism has become one of the ‘market niches’ that is increasingly being discussed in the context of growing potential, i.e. the growth rate of the number of passengers who seeking health services outside the borders of their own country. Today’s medical tourism is certainly an ‘industry’ that generates a significant number of passengers and significant financial turnover on an international level, but establishing a realistic factual state, turnover realized on arrivals and nights (on the emotional and/or receptive side), or financial parameters, is really not an easy task, primarily because there are no international standards for statistical tourism medical monitoring, i.e. the information that is generally known to the public depends on the methodological approaches of the authors.
Medical tourism has had a long gestation period. The very earliest forms of tourism were directly aimed at increased health and well-being. The ﬁrst recorded instance of medical tourism dates back more than 2000 years when visitors, perhaps the ﬁrst pilgrims, travelled from around the Mediterranean to Epidaurus in the Peloponnese, said to be the birthplace and sanctuary of the god of healing, Asklepios, the son of Apollo. In Roman times taking the waters was popular and spas date back more than 2000 years, and health cures linked to water were common to many regions. The numerous spas and sacred sites that remain in many parts of Europe and elsewhere, in some places represented the effective start of local tourism, as people travelled to gain physical beneﬁts. From then onwards particular therapeutic places and landscapes, from springs and mountains to temples and cathedrals, have played signiﬁcant roles in most cultures and regions. Health tourism, in a relatively gentle form, has a long and unbroken history.
What exactly constitutes health tourism varies. Golf, tennis (and other sports) might be pleasant and healthy exercise and sources of well-being for some, but dull or sources of tension and pain for others. Festivals, leisure centres and cruises can stimulate health tourism, and occupational psychology workshops can be a form of wellness. However, such leisure activities, no doubt healthy relaxation for many, extend the notion of health tourism beyond forms of tourism that are speciﬁcally or primarily about health.
Medical tourism is a recent example of niche tourism, with the rapid rise of international travel in search of cosmetic surgery and solutions to various medical conditions, beneﬁting health-care providers, local economies and the tourism industry. While medical tourism may be a new niche in the industry, tourism has always been associated with improved health and well-being, perhaps more usually perceived as occurring through entertainment, rest and relaxation rather than by substantial bodily changes. Indeed travelling for improved health is the most durable niche in the history of tourism. A long history of spa tourism dates back to antiquity, and in more recent centuries variants of a more general health tourism have included phenomena ranging from naturism and hiking/bushwalking to meditation and detoxiﬁcation.
It has become important for many reasons: (i) disappointments with medical treatments at home; (ii) lack of access to health care at reasonable cost, in reasonable time or in a sympathetic context; (iii) inadequate insurance and income to pay for local health care; (iv) the rise of high quality medical care in ‘developing’ countries; (v) uneven legal and ethical responses to complex health issues; (vi) greater mobility; and (vii) perhaps, above all, a growing demand for cosmetic surgery that ties many other factors together.
Medical tourism has also emerged from a greater willingness to accept alternative practices and procedures, and experience different cultures and places, even though most medical tourism is centred on ‘formal’ biomedical procedures. It has, however, followed various social and economic changes encouraging a more holistic approach to health care where health-seeking behaviour has become more likely to reﬂect the views of patients in terms of their own values, beliefs and philosophical orientations towards health and life, rather than those of the ‘medical establishment’. For some this has meant being more involved in such social determinants of health as community, belonging and hope; for others it has meant greater individualism. Ironically therefore greater support for complementary and alternative medicine has grown alongside the rise of cosmetic surgery, a function of an ‘obsession with self that is reaching an all-time high thanks to new media, technology and consumer orientated services’. Yet one of the critical issues in the development of medical tourism is the regulation of standards.
While health was generally perceived as a physical phenomenon, the mind and spirit were rarely excluded. Ill health was often attributed to spiritual and cultural causes, even as biomedicine accompanied scientiﬁc development and a movement away from localized cultural beliefs about health. However, in recent years there has again been a shift of belief systems away from an exclusive regard for biomedicine, and from the primacy of science (evident also in the revival of creationism, and opposition to evolution in some Western societies). While older forms of tourism, with their links to oracles, pilgrimage and particularly venerable sites, might have been seen to emphasize ritual and religion, a sense of spirituality and the particular roles of both mobility and therapeutic places were never completely displaced by ‘new’ forms of knowledge and practices, and in the 20th century were often revived in various contemporary forms. Bodies, minds and belief systems were rarely disconnected. This often took a form where more spiritual and less strenuous activities, such as yoga and massage, once primarily the province of some Asian countries, became absorbed into Western practices with health and well-being becoming more holistic phenomena. Nurturing the mind and the spirit in various ways, for long an important part of tourism, resurfaced in new forms.
Physical and mental well-being are crucial to good health and to health and medical tourism in their many manifestations. Much of health tourism involves various forms of relaxation: diet, exercise and new modes of thought. Although bodies (and minds) were sometimes transformed they were not transformed by surgery or other dramatic procedures. While spirituality may be at the core of health and well-being for some, medical tourism focuses on more physical matters, where the emphasis is very much on biophysical processes, though psychological issues are highly important and spiritual elements are not entirely absent. Some variants of medical tourism, such as cosmetic dentistry, however, may be seen as little to do with health, even for those involved, since they lack dramatic, invasive procedures, and have no ‘medical’ component, and they are given less attention in what follows.
Medical tourism represents only one prong of the growing expansion of global health care. Such medical trade also includes doctors traveling to other countries or regions to offer services, medical corporations investing and developing facilities in remote destinations, and the current and growing practice of tele-medicine in which X-rays are read, diagnoses are made, and even robotic operations are conducted from afar. However, there is little doubt that the phenomenon of travelers seeking medical treatment has the greatest economic impact on a region, both in terms of health and hospitality income gained from such travelers.
Successful medical treatment serves as the primary goal of medical tourism. It is the core competency of hospitals while a hospitality team has expertise in customer care. Both teams have competitive methods to reinforce their core competence and enhance their strengths. However, the greater success in medical tourism is to align these two core competencies from both parties. Productivity and efficiency can be maximized by the alignment. Also, success in medical treatment and memorable customer care are compensating each other to deliver excellent medical tourism experience.
Medical tourism is far from being a recent phenomenon; people have been travelling to access health care in faraway places for centuries. Traditionally, wealthy people travelled from poorer countries, with basic health care facilities, to higher income countries that offered a better range of high-quality services. However, there has been a recent reversal in the direction of travel, with patients travelling from high-income countries in North America and Europe to low- and middle-income countries in Latin America and Asia. This new trend is driven by the ability of private facilities in lower income countries to offer high-quality services, with virtually no waiting time, at a comparatively low cost.
However, despite the ‘hype’ in the media regarding medical tourism, it is worth noting that the majority of this type of trade actually takes place regionally. For instance, patients from the US and Canada often go to destinations such as Brazil and Costa Rica; Western European patients travel to Eastern Europe; and patients from the Gulf countries and Pakistan travel to South and South East Asia, mainly India and Thailand. In addition to regional proximity, the country’s specialty also plays a role in patients’ decision of where to access care. This is because destination countries have specialised in certain procedures. For instance, Thailand and India specialise in orthopaedic and cardiac surgery, whereas Eastern European countries are hotspots for dental surgery.
Compared to other countries of the world, and even to other Western industrialized countries, the majority of citizens in the European Union enjoy excellent, or at least relatively good, coverage of health care and health care costs. However, a closer look reveals a much more differentiated picture. Growing demand of an aging population for health care services and products, growing supply of innovative technology and pharmaceuticals, and increasing health awareness of patients lead to rising expenses for public health care while at the same time rising unemployment rates and increasing state debts reduce the ability of governments to strengthen or even stabilize the financial resources of national health care systems. The answer of European Union Member States is continuous health care reforms focused on cost-containment. The measures include a reduced scope of coverage of public health care, increased insurance rates and/or co-payments—and in some cases rationed care.
The legal context in which cross-border health care in Europe takes place has primarily been given form over time more by economic interests, legislation and jurisprudence than health policies at EU or Member State level. In some sense, therefore, it is a paradox that cross-border care within the EU is deﬁned as much by citizens’ rights as consumer forces.
In many ways, EU citizens consuming health care in a Member State other than their own are no different than any patient travelling for care throughout the world. The European patient may indeed travel to another Member State as a consumer – as many do – to obtain services that are cheaper, better or more accessible in a Member State other than their own.
This process is arguably highly consistent with the original economic intentions and treaty agreements at the heart of the EU and the process of integration that the Union embodies. The EU was founded to secure the free ﬂow across borders of people, money, goods and services.
Medical tourism is niche tourism, like ecotourism, religious tourism, and adventure tourism. Such tourism does not draw masses but rather it appeals to a select number of people whose demand is big enough to generate sufﬁcient business. Medical tourism, with its component medical and tourist parts, has both a market and an audience. Unlike ecotourism, in which a traveler will choose a destination and then seek an ecology focus, in medical tourism the traveler chooses medical care ﬁrst, and only then pairs it with a destination and possibly even a vacation tie-in. As all tourism is goal oriented (in the sense that travelers want to see a sight, or experience a tribal encounter, or touch a historical artifact, or simply party), so too medical tourism occurs with a speciﬁc goal in mind. The traveling patient aims to purchase a particular service and to achieve a deﬁned health goal. That patient seeks to maximize utility subject to his income constraints. In that calculation, medical services dominate, but nonmedical services, including the accommodations, restaurant meals, excursions, and ground transportation, are not insigniﬁcant to the total experience.
In his efforts to minimize costs of health care, the patient has become a tourist. In his efforts to maximize utility, Homo Turisticus has become a niche seeker. That particular niche calls for a seamless integration between the medical and the hospitality industries. The result of this integration is the market for medical tourism.
Medical tourism on a large scale is a recent manifestation of service trade that has grown to considerable economic signiﬁcance at the international level. Destinations are no longer conﬁned to poster child examples in East Asia that were frequented by American, British and regional residents but now extend to numerous countries worldwide that consider themselves and foster their roles as hubs, such as Dubai and Hungary.
There is ample motivation for protagonists in the health care market to scrutinize medical tourism: Patients may beneﬁt from access to higher-quality care or reduced self-payments; public providers may generate extra-budgetary income; private providers may generate both extra income and build a reputation with medical tourists as they are expanding abroad; providers may productively employ a mobile international workforce in an international environment; and insurers may differentiate their services and pursue both quality assurance and cost containment strategies .At the aggregate level, medical tourism may entail both private and public savings through outbound medical tourism or provide cross-funding of domestic services and advanced technology via inbound patients. At a time when both demographics and rapid technological progress strain public resources, medical tourism may alleviate some of that pressure. As a sophisticated service export, medical tourism may further serve as an important driver of economic growth.
Medical tourists are very good targets of opportunities for pathogens. Many are traveling with compromised or suppressed immune systems to destination countries with relatively high infection rates, including the risk of exposure to multi-drug–resistant pathogens. In medicine, it is common to distinguish commensals — the bugs we normally carry on our skin, mouth, digestive tracts, etc. — from pathogens, the harmful bacteria that cause disease through infection. When traveling for medical care, “one person’s commensal bacteria can be another individual’s exotic pathogen.” Medical tourist patients are transporting their commensals and pathogens to the hospital environments of the destination countries to which they travel, and are exposed to the commensals and pathogens of the health care providers, hospitals, and population at large in the destination country. The tourist patients may then bring the unwanted “hitchhiker” home with them to the destination country. The result is that “at any point in the circular migration of patients traveling for medical care, microbes may travel from one location where they constitute a harmless bacteria, or at least a known and treatable infection, to another where they are unknown, making diagnosis and treatment much more problematic.”
Marketing medical tourism and other healthcare services is somewhat different than offering retail products that are often considered tangible goods. In the most general sense, a product is anything that can be offered to the market to satisfy a patient’s need or want. As such, this can include physical goods, such as walkers, wheelchairs, canes, crutches, braces, stem cells, organ transplants, pharmaceutical drugs, and supplies. It can also include services such as surgery, executive checkup, golf swing analysis, diagnostic tests, or even a consultation. For a medical tourism facilitator, a product could be defined as a wellness checkup combined with a cruise, winery tour, amusement park, cooking class, or any other combination experience that can be paired with a medical service such as a massage or spa visit. It could also be interpreted to mean something like a hen night mammography group experience, where a group of women get together, have their mammograms, and then go out for a spa getaway, a night on the town, a weekend away, or some other experience that they share together. In medical tourism, many times we see this type of activity when a group of executive women get together and decide to go off to an exotic place to have a Botox weekend.
Medical tourism is a concept that encompasses travel primarily motivated by the use of medical services (a greater or lesser degree of complexity) – dental, surgical, rehabilitation etc. In recent decades, the emergence of a greater number of people motivated by the use of medical services began to travel beyond the borders of their own state, meta phenomenon has become a focus of media interest and has sparked a stronger expansion of intermediaries in the provision of relevant services (agencies), as well as the expansion of commercial medical service providers that are more or less focused on users from abroad. Combination of different factors – high cost of health care outside the public health system in developed countries of the West, lack of access to certain medical services outside the public health system and/or obligatory/commercial insurance systems, ease and lower prices for international travel, faster development of medical technology and standards care in some countries, have led to an increase in the popularity of such travels.
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