7
The Economics of Medical Tourism
a Mercedes product at Toyota cost
(Bumrungrad Hospital Marketing Director,
quoted in Nicholas and Hyland, 2009: 23)
Cadillacs at Chevy prices
(Bumrungrad CEO, quoted in Anon.,
2008b: 71)
It is remarkably difficult to know who the
majority of medical tourists are, where they
have come from and gone to, and just why
they are there. Measures of the flows of medi-
cal tourists vary enormously, partly because
this defies easy measurement: are they sim-
ply the patients or are they accompanying
family members? More importantly, while
‘business’, ‘convention’ or simply ‘tourism’
are familiar descriptions on most arrival
cards, where they exist, there are no distinct
categories for tourists who may be medical
tourists, despite Egypt listing ‘Medical Proce-
dure’ as one option and India having a spe-
cial visa for long-staying medical tourists.
Even were there to be such a category on
arrival cards there is a reasonable presump-
tion that many medical tourists would ignore
it, and specify tourism rather than risk refer-
ring to health problems. This chapter seeks to
examine who medical tourists are, where
they come from, why they became medical
tourists, where they go and what impact this
has had on (mainly) destination countries. As
with previous chapters there are concerns
112
with the accuracy of much of the data, in the
absence of specific surveys.
‘Standard’ mere tourists (for whom a
minor cosmetic procedure may be part of a
holiday) and clandestine migrants are
excluded from the following discussion which
is centred on deliberate medical tourists. All
data on flows of medical tourists are based
principally on extrapolations from hospital
records, themselves usually unavailable for
scrutiny, at best selectively released, and then
usually to boost future activities. This can be
modified by examining the testimonials on
websites, though these too are limited by some
obvious selectivity, their English-language
content (though some hospitals such as Yan-
hee in Bangkok post many testimonials in
Japanese) and by their use in public-relations
campaigns. Much of what follows must there-
fore be subject to some doubt and debate.
Who Are the Medical Tourists?
Global flows
Beyond ‘temporary’ medical tourists under-
taking minor cosmetic procedures it is usu-
ally assumed that there are two distinct
tourist groups: (i) those from more developed
countries, unable or unwilling to pay sub-
stantial charges and/or wait long times for
© CAB International 2011. Medical Tourism (J. Connell)
 The Economics of Medical Tourism
complicated medical procedures, and who
are not the elite in such countries; and (ii) the
emerging elite from ‘developing countries’ –
those countries where medical standards may
be poor and who prefer to pay to avoid such
national facilities in favour of high quality
care elsewhere. However, these flows, often
assumed to be the core of medical tourism,
may be numerically dominated by diaspora
medical tourism, about which little has been
written, websites ignore and which is not the
target of marketing, hence any typology is
more complicated (Chapter 4).
Only crude data provide comparative
figures on global flows, and these data are
worse than those on destination numbers.
Globally it has been suggested that anywhere
between 50,000 and over five million people
annually are medical tourists, but most esti-
mates are mere ballpark figures. A much-cited
McKinsey consultancy report suggested that
the number of medical tourists in 2007 was
somewhere between 60,000 and 85,000. That
study excluded ‘medicated tourists’, resident
expatriates and ‘wellness tourists’ travelling
for massages or acupuncture. Significantly
the report also excluded ‘patients who travel
in largely contiguous geographies to the clos-
est available care’ thus excluding substantial
cross-border mobility. Omitting such groups
revealed that the largest single segment, with
40% of medical tourists, were patients seek-
ing high quality care in destinations like the
USA and who mainly came from the Middle
East and Latin America. The second largest
segment (with 32% of tourists) were those
seeking better care than they could receive in
their less-developed home countries. Three
remaining segments included those who
were avoiding long waiting times, and those
seeking lower costs for either medically nec-
essary procedures or discretionary proce-
dures (Ehrbeck et al., 2008). It thus challenged
basic assumptions about the main medical
tourism categories. The McKinsey report did
not explain how their numbers were derived
and how they were allocated by sector,
though they probably excluded analysis of
providers without JCI accreditation.
An industry commentator challenged the
assumptions and definitions of the McKinsey
report and, by including non-JCI accredited
113
providers, patients who were not in-patients
(including many dental and cosmetic surgery
patients) and cross-border patients, argued
that the number was more likely to be a
‘conservative estimate’ of over five million
(Youngman, 2009). However, this number
included an unspecified number of ‘wellness
tourists’, on the grounds that their objectives
were no different from those of other medical
tourists, and accepted largely uncritically sev-
eral Asian estimates. At the same time Deloitte
Consulting estimated that 750,000 Americans
alone had gone overseas for health care in
2007, the year of the McKinsey report, and
projected a tenfold growth in the following
decade (Deloitte, 2009). That report was much
welcomed in the industry but, again, the
methodology was unstated. The discrepancies
are considerable even within international
consultancy reports, being based on industry
and national estimates. If 750,000 Americans
did go overseas for medical treatment in 2007
then the USA would be the world leader in
numbers. Somewhat fewer may have been
citizens. Industry sources put the number of
UK patients making personally funded medi-
cal trips to Europe alone in 2006 at over 50,000,
almost half of whom were dental patients
(Treatment Abroad, 2007) a total that is more
plausible than the US one. However, as the
analysis of the Bumrungrad data indicated
(Chapter 5) numbers can easily be exagger-
ated to boost the industry, and destination fig-
ures would have been much greater had that
number of people left the USA. These data do
little more than suggest that flows are proba-
bly dominated by mobility from developing
countries, and that developed countries
remain important destinations.
Regional flows
Despite the qualitative literature centring on
the movement of medical tourists from devel-
oped European countries, especially the UK,
the USA and Australia, the majority of medi-
cal tourists almost certainly come from neigh-
bouring countries (and, in most statistics at
least, include people already in the destina-
tion countries, as workers or tourists) and
from the Gulf. While accounts of medical
114 Chapter 7
tourism in the Western media emphasize
transcontinental journeys most movements
are intra-regional. The projected image of
medical tourism, in the media and on web-
sites, is rather different from reality.
Geography and culture influence mobil-
ity. Australians and New Zealanders are
more likely to visit Thailand and Singapore,
countries that they are more familiar with,
rather than travel further to India. Within
most continental regions there are very sig-
nificant differences in the costs of treatment
and hence considerable mobility. In the EU
region, somewhat ironically as skilled health
workers – nurses and doctors – migrate west-
wards (to the UK, Sweden and Germany),
patients migrate in the opposite direction
(to Hungary, Poland and Latvia). In Latin
America similar regional moves occur, and
Mexican-Americans dominate movements
from the USA to Mexico. Most of those who
travel to Cuba come from nearby Central and
South American (but also Andean) states.
Africa and the Middle East also exhibit
regional movements within the Levant, the
Maghreb and in sub-Saharan Africa. Libyans,
followed by Algerians, dominate movement
to Tunisia, as they also do to Egypt. In Jordan,
the leading destination in the Middle East,
medical tourists mainly come from other
Arabic-speaking countries where the doctor:
population ratio is lower, and the medical
skills of doctors are perceived to be lower,
such as Yemen, Sudan and Libya (Smith and
Puczko, 2009: 163). About 84%, 84% and 87%
of overseas patients in Tunisia, Singapore and
Jordan, respectively, come from neighbour-
ing countries, and 89% of Thailand’s patients
in 2002 were said to be local expatriates or
Asian nationals (Lautier, 2008). Since most
medical tourism is a response to a lack of
finance or insurance cover, either absolutely
or for certain popular procedures, it is largely
funded from personal out-of-pocket expendi-
tures. This favours short distances and low
costs. Insurance companies too are rarely
anxious to fund distant travel, unless proce-
dures are inexpensive. Culture modifies
geography where diasporic tourists, from
Korea, Malta, Taiwan and elsewhere, choose
to travel longer distances for the familiar
comforts of ‘home’.
Data from destinations shed some light
on the geographical origin of medical tourists.
In 2005 those who came to Singapore for med-
ical treatment came mostly from neighbour-
ing countries, especially Indonesia (52%) and
Malaysia (11%), with other significant sources
being the USA/Canada (5%), the UK (4%),
Japan (3%) and Australia/New Zealand (3%)
(Khalik, 2006). Singapore has, however, seen a
shift of its market from Indonesia to the Mid-
dle East, alongside greater numbers of ethnic
Chinese from a diversity of sources. Rich Java-
nese tend to make the short flight to Singa-
pore, while Sumatrans go by ferry to Malaysia.
There is further differentiation in Singapore:
richer Indonesians go to private hospitals and
the poorer go to public hospitals. Regional
arrivals were more likely to come for check-
ups and minor treatments and those from
developed countries for more intensive proce-
dures (Khalik, 2006). Most medical tourists in
Singapore continue to come from nearby
developing countries, despite the high costs,
rather than developed countries, and 2005
was the first year in which Bangladesh and
Myanmar had enough medical tourists there
to be among the top ten countries.
In Malaysia a survey of 121 medical tour-
ists at five hospitals in and around Kuala Lum-
pur revealed that almost half of them (48%)
were from Indonesia, with smaller numbers
from Australia (ten), New Zealand (seven),
Philippines (six), India (four), Sudan (four)
and the UK (four), with fewer from Japan,
Romania, Nigeria and Oman, and just one
patient from each of China, the Netherlands,
France, Germany, Kiribati, the Maldives, Mon-
tenegro, Saudi Arabia, Switzerland, the UAE
and Ukraine (Doshi, 2008: A-21). This geo-
graphical spread, where the methodology
favoured literate English speakers and the
response rate was low, suggests a much wider
geographical distribution and, by implication,
parallel situations elsewhere in Malaysia.
While most of this sample of medical
tourists in Malaysia were from neighbouring
Indonesia they were not necessarily relatively
poor. Of 112 for whom data were available
just eight had only completed primary school
education and 69 had received a college or
university education (Doshi, 2008: A-23).
Most were neither very young (only ten were
 The Economics of Medical Tourism
aged less than 20) or very old (only 11 were
aged more than 61) with half being between
31 and 50. At Bumrungrad most medical tour-
ists were from other parts of South-east Asia
and from the Middle East. However, testimo-
nials on its website paint a different picture.
From 98 testimonials over the 5-year period
2005–2009 where a nationality was given,
some 33 were from the USA, 16 from Thai-
land, ten from Australia and seven from the
UK. No other countries had more than three
testimonials; the remainder came from Asia
(Bangladesh, Cambodia, China, Hong Kong,
Indonesia, Japan, Malaysia, Nepal, Singapore,
Taiwan), Europe (Germany, Ireland and the
Netherlands), and also the UAE, Canada and
New Zealand. Since many patients at Bum-
rungrad are from the Gulf this unrepresenta-
tive sample may represent the products of a
more effusive culture, language issues, or a
marketing ploy for custom from the USA.
Indeed the cover of the principal promotion
document has a group that is primarily Cau-
casian, and also young and seemingly healthy
(Fig. 7.1). A larger sample of 376 patient testi-
monials from Yanhee Hospital’s website early
in 2010, where cosmetic surgery is dominant,
recorded 143 from Australia, 40 from Japan,
39 from the USA, 29 from New Zealand, 22
from the UK, 12 from Singapore and 12 from
Sweden. Just two were from the UAE, and
none from elsewhere in the Middle-East
region. The average age of the Yanhee patients
was 34. In both hospitals such testimonials,
and brochures and web pages, may represent
an idealized geographical distribution rather
than the reality.
Testimonials on the websites of the two
main Indian chains indicate that most patients
are actually from India itself, but otherwise
there is a more global spread, which is prob-
ably indicative of the Indian diaspora. At For-
tis Wockhardt, after 54 testimonials from
India, there are three each from the UK
and the USA, and one each from Afghani-
stan, Australia, Bangladesh, Ethiopia, Israel,
Nigeria and Sri Lanka. By comparison, out of
40 Apollo testimonials, just seven were from
India and 12 from the USA, followed by
Canada (five), Nigeria (five), Seychelles (two)
and one each from Australia, Costa Rica,
Mauritius, Pakistan, Spain, Switzerland, the
115
UK and Uzbekistan. Rather earlier one Chen-
nai (Madras) hospital claimed patients from
Oman, the UAE, Bahrain, Qatar, Saudi Ara-
bia, Mauritius, the Seychelles, the Maldives,
Sri Lanka, Bhutan, Nepal, East Africa, Ger-
many, Australia, Canada and the UK in 2005
(Times of Oman, 11 June 2005). Many are likely
to have been NRIs.
Most major medical tourism destinations
in Asia attract significant numbers from the
Gulf, primarily the UAE (especially Dubai),
Oman, Qatar and Kuwait. As one blog noted:
A middle-aged Arab couple, the man in white
robes and the wife in a burka, plus an elderly
lady in a wheelchair, probably one of their
mothers. The wife was chatty, a bit loud, a bit
heavy. She had a half-face mask, heavily
kohled eyes, smelled very strongly of
perfume and walked with a slight limp that
I’ve noticed on other women in burkas.
Bumrungrad attracts a large number of
customers from the Middle East and the Gulf
states, including many burkaed women,
which seems to phase [sic] nobody. Though
it is interesting to note how something
that is so deliberately unrevealing can be
customized – a discreet black sequinned trim,
an embroidered edge, hot pink painted
fingernails, a pair of very hip black sneakers
peeking out from below. There were others
running here and there: A saffron-robed
monk (and not the fake triad-y ones you see
in Hong Kong). A small black boy who was
lost. Enormously obese Westerners. Dozens
of languages spoken. Bumrungrad has quite
good medical care, but its best feature may be
the people watching.
(http://joycelau1.spaces.live.com/blog/
cns!DFE95C9AB5B43908!186.entry)
Its CEO has effectively concurred: ‘If you
come into our lobby, it’s sort of like going to
Terminal 3 at Heathrow airport’ (quoted in
Anon., 2010c). In the mid-2000s some 70% of
medical tourists from the UAE went to Singa-
pore (Gulf News, 2005). By contrast India was
said to be the preferred destination of Omanis
(Times of Oman, 11 June 2005). In Asia the
number of Gulf tourists was boosted after
9/11 in 2001 and it remains a major source of
medical tourists for South-east Asia. As the
manager of one group of Malaysian hospitals
has said: ‘since 9/11 people started looking to
the Eastern world for holidays and we are
116 Chapter 7

Fig. 7.1. Bumrungrad International Hospital brochure (source: Bumrungrad International Hospital,
Bangkok).
 The Economics of Medical Tourism
trying to capture a fraction of these people.
The Middle East is a huge market for us. Abu
Dhabi Company for Onshore Oil Operations
sends its 36,000 employees to us for check-
ups’ (Gulf News, 2005). There are niche mar-
kets within medical tourism, while cultural
sensitivity is particularly important in a
health context.
Testimonials from Clinica Biblica in
Costa Rica indicate the predictable domi-
nance of the USA; 33 of 36 testimonials came
from there, with two from Canada and one
from the UK. In South Africa, despite the
most famous destination MTC being Surgeon
and Safari with its obvious elite connotations,
the majority of medical tourists are African
nationals from countries such as Botswana,
Ethiopia, Zambia, Angola, Nigeria and other
sub-Saharan states, who turn to South Africa
because medical facilities, equipment and
skills are lacking in their own countries (Wite-
pski, 2005; Easen, 2009). Patients of Surgeon
and Safari itself did, however, come from
greater distances, mainly from the UK fol-
lowed by the USA, were aged between 45 and
65, usually single, and stressed economic fac-
tors (Witepski, 2005). Significantly, with only
rare exceptions, in destination hospitals in
every country by far the majority of patients
are locals, medical tourists make up less than
half of all patients and most are from nearby
countries.
What Procedures? Beyond
Cosmetic Surgery
Much of the literature and many assumptions
about medical tourism suggest that it is pri-
marily concerned with cosmetic surgery, yet it
is very much more diverse. Available data are
again unhelpful. Medical tourism is centred
on a limited range of surgical procedures
(including such minor procedures as teeth
whitening) partly because many illnesses are
too serious to allow mobility which would be
injurious to health. Dentistry probably domi-
nates medical tourism, but prices are lower
hence cost differentials are less dramatic while
the outcomes rarely attract media attention.
Teeth are unexciting. This is equally true for
117
diaspora tourism and regional cross-border
movements which may be about something
as inconsequential as check-ups or as neces-
sary as eye surgery. Media attention is invari-
ably focused on either cosmetic surgery,
where costs are greater and outcomes, good
or bad, are more photogenic, or on some
minority procedures where ethical issues are
paramount (Chapter 8). The web pages of
hospitals and MTCs, indicating what is avail-
able, and the testimonials of patients shed
some light on the range of procedures that are
involved. However, testimonials, like most
media reports, tend to relate to relatively com-
plex procedures, hence check-ups are absent.
Despite the great differences between proce-
dures, from bariatric surgery to infertility
treatment, and from breast augmentation to
gender reassignment, which are very different
in terms of costs, duration of stay and cultural
consequences (let alone pain), useful quanti-
tative differentiation is absent.
Cosmetic surgery is certainly significant
but check-ups and other low-key procedures
are much more likely to be typical rather than
more dramatic, and sometimes glamorous,
procedures. According to the National Coali-
tion on Health Care about 40% of Americans
who have travelled abroad for health care
went for dental work (Apton and Apton,
2010). In Europe dental treatment was mar-
ginally more significant, accounting for 43%
of patients in 2007, with cosmetic surgery
undertaken by 29% and other surgery, scans
and diverse treatments accounting for the
remainder (Treatment Abroad, 2008). An even
higher proportion might be true of the UK
and, since dentistry is rarely life threatening,
more patients may travel independently
rather than use MTCs. International patients
at Bumrungrad came mainly for orthopaedic
procedures, followed by cosmetic surgery
and dentistry (Anon., 2009). In Singapore
patients mainly undertook general surgery,
followed by general medicine, cardiology
and gynaecology (Khalik, 2006). The greatest
proportion (23%) of medical tourists in
Malaysia were there for routine procedures,
such as consultations with specialists, and a
further 15% were having check-ups; 21%
were having plastic surgery of various kinds
(notably tummy tucks, facelifts, nose jobs and
118 Chapter 7
liposuction) and 19% were having other sur-
gical procedures, including cancer treatment
(Doshi, 2008: 80). At least two-thirds of the
patients received treatment for between 1 and
5 days but more than 11% stayed longer than
6 days (Doshi, 2008: A-24). This rare survey of
patients, which probably has wider validity,
indicates that most procedures are brief and
uncomplicated, and few patients stay for
long, which perhaps also indicates the poten-
tial for accompanying ‘tourism’.
The Rationale for Medical Tourism
The main global influences on the growth and
structure of medical tourism have been eco-
nomic, whether for local moves or long-
distance travel, for drop-in procedures or
extensive surgery, or for Europeans, Asians
or elites in a range of countries. An overly
repeated phrase is ‘First World care at Third
World prices’ (though where waiting lists are
long, ‘First World’ care has its limitations). If
medical tourism is primarily a function of eco-
nomic change, social factors – the desire for
cosmetic surgery and cultural connections –
have stimulated and directed flows, while
waiting lists, insurance constraints, quality of
care and desire for privacy all play roles in
decision making. When medical tourists in
Malaysia were queried over their reasons for
choosing their hospitals and destination, the
five most important reasons were: (i) ‘clean
and hygienic physical environment’; (ii) ‘mod-
ern and up-to-date medical treatment’;
(iii) ‘reputable medical services’; (iv) ‘excel-
lent track-record of medical services’; and
(v) ‘wide range of medical services’. By con-
trast the five factors that were least important
were: (i) ‘amenities offered for medical prac-
tices’; (ii) ‘halal food is easily available’;
(iii) ‘relatives and friends are here’; (iv) ‘cul-
tural similarity’; and (v) ‘availability of tourist
attractions’ (Doshi, 2008: 69). While that might
suggest that economic and cultural factors are
of minimal importance, and tourism irrele-
vant, these were most likely to have been so
central to decision making as to be implicit.
None the less they indicate the primacy of
medical care.
While most medical tourists are not
wealthy, few are very poor; even so many
merely cross nearby national borders, or
travel within the same continent. Portuguese
women cross the Spanish border for abor-
tions, Mexicans travel from the USA, Indone-
sians move to Singapore. Short distances can
be a measure of poverty; poor Cambodians
cross into Vietnam rather than Thailand, and
poor Polish women travel to Ukraine and
Moldova whereas their richer compatriots
travel further and westwards and pay more.
Even patients who cross nearby borders
rarely travel far; ‘dental towns’ in Hungary
are close to borders, Bangladeshis often travel
no further than West Bengal and Mexicans in
San Diego (USA) travel either to the border
town of Tijuana or to their own home towns
(Chavez et al., 1985). Perhaps surprisingly,
given many assumptions about wealthy med-
ical tourists, they are rarely as affluent as
health and wellness tourists, for whom such
tourism is very much an optional extra, the
rewards of a good life.
Because of the demand from uninsured
American patients, border crossings and the
return of the diaspora, a significant part of
medical tourism involves the movement of
the relatively poor, and in California at least
the poorest (Laugesen and Vargas-
Bustamante, 2010), across nearby borders.
Movement from very poor countries, such as
Yemen, may also involve some of the poor,
although few can afford to travel, while clan-
destine migration into Australia, Thailand
and elsewhere, is of the poor and often des-
perate. However, high levels of poverty
(often associated with recent migrants with
illegal status) reduces the likelihood of
migration for medical care, especially where
it may jeopardize residential status. More-
over, the very sick (who may also be the very
poor) are unlikely to be able to travel at all.
Yet medical tourism has been particularly
attractive to elites, especially in developing
countries. Nigerians, for example, are said to
spend as much as US$20 billion/year on
health costs outside Nigeria, and an esti-
mated 18,000 wealthy Nigerians go overseas
each year for medical treatment (Easen,
2009). Other economic and political elites in
developing countries similarly go overseas
 The Economics of Medical Tourism
reflecting a clear hierarchy of resort to medi-
cal care. Most Nigerians who go overseas for
medical care are relatively well off, as are
medical tourists from many other parts of
sub-Saharan Africa. However, where local
facilities are particularly poor, less well-off
individuals and households may choose, or
effectively be forced, to travel in search of
adequate care. Medical travel from Yemen is
relatively common, with estimates suggest-
ing over 40,000 people a year, since facilities
for some critical problems are absent. Mum-
bai (India) is the cheapest destination and
the most popular with poorer Yemenis, some
of whom are forced to sell land, livestock,
jewels and property, and take out loans, to
finance travel for necessary medical care
(Kangas, 2007). None the less each patient
spends about US$3000 on medical treatment
abroad; collectively therefore each year as
much as US$120 million may leave one of
the poorest countries in the world. Similarly
in Bangladesh ‘a significant number of
patients are forced to travel abroad at con-
siderable financial and logistic costs to seek
medical advice/care’ (Rahman and Khan,
2007: 144). Even, or perhaps particularly, in
devastated Afghanistan medical tourism has
begun, despite unfamiliarity with foreign
cultures and inadequate health literacy for
informed decision making, since local health
care is dismal (Mohmand, 2009). Many oth-
ers make similar moves at great cost. Yet all
must have the resources to travel beyond
national borders, and pay for care and
accommodation, and their expenditure is
significantly greater than that of ‘standard’
tourists.
Since cancer and cardiovascular services
are absent in Yemen, mobility for health care
occurs across the socio-economic spectrum,
although most resented having to travel.
While the majority travelled to Jordan or
India, relatively cheap and familiar destina-
tions, Iraq and India were the two cheapest
options, while Jordan and Egypt were a little
more expensive but also popular, partly
because the language was the same and
expensive translators were not required. Mos-
cow offered possibilities but Yemenis were
discouraged by crime and the hostile environ-
ment, while Saudi Arabia, seen as comparable
119
to Jordan and Egypt, was inaccessible for
political reasons. Above them in the hierarchy
was Germany, seen as providing excellent but
expensive care, while the more desirable UK
and USA were accessible only to a few well-
off businessmen or senior government offi-
cials. Choices were further influenced by
knowledge of particular places, past experi-
ence, cultural practices and beliefs and family
migration histories and connections: classic
patterns of chain mobility. They were also
influenced by a ‘geography of the body’ where
particular countries had reputations for some
procedures: (i) Russia for eye care; (ii) India
for kidney care; (iii) Jordan for cancer; and
(iv) Egypt for psychiatric medicine (Kangas,
2002). From the same country, elites and the
poor made different choices in negotiating a
variety of options and a hierarchy of places.
The USA, with so many of its population
uninsured or under-insured but able to pay
for some procedures (as Suzanne Rakow’s
case, below, indicates), and close to some Cen-
tral American providers, is the single greatest
national source of medical tourists. Other
developed countries are significant sources,
but without the ‘insurance push’ and the high
costs of the USA, though fewer medical tour-
ists seem to come from Scandinavia, which
may reflect more adequate medical insurance,
affordable and equitable health care and
shorter waiting times. However, despite the
significant flows from the USA, little more
than a third of Americans would move over-
seas even if there were substantial savings (see
p. 60). A poll of 3000 Americans in 2008 found
that older people were less likely to be willing
to travel (if they could save half the cost and
quality was comparable), with only 37% of
[baby] boomers being willing to travel com-
pared with 51% of Generation Y (those less
than about 35) while Hispanics and Asians
were most likely to be willing to go, compared
with Caucasians and African-Americans, and
men more willing to go than women (Deloitte,
2008: 5). By contrast Europeans were much
more willing to travel, influenced by quality
of care and reduced waiting times rather than
reduced costs, but poorer residents of East
European states were less likely to envisage
mobility. While 53% of all EU citizens were
willing to travel overseas proportions varied
120 Chapter 7
from 88% in Cyprus to just 26% in Finland,
where most people professed themselves sat-
isfied with local services. Language barriers,
financial constraints and lack of information
limited willingness to travel; older people,
women and unskilled workers were the least
willing to travel (Gallup Organization, 2007).
Certain groups were reluctant to travel even
where substantial cost savings are involved,
and some may simply forgo medical care. A
further random survey of 5050 Americans
found that no more than 29% would consider
going abroad for medical treatment, such as
heart bypass surgery, knee replacement, plas-
tic surgery and diagnostic procedures; ‘alter-
native’ medical treatments overseas elicited
the greatest interest whereas cosmetic proce-
dures attracted only 10% of respondents. Not
surprisingly those who did not have health
insurance were more likely to consider going
abroad for medical treatment: for example,
37% of respondents without health insurance
would seek cancer care abroad as compared to
22% with insurance. Their greatest concern
was over adequate quality; consequently
when asked whether they would consider
treatment abroad, assuming ‘the quality was
the same and the costs significantly cheaper’
the percentage saying they would consider
medical treatment outside US borders
increased by 12% (Khoury, 2009). Almost two-
thirds of Americans would not consider seek-
ing overseas medical treatment even with cost
savings and where ‘necessary procedures’
were required (Deloitte, 2009: 10). Responses
varied regionally. In more conservative parts
of America such as the Midwest (followed by
the South) people were least willing to con-
sider obtaining treatments outside the coun-
try; in the West they were the most willing.
However, even American college students
were generally unfavourable to medical tour-
ism, again centred on uncertainties about
quality of care that largely resulted from lim-
ited knowledge (Reddy et al., 2010). Distrust,
unfamiliarity and the certainties of home and
family pose significant barriers, as they do for
other forms of mobility, and thus moderate
fundamental economic factors.
Despite social, cultural, political and
psychological factors all being influential, at
least in the USA medical tourism has been so
pervasively associated with cut-price proce-
dures overseas that is has been ridiculed by
high-income observers as the province of the
‘bargain shopper’ (Burkett, 2007: 226). The
New Republic magazine commented ‘What
next – cruises to Cuba for surgery performed
with the more affordable aesthetic of Havana
rum?’ (quoted in Milstein and Smith, 2007:
137). However these are interpreted (and
whether or not transport costs, etc. are also
significant), price differentials underpin
choices in favour of medical tourism and of
particular destinations.
In Praise of Cost Differentials
Costs are higher in developed countries for a
number of reasons, including that wages and
salaries are high (and these equal more than
half the operating costs of hospitals): (i) doc-
tors in middle-income countries earn less than
half the salaries of those in developed coun-
tries; (ii) nurses and allied workers (radiolo-
gists, etc.) earn perhaps a third of comparable
salaries; and (iii) unskilled workers (such as
hospital cleaners) earn very low incomes
(Herrick, 2007; Connell, 2010).Whereas in the
USA labour costs account for 55% of total hos-
pital costs, in Singapore it is 44% and at Bum-
rungrad 18% (Reisman, 2010: 25). In Mexico
medical equipment and imported supplies
are the major costs (Hyo-Mi et al., 2009). Since
costs of technology vary little, reduced labour
costs are critical, which also means that more
health workers can be hired and patients may
have better access to nurses. Technological
change has introduced new procedures,
which are very costly, but in demand by the
ageing baby-boom population. Bureaucracy is
less important and bureaucrats fewer. In most
developed countries markets tend to be con-
strained as insurance companies, govern-
ments or even companies pay a substantial
part of health care, and do not search for the
lowest and most competitive prices so that
health-care providers do not compete on
prices, compared with countries where per-
sonal out-of-pocket expenditure is more sig-
nificant. Marketing by distant providers
competing for discriminating markets ensures
that prices are kept relatively low. While
 The Economics of Medical Tourism
hospital technology has become much the
same as in the West, and doctors are experi-
enced in Western procedures, most labour
costs remain very low and insurance is
less costly.
Medical-care providers in developed
countries, especially the USA, may build
into their costs coverage for possible mal-
practice litigation, whereas in countries such
as India and Thailand a liability insurance
policy costs about 4–5% of that in America.
Thailand does not compensate victims of
negligence for non-economic impacts, and
malpractice awards are much less than in the
USA (Herrick, 2007: 12). Fewer regulations
governing medical care, hire of skilled work-
ers, occupational health and safety and so on
further keep costs down in relatively poor
countries. The theme of insurance has been
emphasized by at least one MTC:
Although many countries have imitated our
world-renowned health care system in terms
of quality and technology, they have not
adopted our legal system completely. Doctors
in the US are required to pay medical
malpractice insurance that usually cost over
[US]$100,000 annually. Foreign doctors are
required to pay medical malpractice
insurance as well, but their costs are as low
as [US]$4000 annually. In addition to this
insurance, certain economies are at different
stages of development than the US. This
absolutely does not mean that their
healthcare technologies and institutions are
behind the US. In fact, most of the private
hospitals in our network use exactly the same
equipment and instruments as the most
advanced hospitals in the US.
(MedRetreat, 2010)
In something of an attack on the structure of
American health care MedRetreat added
other factors that contributed to reduced
costs outside the USA, including:
lower real estate values, lower construction
costs (to build hospitals), favorable exchange
rates, lower government taxes, no accounts
receivable collections issues with medical
tourism patients (cash/credit card payment
before release from hospital), no emergency
room bad debt, less administrative paper
shuffling, less bureaucracy/red tape, cheaper
medical supplies/equipment/medications.
(MedRetreat, 2010)
121
Some of these are also present in other devel-
oped countries. Conversely, as IndUShealth
have pointed out:
Although the leading Indian centers are
equipped with same state-of-the-art
technologies as the premier U.S. medical
centers, they are able to charge far less than
U.S. counterparts because the pay scales are
lower and the patient volumes much higher.
For example, a typical magnetic resonance
imaging scan (MRI) costs [US]$60 at
Bangalore compared to more than [US]$700 in
New York. There is also a dramatic difference
in the malpractice environment – a New York
heart surgeon pays more than [US]$100,000 a
year in malpractice insurance, while his New
Delhi counterpart pays only [US]$4,000.
(IndUShealth, 2010)
Such differences inevitably translate into sub-
stantial price differentials.
Data on price differentials vary within
countries and over time (and advertised data
rarely include all costs, often excluding essen-
tial transport and accommodation costs,
which in any case frequently change). Numer-
ous attempts have been made to depict cost
differentials, many by MTCs and in the
guidebooks. IndUShealth, for example, an
MTC which exclusively links the USA and
India, posts a set of comparative economic
statistics on its web page (Table 7.1) and
explains the inclusions and points out that
these may not be final:
The hospital costs shown include hospital
stay, operating theater costs, doctors’ fees,
anesthesiologist fees, pre and post-surgical
diagnostics, medications, nursing care, and
rehab. The combined costs shown also add
the typical costs of passport/visa fees, air
travel, local transportation, hotel stay and
meals. Please note that in certain cases, costs
may exceed those shown due to special needs
or constraints established by the patient’s
medical history or condition.
(IndUShealth, 2010)
As in this context many cost differentials are
so substantial that smaller differences in
hotel costs and the need to obtain passports,
etc. are inconsequential. Arguments have
been made by opponents of medical tourism
that the initial and obvious costs may not be
all, and the costs of any complications and
122
Table 7.1. Comparative prices (US$) of procedures, March 2010 (source: IndUShealth, 2010).
Median US cost
Type of procedurea (US$)
Hip replacement/resurfacing 50,000
Knee replacement 45,000
CABG (heart bypass) 100,000
Heart valve replacement 125,000
Heart pacemaker/defibrillator 60,000
PTCA (angioplasty) with stent 70,000
Spinal fusion 75,000
Gastric bypass 45,000
Laparoscopic surgeries (gall 20,000–60,000
bladder, hysterectomy, etc.)
aCABG, coronary artery bypass surgery; PTCA, coronary artery angioplasty.
post-operative costs may have to be met in
the patient’s home country, hence there are
disparaging comments that this is ‘fly-in fly-
out’ or ‘itinerant surgery’. Yet the cost differ-
entials are evident.
Other tabulations reveal similar situa-
tions. Comparisons from two other American
MTCs, TourNCare (Table 7.2) and Surgery-
Planet (Table 7.3), for six and five countries,
respectively, reveal very similar patterns but
significant differences in the ‘actual’ costs
quoted, according to how these are calcu-
lated. Overall multiple price comparisons
(repeated in the guidebooks and on numer-
ous other websites) reveal, unsurprisingly,
that price differences are greater for more
complex and demanding procedures and that
differences are particularly great between the
high-cost USA and several Asian countries,
especially India. Indeed these three tables
alone demonstrate the hierarchy from the
USA (and other developed countries),
through Central America to Asia (with a
significant gap between Singapore and India).
For complex surgery economic differ-
ences are particularly great, absolutely and
relatively, and anecdotal data confirm this. In
2003 a small child in the USA with a hole in
her heart was faced with a bill of around
US$70,000 there, but the operation was car-
ried out in Bangalore, India at a cost of
US$4400 (Neelankantan, 2003). Open heart
surgery in the late 2000s cost about US$70,000
in Britain and up to US$150,000 in the USA
Chapter 7
Typical Indian hospital Combined travel and
cost (US$) treatment cost (US$)
7,000–9,000 9,000–14,000
6,000–8,000 8,000–13,000
6,000–9,000 8,000–14,000
7,500–10,000 9,500–15,000
4,000–6,000 6,000–11,000
4,000–7,500 6,000–12,500
5,000–8,000 7,000–13,000
8,500–10,000 10,500–15,000
1,500–5,000 3,500–11,000
but in India it cost between US$3,000 and
US$10,000 depending on how complicated
the procedures were. Heart valve replace-
ment in India is less than 10% of what it
might be in the USA. A colonoscopy that is
about US$2260 in the USA costs US$602 in
Thailand (Butler, 2009a). Dental, eye and
cosmetic surgery costs about a quarter of that
in Western countries, and heart bypass opera-
tions in India are about a sixth of the cost
in Malaysia, hence India has cornered a sub-
stantial part of the market for expensive
procedures.
Price differentials for cosmetic surgery
are considerable since cosmetic procedures
are not usually covered by insurance. A face-
lift in Costa Rica costs about a third of that in
the USA, and rather less in South Africa,
though subsequent possible complications
must be paid for in the patient’s home coun-
try. Tunisia has attracted patients from Europe
since it is relatively close, hence transport
costs are low, and because such plastic sur-
gery procedures as breast augmentation and
liposuction are said to be 40–50% cheaper
than in Europe (Tunisia Online, 2 February
2010). Relatively popular procedures such as
hip and knee replacement (where insurance
may also be limited) are significantly cheaper
in some destinations: Colombia, for example,
undertakes knee replacements for about
US$5000. The relative provision of insurance
cover influences both the choice of proce-
dures undertaken overseas and their location.
 The Economics of Medical Tourism 123

Table 7.2. Comparative prices (US$) of procedures, May 2010 (source: TourNCare, 2010).

Country

Treatment for Costa Rica India Mexico Thailand Singapore USA

Angioplasty 11,000 10,500 16,500 14,500 14,500 61,500

Heart bypass 29,000 11,000 26,500 13,000 22,500 127,000
Heart valve 18,000 12,000 21,500 11,500 15,500 170,000
Hip replacement 13,500 10,500 17,000 13,000 13,500 44,500
Hysterectomy 5,000 5,000 7,000 5,000 7,000 20,000
IVF No data 5,000 No data No data 9,500 14,000
Mastectomy No data 9,000 No data 10,000 14,500 24,000

Table 7.3. Comparative prices (US$) of procedures, April 2010 (source: SurgeryPlanet, 2010).

Country

Surgery USA Costa Rica Singapore Thailand India

CABG (heart bypass) 152,000 25,000 32,000 23,000 8,000

Heart valve replacement 180,000 29,000 23,000 22,000 12,000
Hip replacement 101,000 11,000 16,000 13,000 8,000
Knee replacement 66,000 12,000 19,000 12,500 7,500
Spinal fusion 104,000 16,000 21,000 10,000 8,000
Hysterectomy (vaginal) 32,000 5,000 10,000 4,000 3,500
Economy travel costs (from USA) 0 1100 1,400 1,200 1,800

Routine procedures such as colonoscopies A reasonably typical account of the dom-

and obstetric examinations are much cheaper
and more affordable (and less demanding of
recuperation time). Similarly, while price dif-
ferentials for dentistry are usually not so sub-
stantial, complex procedures can be expensive
and insurance coverage is rare. As one Austra-
lian patient in Manila phrased it somewhat
graphically, after 5 days of treatment:
the final bill is compensation: two porcelain
crowns, six fillings, 20 X-rays, half a root
canal (on the house) and enough painkillers
to kill Keith Richards, for only a fraction over
A$1100. Add to that my budget airline and
the total cost is less than having one pure
porcelain crown done in Australia.
(Shanahan, 2009: 22)
Overall, depending on the location and pro-
cedure, the relative cost advantage from
medical tourism ranges from about 28% to
88% (Deloitte, 2008: 13), at least when
patients move from developed to developing
countries.
inance of economic factors in medical tourism
is that of a Californian patient with breast
cancer:
When Suzanne Rakow was diagnosed with
breast cancer, doctors recommended a mastec-
tomy followed by two months of radiation.
Underinsured and retired, the 59-year-old
Californian was shocked when she heard the
hospital bill would total [US]$100,000 or
more. She had already received a [US]$10,000
doctor’s bill for a second opinion and a
25-minute needle biopsy, and her insurance
wouldn’t cover any of it. ‘I am not poor and I
am not rich’ says Rakow ‘I didn’t know what
I was going to do. If I spend all of my money
now, what if the cancer comes back? I have
to live on something’. A friend she met
recommended she call Planet Hospital, a
medical-travel company that connects
patients with 32 hospitals in 18 countries.
Within 36 hours she was on the phone with
a surgeon at Mount Elizabeth Hospital in
Singapore. Planet Hospital scheduled her
medical procedures and found hotel
124 Chapter 7
accommodation, as well as a local concierge.
Her total bill, including the surgery, radiation,
airfare, hotel, concierge and a two-week side
trip to Bali, was under [US]$30,000. She paid
it out of pocket.
(Butler, 2009a: 51)
While many uninsured but potential patients
would baulk at these costs, and Suzanne is
towards the high-cost end of much medical
tourism, this vignette indicates the financial
benefits from some of the more demanding
procedures. The websites of MTCs and pro-
viders, and the pages of the travel guides,
include many similar stories and testimonials
to cost savings.
Discussion boards demonstrate that
while medical cost differentials are reason-
ably well understood, since the prices of par-
ticular procedures are formalized, knowledge
of associated costs can be slight, especially
where patients are unfamiliar with destina-
tions. A post on Gorgeous Getaways’ discus-
sion board early in 2010 stated:
I’m looking at GG [Gorgeous Getaways] and
seriously thinking of heading over next month
to have breast reduction/lift, full tummy tuck
and wanted a thigh lift but I think I will settle
with the first two. Can anyone tell me who
have been over how much spending money
you would need on day to day things? I have
never been overseas so have no idea what
money I need to have other than my money
for surgery, hotel, etc. I plan to go over by
myself, and not do anything else other than
surgery and back at the hotel – probably
because I would be scared of getting lost and
not knowing my way around.
Uncertainty and unfamiliarity, with cultures
and costs, can be brakes on medical tourism
and, as in this case, indicate the problem and
uncertainty of calculating costs. That uncer-
tainty is a deterrent to travel to distant places.
Even though economic factors are critical,
though less relevant in elite Western destina-
tions, other factors influence particular choices
of destination. A tourist from the USA in South
Africa considered similar economic factors:
If I’d had the treatment in the United States it
would have been performed in a day clinic
and I would have been sent home shortly
afterwards. As a single person, I would have
had no-one to look after me in case things did
go wrong [and they did go wrong, since she
contracted gastric flu] I was extremely
impressed by the way the matter was
handled by Surgeon and Safari – I was taken
to an emergency clinic and given very
considerate care. If I had fallen ill at home the
situation would have been vastly different – I
would have had to phone medical services
myself and there would have been a long
debate about which medical facility I should
go to. I would have wasted hours for
someone to attend to me and paid hundreds
of dollars for the entire experience.
(quoted in Witepski, 2005)
Another client of the same company noted:
I had been interested in having a face lift for
many years. I had the money to have the
procedure done on Harley Street but I’d
become aware of the South African option
through my research on the subject. I found
the idea of having the procedure done here,
rather than in the UK, compelling due to
the fact that the costs covered more than just
the surgery; it included round the clock care
and attention.
(quoted in Witepski, 2005)
As in both these cases, and in Malaysia
(p. 114), other factors, such as the perceived
quality of care, can be crucial while familiar-
ity with destinations and personal recom-
mendations are almost as important.
Ultimately price differentials have pri-
macy hence MedRetreat, after 7 years’ experi-
ence, offered their own simple economic rule,
though that too was mitigated by other factors:
The $6000 Rule. Medical tourists can now
obtain essentially any type of medical or
surgical procedure within reason. However,
there is a simple rule we follow to determine
if it makes financial sense to travel abroad.
We call it the ‘$6000 Rule’. If your procedure
would cost [US]$6000 in the U.S., you may
not realize any financial savings. Although
the surgery would only cost about [US]$1500
abroad, by the time you add the airfare,
post-op hotel accommodations, ground
transportation, and the other essentials of
overseas medical travel, you may only realize
a break-even scenario. This being said, many
people still choose to travel abroad to achieve
complete privacy and anonymity, peaceful
recuperation, and the avoidance of daily
hometown distractions.
(MedRetreat, 2010)
 The Economics of Medical Tourism
Although this makes implicit sense (at least
for medical tourists from developed countries
such as the USA), MedRetreat point to psy-
chological factors (such as fear, worry, doubt
and anxiety) that may discourage those who
could afford it from actually becoming
involved. Similarly the McKinsey report con-
cluded that the required savings would have
to be as much US$10,000 before mobility
occurred (Ehrbeck et al., 2008). There are no
empirical data to support either assertion.
However, the average cost savings of Euro-
pean dental tourists was £3200 in 2007 (Reis-
man, 2010: 99–100) and this was then about
US$6300. Many medical tourists make sub-
stantially smaller savings. Nor is economics
alone any guarantee of becoming a medical
tourist, with many Americans, for example,
refusing to have treatment abroad at almost
any cost savings. Economic factors are never
absolutely dominant.
A Culture of Medical Tourism
While many medical tourists are from devel-
oped countries such as the USA, the UK and
Australia, they are not necessarily originally
from those countries. Hispanic migrants in
the USA return to Latin America for medical
care for economic reasons (including inade-
quate insurance) but also because of: (i) cul-
tural barriers to health care; (ii) discrimination;
(iii) a preference for health care in a familiar
cultural context; and (iv) the opportunity to
catch up with friends and relatives. Such peo-
ple have been making these journeys for sev-
eral decades with numbers increasing over
time as diasporic populations grew and
became wealthier, and services improved in
their home countries. In countries like Mexico
and India they have played a crucial role in
the genesis of medical tourism, their word of
mouth has instigated chain mobility, and over
time the concept spread from this diasporic
culture to neighbours and workmates.
Economic factors thus spill over and
enmesh cultural factors that include a simple
familiarity with languages and processes (for
example, in Korea, patients’ unconstrained
choice of providers, and for Mexicans in the
125
USA, the ability to spend longer periods with
a doctor) among migrants who carry with
them ‘perceptions and expectations gener-
ated in their homeland’ (Lee et al., 2010: 109;
see also Bergmark et al., 2008) which may find
a more culturally adequate response there.
Cultural reasons can complement and over-
whelm economic factors. Only a minority of
Mexicans who returned there for medical
treatment did so because they had a serious
illness that required high-cost treatment.
Most returned to see their families or for
other reasons and to ‘take advantage of their
time in Mexico to seek medical care’ and
especially dental care. Some believed that: (i)
treatment at home was less likely to be turned
into an experiment; (ii) they would experi-
ence less discrimination; (iii) medicines in
Mexico were more effective because they
were more likely to be concentrated and
made from local medicinal plants; and (iv)
treatment would take less time so that they
could return to work more quickly (Bergmark
et al., 2008). Rather differently Koreans in
New Zealand, beyond obvious language
issues, chose to return to Korea for medical
treatments since they: (i) preferred Korean
diagnostic practices; (ii) believed that Korean
doctors were better qualified; and (iii) simply
felt more ‘at home’ in Korean hospitals where
they felt included (Lee et al., 2010). Indians,
Pakistanis and Brazilians do much the same.
In India the majority of medical tourists
are part of the Indian diaspora in the USA, the
UK and elsewhere, despite a gradual shift to a
more diverse patient population. Koreans
routinely return to Korea for medical treat-
ment just as Taiwanese in America go back to
Taiwan. For Koreans returning from New
Zealand, although more expensive than
remaining in New Zealand, the quality of
care is comparable and the cultural context
enables ease of communication and com-
prehension of complex procedures while
enabling patients and their families to visit
friends and relatives (Lee et al., 2010). Both
Korea and Taiwan, neither of which is a low-
cost destination, have sought to develop large
medical tourism industries from this familial
starting point.
Cultural factors may be important in
other contexts, for example in Yemen where
126 Chapter 7
families pay for relatives to go overseas for
medical care to prove that they did every-
thing possible for them. Yemenis also chose
their destinations according to economics,
language, health problem and existing migra-
tion and cultural ties and therefore where
social support would be most forthcoming
at a time of considerable expenditure and
vulnerability (Kangas, 2002, 2007). Similar
extended family support systems are wide-
spread, emphasizing how culture, good
health and family ties are inseparable
(e.g. Andrews, 2009). Travel thus becomes a
marker of social status, a means of acquiring
cultural capital and a route to good health.
Certain procedures, such as IVF treat-
ments, may lend themselves to a form of dia-
sporic tourism. A British Indian couple who
were unable to conceive a child, and were
placed on a waiting list for fertility treatment
in England, travelled to Gujarat and found an
Asian donor-surrogate for half the British
price (Martin, 2009). The website of the
Mumbai Test Tube Baby Clinic states that it
caters specifically to Muslim couples since
IVF will be performed according to Sharia
laws (Mulay and Gibson, 2006: 89). A Japa-
nese couple seeking IVF, since it is illegal
there, travelled to Hawaii, since it was both
the nearest part of the USA and had many
Asian and Asian-American donors, though
they rejected those of Korean ancestry
(Thompson, 2008). Culture dominates many
such intimate procedures.
Language too is important. South Africa
has been a major beneficiary for tourism from
anglophone states in sub-Saharan Africa, and
for visitors from the USA and the UK. Simi-
larly language ties routinely take franco-
phones from sub-Saharan Africa in the
opposite direction to Tunisia or to France.
Libyans travel east and west but remain in
the Arabic-speaking Maghreb. Spaniards
travel to Colombia. Russians and Ukrainians
go to Israel where many doctors speak Rus-
sian. India and the Philippines stress their
English-language credentials, just as many
websites of hospitals feature translation
facilities, or the training of staff in, usu-
ally, English-language contexts. Mexico has
sought to train bilingual English-speaking
nurses. Indonesians travel to Malaysia where
Malay is comprehensible, and also to Singa-
pore, but to the larger private hospitals where
Indonesian is likely to be spoken (Chan,
2007). Where language differences exist there
is some evidence of less adequate treatment
(e.g. Guerrieri, 1985), and the guidebooks
consistently advise against treatment in an
alien linguistic context.
Culture may be significant for stimulat-
ing markets. The Muslim state of Malaysia
has sought to attract Muslims from else-
where, mainly from the Gulf and the Middle
East but also from Brunei and Indonesia,
while Singapore has attracted ethnic Chinese
from a range of countries in the region, such
as Vietnam and Malaysia, where they are
generally minority populations. Thailand has
deliberately sought to build cultural bridges
with Japan in order to boost patient numbers
from there. Malaysia has promoted itself as
the most appropriate destination for Muslim
patients from the Middle East, stressing its
halal food and the ability of Muslim doctors
to say prayers before operations (Straits Times,
6 November 2006). In each case countries and
hospitals have stressed culturally appropriate
contexts of health care, dietary provision and
so on. In complete contrast some medical
tourists seek to escape the cultural complica-
tions of care in their home countries. In Saudi
Arabia and Yemen patients are often shel-
tered from the truth about life-threatening ill-
nesses and may prefer the greater frankness
of Western care (Kangas, 2002; Albers, 2008).
A quite different culture may also be welcome
for those seeking anonymity, peace and quiet.
Getting There: Personal Ties and
Words of Mouth
While geography, cost and culture are impor-
tant, many choices of destination (and also
procedures) are made on little more than
hearsay and friends’ recommendations,
though they usually align with costs, geogra-
phy and language ties. Evidence for idiosyn-
cratic choices is mainly anecdotal. As one
Australian recorded for the Philippines:
Before I went to the Philippines to have my
teeth fixed, I had only a vague understanding
 The Economics of Medical Tourism
of what dental tourism was all about . . .
Many would-be tooth tourists opt for the
Philippines because its dentists have a good
reputation and their qualifications are
recognised in the US. . . . I chose the
Philippines because I wanted to visit a friend
in Manila . . . Arriving in the Philippines it
suddenly occurs to me that I have no idea
how good my dentist will be – I have a
recommendation via a friend of a friend
of a friend who lives locally, but is that
enough? . . . Suddenly I’m struck with the
fear that my snap decision to have dentistry
in the Philippines is a dangerous folly.
(Shanahan, 2009: 22)
The eventual outcome was successful, after a
range of procedures, though he eventually
concluded: ‘Book the dentist not the destina-
tion; this isn’t a holiday’, despite participat-
ing in a number of tourist activities (Shanahan,
2009). Chance meetings may be catalysts.
I’d been thinking about cosmetic surgery for
a while after having my 3 children. I went
to a plastic surgeon in Melbourne for a
consultation. He spent 15 minutes with me
and I was slapped with a A$150 consult fee.
The cost of a breast lift and tummy tuck was
going to cost me A$22,000. I’d heard having
cosmetic surgery overseas was cheaper but
had seen too many horror stories on A Current
Affair and Today Tonight to even consider it.
Then one day when I was at the supermarket
I ran into a friend I hadn’t seen in a while. She
looked so different, not just physically but
there seemed to be a new found confidence
about her. I asked what her secret was for
looking so fresh and rejuvenated. She said
3 words. ‘Face Lift Thailand’ and put me in
touch with Global Health Travel. Four
months later I was on an airplane.
(Global Health Travel, 2010)
A similar sort of process occurred for a resi-
dent of Norfolk Island, an Australian territory
in the western Pacific:
A long-term resident of Norfolk Island, Anne
Howe used to travel to Sydney once a year
for her annual dental check-up. A few years
ago, however, she got more than the scale
and clean she bargained for: her dentist said
her jaw was going out of alignment and she
needed major work. ‘The price I got was
quite horrendous and being a Norfolk Island
resident, we don’t get any benefits like
Medicare. And I remembered reading about
127
someone who had gone to Thailand or
somewhere to have surgery and so I thought
“I’ll have a look on the Web and see what
I can find”.’ Her net surfing led her to
Specialist Dental Group, a clinic attached to
Singapore’s highly regarded Mount Elizabeth
Medical Centre and Hospital. She’d visited
Singapore before, mainly on stopovers en
route to Europe and had always come away
impressed by the island’s cleanliness and
air of efficiency. A few emails later and it
transpired another trip was a real option.
For about the same price as a hospital stay
in Sydney, she could travel to Singapore,
complete her dental work and still have
money left over after accommodation and
air fares. ‘My experience couldn’t have been
better’ she says, back home and problem-free.
‘I was treated exceptionally well, the doctor I
saw was highly qualified, ticked all the boxes,
and my husband who ended up going with
me, ended up going along to the dentist for a
check-up too.’
(quoted in Nicholas and Hyland, 2009: 22)
Many similar examples exist of friends, part-
ners and relatives going along ‘for the ride’,
to provide moral and physical support, to
have a holiday, and then deciding themselves
to take advantage of medical services.
Potential medical tourists are often fear-
ful of some aspects of destinations, from secu-
rity to the quality of care, and simply boredom
if they must recuperate alone in a strange
place, much preferring to travel with others
for social and moral support. Online commu-
nities and discussion boards, such as that of
Gorgeous Getaways, provide means of avoid-
ing that. Early in, 2010 two women posted
such a request:
I am looking to have breast lift and
augmentation and face lift first time and am
nervous because every time I tell someone
they say don’t do it overseas. I have looked
here in Australia and could never afford to
have it done here. I was hoping that there is
maybe someone else who like me is a bit
nervous and maybe we could give each other
some support. I am a 48 year old woman.
I am thinking of going for surgery
approximately end of July. Would love to
meet some-one who is also going at that time.
I am feeling very nervous and would like to
give and receive some support to another
person while I am there [Kuala Lumpur].
128 Chapter 7
Maybe we could go shopping etc together. I
am in my late 60s but bright with a good
sense of humour.
Both requests gained positive responses and
several offers of support and shopping. Many
others have posted similar requests. While
most medical tourists travel with family and
friends, the inevitable uncertainties of medi-
cal tourism in distant places both deter some
and encourage others to network and acquire
new friends. The Internet is invaluable.
These examples, that of Suzanne Rakow
(above) and a host of others scattered through
websites, demonstrate that chance and per-
sonal contacts play a considerable part in
basic knowledge about the world and about
medical tourism, and that the media contrib-
ute selectively to this. Choice of destination
is as likely to follow the experiences of
friends and relatives as the disembodied
suggestions of guidebooks and websites.
Health-care providers in the home country
(mainly Australia in these examples) pro-
vided no advice or assistance, nor initially
did MTCs, while the Web and telephone calls
enabled most arrangements to be made. As
the example of the Australian travelling to
the Philippines suggests, in contexts where
care may be less critical, such as for dentistry,
self-help is more common and choice of des-
tination less important.
Family and friends are influential, in
offering support and finding contacts, and
thus contributing to informal accreditation.
Word of mouth provides the ‘personal’ con-
tacts that websites or guidebooks cannot.
Previous experience is invaluable, and per-
haps also accounts for the dominant role of
former patients within MTC organizations
(Chapter 6). The Kreativ dental clinic in
Budapest treated about 16 British visitors a
month in 2004 but by 2007 that number had
tripled solely by word-of-mouth recommen-
dations, with similar growth occurring from
other northern European nations. Kreativ no
longer apparently found it necessary to
advertise (Haslam, 2007). The largest group
of medical tourists in Malaysian hospitals
(some 57% of 121 patients) were there
because their friends or relatives had told
them about it, or lived nearby; MTCs, who
accounted for 15% of the tourists, were the
only other significant influence (Doshi, 2008:
A-22). Providing ‘meet-and-greet’ sessions
and online discussion boards for aspiring
medical tourists, as Gorgeous Getaways has
done (Chapter 6), creates, builds on and
extends such personal contacts.
Few branches of tourism and even fewer
of medicine are so reliant on the Web as a
source of information. Many medical tourists
learn of opportunities overseas from media
stories and from the recommendations and
advice of friends and acquaintances but, as
interest increases, through Internet websites.
Surfing the net reinforces vague information
from friends. Most websites of MTCs and pro-
viders further reinforce and extend the advice
of friends, providing formal information and
hosting a range of personal stories portraying
satisfied tourists. Most have a similar structure
and format and emphasize economic and
social factors and also personal serendipity.
WorldMed Assist, a growing company in the
expanding industry of medical tourism,
helped save Kevin Stewart’s life. Last
November [2006], Stewart’s liver started to
fail, and by February, he had to endure
hospital visits every two weeks to have his
belly drained of fluids his liver would no
longer process. His doctor said that without a
liver transplant, he would die. Worse, there
was a four-month wait for a transplant, and
no one was sure he had four months. He also
was told it would cost about [US]$350,000.
Stewart, a retired owner of a landscaping
business, had no health insurance. Stewart
now has a newly transplanted liver, courtesy
of his sister, Jo-Ann Hall of Ottawa, Canada.
On Friday, he lands at Miami International,
arriving home from Apollo Hospital in Delhi,
India, where the procedure was performed.
Total cost of surgery and hospitalization
there: [US]$55,000. ‘Having this surgery in the
U.S. would have wiped me out,’ Stewart said.
‘Having someone help me get the transplant I
needed in India – with top-notch doctors in a
great hospital, at a fraction of the cost – saved
me so much money that I flew my girlfriend
and Jo-Ann’s husband to India to help us
recuperate – and still saved [US]$275,000. The
surgery has given me back a life I thought
was lost.’ That life looked pretty bleak when
he got his diagnosis and the price tag. ‘In
early June, I hit the Internet, and eventually
 The Economics of Medical Tourism
landed on the term Medical Tourism. I
searched several firms, saying, “I need a liver
transplant.” Several responded, but I kept
coming back to WorldMed Assist,’ Stewart
said. ‘By late June, they had me on my way to
India, and my surgery was finished on July
11. Pretty amazing. I heard I was the first
American to have a liver transplant in India.’
(WorldMed Assist, 2010)
The Internet abounds in similar stories that
end successfully, through the predictable
ability of MTCs to provide the support
required. The media replicate similar themes:
Liz Danforth has always been healthy, so the
fact that she didn’t have medical insurance
never really worried her – until 2004
when she was gripped with terrible abdomi-
nal pain. After undergoing a series of tests
her doctor gave her the bad news. She had
gallstones. Removing them would cost about
[US]$12,000 – assuming there were no
complications. Danforth, now 55, an
illustrator and game developer in Tucson,
Arizona, was concerned: ‘I had savings and I
could have paid for it but it was a lot of
money’ she says. Then a friend suggested she
get the operation abroad. Danforth was
intrigued by the idea, known as ‘medical
tourism’, and began researching possibilities.
What she found amazed her: vast networks
of hospitals in destinations such as India,
Thailand, Singapore and Costa Rica that
catered to cash-strapped, under-insured or
uninsured Americans looking for expert
medical care at reduced prices. After conduct-
ing her own research Danforth ultimately
chose Bumrungrad International Hospital in
Bangkok – a five star facility accredited by
the Joint Commission International. She
spent two days – as opposed to the six or
eight hours allocated in a US facility – in the
hospital, and then recuperated at a hotel
around the corner. The entire procedure cost
[US]$320 plus [US]$800 in air fare.
(Ellin, 2009)
Evident again are the economic benefits of
medical tourism, the potential for longer hos-
pital stays (and thus more effective after-care)
and the social and instigating role of friends
and relatives.
Some procedures can only be undertaken
in particular places, ensuring that patients
who seek rare services (whether stem cell
therapy or suicide) must go there irrespective
129
of economic factors. For some procedures
medical tourism becomes literally a last resort
where cost is almost irrelevant (Chapter 8).
For every procedure treatment is likely to be
most successful where doctors are familiar
with the particular conditions:
My unscheduled visit to Bumrungrad taught
me an old lesson — and a new one. For
decades, Americans have known they could
obtain cheaper health care abroad, and have
slipped off to Mexico for small surgeries or
Canada for prescription drugs. But more and
more people now recognize foreign hospitals
can deliver not only cheap but also high-
quality health care, and are considering
medical tourism even for serious health
problems. When I returned to the United
States, in fact, I found myself longing for
Bumrungrad. On a follow-up visit to an
American doctor, I waited in a small room
after telling him about my dengue fever
diagnosis. After a while, when he hadn’t
returned, I poked my head into the hall, and
discovered him thumbing through a book to
find information about dengue fever.
(Kurlantzick, 2007)
On the other hand the epidemiological transi-
tion has meant that doctors in developing
countries are thoroughly familiar with life-
style diseases, such as cancer and obesity,
emanating from the West, which no longer
has distinctive health problems. Familiarity
with local and regional circumstances and
cultures, however, explains why much medi-
cal tourism simply crosses nearby borders.
The wider social context of health care is
also influential. Several testimonials and
blogs from the USA commented on the satis-
faction of seeing and using the Starbucks café
in the foyer of Bumrungrad, and on other
aesthetic pleasures the hospital offered:
They’re growing a culture of whatever was
eating my throat up, and I’ll be back at
Bumrungrad (gotta love that name) again
Saturday. Did I mention the other reason it’s
my favorite hospital? There’s a Starbucks in
the lobby, and the nursing staff are . . . how to
put this delicately . . . a bit more aesthetically
pleasing than in any hospital I’ve been in
back in the States. *cough*
(http://blog.hackingbangkok.com/2008/
11/two-weeks-ago-i-caught-some-
mutant-drug.html)
130 Chapter 7
A version of the placebo effect may thus be
important for some, but the familiarity that
comes from well-known cafés and home lan-
guages is valuable. Having Starbucks and
McDonald’s investing in the hospital may
offer independent prestige and accreditation,
for visitors from many countries, and enables
some to have accessible food without step-
ping outside their comfort zone. The redesign
of the atrium of Bumrungrad to include Star-
bucks, McDonald’s and Au Bon Pain, ‘had a
powerful effect on lower-income and middle-
income Americans [who] discovered that
they could afford posh “VIP” services
reserved for only the wealthiest clients at
private American hospitals’ (Turner, 2007a:
116). The effect on visitors from the Gulf,
Eastern Europe and other parts of Asia, where
such outlets are particular symbols of moder-
nity, is probably even greater. Diverse cul-
tural factors may have unpredictable impacts
on choice of destination and eventual
satisfaction.
Institutional Interests and Networking
While medical tourism has largely been seen
as an individual phenomenon, like so many
other components of tourism, where individ-
uals and households make decisions about
destinations, durations and what activities to
engage in, it has become increasingly an insti-
tutional phenomenon. Medical tourists have
been seen to be moving away from the some-
times rigid constraints of national health-care
systems, and their perceived inadequacies,
particularly in the USA but also in Europe.
Increasingly there has been a degree of collu-
sion within state systems, as patients are
encouraged to move within Europe to take
the burden off some national systems, insur-
ance policies provide for the bypass of
national systems and some companies
‘export’ workers for health checks rather than
trust inefficient national systems.
In the future Western insurance compa-
nies may well encourage overseas treatment
to reduce their own costs. In the mid-2000s
the British NHS was sending patients to
Europe to cope with a backlog of cases, but
restricting them to places within 3 hours fly-
ing time (such as France and Spain), and
within the EU market area (Carrera and
Bridges, 2006). Changed circumstances
might lengthen such distances. Insurance
companies are also opting to send patients
overseas to reduce their own costs. One Kol-
kata (Calcutta, India) hospital has signed an
agreement with the British-based transna-
tional insurance company Bupa, for the
transfer of privately insured patients to
India. In the USA an insurance company has
teamed up with an MTC, Companion Global
Healthcare, to send patients overseas.
Through this process, for example, a South
Carolina man was sent overseas for hernia
surgery in San Jose, Costa Rica, for a total
cost of US$3900, which the insurance com-
pany entirely covered; had the surgery been
undertaken in the USA, the bill would have
been US$14,000 of which the patient would
have had to pay US$10,000 and the insurance
company the remainder (Butler, 2009a: 51).
Both company and patient were economic
beneficiaries.
Japan has been a perhaps reluctant pio-
neer in such institutional developments. It has
always been unwilling to accept immigration
hence, as the population ages, has a health-care
system that is under considerable pressure,
without access to migrant health workers as in
most developed countries (Connell, 2010).
Japan has consequently taken particular dis-
tinctive advantage of medical tourism. Some
Japanese companies have sent their employees
to Thailand and Singapore for routine exami-
nations, as the savings on medical fees and
high quality medical care make the airfares
and accommodation costs inconsequential. For
provincial Japanese companies the cost is little
more than that of travelling to Tokyo, reports
are done in Japanese and images sent electron-
ically to Japan. Moreover at least one Bangkok
hospital has an exclusively Japanese wing and
there are many Japanese nursing homes in
Bangkok. Such medical connections have
diversified, with spectacles being made in
Thailand from measurements taken in Japan
and then flown there.
It is likely to become increasingly com-
mon for companies and mainstream health
insurers, at least in the USA, to include
 The Economics of Medical Tourism
foreign providers in their networks of
health-care providers (Bookman and Book-
man, 2007; Herrick, 2007). The Blue Shield
insurance company of California, for exam-
ple, has developed a health network scheme,
Access Baja, enabling people who so choose
to get health care in Mexico, though most of
those who have enrolled in the scheme are
Mexican nationals. In a less culturally defined
context, in 2006 Blue Ridge Paper Products
of North Carolina offered their employees
incentives to have emergency surgeries
undertaken in India and offered to pay air-
fare, extra sick leave and a US$10,000 bonus
(Burkett, 2007: 223). A month after offering
their package, union pressure, focused on
lax overseas medical malpractice laws,
resulted in Blue Ridge withdrawing it.
Concerns were also raised over individuals’
ability and freedom to choose. A year later
Blue Cross Blue Shield of South Carolina
added BIH to its network of providers,
although early after inception no patients had
taken advantage of this option (Herrick, 2007:
21) preferring domestic medical care. Blue
Cross later concluded similar agreements and
by 2010 had agreements with seven overseas
hospitals, in Singapore (three), Thailand, Tur-
key, Ireland and Costa Rica, and in India,
Apollo and Wockhardt both seemed likely to
become partners (Einhorn, 2010b). Variants
continue to reappear:
Douglas Carneau is preparing to travel to
India for two partial hip replacements and
back surgery. Because its costs will be much
lower, Regence BlueCross BlueShield of
Oregon is willing to send Carneau to India,
put him up in hotel, and pay for operations
there. Carneau, a long-time truck driver for
Safeway and a member of his local Teamsters
Union, has health insurance. In fact, he calls it
‘a Cadillac plan,’ and it does provide
top-of-the-line coverage through Regence
BlueCross BlueShield of Oregon. Carneau
isn’t going to India to save money. Instead, he
is taking the idea of shopping around for the
best health care to a new level. And in the
process he is becoming among the first in this
country to go overseas for discount surgery
that will be paid for by his insurer.
(Korn, 2009)
Some US companies have independently
explored the possibilities of overseas medical
131
care for their workers, to avoid high domes-
tic costs. Such proposals have been strenu-
ously opposed by unions, such as United
Steelworkers – the largest union in North
America – who criticized the manner in
which company profits might be increased in
this way, and raised issues of legal liability
overseas and job losses in the American
health-care industry if health care was out-
sourced. In 2008 a supermarket chain based
in Maine began paying the entire medical bill
for employees, with a companion, to travel to
Singapore for hip and knee replacements
(McGinley, 2008). Employers in southern
California particularly have developed
insurance plans where their employees go to
Mexico for routine care. By early 2010 more
than 200 employers in 21 states covered treat-
ment overseas for their employees and some,
like the Maine supermarket chain, included
airfares for two people. Small companies in
the USA consequently became the ‘early
adopters’ (Milstein and Smith, 2007) of the
off-shore provision of health care for their
employees, though Japan had set partial
precedents.
Such institutional linkages are equally
valuable to MTCs like Companion Global
Healthcare and Planet Hospital, which devel-
oped or sought to develop, with insurance
companies, low-cost schemes for overseas
health-care provision that would reimburse
patients the same amount for each particular
procedure independent of where it was
undertaken. The intention was to initially
develop the scheme with El Salvadorians liv-
ing in the USA, who would travel to El Salva-
dor for major medical needs, and then follow
this with similar schemes for countries such
as India and Mexico (Herrick, 2007). Once
again the diaspora led the way in the consoli-
dation of international institutional linkages.
In other countries similar institutional affilia-
tions have been established. Thailand has
gained contracts from the UAE’s police
department and the Oman government (for
the Royal Guard of Oman) both of which
were previously linked to Europe (Levett,
2005). Several Asian countries have organized
trade missions to South-east Asian countries,
such as Myanmar and Vietnam, and Gulf
states, in search of additional formal ties, to
132 Chapter 7
ensure a steady and substantial flow of
patients, rather than merely be the benefi-
ciary of individual decisions.
The Economic Impact
Where medical tourists either come from
developed countries or are elites from poorer
countries, and stay for significant periods in
destinations (as recuperation sometimes
demands), their contribution to local econo-
mies can be substantial. However, there is lit-
tle data and, once again, estimating the
numbers of medical tourists, let alone those
who travel with them (and would not other-
wise have travelled) is problematic. Existing
estimates fail to indicate whether the assumed
economic impacts are based solely on health
expenditure, or on travel and tourism, which
are not easily distinguished (although most
data seem to refer to health expenditure).
Consequently estimates of the economic
impact of medical tourism are usually at best
‘back-of-the-envelope’ calculations, derived
from inaccurate numbers, which have mini-
mal basis in hard data and rigorous economic
analysis. Even the dimensions of the ballpark
are imprecise.
Various country estimates exist but none
have more than relative utility. Recent data
from Thailand suggest that it earned over
US$2 billion from medical tourism in 2008,
and that 2009 would be somewhat down on
that, on medical services alone (Bangkok Post,
30 March 2009). Another estimate was that
medical tourists in Thailand spent US$1.6 bil-
lion in 2003 (Taffel, 2004), while medical tour-
ists in South Africa were estimated to spend
between US$30 and 40 million in the same
year. Medical tourism in Cuba has been said
to generate US$40 million a year, and US$27.6
million in Malaysia in 2004, while medical
tourists from Latin America spend up to
US$6 billion a year overseas (Bookman and
Bookman, 2007: 3). Alternative estimates
suggest between US$40 million and US$103
million in Malaysia in 2003, US$420 million
in Singapore in 2002 and about US$482 mil-
lion in Thailand in 2003 (Arunanondchai and
Fink, 2007: 12). Cuba is elsewhere said to
earn US$30 million from 25,000 foreign
patients, or US$40 million from 20,000 for-
eign patients, and Israel US$30 million from
20,000 foreigners (Reisman, 2010: 102). A
recent estimate has Israel earning just over
US$100 million a year (Haaretz, 22 June 2010).
In Jordan where medical tourism is ‘consid-
ered one of the main contributors to the
national economy’, it is said to bring in reve-
nues that reach US$1 billion annually (Jordan
Times, 29 June 2010). Two juxtaposed esti-
mates for India range from US$433 million in
2005 to US$17 billion a year earlier (Reddy
et al., 2010). Singapore has claimed that
its estimated annual 150,000 international
patients in 2001, about 80% of whom were
from neighbouring Indonesia and Malaysia,
stayed for an average of 5 days, spending
about US$1500 per head. Crude calculations
suggest this adds up to about US$220 mil-
lion. Another version has the average expen-
diture of standard tourists in Singapore at
US$144/day and the expenditure of medical
tourists at US$362/day (Turner, 2007b: 314).
Equally wildly fluctuating estimates have
been attached to the global income generated
from medical tourism, but there are no reli-
able data. Not only is there no basis for any of
these claims, and no hints of methodologies,
but given the various discrepancies, notably
for Malaysia, they are barely even crude indi-
cations. How fast expenditure has grown, in
which countries and from which sources, and
who are the major beneficiaries, are all impos-
sible to assess.
A small number of studies offer slightly
more rigorous data. Some relative newcomers,
like Tunisia where medical tourism is said to
be growing exponentially, have made substan-
tial gains. In 2009 medical tourism was said to
be worth some 5% of all Tunisia’s service
exports, significant in a country where ‘stan-
dard’ tourism is considerable. Moreover these
export earnings were said to account for 24%
of the turnover of private clinics, amounting to
?175 million (U$219 million) (Tunisia Online,
2 February 2010). In Tunisia the direct expen-
diture of medical tourists on health alone
(clinic costs, doctors’ fees and pharmaceuti-
cals) was estimated at US$55 million in 2004,
about a quarter of the total earnings of all pri-
vate clinics, and thus a substantial input to the
 The Economics of Medical Tourism
health sector (but entirely to the private sector,
in the two largest cities). While overseas visi-
tors pay more than Tunisians this raises some
questions about the role of private clinics in
serving the national population (Chapter 8).
Adding to that the total expenditure of patients
and relatives in the hotel, food and transport
sectors (based on an average length of hospital
stay of 3 days and outside stay of 2 days, and
about 1.5 relatives per patient) brought the
overall expenditure figure to US$107 million
(Lautier, 2008). Almost exactly half of all
expenditure was therefore outside the health
sector, and half the jobs created were also out-
side the health sector, broadly within tourism-
related service sector activities.
Every estimate suggests that medical
tourists spend more than standard tourists,
and usually about twice as much, as in Singa-
pore (despite the second Tunisian estimate
above), because of the high costs of medical
services. Another estimate for Tunisia sug-
gests that medical tourists spent between
?2500 and ?4000 compared with the ‘usual
tourists’ who spent ?300–400 (Tourism-
Review.com, 2010), although the latter figure
seems unusually small. It has been said that
an Indian medical traveller spends US$7000
compared with other tourists who spend
US$3000 (Reisman, 2010: 102). Costa Rica has
declared medical tourism to be in the ‘national
interest’ since the Costa Rica Tourism Board
believes that, from 2006 data, medical tourists
spend, on average, twice or three times as
much as a traditional tourist does; that is
to say, US$400–600 (¢228,000–342,000) as
opposed to US$200 (¢114,000) (Costa Rica
Views, 2010). In Korea too medical tourists
stayed longer and spent more money than
other tourists (Chapter 5). Assuming that the
cost of medical treatment is included most
medical tourists will spend more than stan-
dard tourists. A large sample of medical tour-
ists in Malaysia spent an average of US$8720,
of which the single largest component was
the cost of medical treatment (US$3742), fol-
lowed by international airfares (US$1187)
and accommodation (US$1038). Food and
drink (US$468) and domestic transport
(US$159) also took up large sums. Expendi-
ture on evidently tourism-related activities
included US$678 for shopping, alongside
133
entertainment (US$180) and organized tours
(US$489), while there were significant miscel-
laneous costs (US$779). Almost all medical
tourists in Malaysia (108 out of 121) travelled
with at least one other person, usually a rela-
tive (Doshi, 2008: 78), and their expenditure
was not estimated. Had that been included
the already substantial expenditure would
have been greater.
As in Tunisia and Malaysia most medi-
cal tourists do not go alone, nor want to do
so. Several MTCs offer discounts for friends
and relatives. Those travelling to Tunisia
took an average of 1.5 friends and relatives
with them (Lautier, 2008) and Yemenis took
more than one relative with them (Kangas,
2002). Three-quarters of a sample of Bumrun-
grad patients in 2009 travelled with a com-
panion (Anon., 2010b), a little less than the
83% in the MTA’s more general survey
(Anon., 2009). Observations at several hospi-
tals, anecdotal information, alongside the
obvious role of relatives in difficult times,
suggest that this is normal. A substantial
number of additional travellers accompany
medical tourists and their expenditure on
standard tourism activities is significant.
Perhaps predictably tourists from the
Gulf are argued to be relatively high spend-
ers, especially from the UAE, where the gov-
ernment funds medical care overseas, and
provides hotel allowances, and Arabs have a
tradition of purchasing gifts for many family
members back home. Indeed in Singapore,
where at any time between 100 and 200 UAE
citizens are said to be visiting for medical
treatment, the income is likely to be consider-
able since the UAE government pays the full
cost alongside return airfares for two com-
panions and a US$4000-a-week allowance to
cover the cost of hotel and other expenses,
and such ‘high-roller’ patients stay in expen-
sive hotels (Straits Times, 17 April 2006).
Occasionally tourists make their own assess-
ments of expenditure on websites for the
guidance of others. Writing in May 2010 an
Australian woman who had undertaken
plastic surgery through Gorgeous Getaways
in Kuala Lumpur, observed:
I had a tummy tuck & liposuction last July.
For the first week out of hospital I spent very
little money as I was not very mobile & not
134 Chapter 7
hungry. I ate cup noodles & salad. I know
not very healthy! As most of the hotels GG
recommend have kitchens you can do some
food shopping before the operation & then
you do not need to go out to restaurants.
Food is quite cheap in KL compared to
Australia & you will find food that you
recognise in the supermarkets. KL is fantastic
for shopping & taxis during the day are very
reliable & cheap. They are nasty at night
though as they charge you double because
they know it is dark & you will not want to
walk to the hotel :-( The market in China
Town is a must see. You will be able to buy
copy designer handbags, sunglasses, shoes
etc. It is a lot of fun! On my trip over last
year I spent about [US]$500 over the
2 weeks. I am not a big spender but I did
buy some clothes!
(Gorgeous Getaways’ discussion board,
May 2010)
That ignores hotel and travel costs, and the
cost of medical care, but indicates that even
cautious tourists, and those from impover-
ished countries such as Yemen (see p. 119),
may spend significant sums simply because
they stay quite a long time. Some spend much
more. Treatment Abroad (2007) estimated
that in 2007 British medical tourists spent an
average of £3753 abroad (with dental tourists
spending £4189 per head and cosmetic sur-
gery tourists spending £3392) so that overall
overseas expenditure amounted to about
£375 million. A year later they found that
some 11% of dental tourists and 9% of elective
surgery respondents spent over £10,000 over-
seas. A substantial proportion of expenditure
is outside the health-care system.
Beyond direct tourism expenditure
(some of which is invaluable foreign
exchange) and job creation, inside and out-
side the health sector, other benefits include
the possibility of return visits, after a taste of
the country has been acquired, and the diffu-
sion of information to other potential visitors.
Outside the health and tourism sector there
may be some trickle down of revenue into
areas of the economy, such as agriculture,
though tourism sectors in developing coun-
tries are particularly prone to the leakage of
local expenditure. In some places the impacts
of medical tourism are visible. Around Bum-
rungrad hospital, where many patients are
from the Gulf and elsewhere in the Middle
East, a small ‘ethnic ghetto’ – Little Arabia –
has emerged where hotels, travel agents, res-
taurants and stores are oriented to a Muslim
clientele (Fig. 7.2). Palestinian restaurants jos-
tle with Pakistani restaurants, halal food is
widely advertised, some hotels are almost
exclusively occupied by a Gulf clientele of
relatives and recuperating patients, and Ara-
bic-speaking travel agencies and stores meet
other needs (Chapter 9). While some such
economic activities are owned by migrants
from those countries, many are owned by
Thais or leased by them, generating a consid-
erable local income. Dental tourism has sub-
stantially transformed Los Algodones, a
Mexican town of just over 4020 people and
between 200 and 300 dentists, within walking
distance of the US border (Hyo-Mi et al., 2009),
and close to retirement townships in America.
Wikipedia recorded in June 2010 that:
The popularity of both inexpensive
prescriptions and medical care catering to
Canadian and US senior citizens have
prompted a virtual explosion of pharmacies
and dental offices which have largely
displaced a great deal of the open-air shops
and restaurants immediately across the
border and have effectively shifted the town’s
focus from tourism to medicine.
Similar processes have also happened at
places like Piestany (Slovakia) and Sopron
(Hungary).
Most of the above income and expendi-
ture estimates are gross generalizations
based on uncertain numbers, unknown pat-
terns of expenditure, and equally uncertain
durations of stay. Yet there is no doubt that
medical tourism has become a significant
economic niche. It is scarcely surprising that
plastic surgeries in Costa Rica are locally
known as cirugias de oro (surgeries of gold)
though, both there and in Panama, where the
ratio of medical tourists to the local popula-
tion is said to be high, there are no estimates
of the economic significance of medical tour-
ism. However, for small countries like Costa
Rica and Singapore, where numbers seem
substantial, and growth is occurring, the
national economic effects may be very sig-
nificant, while some local effects are even
more substantial.
 The Economics of Medical Tourism 135

Fig. 7.2. Bangkok streetscape, Little Arabia, March 2010.

136 Chapter 7
Cutting Costs
Even during the GFC there was surprisingly
little indication that medical tourism had
declined, other than for some movements
from the USA to Latin America. However,
perhaps somewhat remarkably, the GFC ben-
efited Central America as many North Ameri-
cans found it even more difficult to pay for
health care at home and increased numbers
went overseas. The numbers of international
medical tourists at Bumrungrad fell signifi-
cantly following the GFC as they did else-
where in Thailand. Similar unrest a year later
brought further declines with the largest pri-
vate hospital operator experiencing a down-
turn of 20% in the number of overseas visitors,
especially from Europe and the Gulf, com-
pared with the previous year, and a second
group experiencing a 10% decline (Wiri-
yapong, 2010). On its web page BIH was
forced to warn international patients against
travelling to Bangkok. However, in Australia
during the financial crisis (in a country where
its impacts were well cushioned) the number
of ‘dental tourists’ going overseas through
one agency actually increased from a couple a
week to six, as people were increasingly
unable to afford domestic dentistry (Shana-
han, 2009). Both within and outside times of
crisis economics has been a crucial influence
on medical tourism.
Economic issues have been influential for
both the supply and the demand in medical
tourism. Countries have sought to participate
based on economic disappointments in other
sectors (Chapter 4) and comparative prices
have structured travel and choice of provider.
Insurance companies, and even national
health-care systems have increasingly gone
global, in the search for cheaper (and quicker)
treatment, and hierarchies of destinations
have emerged based on cost and quality. Yet
geography, culture and personal contacts
moderate any crude notions of economic
determinism, and destinations and durations
are influenced by multiple factors. As the Gen-
eral Manager of Singapore’s National Health-
care Group has said: ‘Cost should not be the
deciding factor in selection, but more empha-
sis should be placed on accreditation, clinical
outcome indicators, affordable healthcare, and
PEST (Political, Economic, Social and Techno-
logical) factors’ (quoted in Chan, 2007: 49).
If the economic benefits from medical
tourism have proved elusive to quantifica-
tion they are none the less substantial and
account for the enthusiasm of many countries
to participate and, correspondingly, for grow-
ing attempts by some source countries to dis-
courage mobility and retain patients. In some
circumstances economic benefits have seem-
ingly even overwhelmed ethical consider-
ations, especially in the poorest countries,
anxious to establish profitable ventures, but
not easily able to compete in terms of cost
and quality. Finally, political and economic
factors have influenced and stimulated the
privatization of medical care, and the concen-
tration of financial and human resources in
this sector, perhaps to the disadvantage of
other sectors and some geographical regions.
These complex questions are examined in the
following chapter.