medical tourism medical tourism medical tourism refers to people traveling abroad to obtain medical treatment. in the past, this usually referred to those who traveled from less-developed countries to major medical centers in highly developed countries for treatment unavailable at home. however, in recent years it may equally refer to those from developed countries who travel to developing countries for lower-priced medical treatments. the motivation may be also for medical services unavailable or non-licensed in the home country: there are differences between the medical agencies (fda, ema etc.) world-wide which decide whether a drug is approved in their country or not. even within europe, although therapy protocols might be approved by the european medicines agency (ema), several countries have their own review organizations in order to evaluate whether the same therapy protocol would be "cost-effective", so that patients face differences in the therapy protocols, particularly in the access of these drugs, which might be partially explained by the financial strength of the particular health system. medical tourism most often is for surgeries (cosmetic or otherwise) or similar treatments, though people also travel for dental tourism or fertility tourism. people with rare conditions may travel to countries where the treatment is better understood. however, almost all types of health care are available, including psychiatry, alternative medicine, convalescent care, and even burial services. health tourism is a wider term for travel that focuses on medical treatments and the use of healthcare services. it covers a wide field of health-oriented tourism ranging from preventive and health-conductive treatment to rehabilitational and curative forms of travel. wellness tourism is a related field. history the first recorded instance of people travelling for medical treatment dates back thousands of years to when greek pilgrims traveled from the eastern mediterranean to a small area in the saronic gulf called epidauria. this territory was the sanctuary of the healing god asklepios. spa towns and sanitaria were early forms of medical tourism. in 18th-century europe patients visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis. description factors that have led to the increasing popularity of medical travel include the high cost of health care, long wait times for certain procedures, the ease and affordability of international travel, and improvements in both technology and standards of care in many countries. the avoidance of waiting times is the leading factor for medical tourism from the uk, whereas in the us, the main reason is cheaper prices abroad. furthermore, death rates even in the developed countries differ extremely, i.e. uk versus seven other leading countries, including the us. many surgical procedures performed in medical tourism destinations cost a fraction of the price they do in other countries. for example, in the united states, a liver transplant that may cost us$300,000, would generally cost about us$91,000 in taiwan. a large draw to medical travel is convenience and speed. countries that operate public health-care systems often have long wait times for certain operations, for example, an estimated 782,936 canadian patients spent an average waiting time of 9.4 weeks on medical waiting lists in 2005. canada has also set waiting time benchmarks for non-urgent medical procedures, including a 26-week waiting period for a hip replacement and a 16-week wait for cataract surgery. in developed countries such as the united states, medical tourism has large growth prospects and potentially destabilizing implications. a forecast by deloitte consulting published in august 2008 projected that medical tourism originating in the us could jump by a factor of ten over the next decade. an estimated 750,000 americans went abroad for health care in 2007, and the report estimated that 1.5 million would seek health care outside the us in 2008. the growth in medical tourism has the potential to cost us health care providers billions of dollars in lost revenue. an authority at the harvard business school stated that "medical tourism is promoted much more heavily in the united kingdom than in the united states". additionally, some patients in some first world countries are finding that insurance either does not cover orthopedic surgery (such as knee or hip replacement) or limits the choice of the facility, surgeon, or prosthetics to be used. popular medical travel worldwide destinations include: canada, cuba, costa rica, ecuador, india, israel, jordan, malaysia, mexico, singapore, south korea, taiwan, thailand, turkey, united states. popular destinations for cosmetic surgery include: argentina, bolivia, brazil, colombia, costa rica, cuba, ecuador, mexico, turkey, thailand and ukraine. according to the "sociedad boliviana de cirugia plastica y reconstructiva", more than 70% of middle and upper-class women in the country have had some form of plastic surgery. other destination countries include belgium, poland, slovakia and south africa. some people travel for assisted pregnancy, such as in-vitro fertilization, or surrogacy, or freezing embryos for retro-production. however, perceptions of medical tourism are not always positive. in places like the us, which has high standards of quality, medical tourism is viewed as risky. in some parts of the world, wider political issues can influence where medical tourists will choose to seek out health care. medical tourism providers have developed as intermediaries which unite potential medical tourists with surgeons, provider hospitals and other organizations. in some cases, surgeons from the united states have signed up with medical tourism providers to travel to mexico to treat american patients. the hope is that using an american surgeon may alleviate concerns about going outside the country, and persuade self-insured american employers to offer this cost-effective option to their workers as a way to save money while still provide high-quality care. companies that focus on medical value travel typically provide nurse case managers to assist patients with pre- and post-travel medical issues. they may also help provide resources for follow-up care upon the patient's return. circumvention tourism is also an area of medical tourism that has grown. circumvention tourism is travel in order to access medical services that are legal in the destination country but illegal in the home country. this can include travel for fertility treatments that are not yet approved in the home country, abortion, and doctor-assisted suicide. abortion tourism can be found most commonly in europe, where travel between countries is relatively simple. poland, a european country with highly restrictive abortion laws, has one of the highest rates of circumvention tourism, as did ireland before abortion was made legal in 2018. in poland especially, it is estimated that each year nearly 7,000 women travel to the uk, where abortion services are free through the national health service. there are also efforts being made by independent organizations and doctors, such as with women on waves, to help women circumvent laws in order to access medical services. with women on waves, the organization uses a mobile clinic aboard a ship to provide medical abortions in international waters, where the law of the country whose flag is flown applies. dental tourism is travel for cheaper dentistry or oral surgery. the same porcelain veneer made in a lab in sweden can be as much as 2500 aud in australia, but only 1200 aud in india. the price difference here is not explainable by reference to the material cost. international healthcare accreditation international healthcare accreditation is the process of certifying a level of quality for healthcare providers and programs across multiple countries. international healthcare accreditation organizations certify a wide range of healthcare programs such as hospitals, primary care centers, medical transport, and ambulatory care services. there are a number of accreditation schemes available based in a number of different countries around the world. the oldest international accrediting body is accreditation canada, formerly known as the canadian council on health services accreditation, which accredited the bermuda hospital board as soon as 1968. since then, it has accredited hospitals and health service organizations in ten other countries. in the united states, the accreditation group joint commission international (jci) was formed in 1994 to provide international clients education and consulting services. many international hospitals today see obtaining international accreditation as a way to attract american patients. joint commission international is a relative of the joint commission in the united states. both are us-style independent private sector not-for-profit organizations that develop nationally and internationally recognized procedures and standards to help improve patient care and safety. they work with hospitals to help them meet joint commission standards for patient care and then accredit those hospitals meeting the standards. a british scheme, qha trent accreditation, is an active independent holistic accreditation scheme, as well as gcr.org which monitors the success metrics and standards of almost 500,000 medical clinics worldwide. the different international healthcare accreditation schemes vary in quality, size, cost, intent and the skill and intensity of their marketing. they also vary in terms of cost to hospitals and healthcare institutions making use of them. increasingly, some hospitals are looking towards dual international accreditation, perhaps having both jci to cover potential us clientele, and accreditation canada or qha trent. as a result of competition between clinics for american medical tourists, there have been initiatives to rank hospitals based on patient-reported metrics. risks and criticism medical tourism carries some risks that locally provided medical care either does not carry or carries to a much lesser degree. some countries, such as south africa, or thailand have very different infectious disease-related epidemiology to europe and north america. exposure to diseases without having built up natural immunity can be a hazard for weakened individuals, specifically with respect to gastrointestinal diseases (e.g. hepatitis a, amoebic dysentery, paratyphoid) which could weaken progress and expose the patient to mosquito-transmitted diseases, influenza, and tuberculosis. however, because in poor tropical nations diseases run the gamut, doctors seem to be more open to the possibility of considering any infectious disease, including hiv, tb, and typhoid, while there are cases in the west where patients were consistently misdiagnosed for years because such diseases are perceived to be "rare" in the west. the quality of post-operative care can also vary dramatically, depending on the hospital and country, and may be different from us or european standards. also, traveling long distances soon after surgery can increase the risk of complications. long flights and decreased mobility associated with window seats can predispose one towards developing deep vein thrombosis and potentially a pulmonary embolism. other vacation activities can be problematic as well — for example, scars may become darker and more noticeable if they are sunburned while healing. also, health facilities treating medical tourists may lack an adequate complaints policy to deal appropriately and fairly with complaints made by dissatisfied patients. differences in healthcare provider standards around the world have been recognised by the world health organization, and in 2004 it launched the world alliance for patient safety. this body assists hospitals and government around the world in setting patient safety policy and practices that can become particularly relevant when providing medical tourism services. patients traveling to countries with less stringent surgical standards may be at higher risk for complications. if there are complications, the patient may need to stay in the foreign country for longer than planned or if they have returned home, will not have easy access to follow up care. patients sometimes travel to another country to obtain medical procedures that doctors in their home country refuse to perform because they believed that the risks of the procedure outweigh the benefits. such patients may have difficulty getting insurance (whether public or private) to cover follow up medical costs should the feared complications indeed arise. legal issues receiving medical care abroad may subject medical tourists to unfamiliar legal issues. the limited nature of litigation in various countries is a reason for accessibility of care overseas. while some countries currently presenting themselves as attractive medical tourism destinations provide some form of legal remedies for medical malpractice, these legal avenues may be unappealing to the medical tourist. should problems arise, patients might not be covered by adequate personal insurance or might be unable to seek compensation via malpractice lawsuits. hospitals and/or doctors in some countries may be unable to pay the financial damages awarded by a court to a patient who has sued them, owing to the hospital and/or the doctor not possessing appropriate insurance cover and/or medical indemnity. issues can also arise for patients who seek out services that are illegal in