ARTICLE IN PRESS Tourism Management 27 (2006) 1093–1100 www.elsevier.com/locate/tourman Research article Medical tourism: Sea, sun, sand and y surgery John ConnellÃ School of Geosciences, University of Sydney, NSW 2006, Australia Received 1 November 2005; accepted 29 November 2005Abstract Medical tourism, where patients travel overseas for operations, has grown rapidly in the past decade, especially for cosmetic surgery.High costs and long waiting lists at home, new technology and skills in destination countries alongside reduced transport costs andInternet marketing have all played a role. Several Asian countries are dominant, but most countries have sought to enter the market.Conventional tourism has been a by-product of this growth, despite its tourist packaging, and overall beneﬁts to the travel industry havebeen considerable. The rise of medical tourism emphasises the privatisation of health care, the growing dependence on technology,uneven access to health resources and the accelerated globalisation of both health care and tourism.r 2006 Elsevier Ltd. All rights reserved.Keywords: Health; Medicine; Tourism; Asia; Economics As health care costs skyrocket, patients in the developed been taken to a new level with the emergence of a new and world are looking overseas for medical treatment. India distinct niche in the tourist industry: medical tourism. This is capitalizing on its low costs and highly trained doctors paper seeks to provide a ﬁrst assessment of this emerging to appeal to these ‘‘medical tourists.’’ Even with airfare, phenomenon. the cost of going to India for surgery can be markedly Some of the earliest forms of tourism were directly aimed cheaper, and the quality of services is often better than at increased health and well being: for example, the that found in the United States and UK. Indeed, many numerous spas that remain in many parts of Europe and patients are pleased at the prospect of combining their elsewhere, which in some cases represented the effective tummy tucks with a trip to the Taj Mahal. start of local tourism, when ‘taking the waters’ became Yale Global (www.medical-tourism.us) common by the 18th century. By the 19th century they were evident even in such remote colonies as the French Paciﬁc territory of New Caledonia, while the emergence of1. Introduction hill stations virtually throughout the tropics further emphasised the apparent curative properties of tourism It is a truism that tourism is supposed to be about and recreation in appropriate, often distant, therapeuticrelaxation, pleasure and an increase in well being and even places (Smyth, 2005). Somewhat later, recreation andhealth. Even with the rise in cultural tourism and notions tourism shifted seawards in developed countries, andof tourism also being a learning experience, such learning extended from elites towards the working classes, and seatoo is expected to be relaxing and quite different from bathing became a healthy form of recreation (e.g. Gilbert,classroom memories. Tourists need not necessarily be 1954). Other sports, such as golf, cycling, walking andhedonists, but they anticipate a beneﬁcial outcome. In the mountaineering, similarly became part of the touristpast decade the attempt to achieve better health while on experience and were supposedly pleasurable ways ofholiday, through relaxation, exercise or visits to spas, has combining tourism and well being. Even more recently ÃTel.: +61 02 9351 3244; Fax: +61 02 9351 3644. tourists have travelled in search of yoga and meditation. E-mail address: firstname.lastname@example.org. The legacy of all this is the continued presence of ‘health0261-5177/$ - see front matter r 2006 Elsevier Ltd. All rights reserved.doi:10.1016/j.tourman.2005.11.005
ARTICLE IN PRESS1094 J. Connell / Tourism Management 27 (2006) 1093–1100tourism’ where people visit health spas, for example in United States, must pay—often considerably—for healthKyrgyztan (Schoﬁeld, 2004), with the primary purpose of care. Finally, growing interest in cosmetic surgery, invol-beneﬁcial health outcomes. ving such elective procedures as rhinoplasty, liposuction, With the partial exception of some spas, none of this has breast enhancement or reduction, LASIK eye surgery andinvolved actual medical treatment, but merely assumed so on, or more simply the removal of tattoos, have createdincidental beneﬁts in amenable, relaxing contexts. This new demands. Various forms of dental surgery, especiallypaper is a preliminary attempt to examine a contemporary cosmetic dental surgery, are not covered by insurance inelaboration of this—the rise of ‘medical tourism’, where countries like the UK and Australia; hence dental tourismtourism is deliberately linked to direct medical interven- has become particularly common. In Asia these trends aretion, and outcomes are expected to be substantial and long ‘the unlikely child of new global realities: the fallout ofterm. A distinct tourism niche has emerged, satisfying the terrorism, the Asian economic downturn, internet access toneeds of a growing number of people, mainly in developed price information, and the globalisation of health services’countries, beneﬁting both themselves and a growing (Levett, 2005, p. 27).number of destinations, principally in developing The biggest hurdle that medical tourism has had to face,countries. and continues to face, is the challenge of convincing distant potential visitors that medical care in relatively poor2. A new form of niche tourism countries is comparable with that available at home, in outcome, safety and even in dealing with pain thresholds. In the last decade, and primarily in the present century This has been especially so when medical care systems, inthe notion of well being has gone further than ever before. countries such as India, have been conventionally regardedNo longer is improved health on holiday merely an in the west as inadequate, ‘even’ for India itself. As theanticipated consequence of escape from the arduous German radio station, Deutsche Welle, has pointed outdrudgery of work and the movement to a place with a ‘India is not exactly known for health and hygiene’ yet itcleaner (or warmer) climate, or the outcome of ‘taking the nonetheless anticipates a major market in Germanywaters’, but in some circumstances—the rise of medical (Deutsche Welle, 22 March 2005). Attached to that is thetourism—it has become the central theme of tourism in an parallel perception that ‘you get what you pay for’, henceactive rather than a passive sense. A new niche has emerged cheap medical care may well be inferior. While suchin the tourist industry. While some writers have continued situations have now radically changed the perception ofto use the phrase ‘health tourism’ to cover all forms of inadequacy remains.health-related tourism (e.g. Garcia-Altes, 2005), it seems Advertisements for medical tourism therefore invariablymore useful to distinguish ‘medical tourism’ as one stress technology, quality reliability, and overseas training.involving speciﬁc medical interventions. Advertising in ‘Air Mauritius in-ﬂight magazine the Medical tourism as a niche has emerged from the rapid Challeng’ Hair Paris hair grafting clinic provides ‘beforegrowth of what has become an industry, where people and after’ photographs of European clients and stresses:travel often long distances to overseas countries to obtainmedical, dental and surgical care while simultaneously One of the ﬁve most advanced clinics in the world isbeing holidaymakers, in a more conventional sense. It has located in Mauritius. The international medical teamgrown dramatically in recent years primarily because of the consists of one Plastic Surgeon, a Laureate winninghigh costs of treatment in rich world countries, long doctor from the faculty of Paris and an anesthetist, allwaiting lists (for what is not always seen institutionally as members of the Medical councilyThis clinic, set up topriority surgery), the relative affordability of international European standards and approved by the Ministry ofair travel and favourable economic exchange rates, and the Health is equipped with state of art technologyageing of the often afﬂuent post-war baby-boom genera- (Islander, 38, December 2004).tion. It has thus largely reversed an earlier pattern ofwealthy patients travelling to rich world centres, such as Cuba emphasises that the quality of its professionals inHarley Street in London (but where tourism was not plastic surgery and dentistry is ‘unquestionable as showninvolved). Growth has been facilitated by the rise of the by the health indices given by the World Health Organiza-Internet, and the emergence of new companies, that are not tion’ (www.cubanhealth.com). In all these countries, andhealth specialists, but brokers between international across them, new companies have sprung up, to linkpatients and hospital networks. It has also grown because patients, hospitals, potential medical tourists and destina-of rapidly improving health care systems in some key tions, many with names that either attest to these linkages,countries, where new technologies have been adopted. such as Surgeon and Safari (South Africa), and AntiguaAbove all it has followed the deliberate marketing of health Smiles, that hints at the pleasures associated with bothcare (in association with tourism) as medical care has cosmetic dentistry and visiting the Caribbean. In sourcegradually moved away from the public sector to the private countries too new companies are emerging, such assector, ensuring that a growing majority of people, Gorgeous Getaways in Australia that specialises inespecially in the richest countries, and particularly in the cosmetic surgery in Thailand and Malaysia.
ARTICLE IN PRESS J. Connell / Tourism Management 27 (2006) 1093–1100 10953. The rise of medical tourism in Asia As medical tourism has grown in Asia rich world countries have also sought involvement. Thus the Bavaria Medical tourism has grown in a number of countries, Medical Group (BMG) has developed links with Qatarsuch as India, Singapore and Thailand, many of which Airways and the Sultanate of Oman that have takenhave deliberately linked medical care to tourism, and thus patients from Oman to Germany and also resulted inboost the attractions of nearby beaches etc. But medical specialist BMG doctors visiting Oman (Times of Oman,tourism has also developed in South Africa and in 24 May 2005). However, rich countries can rarely compete,countries not hitherto associated with signiﬁcant levels of and restore the old order, as medical tourism has reversedwestern tourism such as Belarus, Latvia, Lithuania and direction. In a very short time period the global structure ofCosta Rica. Hungary, for example, declared 2003 to be the health tourism has become highly complex.Year of Health Tourism. Eastern European countries have The main region for medical tourism is Asia. Thailandbecome important for dental care and plastic surgery. became known as a destination for medical tourism asJordan serves patients from some parts of the Middle East early as the 1970s because it specialised in sex changewhile Israel caters both to Jewish patients and others from operations, and later moved into cosmetic surgery.nearby countries, through specialising in female infertility, Malaysia became involved after 1998 in the wake of thein vitro fertilisation and high-risk pregnancies. Asian economic crisis and the need for economic diversi- South Africa has grown in prominence in recent years, ﬁcation, as did many Thai hospitals, when local patientsespecially for cosmetic surgery, since its costs are less than were no longer able to afford private health care. Singaporehalf those of the United States, from where most of its has belatedly sought to compete with Malaysia andpatients come. Argentina is also noted for plastic surgery. Thailand, deliberately set rates just below those in Thai-The Caribbean has found it more difﬁcult to enter the land and even set up a stand at the airport with ﬂiers,medical tourism market since, despite its proximity to the information and advice for transit passengers.United States, its prices cannot compete with those in Latin India is usually regarded as the contemporary globalAmerica (Huff-Rousselle, Shepherd, Cushman, Imrie, & centre for medical tourism, and it advertises itself asLalta, 1995). Some Caribbean states have sought to get offering everything from alternative Ayurvedic therapy toaround this by specialisation, hence Cuba specialises in coronary bypasses and cosmetic surgery. To become theskin diseases and Antigua in dentistry. In the Paciﬁc Guam most important global destination it has upgradedhas become a regional dental centre for Palau, the technology, absorbed western medical protocols andFederated States of Micronesia and also Japan (Paciﬁc, emphasised low cost and prompt attention. Since economicJune 2005, p. 23). liberalisation in the mid-1990s private hospitals have As one of the main sources of medical tourists, the expanded and found it easier to import technology andMiddle East—particularly Dubai, but also Bahrain and other medical goods, thus bringing infrastructure in theLebanon—has recently sought to reverse this ﬂow and best hospitals to western levels. The links to India’s highlydevelop its own medical tourism industry. Dubai has just successful IT industry are also advertised as important.built Healthcare City (DHCC) to capture the Middle Moreover, as hospitals improved and speciﬁc salariesEastern market and try and divert it from Asia. Unable to increased, so doctors returned from overseas. Many hadcompete on price the Middle East has largely competed on international qualiﬁcations and western experience thatquality, with Dubai bringing in German doctors to could be advertised to make potential tourists moreguarantee high skill standards, and Lebanon stressing its comfortable. The same liberalisation brought new struc-many doctors trained in Europe and America. Branding is tures of corporatisation that streamlined India’s notoriousseen as important; ‘it remains to be seen if DHCC will bureaucracy and signiﬁcantly improved administration.attract peopleyif there is a single hospital that had one or The principal corporate hospital chains employ teams oftwo good brands that would be good if there was a interpreters, though India has beneﬁted because of itsCleveland Clinic or a Guy’s or Thomas’s Hospital’ widespread English speaking ability. (Thailand’s Phuket(Gulfnews.com, 23 May 2005). Saudi Arabia has sought Hospital provides interpreters in 15 languages and receivesto link medical tourism, and especially cosmetic surgery about 20,000 international patients a year, while the nowand dentistry, with pilgrimage (Hajj) visits to the country, famous Bumrungrad International Hospital in Bangkokwith most patients being from other Gulf countries (Arab claims to employ 70 interpreters, all its staff speak English,News, 27 July 2005), and the Health Minister of Iran and it has 200 surgeons certiﬁed in the United States).has claimed that ‘No Middle East country can compete While technology has become much the same as in thewith Iran in terms of medical expertise and costs’, west, and doctors are experienced in western procedures,comparing the cost of open heart surgery at US$18,000 most labour costs remain very low and insurance is lessin Turkey, $40,000 in UK and $10,000 in Iran so that costly. Success rates, even for procedures that can havepatients ‘can afford the rest on touring the country’ high infection rates, such as heart operations, bone marrow(Persian Journal, 22 August 2004). In 2005 relatively low transplants and kidney transplants, are comparable tocost Jordan remained the main medical tourism destination those at some of the world’s best hospitals. India has anin the Middle East. annual Medical Tourism Expo and it has been predicted
ARTICLE IN PRESS1096 J. Connell / Tourism Management 27 (2006) 1093–1100that medical tourism will earn India as much as US$2 Oman, UAE, Bahrain, Qatar, Saudi Arabia, Mauritius,billion by 2012. Seychelles, Maldives, Sri Lanka, Bhutan, Nepal, East Measures of the ﬂows of medical tourists vary enor- Africa, Germany, Australia, Canada and the UK (Timesmously, partly because this deﬁes easy categorisation of Oman, 11 June 2005). European patients favour India,(either in terms of patients and/or accompanying family Thailand and Malaysia. Early on, Malaysia primarilymembers etc.) and partly because no statistics distinguish focused on the Middle East, stressing its Islamic creden-it. The only speciﬁc survey undertaken appears to have tials, including the presence of halal food and Islamicbeen in Costa Rica where a 1991 university study found practices in hospitals. The manager of one group ofthat 14 percent of all visitors to Costa Rica came to Malaysian hospitals has said ‘since 9/11 people startedreceive some sort of medical care, usually cosmetic surgery looking to the Eastern world for holidays and we are tryingand dental work (www.infocostarica.com/news/20-Jun- to capture a fraction of these people. The Middle East is a2005.html). In terms of origin it has been estimated that huge market for us. Abu Dhabi Company for Onshore Oilabout 50,000 people left the UK in 2003 as medical tourists Operations sends its 36,000 employees to us for check-ups’(Guardian, 11 May 2004). Thailand claims to have the (Gulfnews.com, 14 February 2005). Since 9/11 Thailand haslargest number of medical tourists, with a million patients gained contracts from the UAE’s police department andfrom Japan in 2003 and a 20 percent increase in 2004 the Oman Government, both of which were formerly(www.expresshealthcaremgmt.com/20050315/interview01. linked to Europe (Levett, 2005). Malaysia has alsoshtml), and has been credited by Singapore with having organised trade missions to such south east Asian countries800,000 overseas patients in 2003 (Ai-Lien, 2005) but there as Myanmar and Vietnam, where there is a small potentialare no reliable data to demonstrate this. It has also been elite market (and there are few high-quality medicalreported that in 2004 some 247,238 Japanese, 118,701 facilities), and it receives a large number of medical visitorsAmerican, 95,941 UK and 35,092 Australian patients were from Indonesia (Chaynee, 2003). However, 70 percent oftreated in Thai hospitals, though this includes locally based those people from UAE who travel overseas for healthexpatriates and other injured and sick tourists (Levett, treatment are said to go to Singapore (Gulfnews.com,2005). One estimate for India was of 150,000 medical 14 February 2005) and India is said to be the preferredtourists visiting in 2002, almost half of whom came from destination of Omanis (Times of Oman, 11 June 2005).the Middle East (Neelankantan, 2003), but it has been Many patients in both Malaysia and Singapore areestimated that the number will reach about 500,000 in Europeans and Americans resident in Asia. Singapore2005. Another recent estimate for 2004 put the annual has seen a shift of its market from Indonesia to the Middleinﬂow to India between 10,000 and 20,000 foreign patients East, alongside ethnic Chinese from a diversity of sources.(Indian Express www.expresstravelandtourism.com), and Rich Japanese tend to ﬂy to Singapore, and Sumatransanother repeated the 150,000 ﬁgure (ABC, 8 November go by ferry to Malaysia (M. Wang, Pers. commun.,2005). At the end of the last century the number of foreign 4 October 2005). Thailand has deliberately sought apatients seeking medical treatment in Malaysia was Japanese market, since many doctors have been trainedestimated to have been around 400,000 over a two-year in Japan, and nurses and other staff have been taught toperiod (Chaynee, 2003); this is likely to be an overestimate, speak Japanese; Thailand mainly has patients from Japan,as some 150,000 were reported in 2004 (Chong, Boey, & Brunei, Singapore, Taiwan, Pakistan, China and Bangla-Vathsala, 2005). Singapore claimed an annual 150,000 desh. Cuba has a primarily Latin American market withinternational patients in 2003, was reported as having Argentina, Ecuador and also the Dominican Republic as230,000 foreigners seeking medical care in 2003 (Ai-Lien, the main sources of medical tourists (Huff-Rousselle et al.,2005) and was recently said to have an annual 200,000 1995, p. 10). The global migration of doctors, especiallymedical tourists (Gulfnews.com, 14 February 2005). Cer- from India to Europe and North America has meanttainly numbers are steadily rising in most destinations, but growing familiarity with being treated by Indians andthere are no reliable national ﬁgures for any country. Filipinos. Japan has always been unwilling to accept immigration4. Tourists—the economic rationale? hence has a health care system that is under considerable pressure, especially as its population ages, without access Medical tourists not surprisingly are mainly from rich to migrant health workers as in most other developedworld countries where the costs of medical care may be countries. Consequently Japan has taken particular ad-very high, but where the ability to pay for alternatives is vantage of the notion of medical tourism. Many Japanesealso high. Most are from North America, Western Europe companies even send their employees to Thailand andand the Middle East. In India a majority are part of the Singapore for annual physical examinations, as the savingsIndian Diaspora in the United States, Britain and else- on medical fees and high-quality medical care make thewhere, but include elites from a range of countries, airfare inconsequential. For provincial Japanese companiesincluding several African states, but there has been a the cost is little more that that of travelling to Tokyo,gradual shift to a more diverse patient population. One reports are done in Japanese and images sent electronicallyChennai (Madras) hospital has claimed patients from to Japan (M. Wang, Pers. commun., 2005). Moreover at
ARTICLE IN PRESS J. Connell / Tourism Management 27 (2006) 1093–1100 1097least one Bangkok hospital has an exclusively Japanese Distance offers anonymity. Some medical procedures,wing and there are many Japanese nursing homes in such as sex changes, have become small but signiﬁcantBangkok. parts of medical tourism, especially in Thailand, where Economics effectively calibrates the rise of medical recuperation and the consolidation of a new identity maytourism. Price differentials between most Asian states and be better experienced at a distance from standard daily life.more developed countries are considerable and are Similarly cosmetic surgery patients may prefer recupera-presently diverging even further. This may be accentuated tion in a relatively alien environment.or inﬂuenced by long waiting lists. For complex surgery the For many, what makes medical tourism so appealing isdifferences are considerable. In 2003 a small child in the that no one need know there was anything medicalUnited States with a hole in her heart was faced with a bill about the trip. [A couple from the United States ] visitedof around $70,000 there, but the operation was carried out South Africa a year ago for tummy tucks, liposuctionin Bangalore, India at a cost of $4400 (Neelankantan, and eyelifts. Back from South Africa they threw a2003). Open heart surgery may cost about $70,000 in SuperBowl party ‘‘Friends kept saying we lookedBritain and up to $150,000 in the United States but in fantastic’’. Funny how a good vacation can be such anIndia’s best hospitals it costs between $3000 and $10,000 uplifting experience (Andrews, 2004).depending on how complicated it is. Dental, eye andcosmetic surgery costs about a quarter of that in western Even where privacy may not necessarily seem to becountries (Neelankantan, 2003). The price differentials for crucial to the operation, that it parallels exclusivity can becosmetic surgery are particularly signiﬁcant since cosmetic important. Thus the Mauritius hair grafting clinic, whoseprocedures are not covered by insurance. A face-lift in name suggests an elite Parisian connection, argues ‘situatedCosta Rica costs about a third of that in the United States, not far from most exclusive hotels, the clinic receivesand rather less in South Africa. However, any complica- patients from around the world. Many stars and persons oftions and post-operative costs may have to be met in the international fame, who naturally require the utmostpatient’s home country, hence disparaging comments that discretion, owe the restoration of their hair to this clinic’this is ‘ﬂy in ﬂy out’ or ‘itinerant surgery’. Patients in a (Islander, 38, December 2004).sense are outsourcing themselves. Distance also offers alternatives. Certain operations may Currency ﬂuctuations can be a signiﬁcant inﬂuence. not be available in origin countries. Abortions are bannedWhen the South African Rand rose signiﬁcantly in value in several countries or are restricted to early periods ofagainst the US dollar in 2004, one company went pregnancy. In Britain, for example, health authorities arefrom about 30 patients a month in 2003 to none in 2005 usually unwilling to countenance stomach stapling for(J. Mortensen, Pers. commun., June 2005). patients if they are aged less than 18; this is not the case in India has cornered a substantial part of the market many medical tourism destinations where the ‘customer’ isbecause its fees are signiﬁcantly below those of other more likely to be right.possible destinations. Thus bypass operations in India are The most extreme forms of such travel, where the wordabout a sixth of the cost in Malaysia. Nonetheless, price tourism ﬁts least easily, are those of patients seekingdifferentials between all Asian countries and the west euthanasia. In recent years this has brought a stream ofremain considerable: Thailand can offer liposuction and non-citizens to Switzerland, may have taken ‘deathbreast enhancement surgery for a ﬁfth of the rate this tourists’ to the Netherlands and for a time in the 1990swould cost in Germany, hence it has focused on this took Australians to the Northern Territory (the only partparticular European market. Singapore has sought to of the country where euthanasia was brieﬂy permissible). Acompete on quality rather than price and stresses its ﬁnal form is a variant of ‘transnational retirement’: thesuperior technology, and that Singapore doctors had establishment of overseas nursing homes, where patientscarried out the ﬁrst Asian separation of Siamese twins effectively stay permanently, as in Kenya, where convertedand the ﬁrst South East Asian heart transplant, amongst hotels (as the tourism market declines) have been turnedother similar ‘ﬁrsts’. into homes for east African Asians, retiring and returning While economic beneﬁts are central to medical tourism from the UK, or for Japanese in Thailand and thethey are not the only factors. Waiting lists for non-essential Philippines.surgery such as knee reconstructions may be as long as 18months in the UK. In India the whole procedure can be 5. ‘It’s a ﬁne line between pleasure and pain’. Tourism?done in under a week and patients sent home after a further10 days. Some surgery, such as this, regarded as non- While almost all advertisements for medical tourismessential or low priority in the western world, may be stress the links between surgery and tourism, especiallynecessary for certain forms of employment, and hence during recuperation, the extent to which recuperatingworth travelling for. Similarly, in the UK, waiting times for patients may be able to beneﬁt from ‘normal’ elements offertility treatments may be very long, and at an important tourism may be queried. Is this therefore merely longperiod in couples’ lives, hence many ‘fertility tourists’ have distance migration for surgery, marketed as an attractivegone overseas (Graham, 2005). tourist experience, or is there actual tourism? Indeed
ARTICLE IN PRESS1098 J. Connell / Tourism Management 27 (2006) 1093–1100describing a medical procedure as part of a tourist Bangkok, then join a connecting ﬂight to PhuketyAfterexperience might seem to be in itself merely cosmetic your medical procedure we will then arrange for youradvertising. transfer to the hotel or resort selected by you, for your In some destinations, including Hungary and Mauritius, relaxation and recuperation’ (www.phuket-health-travel.-medical tourism possibilities are advertised in in-ﬂight com). Tourism is certainly an integral part of medicalmagazines and standard government tourist publications, tourism.on the assumption that tourists might avail themselves of If tourism is about travel and the experience of othersmall-scale procedures such as dentistry during otherwise cultures then all medical tourism is tourism. Usually it isstandard tourist visits. In Thailand it is argued that the also rather more than that, if only because medical touristsreputation of the country as a tourist destination has can only return home when they are, in a sense, wellboosted medical tourism to the extent that for the Bangkok enough to be travellers and therefore tourists. TourismDental Spa, which treated about a thousand overseas may involve their relatives rather more than themselves,patients in its ﬁrst year, ‘90 percent of patients already but most patients are able to sample standard touristknow Thailand and love it as a holiday destination’ experiences if they wish to. In a few cases patients have(quoted in Levett, 2005, p. 27). Tourism provides a partial chosen holiday destinations with the secondary goal ofbasis for medical tourism. medical treatment, usually for high-cost low-risk opera- Marketing naturally stresses the pleasures of the tions such as dentistry.destinations. Some sense of the link between tourism isevident in the website for the Nirmalyam Ayurvedic Californian resident Eva Dang decided to take the 24 hRetreat and Hotels company in Kerala, which also stresses ﬂight over the Paciﬁc Ocean for a dental appointment.the possibilities of catamarans and house boats: ‘‘[Singapore] is just as good as America. Doctors are The tourists are attracted by Yoga, Ayurveda and Vedic very professional and caring and very attentive’’. And Astrology, the great sciences which grace Indian culture. cheaper too. What is more she can get to relax by the One of the resorts which supports these sciences is the pool in a tropical climate, grab some food at the hawker famous Nirmalyam Ayurvedic Retreat, where many stalls and catch the sights at the same time tourists come and stay for Ayurvedic treatment and (www.CNN.com, 24 February 2005). enjoyment of scenic beauties in God’s own country, Guravayur, Kerala. Within a couple of kilometres from Similarly, a cosmetic surgery patient in Jamaica ‘recup- Guruvayur, the famous temple city, is the world’s largest erated a few hundred yards from the hospital in a villa elephant sanctuary of 58 elephants, which is visited by furnished in wicker and mahogany, with a terrace and a many a tourist. The Nirmalyam Ayurvedic retreat private pool’ (Andrews, 2004). However, despite its name, functions as an Ayurveda centre as well as a three star patients of the Surgeon and Safari company in South hotel with state of the art 60 rooms with economical Africa may be discouraged from going on safari after rates (www.eastrovedica.com). plastic surgery to ensure proper recovery (Andrews, 2004). However, this is primarily health rather than medical Others may prefer to recuperate at length, throughtourism, involving no more than massage, and tourists who tourism, and later see specialists for a ﬁnal time. Mosthave not experienced invasive procedures may be more visitors spend some time shopping, even if no further thaneasily able to appreciate the delights of elephants and hotel stores, and justify this (where they feel it necessary)catamarans. One Bombay hospital has considered the on the grounds of the money saved through overseas healthslogan ‘open your new eyes on the beach at Juha’ (some care.30 km to the north). Indonesian visitors to Malaysia prefer Ultimately ‘tourism’ is rather more than just a cosmeticto be treated in the large cities of Penang and Malacca, noun for an activity that otherwise has little to do withboth of which have a signiﬁcant tourism industry. conventional notions of tourism, since most visitors and In some contexts hospital chains have become integrated certainly those who accompany them, ﬁnd some time forinto the tourist industry. The principal hospital group in tourism. Moreover, at the same time, the whole infra-Singapore, Rafﬂes, arranges airport transfers, books structure of the tourist industry (travel agents, airlines,relatives into hotels and helps to arrange local tours. hotels, taxis etc) all beneﬁt considerably from this newHotels in Malaysia have similarly become horizontally niche. Indeed, since for a signiﬁcant proportion of patientsintegrated with hospitals. In the wake of the December there may be a lengthy period of recuperation, the rewards2004 tsunami, Thai hospitals in Phuket, like nearby hotels, to the tourist industry, and especially the hotel sector, areoffered special packages (focussed on cosmetic surgery) to considerable. Such beneﬁts are presently unquantiﬁablerevitalise the (medical) tourist industry there. The Phuket though one estimate is that medical tourists in ThailandHealth and Travel website notes ‘in addition to scheduling spent US$1.6 billion in 2003 (Taffel, 2004), while medicalyour medical treatment, we also arrange your travel and tourists in South Africa were estimated to spend betweenaccommodation, as well as any car hire, cruises, tours or US$30–40 million in the same year (J. Mortensen, Pers.other vacation services. You will ﬂy on a scheduled ﬂight to Commun., 2005).
ARTICLE IN PRESS J. Connell / Tourism Management 27 (2006) 1093–1100 10996. Conclusion: ‘ﬁrst world service at third world cost’? destinations, as the economic beneﬁts from employment in that sector become even greater. A higher earning capacity Medical tourism is likely to increase even faster in the plays a small part in reversing the brain drain, a signiﬁcantfuture as medical care continues to be increasingly issue in such developing countries as India, where manyprivatised, and cost differentials remain in place. As the doctors and nurses migrated overseas. Malaysia hasdemand for cosmetic surgery (including dentistry) con- actively sought to encourage doctors to return fromtinues to expand so will demand for overseas services, and overseas, ﬁrstly, to be involved in medical tourism and,this will probably replace heart surgery as the core element secondly, to provide more equitable health care (Chong etin medical tourism. Moreover, as successful outcomes al., 2005). Expansion of the private sector may be at somebecome more evident, demand is likely to increase further. cost to the public sector, where patients have very limitedWestern insurance companies might encourage overseas ability to pay, if skilled health workers move out of thattreatment to reduce their own costs. One Kolkata sector. The recent boom in medical tourism has occurred in(Calcutta) hospital has signed an agreement with the a context where 40 percent of India’s population live belowBritish insurance company, BUPA. Similarly, at the start the poverty line and have no access to basic health care andof 2005, the British National Health Service (NHS) was infant and maternal mortality rates are high. As one healthsending patients to Europe to cope with a backlog of cases, researcher has pointed out:but restricting them to places within 3 h ﬂying time (such as The poor in India have no access to healthcare becauseFrance and Spain). Were waiting lists to increase further an it is either too expensive or not available. We haveextension of this policy might beneﬁt those countries now doctors but they are busy treating the rich in India. Nowseeking medical tourists, and the larger Indian companies we have another trend. For years we have beenhave been in negotiations with the NHS about outsourcing providing doctors to the western world. Now they arethe treatment of British patients to India. coming back and serving foreign patients at home (Ravi The number of countries seeking to develop medical Duggal, quoted in Ramesh, 2005).tourism continues to grow rapidly. The success of medicaltourism in Asia especially has prompted growing global Ethical issues have therefore become signiﬁcant (Bor-interest and competition, and optimism is seemingly man, 2004), both in terms of equity and in the moreunbounded. Singapore, for example, though a relatively competitive involvement of the market in medical care.high-cost destination, is seeking to attract 1 million Over the past decade the Indian health system has becomepatients by 2012, which would generate US$1.8 billion in ever more dichotomous; Apollo argues that it is settingrevenues, create at least 13,000 jobs (Ai-Lien, 2005) and aside free beds for those who cannot afford to pay, buteven restore economic growth after the recession in the IT there is little evidence that these are used (ABC, 8industry at the end of the century. The Philippines has November 2005), and are pioneering telemedicine inrecently declared its interest, based on a new airport and remote parts of India. Apollo argues that ‘India is nowthe familiarity that people all over the world have with ready to heal the world’ but the ABC have noted that ‘theEnglish speaking Filipino doctors. As a consultant noted majority of its own people remain at the back of the queue’‘there used to be a time gap in terms of medical technology (ABC, 8 November 2005). Urban bias in health carereaching the shores of Manila, but not anymore. Also with delivery has been intensiﬁed everywhere. In Malaysiaevery third medical practitioner in the UK or the US health care delivery is increasingly inequitable (Chong etknown to be of Filipino descent, ﬁrst-world patients attach al., 2005) and in Thailand ‘there is a huge drain on thea reasonable amount of conﬁdence and comfort in being public health sector. To practise medicine in Thailand youtreated in the Philippines’ (quoted in Kinavanod, 2005). must pass a Thai language examination, so the boomingDubai has built Healthcare City to discourage Middle private sector can take staff from only one place’ hence ‘inEastern tourists from going to Asia. The largest interna- the past we had a brain drain; doctors wanted to worktional private medical service group in India, Apollo, had outside the country to make more money. Now they don’t37 hospitals in India in 2004, partnerships in hospitals in have to leave the country, the brain drain is another part ofKuwait, Sri Lanka and Nigeria, and plans for others in our own society’ (Levett, 2005, p. 27). And in sourceDubai, Bangladesh, Pakistan, Tanzania, Ghana, Singa- countries: ‘Fertility tourism has always happened and willpore, Philippines, London and Chicago as privatised continue to happen. The real tragedy is that those withcorporations grew and international linkages intensiﬁed. money can always go overseas, but the people who haven’t Medical tourism has been particularly attractive to elites, two brass farthings to rub together are always the peopleeven—perhaps especially—in developing countries; Niger- who lose out’ (Graham, 2005, p. 9).ians for example spend as much as $20 billion per year on In less than a decade the rise of medical tourism hashealth costs outside Nigeria (Neelankantan, 2003). Despite demonstrated that a form of service provision, thethe presence of traditional therapies within Indian medicine provision of health care, so labour intensive that it wasthe medical market is now increasingly oriented towards assumed to be highly localised can now be globalised likehigh-end tourism. One outcome has been the more rapid so many other service activities. Japanese export ofrise of a private health sector in the medical tourism workers, even for medical examinations and of old people
ARTICLE IN PRESS1100 J. Connell / Tourism Management 27 (2006) 1093–1100into nursing homes, has taken this to a contemporary Chaynee, W. (2003). Health tourism to drive earnings. Kuala Lumpur:extreme. This process has followed the growing emphasis Malaysian Institute of Economic Research. Chong, W. Y., Boey, T. S., & Vathsala, N. (2005). Promoting healthon technology, private enterprise and the attitude that tourism in Malaysia. Unpublished paper to APacCHRIE conference,health care can be bought ‘off the shelf’. The trade in Kuala Lumpur.health services is expanding, becoming more competitive, Garcia-Altes, M. (2005). The development of health tourism services.and creating new dimensions of globalisation, all elegantly Annals of Tourism Research, 32(1), 262–266.packaged, and sometimes actually functioning, as the new Gilbert, E. (1954). Brighton: Old ocean’s bauble. London: Methuen.niche of medical tourism. Graham, K. (2005). It was a big leap of faith. Guardian, 21 June, 8–9. Huff-Rousselle, M., Shepherd, C., Cushman, R., Imrie, J., & Lalta, S. (1995). Prospects for health tourism exports for the English-speakingAcknowledgements Caribbean. Washington, DC: World Bank. Kinavanod, N. (2005). French doctor sets sight on medical tourism. Manila Bulletin, 15 April. I am indebted to Ming Wang and two anonymous Levett, C. (2005). A slice of the action. Sydney Morning Herald, 29referees for their comments on an earlier version of this October, 27.paper. Neelankantan, S. (2003). India’s global ambitions. Far Eastern Economic Review, 6 November. Ramesh, R. (2005). This UK patient avoided the NHS list and ﬂew toReferences India for a heart bypass. Is health tourism the future? The Guardian, 1 February.ABC. (2005). India—medical tourism. Foreign Correspondent, 8 November, Schoﬁeld, P. (2004). Health tourism in Kyrgyz Republic: The soviet salt ABC Television. mine experience. In T. V. Singh (Ed.), New horizons in tourism, strangeAi-Lien, C. (2005). Singapore steps up efforts to woo foreign patients. experiences and stranger practices (pp. 135–145). Wallingford: CABI Straits Times, 1 September, H8. Publishing.Andrews, M. (2004). Vacation makeovers. US News and World Report, 19 Smyth, F. (2005). Medical geography: Therapeutic places, spaces and January. networks. Progress in Human Geography, 29, 488–495.Borman, E. (2004). Health tourism: Where health care ethics and the state Taffel, J. (2004). Fixed up in a foreign land. Sydney Morning Herald, collide. British Medical Journal, 328, 60–61. 9 December, 4–5.