Evidence on global medical travel

Ruggeri, Kai; Záliš, Ladislav; Meurice, Christopher R; Hilton, Ian; Ly, Terry-Lisa; Zupan, Zorana; Hinrichs, Saba

doi:10.2471/BLT.14.146027

Abstracts

The potential benefits of travelling across national borders to obtain medical treatment include improved care, decreased costs and reduced waiting times. However, medical travel involves additional risks, compared to obtaining treatment domestically. We review the publicly-available evidence on medical travel. We suggest that medical travel needs to be understood in terms of its potential risks and benefits so that it can be evaluated against alternatives by patients who are seeking care. We propose three domains -quality standards, informed decision-making, economic and legal protection - in which better evidence could support the development of medical travel policies.

Les avantages potentiels de la traversée de frontières nationales pour recevoir un traitement médical résident notamment dans une meilleure prise en charge, des coûts moindres et des temps d'attente réduits. Il est cependant plus risqué de voyager pour bénéficier de soins médicaux que de recevoir un traitement à l'intérieur du pays. Nous avons analysé les données scientifiques publiquement disponibles concernant le tourisme médical. Il nous apparaît essentiel de considérer le tourisme médical en fonction de ses risques et de ses avantages potentiels afin que les patients qui nécessitent des soins puissent le comparer aux autres solutions possibles. Nous estimons que l'amélioration de la qualité des données scientifiques dans trois domaines - normes de qualité, prise de décision éclairée et protection économique et juridique - favoriserait l'élaboration de politiques relatives au tourisme médical.

Los posibles beneficios de cruzar las fronteras nacionales para obtener tratamientos médicos incluyen una mejora de la atención, una disminución de los costes y una reducción de los tiempos de espera. Sin embargo, el turismo sanitario implica riesgos adicionales en comparación con obtener el tratamiento en el país. Se revisaron los datos públicos sobre el turismo sanitario. Nuestra sugerencia es que el turismo sanitario se entienda en términos de sus posibles riesgos y beneficios, de modo que aquellos pacientes que busquen atención médica puedan evaluarlos frente a otras alternativas. Proponemos tres ámbitos (normas de calidad, toma de decisiones informada y protección económica y legal) en los cuales unos datos más claros podrían apoyar el desarrollo de las políticas para el turismo sanitario.

تشمل المنافع المحتملة للسفر عبر حدود الدول للحصول على العلاج الطبي خدمات الرعاية الصحية المحسَّنة، والتكاليف المخفضة، وفترات انتظار أقصر. وعلى الرغم من ذلك، تتضمن السياحة لأغراض طبية بعض المخاطر الإضافية مقارنةً بالحصول على العلاج داخل الدول. وقد أجرينا مراجعة للأدلة المتاحة على المستوى الحكومي فيما يتعلق بالسياحة لأغراض طبية. ونشير إلى الحاجة إلى فهم السياحة لأغراض طبية في إطار المخاطر والمنافع المحتملة لها، ومن ثم يمكن للمرضى الباحثين عن خدمات الرعاية الصحية تقييمها بالمقارنة بغيرها من البدائل. كما نطرح ثلاثة محاور - وهي معايير الجودة، واتخاذ القرارات المستندة إلى المعلومات، والحماية القانونية والاقتصادية - والتي يمكن من خلالها دعم وضع سياسات السياحة لأغراض طبية اعتمادًا على الأدلة.

跨国医疗旅游的潜在好处包括获得更加优质的护理服务、更低的花费和更短的等待时间。但是，与在国内就医相比，医疗旅游存在一些额外的风险。通过审查现有医疗旅游的证据，我们建议寻求医疗护理的患者全面了解医疗旅游的潜在风险和好处，以便与其他医疗方式进行对比评估。我们提议从质量标准、科学的决策制定、经济和法律保护三个方面入手，这三方面的良好证据能够为医疗旅游政策的制定提供支持。

Потенциальные преимущества поездки за границу с целью получения лечения включают лучший уход, снижение затрат и меньшее время ожидания лечения. Однако медицинский туризм подразумевает и дополнительные риски в сравнении с лечением дома. Нами были рассмотрены имеющиеся в общественном доступе свидетельства относительно поездок с медицинскими целями. Мы предлагаем рассмотреть медицинский туризм с точки зрения риска и пользы, чтобы пациенты, нуждающиеся в лечении, могли оценить их и сравнить с альтернативными вариантами. Мы предполагаем три области оценки: стандарты качества, принятие информированного решения, экономическую и юридическую защиту, - в которых наличие лучших свидетельств послужит поддержкой при разработке принципов медицинского туризма.

Introduction

Medical travel is projected to expand globally in the next decade.¹1. Keckley PH, Underwood HR. Medical tourism: consumers in search of value. Washington: Deloitte Center for Health Solutions; 2008. Available from:Available from: http://medicaltourisminturkey.org/panel/Panel1/3Deloitte.pdf [cited 2015 Feb 12].
http://medicaltourisminturkey.org/panel/... ^,²2. KPMG. Issues monitor: Medical tourism gaining momentum. In: KPMG International Issues monitor. London: KPMG; 2011. Available from: Available from: https://www.kpmg.com/CH/en/Library/Articles-Publications/Documents/Sectors/pub-20120207-issues-monitor-healthcare-medical-tourism-en.pdf [cited 2015 Feb 12].
https://www.kpmg.com/CH/en/Library/Artic... Citizens in the United States of America, for instance, already receive significant volumes of services abroad, both for urgent and elective procedures.³3. Alleman BW, Luger T, Reisinger HS, Martin R, Horowitz MD, Cram P. Medical tourism services available to residents of the United States. J Gen Intern Med. 2011 May;26(5):492-7. http://dx.doi.org/10.1007/s11606-010-1582-8PMID:21161425
http://dx.doi.org/10.1007/s11606-010-158... The growth in medical travel is largely due to improved availability of health technology, decreasing costs for travel and advertising by companies wishing to attract patients.⁴4. Alsharif MJ, Labonté R, Lu Z. Patients beyond borders: A study of medical tourists in four countries. Glob Soc Policy. 2010;10(3):315-35.http://dx.doi.org/10.1177/1468018110380003
http://dx.doi.org/10.1177/14680181103800... ^,⁵5. Cattaneo O. Trade in health services: What's in it for developing countries? [World Bank policy research working paper 5115]. Washington: The World Bank; 2009. Available from: Available from:https://openknowledge.worldbank.org/bitstream/handle/10986/4305/WPS5115.pdf?sequence=1 [cited 2015 Sep 3].
https://openknowledge.worldbank.org/bits... Medical tourism has been described as "travel across international borders with the intention of receiving some form of medical treatment. This treatment may span the full range of medical services, but most commonly includes dental care, cosmetic surgery, elective surgery and fertility treatment."⁶6. Lunt N, Smith R, Exworthy M, Green ST, Horsfall D, Mannion R. Medical tourism: treatments, markets and health system implications: a scoping review. Paris: Organisation for Economic Co-operation and Development; 2011. Available from: Available from: http://bit.ly/1Fuf1NH [cited 2015 Feb 12].
http://bit.ly/1Fuf1NH...

Some authors distinguish between medical tourism (travel for wellness, cosmetic or other non-essential procedures) and medical travel (travel with the purpose of receiving treatment that, in the opinion of a health professional, is essential to maintain quality of life). For the purposes of this paper, we define medical travel as including both essential and non-essential treatment. Although it is clear that cost, accessibility and quality are the main motivating factors for medical travel, data are largely limited to anecdotal projects from the perspective of a single country.³3. Alleman BW, Luger T, Reisinger HS, Martin R, Horowitz MD, Cram P. Medical tourism services available to residents of the United States. J Gen Intern Med. 2011 May;26(5):492-7. http://dx.doi.org/10.1007/s11606-010-1582-8PMID:21161425
http://dx.doi.org/10.1007/s11606-010-158... ^,⁷7. Lunt NT, Mannion R, Exworthy M. A framework for exploring the policy implications of UK medical tourism and international patient flows. Soc Pol Admin. 2013;47(1):1-25. http://dx.doi.org/10.1111/j.1467-9515.2011.00833.x
http://dx.doi.org/10.1111/j.1467-9515.20...

8. Bisht R, Pitchforth E, Murray SF. Understanding India, globalisation and health care systems: a mapping of research in the social sciences. Global Health. 2012;8(1):32. http://dx.doi.org/10.1186/1744-8603-8-32PMID:22963264
http://dx.doi.org/10.1186/1744-8603-8-32...

9. Lunt N, Carrera P. Medical tourism: assessing the evidence on treatment abroad. Maturitas. 2010 May;66(1):27-32. http://dx.doi.org/10.1016/j.maturitas.2010.01.017PMID:20185254
http://dx.doi.org/10.1016/j.maturitas.20...

10. Hanefeld J, Smith R, Horsfall D, Lunt N. What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. J Travel Med. 2014 Nov-Dec;21(6):410-7. http://dx.doi.org/10.1111/jtm.12147PMID:25156070
http://dx.doi.org/10.1111/jtm.12147...

11. Turner L. First world health care at third world prices: globalization, bioethics and medical tourism. Biosocieties. 2007;2(3):303-25.http://dx.doi.org/10.1017/S1745855207005765
http://dx.doi.org/10.1017/S1745855207005... ^-¹²12. Hanefeld J, Horsfall D, Lunt N, Smith R. Medical tourism: a cost or benefit to the NHS? PLoS ONE. 2013;8(10):e70406. http://dx.doi.org/10.1371/journal.pone.0070406PMID:24204556
http://dx.doi.org/10.1371/journal.pone.0... While some data on transnational health-care practices are available,¹⁰10. Hanefeld J, Smith R, Horsfall D, Lunt N. What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. J Travel Med. 2014 Nov-Dec;21(6):410-7. http://dx.doi.org/10.1111/jtm.12147PMID:25156070
http://dx.doi.org/10.1111/jtm.12147... ^,¹³13. Bell D, Holliday R, Ormond M, Mainil T. Transnational healthcare, cross-border perspectives. Soc Sci Med. 2015 Jan;124:284-9.http://dx.doi.org/10.1016/j.socscimed.2014.11.014PMID:25467880
http://dx.doi.org/10.1016/j.socscimed.20... current data on the outcomes of medical travel are insufficient and rarely generated using rigorous methods.¹⁴14. Johnston R, Crooks VA, Snyder J, Kingsbury P. What is known about the effects of medical tourism in destination and departure countries? A scoping review. Int J Equity Health. 2010;9(1):24. http://dx.doi.org/10.1186/1475-9276-9-24PMID:21047433
http://dx.doi.org/10.1186/1475-9276-9-24...

The potential benefits of medical travel include improved care, decreased costs and reduced waiting times.¹⁵15. Baker D. Globalising healthcare: A prescription with benefits. OECD Obs. 2010;281:14. Medical travel may increase access to certain treatments for local communities through improved infrastructure and higher demand. In India, for example, a two-tiered approach employed in some hospitals resulted in improved services for local patients and tailored services for medical travellers.⁷7. Lunt NT, Mannion R, Exworthy M. A framework for exploring the policy implications of UK medical tourism and international patient flows. Soc Pol Admin. 2013;47(1):1-25. http://dx.doi.org/10.1111/j.1467-9515.2011.00833.x
http://dx.doi.org/10.1111/j.1467-9515.20... ^,¹⁶16. Herrick DM. Medical tourism: Global competition in health care [NCPA Policy report No. 304]. Dallas: National Center for Policy Analysis; 2007. Available from: Available from: http://w.medretreat.com/templates/UserFiles/Documents/Medical Tourism - NCPA Report.pdf [cited 2015 Feb 12].
http://w.medretreat.com/templates/UserFi... Panama and Thailand have also developed services that were initially intended to attract foreign patients but also resulted in new facilities available for locals.¹⁶16. Herrick DM. Medical tourism: Global competition in health care [NCPA Policy report No. 304]. Dallas: National Center for Policy Analysis; 2007. Available from: Available from: http://w.medretreat.com/templates/UserFiles/Documents/Medical Tourism - NCPA Report.pdf [cited 2015 Feb 12].
http://w.medretreat.com/templates/UserFi... A competitive market for health care could help to control medical spending and increase access by introducing patients to new locations and lower costs for care. For developed countries, medical travel may result in small reductions in national health costs.¹⁷17. Labonté R. Overview: Medical tourism today: What, who, why and where? In: Labonté R, Runnels V, Packer C, Deonandan R, editors. Travelling well: Essays in medical tourism. Ottawa: Institute of Population Health, University of Ottawa; 2013. pp. 6-42.

Medical travel involves additional risks, compared to obtaining treatment domestically. If complications or adverse outcomes occur, additional expenses are likely, but insurance companies may not be willing to cover these costs.¹⁸18. Cheung IK, Wilson A. Arthroplasty tourism. Med J Aust. 2007 Dec 3-17;187(11-12):666-7. PMID:18072912^,¹⁹19. Jeevan R, Armstrong A. Cosmetic tourism and the burden on the NHS. J Plast Reconstr Aesthet Surg. 2008 Dec;61(12):1423-4. http://dx.doi.org/10.1016/j.bjps.2008.10.002PMID:18996337
http://dx.doi.org/10.1016/j.bjps.2008.10... Medical travel may jeopardize the well-being of vulnerable individuals who are ill, in unfamiliar locations or cultures and who lack social support. Factors such as social support, familiarity with language and carers and proximity to home can be important for recovery from clinical procedures.²⁰20. Mavros MN, Athanasiou S, Gkegkes ID, Polyzos KA, Peppas G, Falagas ME. Do psychological variables affect early surgical recovery?. PLoS ONE 2011;6(5):e20306. http://dx.doi.org/10.1371/journal.pone.0020306PMID:21633506
http://dx.doi.org/10.1371/journal.pone.0... ^,²¹21. Gouin JP, Kiecolt-Glaser JK. The impact of psychological stress on wound healing: methods and mechanisms. Immunol Allergy Clin North Am. 2011 Feb;31(1):81-93. http://dx.doi.org/10.1016/j.iac.2010.09.010PMID:21094925
http://dx.doi.org/10.1016/j.iac.2010.09.... Medical travel often involves travel from high-income to low- or middle-income countries,⁵5. Cattaneo O. Trade in health services: What's in it for developing countries? [World Bank policy research working paper 5115]. Washington: The World Bank; 2009. Available from: Available from:https://openknowledge.worldbank.org/bitstream/handle/10986/4305/WPS5115.pdf?sequence=1 [cited 2015 Sep 3].
https://openknowledge.worldbank.org/bits... ^,²²22. Lunt N, Mannion R. Patient mobility in the global marketplace: a multidisciplinary perspective. Int J Health Policy Manag. 2014 May;2(4):155-7.http://dx.doi.org/10.15171/ijhpm.2014.47PMID:24847479
http://dx.doi.org/10.15171/ijhpm.2014.47... with different standards of clinical practice.

The growth in medical travel has implications for health service provision in destination countries. Access to health care for local residents might be adversely affected if local health professionals devote their time to treatment of foreigners rather than local communities. The ethical issues raised by medical travel are particularly acute in countries where access to basic medical care may be unaffordable for the local population. Here we review the scientific literature relevant to development of global policy on medical travel. Medical travel needs to be understood in terms of its potential risks and benefits so that it can be evaluated against alternatives.

Literature search

We carried out a non-systematic literature review. Articles were considered if they were found in any of six databases under the terms "medical tourism" or "medical travel" since the year 2000, with no language restrictions. The databases used were PubMed, EconLit, Google Scholar, the World Bank research database, Europe PubMed Central and EMBASE. We identified primary themes to be reviewed through common arguments used in higher quality sources as well as through common topics in low-quality or potentially very biased material. Papers were included if they provided specific data, policy or practice analyses, or substantial insight to key themes, regarding travel for necessary care. Where available, we extracted estimates of the numbers of medical travellers within the last 10 years.

Available data

Most of the available data on medical travel is of poor quality. Sources are often not accessible or do not explain how estimated figures were calculated.¹⁰10. Hanefeld J, Smith R, Horsfall D, Lunt N. What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. J Travel Med. 2014 Nov-Dec;21(6):410-7. http://dx.doi.org/10.1111/jtm.12147PMID:25156070
http://dx.doi.org/10.1111/jtm.12147... There are variations in the definition of medical travellers and a lack of agreed methods for data collection.²³23. Connell J. Contemporary medical tourism: Conceptualisation, culture and commodification. Tour Manage. 2013;34:1-13. http://dx.doi.org/10.1016/j.tourman.2012.05.009
http://dx.doi.org/10.1016/j.tourman.2012... ^,²⁴24. Singh VK. Public policies for facilitating medical tourism industry in Asia. Rochester: Social Science Electronic Publishing; 2009. Available from: Available from: http://bit.ly/1c4F6cT [cited 2015 Sep 11].
http://bit.ly/1c4F6cT... For example, Singapore collects the data on medical travel using exit polls at the airport, including only travellers who had arrived with a stated primary purpose of obtaining medical care. Thailand counts the number of foreigners obtaining medical care at hospitals, including foreign travellers who did not travel primarily to obtain health care. Estimates are framed as medical travel, potentially including visitors coming for beauty treatments using spa and wellness resorts. These conflate cosmetic and other elective procedures with essential treatments. For example, Hungary is often portrayed as one of the hubs of medical travel in Europe with up to 1.8 million medical travellers annually, yet the majority of those are day visitors on wellness trips or travelling for dental care.²⁵25. Piazolo M, Zanca NA. Medical tourism: A case study for the USA and India, Germany and Hungary. Acta Polytech Hung. 2011;8(1):137-60.^,²⁶26. Travers R, Thelen S, Helmy E, Nabil N, Elmasri A. Medical tourism development strategy [Final report]. Cairo: Industrial Modernization Centre; 2008. Available from: Available from:www.foresightfordevelopment.org/sobipro/download-file/46-431/54 [cited 2015 Feb 12].
www.foresightfordevelopment.org/sobipro/... Thailand reports over 1.5 million medical travellers annually, but it is estimated that only a third travelled specifically for medical treatment.²⁷27. NaRanong A, NaRanong V. The effects of medical tourism: Thailand's experience. Bull World Health Organ. 2011 May 1;89(5):336-44.http://dx.doi.org/10.2471/BLT.09.072249PMID:21556301
http://dx.doi.org/10.2471/BLT.09.072249...

The difference between high and low estimates of medical travellers increases if a wider range of timelines, methods and measures are included.²⁸28. Mattoo A, Rathindran R. Does health insurance impede trade in health care services? [World Bank policy research working paper].; Washington: The World Bank 2005. Available from: Available from: http://elibrary.worldbank.org/doi/book/10.1596/1813-9450-3667 [cited 2015 Aug 17].
http://elibrary.worldbank.org/doi/book/1... Without official national data, numbers presented by some countries and hospitals may be exaggerated, potentially for the purpose of implying growth and success and encouraging private sector investment and national support.²³23. Connell J. Contemporary medical tourism: Conceptualisation, culture and commodification. Tour Manage. 2013;34:1-13. http://dx.doi.org/10.1016/j.tourman.2012.05.009
http://dx.doi.org/10.1016/j.tourman.2012...

Table 1 presents numbers of medical travellers as reported in papers that we reviewed. Considering the limitations of the sources, this table cannot accurately reflect the amount and structure of current medical travel, however it does give a basic overview of what is generally reported by researchers. This table reflects publicly-available data and summarizes the kind of information researchers, policy-makers and health-care professionals may use when making decisions. The data available for different countries and regions indicate a prominent focus on Asian countries, including India, Malaysia, Singapore and Thailand. Additional data, based on narrative and speculative evidence were not included in the table. It does not include reports that required a paid subscription to be accessed.

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Table 1
Reported estimates of medical travellers to receiving countries

Clear parameters are needed for future work on medical travel, to develop an evidence base for policy development. The existing literature on medical travel emphasizes economic interests.⁶6. Lunt N, Smith R, Exworthy M, Green ST, Horsfall D, Mannion R. Medical tourism: treatments, markets and health system implications: a scoping review. Paris: Organisation for Economic Co-operation and Development; 2011. Available from: Available from: http://bit.ly/1Fuf1NH [cited 2015 Feb 12].
http://bit.ly/1Fuf1NH... ^,¹⁷17. Labonté R. Overview: Medical tourism today: What, who, why and where? In: Labonté R, Runnels V, Packer C, Deonandan R, editors. Travelling well: Essays in medical tourism. Ottawa: Institute of Population Health, University of Ottawa; 2013. pp. 6-42.^,²³23. Connell J. Contemporary medical tourism: Conceptualisation, culture and commodification. Tour Manage. 2013;34:1-13. http://dx.doi.org/10.1016/j.tourman.2012.05.009
http://dx.doi.org/10.1016/j.tourman.2012... ^,⁴⁸48. Chuang TC, Liu JS, Lu LY, Lee Y. The main paths of medical tourism: From transplantation to beautification.. Tour Manage 2014;45:49-58.http://dx.doi.org/10.1016/j.tourman.2014.03.016
http://dx.doi.org/10.1016/j.tourman.2014... Below, we discuss international quality standards, the motivation of medical travellers and the legal and economic situation relevant to medical travel.

International quality standards

While many different types of national quality-control measures exist, they are not applicable across international borders and this increases the risk of uninformed decision-making by potential medical travellers.⁴⁹49. Turner LG. Quality in health care and globalization of health services: accreditation and regulatory oversight of medical tourism companies. Int J Qual Health Care. 2011 Feb;23(1):1-7. http://dx.doi.org/10.1093/intqhc/mzq078PMID:21148210
http://dx.doi.org/10.1093/intqhc/mzq078... The lack of international standards further increases the risk for patients and their local care providers as complications may arise after medical travellers return home.¹⁰10. Hanefeld J, Smith R, Horsfall D, Lunt N. What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. J Travel Med. 2014 Nov-Dec;21(6):410-7. http://dx.doi.org/10.1111/jtm.12147PMID:25156070
http://dx.doi.org/10.1111/jtm.12147... ^,¹⁸18. Cheung IK, Wilson A. Arthroplasty tourism. Med J Aust. 2007 Dec 3-17;187(11-12):666-7. PMID:18072912^,¹⁹19. Jeevan R, Armstrong A. Cosmetic tourism and the burden on the NHS. J Plast Reconstr Aesthet Surg. 2008 Dec;61(12):1423-4. http://dx.doi.org/10.1016/j.bjps.2008.10.002PMID:18996337
http://dx.doi.org/10.1016/j.bjps.2008.10... To establish international quality standards, definitions and comparable indicators should be established, with oversight from a major international body.

Patient decision-making

More data on patient decision-making needs to be collected to ensure the practical value of any evidence generated on medical travel. Existing patient choice models indicate that there are a large number of considerations when deciding where to receive care and highly specified measures are needed to evaluate this at a global level.¹⁰10. Hanefeld J, Smith R, Horsfall D, Lunt N. What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. J Travel Med. 2014 Nov-Dec;21(6):410-7. http://dx.doi.org/10.1111/jtm.12147PMID:25156070
http://dx.doi.org/10.1111/jtm.12147... ^,³²32. Crozier GKD, Baylis F. The ethical physician encounters international medical travel. J Med Ethics. 2010 May;36(5):297-301. http://dx.doi.org/10.1136/jme.2009.032789PMID:20439336
http://dx.doi.org/10.1136/jme.2009.03278... ^,⁵⁰50. Hanefeld J, Lunt N, Smith R, Horsfall D. Why do medical tourists travel to where they do? The role of networks in determining medical travel.. Soc Sci Med 2015 Jan;124:356-63. http://dx.doi.org/10.1016/j.socscimed.2014.05.016PMID:24976006
http://dx.doi.org/10.1016/j.socscimed.20... The drivers and barriers that precede medical travel need to be assessed beyond general economic and availability factors.

Knowledge of factors involved in patient choices about cross-border care is sparse.¹⁰10. Hanefeld J, Smith R, Horsfall D, Lunt N. What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. J Travel Med. 2014 Nov-Dec;21(6):410-7. http://dx.doi.org/10.1111/jtm.12147PMID:25156070
http://dx.doi.org/10.1111/jtm.12147... ^,¹⁷17. Labonté R. Overview: Medical tourism today: What, who, why and where? In: Labonté R, Runnels V, Packer C, Deonandan R, editors. Travelling well: Essays in medical tourism. Ottawa: Institute of Population Health, University of Ottawa; 2013. pp. 6-42. Although evidence is starting to emerge,¹⁰10. Hanefeld J, Smith R, Horsfall D, Lunt N. What do we know about medical tourism? A review of the literature with discussion of its implications for the UK National Health Service as an example of a public health care system. J Travel Med. 2014 Nov-Dec;21(6):410-7. http://dx.doi.org/10.1111/jtm.12147PMID:25156070
http://dx.doi.org/10.1111/jtm.12147... there is an overall deficiency in the literature as to why potential patients travel to specific locations for medical treatment. Future research could build on national studies, which have clearly indicated that cost, quality and availability are critical in the decision-making process.⁵¹51. Exworthy M, Peckham S. Access, choice and travel: implications for health policy. Soc Pol & Admin. 2006;40(3):267-87. http://dx.doi.org/10.1111/j.1467-9515.2006.00489.x
http://dx.doi.org/10.1111/j.1467-9515.20... Such evidence would make a significant contribution, particularly if coinciding with better mapping of the flow of medical travellers.⁶6. Lunt N, Smith R, Exworthy M, Green ST, Horsfall D, Mannion R. Medical tourism: treatments, markets and health system implications: a scoping review. Paris: Organisation for Economic Co-operation and Development; 2011. Available from: Available from: http://bit.ly/1Fuf1NH [cited 2015 Feb 12].
http://bit.ly/1Fuf1NH... ^,⁷7. Lunt NT, Mannion R, Exworthy M. A framework for exploring the policy implications of UK medical tourism and international patient flows. Soc Pol Admin. 2013;47(1):1-25. http://dx.doi.org/10.1111/j.1467-9515.2011.00833.x
http://dx.doi.org/10.1111/j.1467-9515.20... Finally, if patients, carers, insurers and other stakeholders are to be expected to make informed decisions, responsibility for costs needs to be clarified. Understanding the cultural factors that influence patients' decisions will provide essential background for the development of medical travel policies.⁵¹51. Exworthy M, Peckham S. Access, choice and travel: implications for health policy. Soc Pol & Admin. 2006;40(3):267-87. http://dx.doi.org/10.1111/j.1467-9515.2006.00489.x
http://dx.doi.org/10.1111/j.1467-9515.20...

Frameworks

To prevent harm, legal and economic frameworks for medical travel are needed.⁶6. Lunt N, Smith R, Exworthy M, Green ST, Horsfall D, Mannion R. Medical tourism: treatments, markets and health system implications: a scoping review. Paris: Organisation for Economic Co-operation and Development; 2011. Available from: Available from: http://bit.ly/1Fuf1NH [cited 2015 Feb 12].
http://bit.ly/1Fuf1NH... ^,⁵²52. Whittaker A, Manderson L, Cartwright E. Patients without borders: understanding medical travel. Med Anthropol. 2010 Oct;29(4):336-43.http://dx.doi.org/10.1080/01459740.2010.501318PMID:21082481
http://dx.doi.org/10.1080/01459740.2010.... Existing governance structures and legal frameworks on treatment and care standards need to be harmonized and international quality standards need to be enforced and maintained. The current lack of regulation in medical travel creates risks for patients due to a lack of oversight and variable standards of practice.³³33. Warf B. Do you know the way to San José? Medical tourism in Costa Rica . J Lat Am Geogr. 2010;9(1):51-66. http://dx.doi.org/10.1353/lag.0.0074
http://dx.doi.org/10.1353/lag.0.0074... Economic protection through regulated insurance for patients as well as through local regulation (to avoid negative effects on access to care for local residents) must be in place. This regulation will be critical as some health systems face increased demand from an international market that may result in unwanted increases in costs of care for locals.⁵³53. Carrera MP, Bridge JFP. Health and medical tourism: what they mean and imply for health care systems. Geneva: The Geneva Association, Risk & Insurance Economics; 2006. Available from: Available from: http://bit.ly/1dka0iT [cited 2015 May 16].
http://bit.ly/1dka0iT...

Legal frameworks need to clarify liabilities for adverse events and ensure equality of access for the local population. Access to health care has implications beyond individual care, including the perception of health-care system quality, which in turn influences individual well-being.⁵⁴54. Deaton A. Income, health, and well-being around the world: evidence from the Gallup World Poll. J Econ Perspect. 2008 Spring;22(2):53-72.http://dx.doi.org/10.1257/jep.22.2.53PMID:19436768
http://dx.doi.org/10.1257/jep.22.2.53... Evaluations of medical travel should measure the impact on access to care for local communities, to ensure they are not negatively affected by such changes.⁵⁵55. Kim MK, Blendon RJ, Benson JM. What is driving people's dissatisfaction with their own health care in 17 Latin American countries? Health Expect. 2013 Jun;16(2):155-63. http://dx.doi.org/10.1111/j.1369-7625.2012.00777.xPMID:22512774
http://dx.doi.org/10.1111/j.1369-7625.20...

Conclusion

There are considerable gaps in the current literature concerning the extent to which international health services are consumed and the needs of medical travellers are met. We suggest three key domains (quality standards, informed decision-making, economic and legal protection) for which scientific evidence would support the development of medical travel policies. There are challenges to obtaining such data, including barriers to accessing up-to-date information in governmental records, in health systems reviews, and in confidential databases kept by insurance firms. It is also difficult to find representative samples of patients who travel for care. There is currently a lack of consistent data on the specific procedures these patients seek, how many patients are involved and how much expenditure occurs. Effective research in medical travel as a global phenomenon requires consideration of all three domains, with the overall goal of improving access, quality of care, and health equity.

Acknowledgements

We thank Dean Baker, Ingeborg Farver-Westergaard, Bettina Moltrecht, Enikõ Németh, Dimitris Parperis, Pawel Piotr Sleczka and Saša Zorjan, and the Junior Researcher Programme 2011-12 cohort. KR is also affiliated with the Engineering Design Centre, University of Cambridge.

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⁵²
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⁵³
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Publication Dates

Publication in this collection
Nov 2015

History

Received
20 Aug 2014
Reviewed
21 May 2015
Accepted
05 Aug 2015

This is an open-access article distributed under the terms of the Creative Commons Attribution License

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» http://dx.doi.org/10.1007/s11606-010-1582-8

[4] ⁴
Alsharif MJ, Labonté R, Lu Z. Patients beyond borders: A study of medical tourists in four countries. Glob Soc Policy. 2010;10(3):315-35.http://dx.doi.org/10.1177/1468018110380003
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[5] ⁵
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» http://dx.doi.org/10.1371/journal.pone.0070406

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» http://dx.doi.org/10.1016/j.socscimed.2014.11.014

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Receiving country	Estimated no. of annual medical travellers	Year and reference
Australia	13 000	2010²⁹29. Medical tourism in Australia: a scoping study. Canberra: Deloitte Access Economics; 2011.
Brazil	49 000-180 000	2005¹⁷17. Labonté R. Overview: Medical tourism today: What, who, why and where? In: Labonté R, Runnels V, Packer C, Deonandan R, editors. Travelling well: Essays in medical tourism. Ottawa: Institute of Population Health, University of Ottawa; 2013. pp. 6-42. and 2009³⁰30. Johnston K, Puczkó L, Smith M, Ellis S. Wellness tourism and medical tourism : where do spas fit? New York: Global Spa Summit; 2011. Available from: Available from: http://bit.ly/1JzS6oq [cited 2015 Feb 12]. http://bit.ly/1JzS6oq...
Costa Rica	25 000-150 000	2006,³¹31. Giacalone JA. Modeling the market for medical travel. American Society of Business and Behavioral Sciences Proceedings. 2011;18:668-76. 2007³²32. Crozier GKD, Baylis F. The ethical physician encounters international medical travel. J Med Ethics. 2010 May;36(5):297-301. http://dx.doi.org/10.1136/jme.2009.032789PMID:20439336 http://dx.doi.org/10.1136/jme.2009.03278... and 2008³³33. Warf B. Do you know the way to San José? Medical tourism in Costa Rica . J Lat Am Geogr. 2010;9(1):51-66. http://dx.doi.org/10.1353/lag.0.0074 http://dx.doi.org/10.1353/lag.0.0074...
Cuba	3500	2003²⁶26. Travers R, Thelen S, Helmy E, Nabil N, Elmasri A. Medical tourism development strategy [Final report]. Cairo: Industrial Modernization Centre; 2008. Available from: Available from:www.foresightfordevelopment.org/sobipro/download-file/46-431/54 [cited 2015 Feb 12]. www.foresightfordevelopment.org/sobipro/...
Cuba	200 000	2007³²32. Crozier GKD, Baylis F. The ethical physician encounters international medical travel. J Med Ethics. 2010 May;36(5):297-301. http://dx.doi.org/10.1136/jme.2009.032789PMID:20439336 http://dx.doi.org/10.1136/jme.2009.03278...
Egypt	68 000-108 000	2003,³⁴34. Siddiqi S, Shennawy A, Mirza Z, Drager N, Sabri B. Assessing trade in health services in countries of the Eastern Mediterranean from a public health perspective. Int J Health Plann Manage. 2010 Jul-Sep;25(3):231-50.http://dx.doi.org/10.1002/hpm.989 PMID:19676048 http://dx.doi.org/10.1002/hpm.989... 2004,²⁸28. Mattoo A, Rathindran R. Does health insurance impede trade in health care services? [World Bank policy research working paper].; Washington: The World Bank 2005. Available from: Available from: http://elibrary.worldbank.org/doi/book/10.1596/1813-9450-3667 [cited 2015 Aug 17]. http://elibrary.worldbank.org/doi/book/1... 2005²⁸28. Mattoo A, Rathindran R. Does health insurance impede trade in health care services? [World Bank policy research working paper].; Washington: The World Bank 2005. Available from: Available from: http://elibrary.worldbank.org/doi/book/10.1596/1813-9450-3667 [cited 2015 Aug 17]. http://elibrary.worldbank.org/doi/book/1... and 2006³⁵35. Helmy EM. Benchmarking the Egyptian medical tourism sector against international best practices: an exploratory study. Tourismos. 2011;6(2):293-311.
Germany	50 000-70 000	2008²⁸28. Mattoo A, Rathindran R. Does health insurance impede trade in health care services? [World Bank policy research working paper].; Washington: The World Bank 2005. Available from: Available from: http://elibrary.worldbank.org/doi/book/10.1596/1813-9450-3667 [cited 2015 Aug 17]. http://elibrary.worldbank.org/doi/book/1... and 2009²⁹29. Medical tourism in Australia: a scoping study. Canberra: Deloitte Access Economics; 2011.
Hungary	1 500 000-1 800 000	2007²⁸28. Mattoo A, Rathindran R. Does health insurance impede trade in health care services? [World Bank policy research working paper].; Washington: The World Bank 2005. Available from: Available from: http://elibrary.worldbank.org/doi/book/10.1596/1813-9450-3667 [cited 2015 Aug 17]. http://elibrary.worldbank.org/doi/book/1... and 2009²⁷27. NaRanong A, NaRanong V. The effects of medical tourism: Thailand's experience. Bull World Health Organ. 2011 May 1;89(5):336-44.http://dx.doi.org/10.2471/BLT.09.072249PMID:21556301 http://dx.doi.org/10.2471/BLT.09.072249...
Hungary	300 000	2008³⁰30. Johnston K, Puczkó L, Smith M, Ellis S. Wellness tourism and medical tourism : where do spas fit? New York: Global Spa Summit; 2011. Available from: Available from: http://bit.ly/1JzS6oq [cited 2015 Feb 12]. http://bit.ly/1JzS6oq...
India	1 000 000-1 180 000	2004³⁶36. Horowitz MD, Rosensweig JA. Medical tourism-health care in the global economy. Physician Exec. 2007 Nov-Dec;33(6):24-6, 28-30. PMID:18092615 and 2005³⁷37. Sen Gupta A. Medical tourism in India: winners and losers. Indian. J Med Ethics 2008 Jan-Mar;5(1):4-5. PMID:18630244
India	100 000-150 000	2005²⁴24. Singh VK. Public policies for facilitating medical tourism industry in Asia. Rochester: Social Science Electronic Publishing; 2009. Available from: Available from: http://bit.ly/1c4F6cT [cited 2015 Sep 11]. http://bit.ly/1c4F6cT... ^,²⁹29. Medical tourism in Australia: a scoping study. Canberra: Deloitte Access Economics; 2011.^,³⁸38. Lautier M. Export of health services from developing countries: the case of Tunisia.. Soc Sci Med 2008 Jul;67(1):101-10. http://dx.doi.org/10.1016/j.socscimed.2008.01.057PMID:18468756 http://dx.doi.org/10.1016/j.socscimed.20... 39. Chanda R. Medical value travel in India: prospects and challenges. In: Labonté R, Runnels V, Packer C, Deonandan R, editors.. Travelling well: Essays in medical tourism; Ottawa: Institute of Population Health, University of Ottawa 2013. pp. 62-48.^-⁴⁰40. Newman BY. Medical tourism. J Am Optom Assoc. 2006;77(12):581.
India	300 000-731 000	2006,⁴¹41. Manuel CR. Medical tourism: a growth strategy: a multi-dimensional view on medical tourism. Makati City: Asian Institute of Management, Dr. Stephen Zuellig Center for Asian Business Transformation; 2011. Available from: Available from: http://zuellig.aim.edu/files/download/215 [cited 2015 Sep 11]. http://zuellig.aim.edu/files/download/21... 2007,¹1. Keckley PH, Underwood HR. Medical tourism: consumers in search of value. Washington: Deloitte Center for Health Solutions; 2008. Available from:Available from: http://medicaltourisminturkey.org/panel/Panel1/3Deloitte.pdf [cited 2015 Feb 12]. http://medicaltourisminturkey.org/panel/... 2008⁵5. Cattaneo O. Trade in health services: What's in it for developing countries? [World Bank policy research working paper 5115]. Washington: The World Bank; 2009. Available from: Available from:https://openknowledge.worldbank.org/bitstream/handle/10986/4305/WPS5115.pdf?sequence=1 [cited 2015 Sep 3]. https://openknowledge.worldbank.org/bits... and 2010³⁹39. Chanda R. Medical value travel in India: prospects and challenges. In: Labonté R, Runnels V, Packer C, Deonandan R, editors.. Travelling well: Essays in medical tourism; Ottawa: Institute of Population Health, University of Ottawa 2013. pp. 62-48.
Israel	35 000	2009³²32. Crozier GKD, Baylis F. The ethical physician encounters international medical travel. J Med Ethics. 2010 May;36(5):297-301. http://dx.doi.org/10.1136/jme.2009.032789PMID:20439336 http://dx.doi.org/10.1136/jme.2009.03278...
Jordan	120 000-250 000	2002,³⁴34. Siddiqi S, Shennawy A, Mirza Z, Drager N, Sabri B. Assessing trade in health services in countries of the Eastern Mediterranean from a public health perspective. Int J Health Plann Manage. 2010 Jul-Sep;25(3):231-50.http://dx.doi.org/10.1002/hpm.989 PMID:19676048 http://dx.doi.org/10.1002/hpm.989... 2004²⁸28. Mattoo A, Rathindran R. Does health insurance impede trade in health care services? [World Bank policy research working paper].; Washington: The World Bank 2005. Available from: Available from: http://elibrary.worldbank.org/doi/book/10.1596/1813-9450-3667 [cited 2015 Aug 17]. http://elibrary.worldbank.org/doi/book/1... and 2009³⁰30. Johnston K, Puczkó L, Smith M, Ellis S. Wellness tourism and medical tourism : where do spas fit? New York: Global Spa Summit; 2011. Available from: Available from: http://bit.ly/1JzS6oq [cited 2015 Feb 12]. http://bit.ly/1JzS6oq...
Malaysia	300 000-489 000	2006,⁴¹41. Manuel CR. Medical tourism: a growth strategy: a multi-dimensional view on medical tourism. Makati City: Asian Institute of Management, Dr. Stephen Zuellig Center for Asian Business Transformation; 2011. Available from: Available from: http://zuellig.aim.edu/files/download/215 [cited 2015 Sep 11]. http://zuellig.aim.edu/files/download/21... 2007,²⁴24. Singh VK. Public policies for facilitating medical tourism industry in Asia. Rochester: Social Science Electronic Publishing; 2009. Available from: Available from: http://bit.ly/1c4F6cT [cited 2015 Sep 11]. http://bit.ly/1c4F6cT... ^,²⁹29. Medical tourism in Australia: a scoping study. Canberra: Deloitte Access Economics; 2011.^,⁴²42. Pocock NS, Phua KH. Medical tourism and policy implications for health systems: a conceptual framework from a comparative study of Thailand, Singapore and Malaysia.. Global Health 2011;7(12):1-12. PMID:21539751 2008⁵5. Cattaneo O. Trade in health services: What's in it for developing countries? [World Bank policy research working paper 5115]. Washington: The World Bank; 2009. Available from: Available from:https://openknowledge.worldbank.org/bitstream/handle/10986/4305/WPS5115.pdf?sequence=1 [cited 2015 Sep 3]. https://openknowledge.worldbank.org/bits... and 2010³⁹39. Chanda R. Medical value travel in India: prospects and challenges. In: Labonté R, Runnels V, Packer C, Deonandan R, editors.. Travelling well: Essays in medical tourism; Ottawa: Institute of Population Health, University of Ottawa 2013. pp. 62-48.
Philippines	100 000-250 000	2006,²⁴24. Singh VK. Public policies for facilitating medical tourism industry in Asia. Rochester: Social Science Electronic Publishing; 2009. Available from: Available from: http://bit.ly/1c4F6cT [cited 2015 Sep 11]. http://bit.ly/1c4F6cT... ^,⁴¹41. Manuel CR. Medical tourism: a growth strategy: a multi-dimensional view on medical tourism. Makati City: Asian Institute of Management, Dr. Stephen Zuellig Center for Asian Business Transformation; 2011. Available from: Available from: http://zuellig.aim.edu/files/download/215 [cited 2015 Sep 11]. http://zuellig.aim.edu/files/download/21... 2009²2. KPMG. Issues monitor: Medical tourism gaining momentum. In: KPMG International Issues monitor. London: KPMG; 2011. Available from: Available from: https://www.kpmg.com/CH/en/Library/Articles-Publications/Documents/Sectors/pub-20120207-issues-monitor-healthcare-medical-tourism-en.pdf [cited 2015 Feb 12]. https://www.kpmg.com/CH/en/Library/Artic... and 2010⁴³43. Picazo OF. Medical tourism in the Philippines: market profile, benchmarking exercise and SWOT analysis. Makati City: Philippine Institute for Development Studies; 2013. Available from: Available from: http://bit.ly/1R3gLnm [cited 2015 Feb 12]. http://bit.ly/1R3gLnm...
Republic of Korea	60 000	2009²2. KPMG. Issues monitor: Medical tourism gaining momentum. In: KPMG International Issues monitor. London: KPMG; 2011. Available from: Available from: https://www.kpmg.com/CH/en/Library/Articles-Publications/Documents/Sectors/pub-20120207-issues-monitor-healthcare-medical-tourism-en.pdf [cited 2015 Feb 12]. https://www.kpmg.com/CH/en/Library/Artic... ^,²⁹29. Medical tourism in Australia: a scoping study. Canberra: Deloitte Access Economics; 2011.
Singapore	270 000-450 000	2004,³¹31. Giacalone JA. Modeling the market for medical travel. American Society of Business and Behavioral Sciences Proceedings. 2011;18:668-76. 2005,²⁴24. Singh VK. Public policies for facilitating medical tourism industry in Asia. Rochester: Social Science Electronic Publishing; 2009. Available from: Available from: http://bit.ly/1c4F6cT [cited 2015 Sep 11]. http://bit.ly/1c4F6cT... ^,⁴⁰40. Newman BY. Medical tourism. J Am Optom Assoc. 2006;77(12):581. 2006¹1. Keckley PH, Underwood HR. Medical tourism: consumers in search of value. Washington: Deloitte Center for Health Solutions; 2008. Available from:Available from: http://medicaltourisminturkey.org/panel/Panel1/3Deloitte.pdf [cited 2015 Feb 12]. http://medicaltourisminturkey.org/panel/... ^,²⁹29. Medical tourism in Australia: a scoping study. Canberra: Deloitte Access Economics; 2011. and 2008⁵5. Cattaneo O. Trade in health services: What's in it for developing countries? [World Bank policy research working paper 5115]. Washington: The World Bank; 2009. Available from: Available from:https://openknowledge.worldbank.org/bitstream/handle/10986/4305/WPS5115.pdf?sequence=1 [cited 2015 Sep 3]. https://openknowledge.worldbank.org/bits...
Singapore	571 000-725 000	2007,⁴²42. Pocock NS, Phua KH. Medical tourism and policy implications for health systems: a conceptual framework from a comparative study of Thailand, Singapore and Malaysia.. Global Health 2011;7(12):1-12. PMID:21539751 2008²2. KPMG. Issues monitor: Medical tourism gaining momentum. In: KPMG International Issues monitor. London: KPMG; 2011. Available from: Available from: https://www.kpmg.com/CH/en/Library/Articles-Publications/Documents/Sectors/pub-20120207-issues-monitor-healthcare-medical-tourism-en.pdf [cited 2015 Feb 12]. https://www.kpmg.com/CH/en/Library/Artic... and 2010³⁹39. Chanda R. Medical value travel in India: prospects and challenges. In: Labonté R, Runnels V, Packer C, Deonandan R, editors.. Travelling well: Essays in medical tourism; Ottawa: Institute of Population Health, University of Ottawa 2013. pp. 62-48.
South Africa	330 000	2010⁴⁴44. Crush J, Chikanda A, Maswikwa B. South-South and North-South medical tourism: the case of South Africa. In: Labonté R, Runnels V, Packer C, Deonandan R, editors.. Travelling well: Essays in medical tourism; Ottawa: Institute of Population Health, University of Ottawa 2013. pp. 43-61.
Thailand	450 000-700 000	2004,⁴⁵45. Whittaker A. Pleasure and pain: medical travel in Asia. Glob Public Health. 2008;3(3):271-90. http://dx.doi.org/10.1080/17441690701463936 http://dx.doi.org/10.1080/17441690701463... 2006⁴¹41. Manuel CR. Medical tourism: a growth strategy: a multi-dimensional view on medical tourism. Makati City: Asian Institute of Management, Dr. Stephen Zuellig Center for Asian Business Transformation; 2011. Available from: Available from: http://zuellig.aim.edu/files/download/215 [cited 2015 Sep 11]. http://zuellig.aim.edu/files/download/21... and 2007²⁵25. Piazolo M, Zanca NA. Medical tourism: A case study for the USA and India, Germany and Hungary. Acta Polytech Hung. 2011;8(1):137-60.
Thailand	1 000 000-1 580 000	2004,³⁶36. Horowitz MD, Rosensweig JA. Medical tourism-health care in the global economy. Physician Exec. 2007 Nov-Dec;33(6):24-6, 28-30. PMID:18092615^,³⁸38. Lautier M. Export of health services from developing countries: the case of Tunisia.. Soc Sci Med 2008 Jul;67(1):101-10. http://dx.doi.org/10.1016/j.socscimed.2008.01.057PMID:18468756 http://dx.doi.org/10.1016/j.socscimed.20... 2006,⁴⁶46. Rerkrujipimol J, Assenov I. Marketing strategies for promoting medical tourism in Thailand. J Tour Hosp Cul Arts. 2011;3(2):95-105. 2007,¹1. Keckley PH, Underwood HR. Medical tourism: consumers in search of value. Washington: Deloitte Center for Health Solutions; 2008. Available from:Available from: http://medicaltourisminturkey.org/panel/Panel1/3Deloitte.pdf [cited 2015 Feb 12]. http://medicaltourisminturkey.org/panel/... 2008⁵5. Cattaneo O. Trade in health services: What's in it for developing countries? [World Bank policy research working paper 5115]. Washington: The World Bank; 2009. Available from: Available from:https://openknowledge.worldbank.org/bitstream/handle/10986/4305/WPS5115.pdf?sequence=1 [cited 2015 Sep 3]. https://openknowledge.worldbank.org/bits... ^,²⁹29. Medical tourism in Australia: a scoping study. Canberra: Deloitte Access Economics; 2011. and 2010³⁹39. Chanda R. Medical value travel in India: prospects and challenges. In: Labonté R, Runnels V, Packer C, Deonandan R, editors.. Travelling well: Essays in medical tourism; Ottawa: Institute of Population Health, University of Ottawa 2013. pp. 62-48.
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