51313466

Original Article

Medical tourism today: What is the state ofexisting knowledge?

Laura Hopkinsa, Ronald Labonteb,*, Vivien Runnelsb, andCorinne Packerb

aSchool of Public Health, Health Sciences Building, University of Saskatchewan,107 Wiggins Road, Saskatoon, Saskatchewan, Canada S7N 5E5.

bGlobalization and Health Equity, Institute of Population Health, University ofOttawa, 1 Stewart Street, Ottawa, ON, Canada K1N 6N5.E-mail: [email protected]

*Corresponding author.

Abstract One manifestation of globalization is medical tourism. As itsimplications remain largely unknown, we reviewed claimed benefits and risks.Driven by high health-care costs, long waiting periods, or lack of access tonew therapies in developed countries, most medical tourists (largely from theUnited States, Canada, and Western Europe) seek care in Asia and LatinAmerica. Although individual patient risks may be offset by credentialing andsophistication in (some) destination country facilities, lack of benefits to poorercitizens in developing countries offering medical tourism remains a genericequity issue. Data collection, measures, and studies of medical tourism all needto be greatly improved if countries are to assess better both the magnitude andpotential health implications of this trade.Journal of Public Health Policy (2010) 31, 185198. doi:10.1057/jphp.2010.10

Keywords: medical tourism; global health equity; cross-border health care

Introduction

A rapidly emerging manifestation of global commercialization ofhealth care is medical tourism (health tourism, medical travel).The term refers to cross-border health care motivated by lower cost,avoidance of long wait times, or services not available in ones owncountry. Such care is increasingly linked with tourist activities to easeforeign patients into a new cultural environment and to occupy themduring the pre- and post-operative periods. Proponents claim that

r 2010 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 31, 2, 185198www.palgrave-journals.com/jphp/

growth of medical tourism will have positive economic anddevelopment impacts on destination countries. Skeptics raiseconcerns about patient safety, ethics of specific care (notablyreproductive or transplant tourism), and growth of privatemarkets in developing countries at the expense of adequately staffedand resourced public systems. What those on both sides of thisdebate agree is that the market for out-of-country care, notably theflow of patients from the wealthier north to the developing south,is likely to increase.We undertook a systematic search of the literature to determine

how much was known about this burgeoning industry, and how itmight affect health equity within and between nations participatingin this trade (Box 1). We focus on cross-border flows from developedcountries (the north) to developing countries (the south). Thegeographic designations oversimplify recent shifts in the globaldistributions of wealth and power, but capture the general and mostfrequently encountered direction of medical tourism, and the onethat has raised the most concerns about health equity. We begin witha brief review of the medical tourism industry itself, then describeclaimed advantages and disadvantages of the industry both topatients, and to source and destination countries. We conclude withsome comments about the requirements for future study.

Box 1: Search strategy

To search the literature systematically, we used PubMed, Scopus, CINAHL, and CAB

HEALTH databases, as well as internet search engines. Medical tourism has yet to beestablished as a searchable medical subject heading (MeSH) or otherwise indexed term.

As a result, we used an extensive number or terms, alone or in combination: medical

tourism, health tourism, medical, health, surgery, surgical, reproductive, fertility, stemcell, dental, dentistry, organ, transplant, tourism, travel, tourist, developing countries,

developed countries, cross border care, patient mobility, and internationality.

Results yielded: 803

Sample reviewed and deemed relevant: 212We assessed this sample according to a gradient of complexity modeled after an approach

by Smith:1

High (included new empirical data): 46

Medium (referenced empirical data, strong analytical arguments): 136Low (commentary only): 30

Final sample of articles studied, low complexity literature excluded: 182

Hopkins et al

186 r 2010 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 31, 2, 185198

The Medical Tourism Industry

Medical travel is not new, but the global nature of the cross-bordermedical care industry is recent and has developed rapidly. Theindustry is facilitated by a growing number of internet-basedbrokerages, linking patients to facilities.2,3 Interactive websitesallow consumers to schedule services, contact their surgeons orother specialists, book airfare and accommodation, and arrangefor tourist excursions.2 Cost savings available in low- and middle-income countries is the primary focus of these sites.48 WhileAsian countries first embraced this new health-care industry (andoffered considerable cost advantages) many South Americancountries aggressively promote surgical, cosmetic, and reproductiveservices to (largely) English-speaking and presumably Americanconsumers.Medical tourism brokerages emphasize the quality of care,

frequently noting the western licensing and training of medicalfacilities, and their international accreditation by the Joint Commis-sion on Accreditation for Healthcare Organizations through itsaffiliate, Joint Commission International (JCI). JCI has accreditedmore than 123 medical facilities and organizations across Asia,Europe, the Middle East, the Caribbean, and South America. Mostof these facilities gained accreditation in late 2005 and 2006,reflecting the growing popularity of medical tourism.8 A number ofinternational medical facilities found partners in western medicalteaching facilities and hospitals with prestigious and familiar namesto signal quality to prospective consumers. Harvard MedicalInternational and the Mayo Clinic partnered with the DubaiHealthcare City; Wockhardt Group medical facility, one of the mostprominent chains of health-care facilities in India, affiliated withHarvard Medical International. Wockhardts main competitor inIndia, the Apollo group of hospitals, partnered with Johns HopkinsMedicine International.

Advantages for the North

According to the most widely accepted estimate, nearly 350 000patients from developed nations traveled to a variety of developingcountries for health care in 2003.9 A 2008 report by Deloitte Center

Medical tourism today

187r 2010 Macmillan Publishers Ltd. 0197-5897 Journal of Public Health Policy Vol. 31, 2, 185198

for Health Solutions, based on an online survey sample of 3000 inthe United States and internal analyses (the methods for whichare not described), forecasts the number of medical tourists torise from 750000 in 2007 to approximately 5.25 and 6.25 millionby 2010, and approximately 10.5 and 23.2 million by 2017.7

We use these estimates with caution for lack of an alternative noting that in other developed countries waiting times mayincrease the numbers.10 As one indicator of increasing cross-borderpatient flows, even from countries with publicly financed universalhealth care, the province of Ontario, Canada saw a 450 per centincrease from 2001 to 2008 in the number of patients reimbursed forout-of-country medical treatment.11 Even though much of this carelikely took place in the United States, the substantial increase signalsthe potential of new involvement of public health systems withforeign care facilities, including one that Indian hospital representa-tives recently sought to promote at a medical tourism conference inToronto, Canada in late 2009.Lower labor and living costs, the availability of inexpensive

pharmaceuticals, and the low cost or absence of malpracticeinsurance allow many developing countries to offer some proceduresat 10 per cent of the cost in the United States, inclusive of travel andaccommodation (see Figure 1). Similar price differences exist for

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

180,000

Heart valve replacementHeart bypassAngioplastyKnee replacementSpinal fusionHysterectomyHip replacement

United States India Thailand Singapore Malaysia

Figure 1: Comparative costs of selected medical services (US$).Sources: ESCAP,12 York;13 except angioplasty, hip replacement, and all Malaysia data, takenfrom Woodman.14 Costs are based on surgery and hospital only, excluding travel and

additional tourism costs.

Hopkins et al


other developed nations. A shoulder operation performed privatelyin the United Kingdom would cost 10 000, compared to only 1700in India, with only a little more than 1 week of waiting time fromthe initial contact.15 A recent cost analysis of surgical proceduresfor 15 non-acute health problems estimated annual savings ofUS$1.4 billion comparing United States public insurance for theelderly and disabled (Medicare) to developing country facilitycharges.6 If coronary artery bypass surgery were included, the costsavings would be more than $2 billion annually. A more inclusivelist of procedures for which north-based consumers are known totravel abroad would have produced a substantially higher estimateof savings.The private health insurance industry, notably in the United States,

is being encouraged to exploit the cost advantages of medicaltourism.7 Some economists argue that a combination of importingforeign trained health workers (something at which the UnitedStates already excels) and of exporting patients to developingcountries is the simplest and most cost-efficient solution to itshealth-care problems.16 Medical tourism brokerages operatingout of the United States (Planet Hospital and Med Retreat, asexamples) negotiate with insurance providers to develop policiesfor their client/patients, recognizing that the non-portability ofinsurance coverage poses one of the most significant barriers tothe growth of medical tourism.13 Both self-insured companies andlarge insurance firms find the low-cost provider networks offeredby the medical tourism industry attractive; they also encounteropposition. In 2007, a South Carolina company offered financialinducements to employees for accepting treatment in India, thenrescinded the offer after the union condemned the policy,pointing to lax overseas medical malpractice laws.2,17,18 A 2006attempt by West Virginia to adopt such a policy for its stateemployees similarly failed.4 At the same time, a European-owned supermarket chain in the United States successfully initiateda similar policy out of concern with the high costs of US-basedhealth care.19

Apart from cost motivations (for patients paying for themselves,or through private health insurers), medical travelers to developingcountry facilities sometimes pursue technologies and proceduresthat are not yet available or approved in their home countries.



Until 2006, the United States had not approved hip resurfacing,a less invasive alternative to hip replacement,20 although it wasavailable in Canada, Europe, and in some (much lower cost) Asiandestination countries. In India, the Wockhardt Group of hospitalsis the only one in the world to perform conscious off-pumpcoronary artery bypass, a heart surgery designed for individualswho are not good candidates for surgery using anesthesia.21 Medicaltravelers from the developed world also seek medical proceduresunavailable domestically owing to legal constraints, includingorgan transplantation from living donors motivated by poverty22,23

(Box 2) or assisted reproduction using legally restricted techno-logies or paid surrogates.24,25 Even though these practicesare ethically the most immediately problematic, they may notcomprise the largest or most troubling global health equityconcern.

Box 2: Transplantation tourism

Several countries specifically advertise transplantation tourism, notably Colombia,India, Pakistan, and the Philippines; China, Bolivia, Brazil, Iraq, Israel, Moldova, Peru,

South Africa, and Turkey are also significant exporters of commercially donated

organs.22,23 Most of the literature regarding transplantation tourism is negative. A smallminority of the organ trade involves the transfer of cadaver organs to individuals from the

north; the majority of transplantations occur between live, unrelated donors motivated

by financial incentives, often extreme poverty, and individuals from affluent countries,

with the ability to purchase.2628 Even though donors from the south may technicallyconsent to this transfer, the practice involving vulnerable populations has been deemed

implicitly and explicitly coercive.2931 Many organs transplanted in China come from

executed prisoners, raising questions of due process and informed consent in that

country.22 Although transplantation tourism and organ trafficking is illegal in the nationsnamed above, a number of these governments are alleged to be complicit by refusing to

enforce transplant bans.23 In Pakistan, where the transplant tourism industry is

unofficially sanctioned, more than 2000 kidney transplants are performed each year onforeign patients.32 Although some contend that a sellers decision to avoid extreme

poverty in a properly regulated and remunerated market should not be denied,33 the

health status for the majority of financially motivated donors worsens after the

procedure, costing them more in lost employment or out-of-pocket remedial care than the(usually) minimal donation they receive for offering their organ to a broker.32 Donors

may also be subject to extreme forms of social ostracism.34 Of all forms of medical

tourism, transplantation tourism raises the largest number of immediate ethical

questions.

Hopkins et al


Risks for the North

Many hospitals and clinics in developing countries offer high-qualitycare. The Indian Apollo chain claims a 99 per cent success rate withcardiac surgeries, comparable to any specialized facility in the UnitedStates,35 although the company did not reveal how it measured thisrate of success. Most medical facilities marketed to potentialpatients from the global north do not boast similar success rates;concerns persist about the quality of care in facilities in developingcountries.3,10,21,36 Our search failed to locate statistical data oncomplication rates, but anecdotal accounts of malpractice or medicalmisadventure are frequent in the literature,37,38 including novelinfections and post-operative complications. Some argue thesubsequent financial costs borne by the public health systems ofpatients home countries to be extensive.39

Lacking or lax enforcement of malpractice laws in developingcountries poses another risk. Little or no malpractice insurance costsallow developing country practitioners and facilities to maintain lowprices but leave medical tourists with few options if malpractice issuspected. In Singapore and Malaysia, courts overseeing malpracticesuits defer to the opinions of attending physicians, essentiallyrequiring a physician to confess to malpractice in order for anycompensatory damages to be awarded.8

Advantages for the South

From the destination country perspective, the most powerfulargument for burgeoning medical tourism derives from trickledown economics. The industry increases an inward flow offoreign currency; this supports growth in health, tourism, andinfrastructure industries, thereby improving aggregate economicdevelopment and sophisticated health-care facilities. Both eventuallybenefit the greater population.1,40 Estimated annual earnings forfour major Asian destinations, although not (yet) huge, aresubstantial (Table 1).A further benefit of medical tourism is a slow-down or reversal

of the migration of medical professionals to developed countries.The Apollo group in India claims to have attracted more than 123expatriate medical professionals to return by offering more



competitive salaries and the opportunity to live and work in theircountry of origin while still being able to practice advancedhealth care.2 This represents just 10 per cent of the number ofIndian-trained physicians entering US medical residencies eachyear,43 and scarcely makes a dent in the estimated need for800 000 more physicians in India over the next decade.44

Medical tourism has also allowed some developing countries withsmaller populations to sustain and subsidize advanced medical careand technology, as well as to maintain critical medical specialtieswith low domestic demand. Singapore, (a middle- to high-incomecountry) with a population of only 4.5 million would find many sub-specialties too expensive or difficult to sustain without attractingmedical tourists to ensure sufficient demand for such services.44

Underpinning the rise in medical tourism is the increased globalcommercialization of health care. A number of medical tourismdestinations, including India, Thailand, Indonesia, and Nepal, havelowered restrictions on foreign direct investment in recent years,hoping to encourage growth in the commercial health sector.2,45

Trade agreements may facilitate these investment flows, although atpresent few of the major medical tourism destination countries havemade liberalization commitments in trade treaties (Box 3).

Disadvantages for the South

Critics of the northsouth flow question the bases of the claimedbenefits, arguing (often with substantiating empirical evidence) that

Table 1: Estimated patients treated and money spent in selected countries

Country Patients treated Estimatedearnings (US$)

Major services provided

Thailand 900000 (2008) 850 million

(2008)

Cosmetic surgery, organ transplants, dental

treatment, joint replacements

India 450000 (2007) 480 million

(2005)

Cardiac surgery, joint replacements, eye

surgerySingapore 410000 (2006) 560 million

(2004)

Liver transplants, joint replacements, cardiac

surgery

Malaysia 350000 (2007) 43 million

(2005)

Cardiology, cardio-thoracic surgery, cosmetic

surgery

Sources: ESCAP;12 DiscoverMedicalTourism.com;41 Health-Tourism.com.42

Hopkins et al


the prime beneficiaries are limited to medical tourists and theenterprises that provide services. The global entrenchment of two-tiered health care following medical tourism poses the broader andlarger ethical health equity concern.Policies and regulations to ensure that revenues generated through

medical tourism be taxed sufficiently and reinvested back into publichealth care are absent or unenforced in most developing nations;48

benefits purported to occur from medical tourism have yet to berealized by the majority of the population of these countries. InThailand, the high-quality medical care available to medical touristsremains financially out of reach of the majority of the Thai

Box 3: Globalization, trade and the growth in medical tourism

Medical tourism is best understood as a manifestation of an increasingly privatized global

medical market arising in the wake of globalization and the diffusion of neoliberal

economic policies that expanded space for private health care market growth in much ofthe world.46 Meghani examines this trend with specific reference to those from the United

States who seek care in India, noting the influence of neoliberal economic policy in the

subsidies the Indian state provides to private hospitals, its explicit policy to expand

medical tourism for foreign currency earnings, and its treatment of such earnings asdeemed exports eligible for fiscal incentives.47 These national decisions are abetted by

commitments India has made under the multilateral General Agreement on Trade in

Services (GATS). This allows countries to make binding liberalization commitments in

four modes: (1) cross-border supply (telehealth or laboratory services), (2) consumptionabroad (medical tourism), (3) commercial presence (foreign investment in health

facilities) and (4) natural persons (temporary migration of health workers abroad).

Several countries have committed hospital services under mode (2) (consumptionabroad), meaning that they must treat foreign patients no differently than patients from

their own countries. Few countries developing medical tourism industries have done so,

probably because they do not need such commitments to grow their industry. Some

(such as India) are nonetheless requesting in GATS negotiations that developed countriescommit to extending their domestic health insurance coverage to services provided

abroad an issue of who pays that presently comprises the greatest single brake to

growth in the industry. Mode (3) (commercial presence) is the more important force in

entrenching medical tourism. Countries that liberalize health services in this modecommit to remaining open to foreign private investors (some 35 countries have fully or

partially done so). Foreign capital can be important in financing high-quality hospitals

catering to foreign (and wealthy domestic) patients. This has been the case with India,with international investment banks and other foreign firms based in Europe, the United

States, Canada, and Australia holding extensive shares in Indian hospitals or clinics

serving foreign patients (up to 100 per cent in some cases).47 But not all medical tourism

destination countries have found it necessary to make such trade treaty commitments inorder to grow their industry.



population.49 Thailand also provides evidence for another concern:that medical tourism will weaken public health care by incentivizingan internal brain drain of providers to private facilities offeringhigher salaries and better working conditions. Almost 6000 positionsfor medical practitioners in Thailands public system remainedunfilled in 2005, as an increasing number of physicians followed thehigher wages and more attractive settings available in private care.49

For countries such as Ghana, Pakistan, and South Africa, which loseapproximately half of their medical graduates every year to externalmigration, the addition of internal brain drain from public toprivate health care may be especially damaging.2

A further financial burden to the public is the cost of trainingmedical practitioners who choose to work in the medical tourismindustry. In India, medical professionals are trained in highlysubsidized public facilities.15 The annual value of these publictraining subsidies to the private sector where many physicianseventually work is estimated at more than $100 million,15 at leastsome of which accrues to the medical tourism industry.48 This divertspublic funds that might otherwise have gone into improving publichealth care for the poor to private care for more affluentindividuals. This is a particular concern in India, where publichealth expenditures are very low even by developing countrystandards, and where almost all growth in the sector is now drivenby private enterprise.45 Finally, medical tourism imposes a specificwestern biomedical model on developing nations that may under-mine culturally specific and traditional approaches to healing andwellness.49

Conclusion

On the basis of our consolidation of searchable-knowledge aboutmedical tourism, we found a lack of hard data on the magnitude ofmedical tourism, with anecdotes, brokerage claims, and theoreticalconjectures substituting for more deliberative study. This lack of dataapplies not only to patient flows, but to the scale of revenuesgenerated directly and indirectly, and to detailed accounts ofwho may benefit and who may lose from the likely (thoughnot definitively established) growth of this industry. Nationalhealth and economic statistics can assist in developing metrics of

Hopkins et al


public/private revenues, benefits, and aggregate welfare gains frommedical tourism, although detailed within-country studies would beneeded to ascertain the distributional impact of net health gains andlosses. Some measure of patient flows could be estimated from datacollected by medical tourism brokerages or destination countryhealth-care facilities, but such information may be consideredconfidential or the companies involved may be unwilling to releaseit. Surveys of patients obtaining cross-border care are other potentialsources of useful data, but this also requires the cooperation ofmedical tourism facilities.Obtaining a competent empirical grasp of the nature of this

industry will not be easy. Any new research on medical tourismshould also locate its questions and analyses within the broaderframe of global health sector reform, which for the past severaldecades has been characterized by decreasing public or not-for-profitcare provision and increasing private sector involvement. The weightof evidence suggests the latter is not well regulated, but is highlyinequitable in access and impact.50,51

The key question about medical tourism is whether the ability ofelites to benefit imposes costs on access for poorer groups. That thisquestion underpins many other aspects of health systems and policy,and indeed of contemporary globalization itself, does not make itany less important or urgent to address.

About the Authors

Laura Hopkins is an MPH student in the School of Public Health atthe University of Saskatchewan. She undertook the narrative reviewof medical tourism literature during her practicum with theGlobalization and Health Equity Research Unit at the University ofOttawa.

Ronald Labonte (PhD) is Professor in the Faculty of Medicine, andCanada Research Chair in Globalization and Health Equity in theInstitute of Population Health at the University of Ottawa. Hisresearch interests include globalization and health, health humanresources migration, comprehensive primary health care, globalhealth ethics, medical tourism, and social determinants of health.



Vivien Runnels is a PhD student in Population Health, and a researchassociate of the Globalization and Health Equity Research Unit inthe Institute of Population Health at the University of Ottawa.

Corinne Packer (PhD) is Senior Researcher in the Institute ofPopulation Health at the University of Ottawa, with principalinterests in health human resources migration, medical tourism, andhealth equity in general.

References

1. Smith, R.D. (2004) Foreign direct investment and trade in health services: A review of the

literature. Social Science & Medicine 59(11): 23132323.2. Cortez, N. (2008) Patients without borders: The emerging global market for patients and

the evolution of modern health care. Indiana Law Journal 83: 71132.3. Reed, C.M. (2008) Medical tourism. Medical Clinics of North America 92(6):

14331446.

4. Turner, L. (2007a) First world health care at third world prices: Globalization, bioethicsand medical tourism. Biosocieties 2: 303325.

5. Turner, L. (2007b) Medical tourism: Family medicine and international health-related

travel. Canadian Family Physician 53(10): 16391641.6. Burkett, L. (2007) Medical tourism. Concerns, benefits, and the American legal

perspective. Journal of Legal Medicine 28(2): 223245.7. Deloitte Center for Health Solutions. (2008) Medical tourism: Consumers in search of

value, http://www2.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/

us_chs_MedicalTourismStudy(1).pdf, accessed 9 December 2009.8. Forgione, D.A. and Smith, P.C. (2007) Medical tourism and its impact on the US health

care system. Journal of Health Care Finance 34(1): 2735.9. Horowitz, M.D., Rosensweig, J.A. and Jones, C.A. (2007) Medical Tourism: Globalization

of the healthcare marketplace. Medscape General Medicine (The Medscape Journal ofMedicine ) 9(4): 2430.

10. MacReady, N. (2007) Developing countries court medical tourists. The Lancet 369(9576):18491850.

11. The Canadian Press. (2009) Keeping health-care money home. Metro Weekend 2729November: 5 (Toronto Edition).

12. ESCAP. (2007) Medical Travel in Asia and the Pacific. Challenges and Opportunities.Bangkok: United Nations Economic and Social Commission for Asia and the Pacific.

13. York, D. (2008) Medical tourism: The trend towards outsourcing medical procedures to

foreign countries. The Journal of Continuing Education in the Health Professions 28(2):99102.

14. Woodman, J. (2008) Patients Beyond Borders: Everybodys Guide to Affordable, World-Class Medical Travel, 2nd edn. Chapel Hill, NC: Healthy Travel Media.

15. Sengupta, A. and Nundy, S. (2005) The private health sector in India. British MedicalJournal 331(7526): 11571158.

16. Bhagwati, J. and Madan, S. (2008) Comprehensive healthcare in US can be realised. (Letter

to the editor). FT.com, http://www.ft.com/cms/s/0/fc8a870a-d091-11dd-ae00-000077b07658.html?nclick_check=1, accessed 27 January 2010.

Hopkins et al


17. McLean, T.R. (2007) Commentary: The industrialization of medical tourism and the Blue

Ridge Paper claim. Journal of Controversial Medical Claims 14(1): 1819.18. Higgins, L.A. (2007) Medical tourism takes off, but not without debate. Managed Care

16(4): 4547.

19. Carroll, J. (2008) Aetna and Hannaford make a Singapore connection. Managed Care17(3): 4447.

20. Food and Drug Administration. (2008) Birmingham hip resurfacing system approval,http://www.accessdata.fda.gov/cdrh_docs/pdf4/p040033a.pdf, accessed 27 January 2010.

21. Dunn, P. (2007) Medical tourism takes flight. Hospitals and Health Networks 81(11):4044.

22. Shimazono, Y. (2007) The state of the international organ trade: A provisional picture

based on integration of available information. Bulletin of the World Health Organization85(12): 955962.

23. Turner, L. (2008) Medical tourism initiatives should exclude commercial organtransplantation. Journal of the Royal Society of Medicine 101(8): 391394.

24. Pennings, G. (2002) Reproductive tourism as moral pluralism in motion. Journal ofMedical Ethics 28(6): 337341.

25. Mulay, S. and Gibson, E. (2006) Marketing of assisted human reproduction and the IndianState. Development 49: 8493.

26. Khamash, H.A. and Gaston, R.S. (2008) Transplant tourism: A modern iteration of an

ancient problem. Current Opinion in Organ Transplantation 13(4): 395399.27. Budiani-Saberi, D.A. and Delmonico, F.L. (2008) Organ trafficking and transplant

tourism: A commentary on the global realities. American Journal of Transplantation 8(5):925929.

28. Epstein, M. (2009) Sociological and ethical issues in transplant commercialism. CurrentOpinion in Organ Transplantation 14(2): 134139.

29. Noorani, M.A. (2008) Commercial transplantation in Pakistan and its effects on Western

countries. British Medical Journal 336(7657): 1378.30. Cohen, L. (1999) Where it hurts: Indian materials for an ethics of organ transplantation.

Daedalus 128(4): 135165.31. Phadke, K.D. and Anandh, U. (2002) Ethics of paid organ donation. Pediatric Nephrology

17(5): 309311.32. Naqvi, S.A., Ali, B., Mazhar, F., Zafar, M.N. and Rizvi, S.A. (2007) A socioeconomic

survey of kidney vendors in Pakistan. Transplant International 20(11): 934939.33. Bakdash, T. and Scheper-Hughes, N. (2006) Is it ethical for patients with renal disease to

purchase kidneys from the worlds poor? PLoS Medicine 3(10): 16991702, (e349).34. Scheper-Hughes, N. (2002) The ends of the body Commodity fetishism and the global

traffic in organs. SAIS Review 22(1): 6180.35. Mattoo, A. and Rathindran, R. (2006) How health insurance inhibits trade in health care:

Eliminating the current bias in health plans against treatment abroad could lead tosignificant cost savings. Health Affairs 25(2): 358368.

36. Wapner, J. (2008) American Medical Association provides guidance on medical tourism.

British Medical Journal 337: a575.37. Newman, M.I., Camberos, A.E. and Ascherman, J. (2005) Mycobacteria abscessus

outbreak in US patients linked to offshore surgicenter. Annals of Plastic Surgery 55(1):107110.

38. Healy, C. (2009) Surgical tourism and the globalisation of healthcare. Irish Journal ofMedical Science 178(2): 125127.

39. Jeevan, R. and Armstrong, A. (2008) Cosmetic tourism and the burden on the NHS.

Journal of Plastic, Reconstructive & Aesthetic Surgery 61(12): 14231424.



40. Bookman, M.Z. and Bookman, K.R. (2007) Medical Tourism in Developing Countries.New York: Palgrave Macmillan.

41. Discover Medical Tourism. (2008) Medical tourism statistics, http://www.discovermedicaltourism.com/statistics/#, accessed 26 January 2010.

42. Health-Tourism.com. (2009) http://www.health-tourism.com/destinations, accessed 26

January 2010.

43. Mullan, F. (2006) Doctors for the world: Indian physician emigration. Health Affairs25(2): 380393.

44. Otley, T. (2007) Patients without borders. Business Traveller 11 November: 3637.45. Chanda, R. (2007) Foreign Investment in Hospitals in India: Status and Implications.

India: Ministry of Health and Family Welfare and WHO Country Office.

46. Labonte, R., Schrecker, T., Packer, C. and Runnels, V. (eds.) (2009) Globalization andHealth: Pathways, Evidence and Policy. New York: Routledge.

47. Meghani, Z. (forthcoming) A robust, particularist ethical assessment of medical tourism.Developing World Bioethics, in press.

48. Sen Gupta, A. (2008) Medical tourism in India: Winners and losers. Indian Journal ofMedical Ethics 5(1): 45.

49. Saniotis, A. (2007) Changing ethics in medical practice: AThai perspective. Indian Journalof Medical Ethics 4(1): 2425.

50. Gilson, L., Doherty, J., Loewenson, R. and Francis, V. (2007) Challenging Inequity

through Health Systems. Geneva: World Health Organization. Final Report of theKnowledge Network on Health Systems.

51. World Health Organization. (2008) Primary Health Care: Now More Than Ever. Geneva:

WHO. The World Health Report 2008.

Hopkins et al


Copyright of Journal of Public Health Policy is the property of Palgrave Macmillan Ltd. and its content may notbe copied or emailed to multiple sites or posted to a listserv without the copyright holder's express writtenpermission. However, users may print, download, or email articles for individual use.