Medical tourism has become an important mechanism of obtaining medical care services and it is estimated that total value of medical tourism has become more than $100 billion per year. The number of patients travelling internationally will continue to increase with lower effective travel cost, improvements in quality of care in “medical hubs”, and the cost-advantage of obtaining services elsewhere. The flow of patients is not unidirectional; patients flow from developed to developing regions, between developing areas as well as from developing areas to developed economies. A number of factors affect the size and direction of the flow. Turkey is now competing with other regional hubs to develop its medical tourism industry. Since medical tourism focus on services that show little or no decline in value with delayed receipt of services, it is not surprising that dental care, cosmetic surgeries, etc. are being promoted. The purpose of this study is to better understand the factors associated with increased popularity of medical tourism in Turkey. To better understand the process of development of medical tourism for specific type of medical care, this study examines one specialized intervention, In Vitro Fertilization (IVF), as the case study. In the past few years IVF has become an important medical tourism service for Turkey and analysis of its development can indicate how medical tourism evolves within a “hub” and how it can lead to development of other services for increasing the demand for general medical care by foreign patients. Cost of medical services in Turkey is only about 30% of the costs in Western Europe and the USA but the high demand for IVF services is not due to cost-advantage only; the success rate of IVF is found to be higher in Turkey than in the USA. Therefore, after correcting for the success rate, the cost-advantage per successful case becomes even higher. Over the last few years, quality indicators of Turkish hospitals in major medical tourism cities are also showing significant improvements implying that Turkey is moving towards creating significant comparative advantage in medical tourism. This research indicates that most medical hubs like Turkey are going through rapid changes in their domestic medical care markets. Turkey has been successful in maintaining significant cost-advantage per unit of service provided compared to the cost in developed countries. Despite relatively low cost of care, the quality indices are showing significant improvements. In this case study we observe that the success rate of IVF has become better in Turkey than in the USA. If this trend of lower-cost but high quality continues, demand for medical tourism is likely to expand at a very rapid rate. In fact, higher level of medical tourism will be welfare improving for all and should be encouraged.

1. Turkey as a Medical Tourism
Destination:
Cost-advantage, specialization and subsequent quality
improvement in medical tourism hubs
YILDIZ Mustafa Said, KHAN Mahmud, HIKMET, Neset
(Presented in International Health Economics Conf 2013)

2. Medical Tourism
• Medical Tourism takes place when individuals travel
with the primary intention of receiving medical
(usually elective surgery) treatments.
• Journeys may be short distance, long–distance and
even intercontinental.
• The flow of patients is not unidirectional; patients
flow from developed to developing regions, between
developing areas as well as from developing areas to
developed economies.

3. Number of Medical Tourists
• TRAM(Tourism Research and Marketing) reported that the global medical
tourism market comprised over 19 million trips in 2005, with a total value
of $20 billion and many countries are experiencing double-digit growth in
medical tourism, which is forecast to grow to 40 million trips, or 4% of
global tourism volume by 2010. (http://www.tram-research.com/MedicalTourism.PDF)
• Medical Tourism Survey (2007) estimated that 50,000 UK Medical tourists
spent £161 million on medical tourism per annum (Survey reveals that
India, Hungary and Turkey are amongst the most popular medical tourism
destinations for UK patients.) (http://www.treatmentabroad.com/about/medical-tourism-survey/)
• McKinsey report(2008) estimated the number of Medical Tourists 75.000
by excluding expatriates and emergency cases,
• Deloitte Medical Tourism Report (2008) said approximately 750.000
Americans traveled outbound for medical care in 2007. Deloitte projected
a 100% annual growth in that number through 2010.

4. Foreign Visitors for Medical Purpose to Turkey
(Tourist declared health reasons in custom)
Source: Turkey Statistics Agency – TUIK Data Bank http://www.tuik.gov.tr/

5. Is Turkey
a competitive country in medical tourism?
• Turkey has the highest number of JCI accredited hospitals in the world.
(28 hospitals, 3 Genetics Diagnostic Centers, independent laboratories,
over 4.000 inpatient beds and 957 ICU beds, 179 operating theaters and
2.000 physicians employed)
• Affiliations and collaborations with prestigious medical centers like;
Harvard Medical International, Johns Hopkins Medicine International,
Mayo Clinic, Houston Memorial, Sloan-Kettering Cancer Centre…
• Turkey has capabilities & Expertise in high level medicine including Liver,
Kidney and Pancreas Transplantations, Robotic Surgery, Bone Marrow
Transplantations, Cardiology and Cardiovascular Surgery…
• Hospitals with high quality levels has significant cost advantages
YILDIRIM, R Turkish Accredited Hospital Association Presentation, Medical Tourism in Turkey, March 12-13, 2010 – Chicago,
http://www.medicaltourisminturkey.org/docs/Day1S2RusenYildirim.pdf (06,12,2012)

6. Advantages of Turkey in Medical
Tourism
• Lower Cost and High Quality Service,
• Use of advanced technology in medical care,
• Convenience (accommodation and transportation
services managed by hospitals and translation
supports that makes travel easier for patients ),
• Minimum waiting times,
• Well trained doctors and teams (Medical education
of country with good reputation),

7. COST COMPARISON
(TURKEY AND SOUTHEAST USA AVARAGE)
Turkey Southeast USA
daVinci Prostatectomy 17,250 102,400
Heart Bypass (CABGx4) 12,250 144,317
Health Valve Replacement 13,750 177,665
Hip Replacement 12,000 100,047
Hysterectomy(Vaginal) 5,000 31,474
Knee Replacement 11,500 65,918
Spinal Fusion 18,000 103,761
Companion Global Healthcare web site http://www.companionglobalhealthcare.com/employers/comparecosts.aspx

8. Reasons of Lower Treatment Cost -
Turkey
• Lower labor costs
• Lower facility costs
• Higher efficiency
• Less Malpractice liability
• Less third party payment
• Financially strong Hospitals

9. IVF technique
• IVF technique has remained relatively unchanged over 30
years in reproductive health.
• Treatments start with the stimulation of ovaries so that they
can produce large number of eggs and retrieval of the eggs.
• Retrieved eggs are placed in a tube, filled with a liquid
providing a special culture and then introduced to sperm of
high quantity and quality.
• After 2-5 days, the fertilized embryos are transferred into the
uterus of the mother-to-be with the help of a catheter.

10. IVF market
• It is estimated that at least 20,000 to 25,000 couples receive
in vitro fertilization (IVF) care abroad each year.(Peter Kovacs. Seeking
IVF Abroad: Medical Tourism for Infertile Couples. Medscape. Jun 14, 2010.)
• Turkey is 7th
in IVF market. Total number of baby born with IVF
is 44.000. Total number of Assisted Reproduction Centers is
more than 120. (2010) INHORN M.C, GÜRTIN Z.B, Infertility and Assisted Reproduction in
the Muslim Middle East: Social, Religious, and Resource Considerations FVV in ObGyn, 2012, MOnOGraph:
24-29
• In a report(2008), the fertility industry was being seen to be
slated to bring in additional revenue of $1-2 billion by 2012
SAROJINI N, MARWAH V, SHENOI A, Globalisation of birth markets: a case study of assisted reproductive
technologies in India Globalization and Health 2011, 7:27

11. Reasons for travelling abroad
for IVF
• Prohibitions (reproductive exile)
• Restrictions and regulations (age limitations, rules)
• Significant cost differences (cost saver)
• Higher IVF success rates abroad
• Long waiting times and limited access to service in
home country
• Low malpractice risk of IVF (usually a outpatient
treatment)
• Lesser hospital visit essentiality (opportunity of
touristic travel in the destination country)

12. IVF treatment as a cost saver
Walker, Russel Turkey as a destination and a partner: Contribution to US Economy, Medical Tourism Congress, Chicago, 2010
http://www.medretreat.com/procedures/pricing.html
http://www.treatmentabroad.net/cost/surgery-abroad-cost/

13. Why patients choose Turkey for
IVF
• Egg donation, surrogacy and sex selection is
officially prohibited in Turkey. So Turkey is
not a IVF medical tourism destination for
these reasons.
• Cost, convenience, success rate and quality
are the main factors.
• Opportunity to combine tourism in Turkey and
IVF treatment.

14. Medical Tourism Concerns and IVF
(quality, malpractice, continuous care)
• General clinical quality(like infection rate) is not
effective on IVF treatment. IVF is independent from
other hospital transactions. IVF success rate is a
widely accepted indicator and it’s easy to measure
and compare.
• Malpractice risk is naturally low in IVF.
• Continuous care that is another concern of health
tourism. But IVF treatment doesn’t require long term
continuity of care.

15. Medical Tourism Concerns and IVF
(impact on Turkish citizens’ access)
• Impact of medical tourism on host country citizens’
healthcare access may be concern about Medical tourism. In
that aspect IVF can be considered as mutually beneficial type
of medical tourism.
• Medical Tourism for IVF has minimum concern of reducing
access to health care for the destination country’s citizens.
There is enough (more than 100) IVF laboratories in Turkey
and so access to IVF services is not a concern.
• Medical tourism for IVF doesn’t increase cost of treatment
for Turkish citizens. First and second cycles of IVF is paid by
governmental social security agency in Turkey.

16. Anadolu Medical Center
• 209 bed, 59 ICU bed capacity,
• 136 doctors (internationally experienced and
English speaking) 384 nurses.
• 36.336 total inpatient, 136.997 outpatient
visit, 3358 surgeries (2011),
• Advanced healthcare technology use (da Vinci
surgical system, CyberKnife robotic surgery…)
• On campus hotel for medical tourism patients,
• Dedicated International Patient Department,

17. Anadolu Medical Center
• Joint Commission International (JCI) accredited,
• Affiliated with Johns Hopkins Medicine,
• ESMO-European Society for Medical Oncology
(Certificate of Excellence)
• Integrated Management System ISO 9001-2008,
• ISO 14001-2004,
• OHSAS 18001-2007,
• Baby-Friendly Hospital (MoH-WHO/UNICEF)

18. CLINIC QUALITY INDICATOR USA DATA ANADOLU HOSPITAL DATA
(2011)
Urinary Tract Infections (UTI) (per 1000 catheter days) Medical Major
Teaching hospitals pooled mean(1) (lower is better)
2,4 2,2
Catheter related blood stream infections (per 1000 catheter days)
Medical Major Teaching hospitals pooled mean(2) (lower is better)
1,8 0,7
Patient Falls (Per 1000 Inpatient Days) mean in hospitals over 500
beds in 2007, Massachusetts(3) (lower is better)
4,76 0,6
Pressure Ulcer (Per 1000 Inpatient Days) Among community hospitals
in the Healthcare Cost and Utilization Project, the risk-adjusted rate of
this indicator in 2008 (4) (lower is better)
5.18 0,6
Prophylactic Antibiotic Selection for Surgical Patients in US National
data (April 2011-March 2012) (higher is better)
98 100
Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision (higher is better)
98 99,4
Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time (higher is better)
97 97,3
(1, 2) http://www.cdc.gov/nhsn/PDFs/dataStat/NHSN-Report_2010-Data-Summary.pdf
(3) http://www.qualitymeasures.ahrq.gov/content.aspx?id=36945
(4) http://www.qualitymeasures.ahrq.gov/content.aspx?id=38513
(5, 6, 7) http://www.baptisthealthmadisonville.com/quality-indicators-data
CLINIC QUALITY AND PATIENT SAFETY
(USA AVARAGE AND ANADOLU HOSPITAL)

19. IVF Department Team of AMC
• Anadolu Medical Center has a embryology lab
with advanced technologies. Chief of IVF
department is an American Board of
Obstetrics and Gynecology certificated and
USA IVF licenced Yale University professor.
• Team is composed of experienced and English
speaking members.
• ICSI (Intracytoplasmic Sperm Injection)
method is generally performed to extract
several oocytes from a woman.

20. IVF process
• Husband and wife takes some medical tests in home country
and sends to Turkey. Doctors evaluate the patients’ eligibility
for treatment and potential chance of success for the couple’s
case.
• After first day ultrasound, patient takes stimulating injections
for 10 days OPU(embrio collection) is made. 3-5 days after
OPU, transfer is done. After 2 days patient can leave Turkey.
• Patient takes the pregnancy test and sends results. Doctors
informs the patient which medications she continue till the 9th
week of pregnancy.
• Then patient’s doctor in her home country takes over the
process.

21. IVF Cost Comparison
IVF cost
(per cycle)
Italy $5,504
Spain $5,600
Norway $4,523
Sweden $5,300
Canada $5,766
USA $12,146
Turkey $2,500
Source: www.ivfcost.net

22. Cost includes
• Monitoring, Ultrasonography Exams, Medical Fees.
• Egg Retrieval, Anesthesia, IVF.
• Embryology Laboratory Services, Assisted Hatching,
IMSI, Blastocyst, Embryo Transfer.
• Airport/hospital or hotel/hospital ground
transportation.
• Hotel and trip arrangements.
• 24/7 translator assistance.

23. IVF cost comparison
• The cost difference between western
countries and Turkey is so significant that
travel and accommodation expenses are
relatively small.
• Due to huge cost savings medical tourism for
IVF treatment is increasing over years and
patients are coming from long distances.

24. Anadolu Medical
Center
Hospital in
United States
Medical Cost 2500 12000
Airfare (15-20 percent
Turkish airlines discount for
medical tourism patient)
2500 -
Hotel (located in hospital
campus / IVF package)
1500 -
Other (Trip expenses 100
USD for a day)
2000 -
TOTAL 8500 12000

25. IVF SUCCES COMPARISON
(ANADOLU HOSPITAL AND USA AVARAGE)
Source: Society for Assisted Reproductive Technology web page https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=0
Anadolu USA
< 35 age 68 48
35-37 years 63 39
38-40 years 44 30
41-42 years 32 20
> 42 years 9 9

26. Succes rate and cost
• High number of IVF transaction in Turkey (50.000 a year -
2010) increases the experience and success.
• Success rate in IVF is also important for cost comparison.
Unsuccessful IVF treatment can be considered as a indirect
cost factor.
• Cost of medical services in Turkey is only about 30% of the
costs in Western Europe and the USA but the high demand
for IVF services is not due to cost-advantage only; the success
rate of IVF is found to be higher in Turkey than in the USA.
Therefore, after correcting for the success rate, the cost-
advantage per successful case becomes even higher.

27. Patient experiences
A blog site from an American couple about their IVF experience in Turkey-
Anadolu Hospital;
http://www.abroadivf.blogspot.com/
Comment from an another American couple:
“We are truly glad that we have been to Anadolu Medical Center. We
chose this center among many others and came all the way from the
other side of the world. It was quite risky. But we were never
disappointed. Our doctor supported us in every aspect and comforted us
when necessary. He is a perfect doctor. We never had to wait during
procesedures, everyone was very keen about us. Our treatment was very
successful too. We are very happy. We want to come back to Anadolu
Medical Center for our second child.”
http://www.anadolumedicalcenter.com/en/patient-case-
detail.aspx/68/1/stacey--andrew-denslyz.aspx

28. Conclusion
• If this trend of lower-cost but high quality continues, demand
for medical tourism is likely to expand at a very rapid rate.
• With Medical tourism dedicated and well organized hospitals,
successful and experienced staff and high technology usage,
Turkey is competing with other regional hubs to develop its
medical tourism industry
• Quality indicators of Turkish hospitals (especially accredited
ones) are showing significant improvements implying that
Turkey is moving towards creating significant comparative
advantage in medical tourism.
• In fact, higher level of medical tourism will be welfare
improving for all and should be encouraged.

29. References
• BIRDAL, Erginer, Medical Tourism Research 2011, Ministry of Health of Turkey, 2011
• INHORN M.C, GÜRTIN Z.B, Infertility and Assisted Reproduction in the Muslim Middle East: Social,
Religious, and Resource Considerations FVV in ObGyn, 2012, MOnOGraph: 24-29
• KOVACS P, Seeking IVF Abroad: Medical Tourism for Infertile Couples. Medscape. Jun 14, 2010.)
• SAROJINI N, MARWAH V, SHENOI A, Globalisation of birth markets: a case study of assisted reproductive
technologies in India Globalization and Health 2011, 7:27
• Society for Assisted Reproductive Technology Clinic Summary Report
https://www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?ClinicPKID=0 (05.03.2012)
• TRAM Tourism Research and Marketing Report on Medical Tourism (http://www.tram-
research.com/MedicalTourism.PDF) (06.12.2012)
• Treatment Abroad Medical Tourism Survey, 2007
(http://www.treatmentabroad.com/about/medical-tourism-survey/) (06.12.2012)
• Turkish Statistical Institute(TURKSTAT) Tourism Statistics http://www.turkstat.gov.tr/MetaVeri.do?
alt_id=51
• WALKER, Russel Turkey as a destination and a partner: Contribution to US Economy, Medical Tourism
Congress, March 12-13, 2010 – Chicago,
• YILDIRIM, R Turkish Accredited Hospital Association Presentation, Medical Tourism in Turkey, March 12-
13, 2010 – Chicago,

30. Thank you