Medical tourism is on the rise; however this healthcare trend raises significant issues related to the safety and appropriateness of care. Medical tourists travel to undergo executive health evaluations, ophthalmologic care, cosmetic dentistry and oral surgery, joint resurfacing or replacement, cardiac surgery, organ and stem cell transplantation, gender reassignment surgery, and in-vitro fertilization.

Medical tourism has been defined as travel with the express purpose of obtaining health services abroad. Although medical tourism may also be defined as travel for the purpose of delivering healthcare (Bishop & Litch, 2000; Comarow, 2008), this article will focus on medical tourism that seeks to obtain healthcare in another country.

The purpose of this article is to provide healthcare professionals with a better understanding of the phenomenon of medical tourism. The authors will begin by reviewing the history of medical tourism, noting specific medical tourism destinations, and presenting various reasons for this increase in medical tourism. Next they will discuss quality and safety issues associated with medical tourism, provide criteria to assess quality of care in other countries, and address ethical and legal consideration inherent in medical tourism. They will conclude by considering the nursing role in medical tourism.

History of Medical Tourism

...historical accounts abound with reports of those who have traveled to seek improvement for their health. Medical tourism is not a new phenomenon. Even in ancient times, people traveled to other countries for health-related purposes (Bookman & Bookman, 2007; Horowitz, Rosensweig, & Jones, 2007). The ancient Greeks and Egyptians went to hot springs and baths to improve their health. The first recorded case of medical tourism describes Greek pilgrims who traveled from the Mediterranean Sea to Epidaurus, a small territory in the Sardonic Gulf. It was said that this small territory was the sanctuary of Asclepius, known as the healing god. Since the 1500s India has enjoyed a rich history of providing yoga instruction as well as Ayurvedic healing to patients from around the world. In the 18th and 19th centuries, Europeans and Americans flocked to health spas and sanitariums, sometimes in remote places, in the hope that they would obtain relief from their disabling conditions, such as tuberculosis, gout, bronchitis, or liver diseases. Especially in Europe, well-to-do people, over the years, have traveled to spas to “take the waters” for various cures. In summary, historical accounts abound with reports of those who have traveled to seek improvement for their health.  

However, traveling for the purpose of receiving treatments, such as dental surgery, cosmetic surgery, and other complex procedures is a relatively new phenomenon, having begun only in the 1980s (Horowitz  & Rosensweig, 2007; Smith & Puczko, 2008). Such travels are becoming increasingly common today, as patients seek more affordable healthcare options and/or options other than those offered in their home country.

Current Medical Tourism Destinations

Many countries today are seeking to compete successfully in the medical tourism marketplace by advertising a wide variety of medical, surgical, and dental services in comfortable, modern facilities. Table 1 lists popular medical tourism destinations around the world.

Several countries in Central and South America have developed strong reputations for cosmetic and plastic surgery and dental care (Hancock, 2006; Schult, 2006; Woodman, 2007). Some destinations in Asia are particularly popular for orthopedic and cardiac surgeries. Thailand, India, and Israel are well-established medical tourism destinations, attracting large numbers of foreign patients and generating substantial revenue from the services provided. These countries have large, modern medical facilities that are staffed by well-trained physicians who perform complex procedures, such as minimally invasive/off-pump heart surgery, correction of congenital cardiac abnormalities in children, thoracic organ transplantation, and implantation of mechanical cardiac devices (Appleby & Schmidt, 2006; Lancaster, 2004). Thailand’s international hospitals have a reputation for having modern, high-tech equipment, excellent quality medical care, and superior hospitality services (Horowitz et al., 2007; Horowitz & Rosensweig, 2007). India has a reputation for high quality care in a number of major hospitals (Connell, 2006; Horowitz & Rosensweig); and Israel has emerged as a popular, medical tourism destination due its reputation for the high standards in the care that it offers (Edelheit, 2008; Fried & Harris, 2007). Israel is well situated geographically with relatively easy flight access from Europe, Africa, and Asia. Many of Israel’s facilities maintain regular contacts with major medical and scientific research centers abroad; and Israel is frequently the host venue for international conferences focusing on a variety of medical topics (Gradstein, 2008).

Table 1. Popular medical tourism destinations around the world.

Reasons for the Increase in Medical Tourism

Medical tourism has become a US$60 billion dollar-a-year business and is growing by 20% each year (Jones & Keith, 2006; MacReady, 2007). The spiraling high cost of healthcare, has contributed to this worldwide explosion of medical tourism (Connell, 2006; Garcia-Altes, 2005). Widespread Internet access has enabled consumers worldwide to purchase a North American or Western European standard of healthcare (Roberts, Calhoun, Jones, Sun, & Fottler, 2000). MacReady predicts businesses and governments in developed countries will soon join the trend, “outsourcing” medical services to low-cost providers abroad. Other countries recognize the inadequacy of their own public health systems in meeting citizens' needs; they are piloting programs and exploring options to provide new private healthcare options.

Medical tourists believe that for a considerably lower cost and with a shorter waiting period they can obtain treatment that is equal to, if not even better than what they would receive at home. The fundamental premise of medical tourism is that the same care, or even better quality of care, may be available in other countries, and obtained at a more affordable cost than in the home country (Medical Tourism Association, 2008). Medical tourists believe that for a considerably lower cost and with a shorter waiting period they can obtain treatment that is equal to, if not even better than what they would receive at home (Horowitz & Rosensweig, 2007; MacReady, 2007).

This lower cost is especially important for a patient who does not have health insurance and for whom a procedure may be financially crippling in the home country, but affordable in another one. One such example is coronary artery bypass surgery. The estimated cost of this surgery in the United States (US), one of the countries for which such statistics are available, is US$150,000, while the total cost of surgery and a 20 day stay in India, is cited as US$10,000 (Herrick, 2007).

According to the National Coalition on Health Care (NCHC), long waiting lists also serve as a catalyst for many citizens to seek care overseas. For that reason approximately 500,000 Americans alone traveled overseas in 2007 for medical treatment (NCHC, 2007). Nor is this phenomenon exclusive to the US. Large numbers of Britons also seek care overseas (Terry, 2006). Donnelly and Sawer (2007) reported that, in 2007, 70,000 Britons traveled overseas for treatment for diverse surgical procedures including cataracts, hip operations, and cardiac surgery.

The typical medical tourist is described as someone aged 50 years or more and in need of an elective surgical or medical procedure. Elective procedures commonly offered include rhinoplasty, dental care, fertility treatment, and breast enlargement (Public Citizens Health Research Group, n.d.). These patients are unwilling or unable to pay for the necessary care at home, or endure long hospital waiting times that are typical of some countries. While the patient's budget may have limits, it can accommodate travel to a developing country for good care at a reasonable price (Horowitz & Rosensweig, 2007; MacReady, 2007).

However, medical tourism today may...include life-saving surgery, such as coronary artery bypass surgery. However, medical tourism today may also include life-saving surgery, such as coronary artery bypass surgery. The Save A Child's Heart Program at Edith Wolfson Hospital in Israel is a humanitarian program that funds cardiac surgery for children. Children from Rwanda, Lebanon, and Sudan, among other countries, are subsidized by a special fund that enables the children to receive the complex cardiac surgery in Israel that is not available in their home countries (Leyden, 2009). As medical tourism increases, organ transplant tourism is also a growing phenomenon (Cohen, 2009). However, receiving an organ transplant abroad does raise a number of issues, including ongoing care of the patient as well as the source of the organs used.

Another feature of medical tourism, namely distance from home, may offer desired anonymity. Some medical procedures, such as gender changes, have become small but significant parts of medical tourism, especially in Thailand, where recuperation and the consolidation of a new identity may be better experienced at a distance from standard daily life (Connell, 2006).

For some countries, the rationale for engaging in medical tourism is to improve their Gross Domestic Product (GDP) as  overseas patients bring needed cash to pay for procedures. GDP is the primary indicator used to gauge the health of a country's economy (Investopedia 2009a, 2009b, 2009c). It represents the total dollar value of all goods and services produced over a specific time period. Another commonly cited reason to support the marketing of medical tourism is the belief that overseas patients expect an even higher standard of care than had been typical their home country, thus prompting hospitals to upgrade their institutions so as to remain competitive in a thriving market. Theoretically, the money derived from this source should be used to upgrade health services for local patients. However, that may not always be the case.

Although this business of medical tourism can provide lifesaving care, it ultimately, remains a business enterprise to import currency... As a consequence of the development of medical tourism, a number of countries actively advertise their services and have companies that specialize in arranging overseas medical care (Cortez, 2008). These countries market various procedures as an attractive package that combines both hospital care and also tourist activities. They recognize that individuals and/or family members may spend additional money on tourist pursuits both while care is being provided and after the care has been completed.

Today many countries are engaged in medical tourism, and vast numbers of patients are seeking care outside their home country (Connell, 2006; Cortez, 2008; Horowitz & Rosensweig, 2007). Although this business of medical tourism can provide lifesaving care, it ultimately, remains a business enterprise to import currency, especially if the procedures offered are approved by the patient’s healthcare funder/insurance provider.

Quality and Safety in Medical Tourism

Although medical tourism offers benefits for many patients, quality-of-care issues abound. Many of the hospitals that advertise heavily to medical tourists are in low-cost, developing countries that may be experiencing social, political, and cultural issues. These issues may detract from the quality of care received, thus resulting in a less than optimal environment for the medical tourist seeking quality care (Forgione & Smith, 2007). However, each situation needs to be assessed individually. Donnelly and Sawer (2007) noted that patients who had undergone medical procedures in India reported that hospitals in India had already introduced screening policies for Methicillin-Resistant Staphylococcus Aureus (MRSA) which at that point in time had not yet been introduced in Britain.

Although medical tourism offers benefits for many patients, quality-of-care issues abound. Another cause for concern regarding medical tourism is the often lengthy airplane trips needed to arrive at a far-away country. These long trips have been associated with known health risks, such as lung disease and thrombosis. The lower oxygen level in airplanes could be problematic for a patient with lung disease taking a 14-hour flight to a developing country. Long flights can also contribute to the development of deep-vein thrombosis (DVT). Both of these conditions are of serious concern for surgical patients (Patient United Kingdom, 2006; Reed, 2008).

Concerns have also been voiced regarding complications that might result from vacation activities and travel in the postoperative period. There is a need to address both the management of postoperative complications occurring after a patient leaves a foreign medical facility, and also the resulting financial costs associated with such care. These complications present difficult issues that remain unresolved and merit further investigation and discussion to better establish the true economic benefit of medical tourism for patients (MacReady, 2007).

Other quality of care issues include appropriate follow-up care, as well as adequate communication between providers and patients. Provisions to assure the quality of this long-term, follow-up care, and also to provide for the cost of this care need to be considered to before undergoing procedures in other countries. Cultural barriers and language, including medical jargon, may be problematic, even with the assistance of interpreters. Serious misunderstandings may occur on both the part of the patient and the provider. Both the patient and provider need to share with each other all the necessary information before initiating the procedure designed to promote quality outcomes.

Another issue to address is the quality of the hospital environment. Patients should carefully assess the quality and the standards that they expect and have been promised. This assessment should include the environment outside the hospital. In some countries the quality of the water and the air, as well as hygienic standards, may be quite different from patients’ expectations and may compromise their convalescence. For example, the World Health Organization (2008) has reported that data collected in 2006 from 132 countries demonstrated that 31 countries (or 23.5%) have less 100% screening for at least one of four common infection markers: HIV, HBV, HCV, and syphilis. WHO noted that many countries cannot provide complete information related to the screening process; even with testing of blood products, the testing process may often be incomplete or lack a quality assurance mechanism. Thus, patients risk becoming sicker through their travel to another country, rather than gaining an improved state of health.

Guidelines for Selecting Medical Tourism Sites

Although well-trained physicians and modern, well equipped hospitals provide high quality care in a number of medical tourism destinations, medical tourists, faced with a variety of medical institutions in numerous countries around the world, may find it very difficult to identify the well trained healthcare providers and modern hospitals that consistently provide high quality care (Aiken, Clarke, Cheung, Sloane, & Silber, 2003). It is a critical challenge for potential medical tourists to select the best possible destination for the specific service(s) needed. It also remains a daunting task for patients considering medical care abroad to differentiate desirable destinations from those having incompetent practitioners working in unsafe facilities. Some help may be gained from medical tourism agents who have backgrounds in healthcare, and who are knowledgeable regarding the quality and outcomes of care achieved in different countries and by different medical institution abroad.

The type of accreditation held by various institutions can provide guidance in selecting the most appropriate institution. The Joint Commission International (JCI), a subsidiary of the U.S. Joint Commission, which assesses and accredits healthcare organizations in the US, accredits international healthcare facilities and also provides educational and consulting services to hospitals around the world. The JCI has recently accredited hospitals in Turkey, Thailand, and Singapore (MacReady, 2007; Medical Tourism Canada, 2004).The number of JCI-accredited hospitals outside of North America has increased from three accredited hospitals in 2000 to seventy one accredited facilities in 2006 (MacReady). Both the JCI and the International Organization of Standardization (ISO) are able to provide useful and reassuring benchmarks for patients in selecting offshore medical facilities (Connell, 2006; Forgione & Smith, 2007; Horowitz & Rosensweig, 2007).

...professional websites are...helpful in identifying quality care. Certification and professional websites are also helpful in identifying quality care. The International Society of Plastic Surgery certifies approximately 1,500 surgeons in 73 countries who meet U. S. standards of care. The American Dental Association website includes information addressing travel, dental care, and dental tourism. This site provides a link to A Traveler’s Guide to Dental Care, which is available through the Global Dental Safety Organization for Safety and Asepsis Procedures (Reed, 2008).

The American Medical Association (AMA) has developed guiding principles for employers, insurance companies, and other bodies that facilitate or offer incentives for care outside the US. These principles were adopted at the June 17, 2008, annual session of the AMA. The principles stipulate the following:

• international care must be voluntary and provided by accredited institutions
• financial incentives should not limit or restrict patient options inappropriately
• continuity of care, including coverage of costs upon return, should be provided 
• patients should be informed of their rights and legal recourse before travel
• patients should have access to licensing, outcome, and accrediting information when seeking care
• medical record transfers should comply with the Health Insurance Portability and Accountability Act guidelines
• patients should be informed of the potential risks of combining surgical procedures with long flights and vacation activities (Reed, 2008).

Jutabha (2007) recommended that professionals apply a checklist called "The Four D’s,” when investigating a hospital outside their country. These Four D’s include: Domain, Doctors, Data, and Disaster. A summary of these D’s and the other criteria we have discussed above is presented in Table 2.

Table 2. Criteria for Assessing Quality of Care.

Ethical and Legal Considerations in Medical Tourism

Despite the benefits of lower cost and decreased waiting periods for medical tourists, ethical dilemmas associated with this tourism must be acknowledged. Despite the benefits of lower cost and decreased waiting periods for medical tourists, ethical dilemmas associated with this tourism must be acknowledged. One of the most significant of these dilemmas may be the disproportionate siphoning of technology to the private sector for the care of international patients (Morgan, 2001). When this happens, the local population does not benefit from the currency injected into the system because those funds must be used to continue to support the care required for international patients. The ethical principle of respect for persons may thus be violated (Beauchamp & Childress, 2000).

A legal concern may be the lack of legal resources available to the medical tourist patient. Should a patient experience a preventable, adverse event as a result of receiving care overseas, there may be limits to the damage award the patient can receive. In such cases, the hospital staff may be protected from any litigation and the patient will suffer the damage with no legal recourse and no financial compensation (Cartwright, 2000; Richter, 1999). The principle of nonmaleficence, primum non nocere, commonly translated as "first, do no harm," is called into question in these situations (Beauchamp & Childress, 2000).

The Nursing Role

Nurses have a dual role in medical tourism, namely to help clients find appropriate sites in which to obtain the desired care in other countries and also to warn clients of possible risks and ethical/legal dilemmas. Serving as a client coordinator may become a more common nursing role in medical tourism as this phenomenon expands. However, despite an extensive search, we found no literature that discusses this role in either nursing or medicine.

Considering the ethical and legal questions noted above, along with the probability that medical tourism will continue as a growth area in healthcare, it is necessary to raise important questions regarding this role. Questions to ask include the following:

• What qualifications are required for a nurse working in medical tourism? 
• Do these qualifications include advanced clinical skills, business skills, and a strong background in transcultural nursing?
• What preparation should the nurse undertake for this role?
• What are the particular challenges associated with nursing in this context?

It is important to ask whether nurses involved in medical tourism are aware of the potential medical/ethical/legal issues previously cited or whether they merely believe they are actively contributing to the care of those who would not receive needed care in their home country. Programs should be developed to better prepare nurses for the many responsibilities involved in this growing medical tourism industry. It would be reasonable to expect such a course of study would include strong transcultural elements, as well as business and management studies, and ethical and legal discussions that relate to the care of patients in such circumstances.

Programs should be developed to better prepare nurses for the many responsibilities involved in this growing medical tourism industry. Nurses who wish to learn more about medical tourism can do so in several ways. A first step would be to enhance their knowledge base and skills in business and management because medical tourism is essentially a business. Nurses interested in this field are also encouraged to search the Internet to identify hospitals that have medical tourism centers and to contact nurses that work directly in these centers. Additionally, attending conferences designed for health professionals interested in medical tourism would be a valuable step in learning more about this field. Recently there have been several conferences focusing on medical tourism for health professionals. Nurses can gain valuable information by attending the various lectures presented at these conferences and also by making contacts with others in the field to learn firsthand from professionals already experienced in medical tourism.

Summary and Conclusion

Medical tourism is likely to increase over the next decade as more patients are able to access the Internet and acquire information relevant to care offered overseas at an affordable price. While some patients will benefit immensely from treatment as a medical tourist, many legal and ethical issues will also arise. Nurses need to familiarize themselves with the benefits of medical tourism while also acknowledging its inherent dangers. Potential medical tourists will benefit from the services of a knowledgeable health professional in their home country who can discuss the many issues that relate to this medical tourism. It is expected that medical tourism will provide a new role for nurses as this healthcare trend expands around the world.

Authors

Merav Ben-Natan, RN, BA, MA, PhD
E-mail: meraav@hy.health.gov.il

Dr. Merav Ben-Natan is a lecturer at the Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, and an instructor at the Department of Nursing in Tel Aviv University. She received her BA and MA degrees from the Department of Nursing at Tel Aviv University, and her PhD from Haifa University. Dr. Ben-Natan’s research interests include the phenomenon of medical tourism, transcultural nursing, women’s health, and elder abuse.

Ellen Ben-Sefer, RN, BS, MN, PhD
E-mail: ebensef@yahoo.com.au

Dr. Ellen Ben-Sefer received her baccalaureate degree from Boston University, her MN from the University of Western Sydney in child and family health nursing, and her PhD from Macquarie University, both in Sydney, Australia. Until recently she served as a Senior Lecturer and Coordinator of Children’s Nursing at the University of Technology in Sydney. She currently is Senior Lecturer at Schoenbrun College of Nursing, an Affiliate of Tel Aviv University, and a coordinator of research projects. When Dr. Ben-Sefer worked at Hadassah Hospital in Jerusalem a number of years ago, she often saw children coming from other countries, especially Iran in those days, but also a variety of other places and still recalls how challenging it was to care for these patients from other countries. She has recognized that today medical tourism is an emerging trend in healthcare, and that we need to take a serious look at this trend as it emerges so that our patients can receive the best care possible wherever they seek their healthcare.  

Malka Ehrenfeld, RN, PhD
E-mail: ehrenfel@post.tau.ac.il

Dr. Malka (Mally) Ehrenfeld is currently the head of the department of Nursing, Tel-Aviv University in Israel, and an Associate Professor of Nursing at the University. She earned her RN at the Hadassah-Henrietta Szold School of Nursing, followed by her BA and Master of Public Health degrees at the Hebrew University in Israel. She then received her PhD from the University of Toronto in Canada. In addition to her clinical work as a nurse at the Hadassah University Hospital in Jerusalem, she has served as a founding member of the small group that opened the first generic program of nursing in Israel, and coordinator, at the Tel Aviv University, of the generic nursing program, the Master's program, and the PhD program. Later she became the director of the Department of Nursing at the School of Health Professions in the Tel Aviv University. Among her international activities, Dr. Ehrenfeld serves as the national Israeli representative for the International Council of Nurses and the Workgroup of European Nurse Researchers. She has published extensively and presented papers at national and international nursing conferences. Her specific fields of interest include nursing education, public health, and women's health with a focus on health promotion.