International Journal of Research Studies in Medical and Health Sciences Volume 4, Issue 3, 2019, PP 21-25 ISSN : 2456-6373

Medical Tourism Has Become a Phenomenon

Siniša Franjić Faculty of Law, International University of Brcko District, Brcko, Bosnia and Herzegovina *Corresponding Author: Siniša Franjić, Faculty of Law, International University of Brcko District, Brcko, Bosnia and Herzegovina, Europe.

ABSTRACT Medical tourism has become one of the "market niches" that is increasingly being discussed in the context of growing potential, ie the growth rate of the number of passengers who seeking health services outside the borders of their own country. Today's medical tourism is certainly an "industry" that generates a significant number of passengers and significant financial turnover on an international level, but establishing a realistic factual state, turnover realized on arrivals and nights (on the emotional and/or receptive side), or financial parameters, is really not an easy task, primarily because there are no international standards for statistical tourism medical monitoring, ie the information that is generally known to the public depends on the methodological approaches of the authors. Keywords: Medicine, Health, Tourism, Economy

INTRODUCTION doubt healthy relaxation for many, extend the notion of health tourism beyond forms of Medical tourism has had a long gestation period tourism that are specifically or primarily about [1]. The very earliest forms of tourism were health. directly aimed at increased health and well- being. The first recorded instance of medical Medical tourism is a recent example of niche tourism dates back more than 2000 years when tourism, with the rapid rise of international visitors, perhaps the first pilgrims, travelled travel in search of cosmetic surgery and from around the Mediterranean to Epidaurus in solutions to various medical conditions, the Peloponnese, said to be the birthplace and benefiting health-care providers, local sanctuary of the god of healing, Asklepios, the economies and the tourism industry [1]. While son of Apollo. In Roman times taking the waters medical tourism may be a new niche in the was popular and spas date back more than 2000 industry, tourism has always been associated years, and health cures linked to water were with improved health and well-being, perhaps common to many regions. The numerous spas more usually perceived as occurring through and sacred sites that remain in many parts of entertainment, rest and relaxation rather than by Europe and elsewhere, in some places substantial bodily changes. Indeed travelling for represented the effective start of local tourism, improved health is the most durable niche in the as people travelled to gain physical benefits. history of tourism. A long history of spa tourism From then onwards particular therapeutic places dates back to antiquity, and in more recent and landscapes, from springs and mountains to centuries variants of a more general health temples and cathedrals, have played significant tourism have included phenomena ranging from roles in most cultures and regions. Health naturism and hiking/bushwalking to meditation tourism, in a relatively gentle form, has a long and detoxification. and unbroken history. It has become important for many reasons: (i) What exactly constitutes health tourism varies. disappointments with medical treatments at Golf, tennis (and other sports) might be pleasant home; (ii) lack of access to health care at and healthy exercise and sources of well-being reasonable cost, in reasonable time or in a for some, but dull or sources of tension and pain sympathetic context; (iii) inadequate insurance for others. Festivals, leisure centres and cruises and income to pay for local health care; (iv) the can stimulate health tourism, and occupational rise of high quality medical care in ‗developing‘ psychology workshops can be a form of countries; (v) uneven legal and ethical responses wellness. However, such leisure activities, no to complex health issues; (vi) greater mobility;

International Journal of Research Studies in Medical and Health Sciences V4 ● I3 ● 2019 21 Medical Tourism Has Become a Phenomenon and (vii) perhaps, above all, a growing demand countries, became absorbed into Western for cosmetic surgery that ties many other factors practices with health and well-being becoming together. more holistic phenomena. Nurturing the mind and the spirit in various ways, for long an Medical tourism has also emerged from a important part of tourism, resurfaced in new greater willingness to accept alternative forms. practices and procedures, and experience different cultures and places, even though most Physical and mental well-being are crucial to medical tourism is centred on ‗formal‘ good health and to health and medical tourism biomedical procedures. It has, however, in their many manifestations [1]. Much of health followed various social and economic changes tourism involves various forms of relaxation: encouraging a more holistic approach to health diet, exercise and new modes of thought. care where health-seeking behaviour has Although bodies (and minds) were sometimes become more likely to reflect the views of transformed they were not transformed by patients in terms of their own values, beliefs and surgery or other dramatic procedures. While philosophical orientations towards health and spirituality may be at the core of health and life, rather than those of the ‗medical well-being for some, medical tourism focuses on establishment‘. For some this has meant being more physical matters, where the emphasis is more involved in such social determinants of very much on biophysical processes, though health as community, belonging and hope; for psychological issues are highly important and others it has meant greater individualism. Ironically therefore greater support for spiritual elements are not entirely absent. Some complementary and alternative medicine has variants of medical tourism, such as cosmetic grown alongside the rise of cosmetic surgery, a dentistry, however, may be seen as little to do function of an ‗obsession with self that is with health, even for those involved, since they reaching an all-time high thanks to new media, lack dramatic, invasive procedures, and have no technology and consumer orientated services‘. ‗medical‘ component, and they are given less Yet one of the critical issues in the development attention in what follows. of medical tourism is the regulation of Medical tourism represents only one prong of standards. the growing expansion of global health care [2]. HEALTH Such medical trade also includes doctors While health was generally perceived as a traveling to other countries or regions to offer physical phenomenon, the mind and spirit were services, medical corporations investing and rarely excluded [1]. Ill health was often developing facilities in remote destinations, and attributed to spiritual and cultural causes, even the current and growing practice of tele- as biomedicine accompanied scientific medicine in which X-rays are read, diagnoses development and a movement away from are made, and even robotic operations are localized cultural beliefs about health. However, conducted from afar. However, there is little in recent years there has again been a shift of doubt that the phenomenon of travelers seeking belief systems away from an exclusive regard medical treatment has the greatest economic for biomedicine, and from the primacy of impact on a region, both in terms of health and science (evident also in the revival of hospitality income gained from such travelers. creationism, and opposition to evolution in some Western societies). While older forms of Successful medical treatment serves as the tourism, with their links to oracles, pilgrimage primary goal of medical tourism [3]. It is the and particularly venerable sites, might have core competency of hospitals while a hospitality been seen to emphasize ritual and religion, a team has expertise in customer care. Both teams sense of spirituality and the particular roles of have competitive methods to reinforce their core both mobility and therapeutic places were never competence and enhance their strengths. completely displaced by ‗new‘ forms of However, the greater success in medical tourism knowledge and practices, and in the 20th is to align these two core competencies from century were often revived in various both parties. Productivity and efficiency can be contemporary forms. Bodies, minds and belief maximized by the alignment. Also, success in systems were rarely disconnected. This often medical treatment and memorable customer care took a form where more spiritual and less are compensating each other to deliver excellent strenuous activities, such as yoga and massage, once primarily the province of some Asian medical tourism experience.

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MEDICAL TRAVELING of public health care, increased insurance rates and/or co-payments—and in some cases Medical tourism is far from being a recent rationed care. phenomenon; people have been travelling to access health care in faraway places for The legal context in which cross-border health centuries [4]. Traditionally, wealthy people care in Europe takes place has primarily been travelled from poorer countries, with basic given form over time more by economic health care facilities, to higher income countries interests, legislation and jurisprudence than that offered a better range of high-quality health policies at EU or Member State level [6]. services. However, there has been a recent In some sense, therefore, it is a paradox that reversal in the direction of travel, with patients cross-border care within the EU is defined as travelling from high-income countries in North much by citizens‘ rights as consumer forces. America and Europe to low- and middle-income In many ways, EU citizens consuming health countries in Latin America and Asia. This new care in a Member State other than their own are trend is driven by the ability of private facilities no different than any patient travelling for care in lower income countries to offer high-quality throughout the world. The European patient may services, with virtually no waiting time, at a indeed travel to another Member State as a comparatively low cost. consumer – as many do – to obtain services that However, despite the ‗hype‘ in the media are cheaper, better or more accessible in a regarding medical tourism, it is worth noting Member State other than their own. that the majority of this type of trade actually This process is arguably highly consistent with takes place regionally. For instance, patients the original economic intentions and treaty from the US and Canada often go to destinations agreements at the heart of the EU and the such as Brazil and Costa Rica; Western process of integration that the Union embodies. European patients travel to Eastern Europe; and The EU was founded to secure the free flow patients from the Gulf countries and Pakistan across borders of people, money, goods and travel to South and South East Asia, mainly services. India and Thailand. In addition to regional MARKET proximity, the country‘s specialty also plays a Medical tourism is niche tourism, like role in patients‘ decision of where to access ecotourism, religious tourism, and adventure care. This is because destination countries have tourism [7]. Such tourism does not draw masses specialized in certain procedures. For instance, but rather it appeals to a select number of people Thailand and India specialize in orthopedic and whose demand is big enough to generate cardiac surgery, whereas Eastern European sufficient business. Medical tourism, with its countries are hotspots for dental surgery. component medical and tourist parts, has both a EUROPEAN CROSS-BORDER HEALTH CARE market and an audience. Unlike ecotourism, in which a traveler will choose a destination and Compared to other countries of the world, and then seek an ecology focus, in medical tourism even to other Western industrialized countries, the traveler chooses medical care first, and only the majority of citizens in the European Union then pairs it with a destination and possibly even enjoy excellent, or at least relatively good, a vacation tie-in. As all tourism is goal oriented coverage of health care and health care costs [5]. (in the sense that travelers want to see a sight, or However, a closer look reveals a much more experience a tribal encounter, or touch a differentiated picture. Growing demand of an historical artifact, or simply party), so too aging population for health care services and medical tourism occurs with a specific goal in products, growing supply of innovative mind. The traveling patient aims to purchase a technology and pharmaceuticals, and increasing particular service and to achieve a defined health health awareness of patients lead to rising goal. That patient seeks to maximize utility expenses for public health care while at the subject to his income constraints. In that same time rising unemployment rates and calculation, medical services dominate, but increasing state debts reduce the ability of nonmedical services, including the governments to strengthen or even stabilize the accommodations, restaurant meals, excursions, financial resources of national health care and ground transportation, are not insignifi cant systems. The answer of European Union to the total experience. Member States is continuous health care reforms focused on cost-containment. The In his efforts to minimize costs of health care, measures include a reduced scope of coverage the patient has become a tourist. In his efforts to

International Journal of Research Studies in Medical and Health Sciences V4 ● I3 ● 2019 23 Medical Tourism Has Become a Phenomenon maximize utility, Homo Turisticus has become a environments of the destination countries to niche seeker. That particular niche calls for a which they travel, and are exposed to the seamless integration between the medical and commensals and pathogens of the health care the hospitality industries. The result of this providers, hospitals, and population at large in integration is the market for medical tourism. the destination country. The tourist patients may then bring the unwanted ―hitchhiker‖ home with Medical tourism on a large scale is a recent them to the destination country. The result is manifestation of service trade that has grown to that ―at any point in the circular migration of considerable economic significance at the patients traveling for medical care, microbes international level [8]. Destinations are no may travel from one location where they longer confined to poster child examples in East constitute a harmless bacteria, or at least a Asia that were frequented by American, British known and treatable infection, to another where and regional residents but now extend to they are unknown, making diagnosis and numerous countries worldwide that consider treatment much more problematic.‖ themselves and foster their roles as hubs, such as Dubai and Hungary. MARKETING There is ample motivation for protagonists in Marketing medical tourism and other healthcare the health care market to scrutinize medical services is somewhat different than offering tourism: Patients may benefit from access to retail products that are often considered tangible higher-quality care or reduced self-payments; goods [10]. In the most general sense, a product public providers may generate extra-budgetary is anything that can be offered to the market to income; private providers may generate both satisfy a patient‘s need or want. As such, this extra income and build a reputation with can include physical goods, such as walkers, medical tourists as they are expanding abroad; wheelchairs, canes, crutches, braces, stem cells, providers may productively employ a mobile organ transplants, pharmaceutical drugs, and international workforce in an international supplies. It can also include services such as environment; and insurers may differentiate surgery, executive checkup, golf swing analysis, their services and pursue both quality assurance diagnostic tests, or even a consultation. For a and cost containment strategies. At the medical tourism facilitator, a product could be aggregate level, medical tourism may entail both defined as a wellness checkup combined with a private and public savings through outbound cruise, winery tour, amusement park, cooking medical tourism or provide cross-funding of class, or any other combination experience that domestic services and advanced technology via can be paired with a medical service such as a inbound patients. At a time when both massage or spa visit. It could also be interpreted to demographics and rapid technological progress mean something like a hen night mammography strain public resources, medical tourism may group experience, where a group of women get alleviate some of that pressure. As a together, have their mammograms, and then go sophisticated service export, medical tourism out for a spa getaway, a night on the town, a may further serve as an important driver of weekend away, or some other experience that they economic growth. share together. In medical tourism, many times we see this type of activity when a group of executive TOURISTS women get together and decide to go off to an Medical tourists are very good targets of exotic place to have a Botox weekend. opportunities for pathogens [9]. Many are traveling with compromised or suppressed CONCLUSION immune systems to destination countries with Medical tourism is a concept that encompasses relatively high infection rates, including the risk travel primarily motivated by the use of medical of exposure to multi-drug–resistant pathogens. services (a greater or lesser degree of In medicine, it is common to distinguish complexity) - dental, surgical, rehabilitation etc. commensals—the bugs we normally carry on In recent decades, the emergence of a greater our skin, mouth, digestive tracts, etc.—from number of people motivated by the use of pathogens, the harmful bacteria that cause medical services began to travel beyond the disease through infection. When traveling for borders of their own state, meta phenomenon medical care, ―one person‘s commensal bacteria has become a focus of media interest and has can be another individual‘s exotic pathogen.‖ sparked a stronger expansion of intermediaries Medical tourist patients are transporting their in the provision of relevant services (agencies), commensals and pathogens to the hospital as well as the expansion of commercial medical

24 International Journal of Research Studies in Medical and Health Sciences V4 ● I3 ● 2019 Medical Tourism Has Become a Phenomenon service providers that are more or less focused Medical Tourism and Transnational Health on users from abroad. Combination of different Care―, Palgrave Macmillan, Basingstoke, UK, factors - high cost of health care outside the pp. 209. – 210. public health system in developed countries of [5] Meyer, H. J. (2013.): „Current Legislation on the West, lack of access to certain medical Cross-Border Health Care in the European services outside the public health system and/or Union― in Cohen, I. G. (ed): „The Globalization obligatory/commercial insurance systems, ease of Health Care - Legal and Ethical Issues―, and lower prices for international travel, faster Oxford University Press, Oxford, UK, pp. 83. development of medical technology and [6] Mainil, T.; Commers, M.; Michelsen, K. standards care in some countries, have led to an (2013.): „The European Cross-Border Patient increase in the popularity of such travels. as Both Citizen and Consumer: Public Health and Health System Implications― in Botterill, REFERENCES D.; Pennings, G.; Mainil, T. (eds): „Medical [1] Connell, J. (2011.): „ Medical Tourism―, CAB Tourism and Transnational Health Care―, International, Wallingford, UK, pp. 12.; 1. – 2.; Palgrave Macmillan, Basingstoke, UK, pp. 133. 23. ; 42. [7] Bookman, M. Z.; Bookman, K. R. (2007.): „ [2] Cormany, D. (2017.): „ Introduction to the Medical Tourism in Developing Countries―, Phenomenon of 'Medical Tourism'― in DeMicco, Palgrave Macmillan, New York, USA, pp. 41. F. J. (ed): „ Medical Tourism and Wellness - [8] Schmerler, K. (2018.): „Medical Tourism in Hospitality Bridging Healthcare (H2H)―, Apple Germany - Determinants of International Academic Press, Inc., Oakville, Canada, pp. 41. Patients‘ Destination Choice―, Springer Nature, [3] DeMicco, F. J.; Poorani, A. (2017.):„ Cham, Switzerland, pp. 1. Improving the Health Care: The Patient/Guest [9] Cohen, I. G. (2015.): „ Patients with Passports - Experience Academy― in DeMicco, F. J. (ed): „ Medical Tourism, Law and Ethics―, Oxford Medical Tourism and Wellness - Hospitality University Press, Oxford, UK, pp. 48. – 49. Bridging Healthcare (H2H)―, Apple Academic Press, Inc., Oakville, Canada,pp. 104. [10] Todd, M. K. (2012.): „Handbook of Medical [4] Álvarez, M. M.; Smith, R. D.; Chanda, R. Tourism Program Development - Developing (2013.): „ The Impact of Medical Tourism in Globally Integrated Health Systems―,CRC Low- and Middle-Income Countries― in Press, Taylor & Francis Group, Boca Raton, Botterill, D.; Pennings, G.; Mainil, T. (eds): „ USA, pp. 45.

Citation: Siniša Franjić, “Medical Tourism Has Become a Phenomenon”, International Journal of Research Studies in Medical and Health Sciences. 2019; 4(3): 21-25. Copyright: © 2019 Siniša Franjić, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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