Heading abroad for health

Few minutes to read
By Robert Bartram
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With the current level of income disparity between nations, even those geographically close to one another, it is hardly surprising that the provision of public services can vary a great deal from country to country. This is nowhere more the case than with healthcare, in which the relatively new phenomenon of “medical tourism” is already booming.

Paul Webster, 43, from Highbury, London, is a seasoned medical tourist who has travelled abroad for a variety of procedures over the last five years. These include cosmetic surgery in Thailand, a knee arthroscopy in India following a rugby injury, and a slipped disc in Cape Town, South Africa, where he spent his recovery time relaxing by the pool. Paul opted to go abroad for surgery as he was able to avoid a waiting list at his local hospital and the cost of treatment was around 30 % of the cost of private treatment at home. More recently, having struggled to find a good local dentist, Paul’s dental clinic is now in Krakow, Poland – a low-cost flight away.

It’s not something most people would choose to do unless they really had to. Illness, short or long term, is unpleasant and painful enough, but to travel whilst ill would, to many people, seem unconscionable. And yet, to many more, it is exactly what must be done. Quite simply, if an individual’s home country is unable, for whatever reason, to provide the requisite healthcare, why should they not seek it elsewhere? Medical tourism, as it has become known, is a booming and massive industry.

The organization Patients Without Borders estimates that “the market size [for medical tourism] is USD 65 to 87.5 billion, based on approximately 20 to 24 million cross-border patients worldwide spending an average of USD 3 410 per visit, including medically-related costs, cross-border and local transport, inpatient stay and accommodations"1). By any consideration, therefore, medical tourism is already a huge market and one that, in the short and medium terms, is only likely to grow.

Dentist showing patient's teeth on X-ray.

Healthcare elsewhere

A word should first be said about what exactly is meant by the phrase “medical tourism”. Monica Figuerola Martín has been the Managing Director of Spaincares (the Spanish Health Tourism Cluster) for the last two years, as well as General Director of Tourism in the Government of La Rioja for 12 years; she also holds a PhD in tourism. As Convenor of working group WG 2, Health tourism services, of ISO’s technical committee on tourism (ISO/TC 228), which is developing the future ISO 22525, an International Standard for medical tourism, she is keen to draw a distinction between “medical tourism” and “touristic medicine”. At its simplest, the latter is “when someone is travelling and falls ill or has an accident and has to go to hospital”. She prefers the word “travel” because tourism is something more superficial – but when someone travels for medical reasons, they are not tourists, they are patients. The primary motivation is to travel for medical treatment not available in their home countries. Indeed, it is for this reason that Figuerola Martín would prefer to go even further and for the phenomenon to be referred to as “medical travel”, for the avoidance of any ambiguity at all.

So what are the most common conditions for which people become medical tourists? The short answer to this seems to be almost anything. Patients Without Borders publishes a long list of illnesses and conditions: from non-life-threatening cosmetic surgery and dentistry to cancer and reproductive care. And it is precisely because there are so many different treatments now on offer for so many different conditions that International Standards are so vital for the world’s medical travellers.

Another question closely related to this, of course, is why do people travel for medical care? The obvious answers are the high costs for treatment and lengthy waiting times for medical procedures in many countries, supported by easier and cheaper international travel. But these are not the only reasons. Some patients value the better quality of the medical infrastructure in certain countries and undergo measures that cannot legally be offered at home, such as fertility treatment for those who want children.

Sometimes, a particular country may have an excellent reputation for treatment of a certain condition and patients may even opt for a medical trial that is not taking place anywhere else in the world, let alone their home country. 

Sometimes the reason for travelling can be something as seemingly banal as the weather: many people find dialysis, for instance, much more comfortable when they can receive treatment beside the sea and under a sunny blue sky.

Doctor and nurse with tools in their hands in a operating room.

Staying safe

So what challenges does medical tourism face and how can International Standards help? Safety is without doubt the top priority. Most of the treatments under offer are very expensive and many countries propose various and varying medical treatments. However, this does not mean that every country is offering the same, let alone best, treatments. Safety needs to be improved along with protocols because as far as it is possible within the parameters of any given procedure, there needs to be a guarantee that the treatment is going to be successful, that the patient experience is going to be the best it can be.

More broadly, there is a huge number of stakeholders in medical tourism and the value chain for medical tourism is long and often complex. It stretches from the very first moment a company contacts a hospital to request a quotation to post-treatment when the patient goes home. There are very many critical points along the way and it’s important for certain countries to develop this kind of business – as long as it is undertaken in a very secure way.

Yosr Nefzaoui, Project Leader of ISO 22525 on medical tourism, is the manager of Tunisia-based travel agency SAFAR – a subsidiary of the Service Medical International Group (SMEDI) which has been operating in Africa since 2007 – as well as holding the presidency of the Medical Tourism Committee at the Tunisian Federation of Travel and Tourism Agencies. She points out that Tunisia is receiving many patients from North and sub-Saharan Africa where the healthcare systems are not meeting the needs of patients.

Tunisia’s current stance on healthcare is very impressive, in both the public and private sectors. A brief look at the statistics says it all: there are 115 health clinics, with 4 700 beds, 100 haemodialysis centres, 150 diagnostic X-ray centres, 232 laboratories for medical analysis, over 5 300 GPs’ surgeries, over 1 600 dental offices and nearly as many pharmacies. And yet it is probably fair to suggest that Tunisia does not have the reputation in healthcare in the same way that countries like Germany and Switzerland do. These two countries are renowned for being organized and efficient but there is no real reason why Tunisia, and similar countries, should not receive some recognition and that is where International Standards will bring so much benefit.

Doctor doing a heart ultrasound to a man-patient.

Keeping up with market needs

The first step in the development of an International Standard is to confirm the market demand and it has been long established that the number of people travelling for healthcare has increased dramatically in recent years. As a consequence, there has been a crying need to develop International Standards which define, at international level, the minimum quality requirements for the whole process. Medical tourism introduces a range of attendant risks and opportunities for patients, along with many stakeholders. ISO 22525, still in draft, but to be published very soon, will focus on intermediaries in the value chain where control is non-existent but where the risk is high.

To avoid any harm to the health of travellers, all players in the value chain should comply with certain requirements in order to limit the risks. International Standards will define the very broad range of requirements for various sectors concerned, from the organization of the stay by travel agencies to the quality of care delivered by the healthcare facilities.

In this case, the International Standards under development are focused on four areas:

  • Pre-travel and pre-treatment process
  • Treatment process
  • Post-treatment process
  • Return home and follow-up

Clinical excellence

Elderly woman being comforted by a female doctor before an MRI.For the end users, this standard aims to restrict the healthcare participants who do not respond to these norms, thereby limiting the risks and ensuring better care. Paradoxically perhaps, patients may often have little idea about the concept of “standards” and are probably unaware that they are required by health centres and other stakeholders. But it is for these centres that International Standards are so important because they are taking more and more patients from abroad. Centres of healthcare need certification, otherwise governments will simply refuse to recognize them. Medical excellence along with international accreditation are the key factors fuelling a majority of international patient flows, continually boosting international medical tourism.

Overall, standardization of the patient’s experience of medical tourism will improve the quality of care and patient safety as well as the satisfaction of the patient. This can be of great value not just to patients but to all stakeholders, and to all of us. And, as so often, the committees who draft and deliver International Standards are undertaking vital – and in the case of medical tourism, perhaps even life-saving – but invisible work.

 1) Patients Beyond Borders: “Medical Tourism Statistics & Facts”, (accessed April 2019)

Elizabeth Gasiorowski-Denis
Elizabeth Gasiorowski-Denis

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Elizabeth Gasiorowski-Denis
Editor-in-Chief of ISOfocus