The Niger State government has resolved to stop outbound medical tourism outside the country and entered into a partnership with Primus Hospital based in Abuja for referral treatments. The state governor Israel A. Ebije has agreed to money being used to encourage Nigerians to rely on hospitals within the country and wants to encourage hospitals in the country to attain the status of those abroad- “Niger state government is interested in curbing the shameful traffic of Nigerians on medical tourism in foreign countries by directing attention to home based hospitals for referrals instead. Though Primus is owned by Indians, it’s a positive step towards encouraging home based hospitals grow. Already the partnership between Niger state government and Primus hospital is yielding results as over 400 referral cases have been seen. Successful knee and spine surgery and dialysis have been carried out. Niger state government and the hospital will jointly establish a diagnostic center with MRI and other modern technology by the end of the year. Land next to the hospital has been donated by the state as its contribution to the diagnostic Centre. It is expected to take patients from all 25 local government areas of Niger state and patients from nearby Nigerian states. Another country where there is a growing undercurrent against medical tourism is Zambia. While most of the population suffer a poor or non-existent local healthcare service, the same politicians who claim there is not enough money to improve healthcare, seem to find money from the public purse to pay for medical care in other countries. Recently, President Sata has flown to Israel, the UK and South Africa to get state paid private treatment. In his latest venture abroad President Michael Sata was booked into Assuta Medical Centre in Tel Aviv for major cancer treatment. Sata was very ill when he was evacuated and needed an air ambulance. The cover story that Sata was there for a political meeting with Israel politicians was not believed by the Zambian press. Conflicting information on the health and whereabouts of the president even led to his party claiming he was in the country when he was in a hospital bed in Israel. The Lusaka High Court refused the request for a judicial review proposed by civil rights activist Brebner Changala asking the court to constitute a medical board to examine the physical and mental status of President Michael Sata. When Kazimu Sata, the son of President Michael Sata, suffered injuries in a terrifying road accident recently, he was swiftly evacuated to South Africa for treatment by air ambulance. But his two friends, who were passengers in the vehicle and who also suffered serious injuries, were left behind to recuperate at the less glamorous Ndola Central Hospital. Most members of Zambia’s political elite travel abroad for their medical care – most often to South Africa, but in the case of President Sata, there have been many trips to both the United Kingdom and India. There is nothing wrong with seeking the best available care, and most Zambians have the common humanity to wish a speedy recovery to both Kazimu Sata as well as his father. But just as is happening in Nigeria, there is increasing local anger that so many wealthy people choose to travel abroad for their care instead of working to develop Zambia’s medical capacity hurts the national interest. At the University Teaching Hospital (UTH) in Lusaka recent problems over low wages and poor equipment, led to a nurses strike. Everybody admits that Zambian hospitals simply do not have the funding for specialist care, or often even good care. But those politicians can simply hop on a flight whenever they are not feeling well, often with all costs paid by the state- and doing little or nothing to improve Zambian health, is causing problems. Following suggestions from Nigeria, there is a slow groundswell suggesting that all elected politicians and their families should be obliged to receive their care in Zambian hospitals as that would see an immediate improvement to the training, equipment, funding, and innovation of healthcare facilities throughout the country. For an interim measure, Zambians want politicians to pay out of their own pocket for any overseas care.

Are Indonesians travelling as medical tourists to Malaysia helping the destination country at the expense of the Indonesian healthcare system? According to a new academic paper by Meghann Ormond, ’Solidarity by demand? Exit and voice in international medical travel’, just published in Social Science & Medicine, the volume of Indonesians traveling to Malaysia for healthcare does not help the struggling Indonesian healthcare system and has measurable micro and macro economic and social impact. It also suggests that medical tourism is not a benign commercial animal but is a form of political engagement that effects healthcare, economy and social attitudes in both home and destination countries. Following on the identification of medical tourism as a growth sector by the Malaysian government in 1998, over the last 15 years significant governmental and private sector investment has been channeled into the development of the industry. This development is unfolding within the broader context of social services being devolved to for-profit enterprises and market-capable segments of society becoming sites of intensive entrepreneurial investment by both the private sector and the state. The paper attempts to meaningfully assess medical travel’s real and potential economic and healthcare equity impacts in Malaysia with attention to the Malaysian government’s multiple roles as funder and provider of public-sector healthcare, regulator and pre-eminent investor in commercial healthcare. Notwithstanding their diverse engagements with the Malaysian government, medical travel industry and healthcare providers and users, the author acknowledges that both industry and healthcare equity perspectives are hamstrung by the scant empirical data currently publicly available for medical travel. Steps are proposed for overcoming these challenges in order to allow for improved identification, planning and development of resources appropriate to the needs, demands and interests of all those with a stake in medical travel. Globally, more patients are said to be intentionally travelling abroad as consumers for medical care. However, while scholars have begun to examine international medical travel’s impacts on the people and places that receive medical travellers, study of its impacts on medical travellers’ home contexts has been negligible and largely speculative. While proponents praise the potential to make home health systems more responsive to the needs of market-savvy healthcare consumers, critics identify it, as a way to further de-politicise the satisfaction of healthcare needs. This paper draws from work on political consumerism, health advocacy and social movements to argue for a reframing of medical tourism not as a one-off statement about or an event external to struggles over access, rights and recognition within medical travellers’ home health systems but rather as one of a range of critical forms of on-going engagement embedded within these struggles. To do this, the limited extant empirical work addressing domestic impacts of is reviewed and a case study of Indonesian medical travel to Malaysia is presented. The case study material draws from 85 interviews undertaken in 2007-08 and 2012 with Indonesian and Malaysian respondents involved as care recipients, formal and informal care-providers, intermediaries, promoters and policymakers. Evidence from the review and case study suggests that medical tourism may effect political and social change within medical travellers’ home contexts at micro and macro levels by altering the perspectives, habits, expectations and accountability of, and complicity among, medical travellers, their families, communities, formal and informal intermediaries, and medical providers both within and beyond the home country. Impacts are conditioned by the ideological foundations underpinning home political and social systems; the status of a medical traveller’s ailment or therapy; and the existence of organised support for recognition and management of these in the home context.

The Coeur d’Alene Resort and Northwest Specialty Hospital in Post Falls, North Idaho are teaming up to provide bundled pricing to Canadians and others who receive medical care at the hospital and whose family members are staying in Coeur d’Alene at the same time. Vaughn Ward for the hospital says, "The vision of Northwest Specialty Hospital is, and has been, to provide high-quality medical care at an affordable cost. Our launch into Canada represents an opportunity for us to extend those services beyond our own borders in a way that provides life-changing services to those desperately in need of them. The bundled pricing will be offered to anyone, but the focus is to tap into the Canadian market. Our neighbors to the North are heading south for medical care in increasing numbers due to long wait times for procedures. If you are suffering from obesity and your life is in jeopardy, you may not have time to wait six months. We are giving Canadians the ability to move to the proverbial front of the line to access our health care. We believe that anybody can compete with what we are offering." NWSH anticipates the highest demand for its services will come from Canadians looking for knee replacements. The total bundled price for a knee replacement, for example, including a five-night stay at The Resort would be $22,500, which is nearly $10,000 cheaper than advertised comparable bundled packages at some competitors in other tourist areas.

Medical tourism in Cyprus has the potential for further development and establishment as a sustainable lever for economic growth. This is the main finding of a small research report published in Health Management by Marios Georgiou of Karaiskakio Foundation, “Medical tourism in Cyprus: challenges and prospectives" which looks at the current state of medical tourism in Cyprus. It investigates what is happening plus associated problems and weaknesses. It suggests some solutions. The report is limited as it is a detailed study of the views and opinions of 23 people with local knowledge of the subject. The findings reveal a high degree of consensus (75%) in most of the questions answered by the experts. The promotion of medical tourism, the accreditation of medical facilities, the quality of the associated services, the generation of incentives and the active participation of the government through public-private ventures are among the proposals put forward for the development of medical tourism in Cyprus Proper analysis of the key aspects of medical tourism in Cyprus must entail the identification and assessment of many parameters that affect the organisation and prospects of the medical tourism product. Recent years have witnessed significant investments in the health industry. Beyond the public sector, a number of modern private hospitals and clinics as well as specialised medical centres and clinical laboratories have been established. The potential of Cyprus to establish itself as an important destination of medical tourism depends, in equal measure, on both the existing health infrastructure of the country as well as any economic and other advantages (in relation to its competitors) that it can offer. On the question on why should Cyprus be interested in developing medical tourism, the findings of the study highlight a number of primarily economic motivations. These include: • Increase of revenues of medical facilities and associated incomes of physicians and medical/paramedical staff.• Increase in the number of tourist accommodation units.• More effective and efficient utilisation of existing health infrastructure.• Improvement of provided health services.• Increase of state revenues. Among the principal advantages associated with the development of medical tourism in Cyprus are: • The extensive use of the English language. • The geographical position of Cyprus and the desirable climatic conditions.• The competence and experience of doctors as well as medical and paramedical personnel. On the other hand the main disadvantages include:• The absence of an organised public health system.• The shortage of accredited medical centres.• The absence of a strategic plan.• Limited levels of cooperation between the stakeholders.• The lack of an appropriate assessment study (by both the public and the private sectors) on the significance and development prospects of medical tourism in Cyprus. Government bodies (Cyprus Tourism Organisation, Ministry of Health, Ministry of Commerce,) should play a pivotal role since medical tourism is not an issue for private initiatives alone but depends critically on the active participation, collaboration and general endeavours of the public sector and associated services. But they have all significantly failed to do this. It was suggested that these government bodies should provide incentives to interested entrepreneurs and strive to promote Cyprus through a targeted advertisement campaign as an attractive destination for medical tourists with state-of-the-art infrastructure that offers high calibre medical services. Procedures for the issuance of licences should be made easier, planning and organisation issues should be made more flexible and there should be coordination between the various government bodies and with the private sector. The private sector has an important role to play in increasing investment in medical tourism, promoting Cyprus as an important destination, and drafting of agreements with foreign organisations to attract medical travellers. The private sector should target a significant improvement in the quality of services, upgrade the existing infrastructure, and develop attractive packages at affordable prices, by taking advantage of what Cyprus has to offer. Cyprus should target medical tourists who reside in countries with long waiting lists, countries in which the associated medical fees are higher than in Cyprus and, countries that have easy access to the island through direct short flights. These are mainly developed Western European countries since Cyprus has established itself as a well-known destination for their citizens. Cyprus could prove an attractive destination for medical tourists from many countries of the Middle East due to their proximity to Cyprus and because the quality of the provided medical services in many of these countries is not particularly high. Key to success is international accreditation of private medical facilities because it will contribute to the upgrading of the quality of the provided medical services. Accredited hospitals and clinics will naturally gain the trust and attract the interest of health insurance providers plus organised groups and individual health travellers. Quality assurance through accreditation is an element that will undoubtedly facilitate the promotion of Cyprus as a safe destination for health tourists, and will encourage the various insurance funds and private insurance companies to establish agreements with private healthcare facilities. The study highlights the importance and significant role of medical travel agents in the creation of attractive packages offering security and promoting targeted specialised services. A successful implementation plan should include: • Advertisement and promotion of the medical tourism product in Cyprus.• Accreditation of healthcare facilities.• Quality of services with targeted endorsement and sustained upgrading of the services in the health and tourism industries. The results of the current study represent an initial approach with the objective of establishing Cyprus as a modern and quality destination able to command a share of the ever-increasing market of medical tourism. It is urgent to have a medium- to long-term strategic plan for the development of medical tourism in Cyprus. To do this there needs to be active participation of the government through private-public ventures. Cyprus, due to its significant comparative advantages, can increase its market share and be established as a modern and quality destination of medical tourism in the area through coordinated and targeted activities that should be implemented under the umbrella of a strategic plan. Effectively the report repeats various reports and initiatives over the last five years that mostly faded to nothing. A key problem that the report did not answer is the country is bankrupt after the banking crisis that is still having a major impact on the local economy and financial sector. With neither government nor private companies have money to promote or invest, where is the money coming from?

New Zealand has limited medical facilities so it is common for locals to go to Australia for some treatment. A new health insurance from a local insurer acknowledges this by covering treatment in both countries with limited treatment elsewhere. Another tweak is that the insurer will effectively pay its customers’ health insurance if they choose not to claim and instead opt to use the public system. The country’s biggest life insurer, Sovereign, has revamped its health insurance range. Private Health Cover and Private Health Plus, give customers fast access to private treatments such as diagnostic scans and surgical treatment, avoiding lengthy waiting times in the public health system. If a policyholder opts to use the public system for a treatment that would have been covered by the policy, the following year’s premium will be free, as long as the treatment required a stay in hospital of two nights or more. The new policies also allow for higher excesses of up to $4000, in response to calls from older policyholders who are struggling to pay rising health-insurance premiums as the cost of treatment continues to race up faster than inflation. The two new policies also allow people to seek treatment in Australia. They can also go anywhere else in the world in the rare case that the wait for private treatment in New Zealand is longer than six months. Sovereign will also pay $30,000 a year towards treatment overseas if the same treatment is not available in New Zealand. There is a $300,000 a year limit for surgical treatment, and the same limit for cancer treatment.

A study by the Tourism Observatory of Baja California says the state could attract hundreds of thousands of visitors from California whose purpose of travel is related to health. But most of these are not medical tourists or even health tourists; they are just buying cheap legal drugs. The state of Baja California sees health related tourism as a boom area for economic development that is strongly backed by the State Government as it foresees huge demand for medical services by Americans. Within the state are a number of private hospitals and clinics including SIMNSA Hospital in Tijuana, Excel Medical Center, Hospital Angeles Tijuana, Codet Vision Institute, Vita Spa Tijuana, Protegencell, Cosmed and Hospital and Medical Center Prado. In Playas de Rosarito are Serena Senior Care and Hospital Almater Mexicali, Family Hospital, the Hospital Hispano Americano and Women’s Hospital. According to the Tourism Observatory study "Characterization of international visitors in the border cities of Baja California: Mexicali and Tijuana" done in winter 2012 and 2013 by the Tourism Observatory Baja California state attracted a flow of 840, 000 visitors from California whose purpose of travel was related to health. This is a massive number for the 13 hospitals and clinics it lists in the region. The figures are a grossing up of numbers from a relatively small sample of actual visitors. The size of the sample is not known. Ethnicity percentages were 37 % Anglo, 52 % Hispanic and 10 % other. Almost all these are adults and most of them are older adults. Only 7 % are under 25, 36% were between 45 and 64 years and only 9% are over 65. 19 % of those visitors has less than $ 20,000 annual income, 31 % have an income of between 20 and 40 thousand dollars, which is the average income in the United States. The state has created the Tourism and Health Tourism Board of Health. Most members are based in Tijuana, Mexicali or Los Algodones and include hospitals, clinics and laboratories. Oscar Escobedo Carignan, tourism secretary for Baja California says, "We have a database of laboratories, hospitals, clinics, and doctors. This is being developed so we will be able to target customers and they will be able find a specialist. 2014 will see 500,000 health tourists that generate 230 to 350 million dollars." In the Tourism Observatory Baja California study the estimate for 2012 and 2013 combined was 840,000 health visitors who spent at least one night in the main destination. There is a danger that some people will convert the 840,000 for two years - or the estimate of 500,000 for 2014 into figures for medical tourists. But, the study points out that the vast majority of that number do not get any medical or dental care, but simply travel to Mexico to buy legal drugs at prices far below those in California. The study that is exact on age and ethnicity, is very fuzzy on figures and reluctant to state how many of that 840,000 are just buying drugs.

A University of Leeds led study on cosmetic surgery tourism ’Exploring the Cosmetic Surgery Tourism Industry’ offers many insights into the business but also warns that better regulation is vital to protect patients. Surgeons and clinics should be accredited and inspected. The regulation must be transnational not national, and patients find legal redress difficult to access if surgery goes wrong. Key findings-• Patients are ordinary people on modest incomes.• They tend to spend as little time away from home and family as is possible/ recommended by their surgeon because want to get home to families/ friends.• Cosmetic surgery pathways often follow cheap flights.• Clinics are often located at tourist resorts.• Different patients have surgery for different reasons.• Nobody wants to look like a particular celebrity or achieve a perfect body.• Patients do not make snap decisions• Most patients considered surgery for 5 to 10 years before they decided to have it. Once they made the decision they want surgery as quickly as possible to minimise the time spent dwelling on risks.• Patients lack knowledge of the places they travel to.• Patients are mostly not well travelled and have poor foreign language skills. Most have never visited their destination country prior to surgery.• Patients experience positive outcomes.• 97% are happy with the outcomes of their surgery and would recommend their surgeon to a friend.• Cosmetic surgery tourism agents play a key role in patient experience of place and surgery and in managing patient expectations.• As well as surgeons based in the destination country, many travel to treat patients. • 17% experienced complications. 9% received further treatment in the NHS or Medicare upon returning home. • Private surgeons in home countries are characterised as aloof, inattentive, uncaring and as seeing patients as walking cheque books. The research charts the experiences of British, Chinese and Australian patients travelling abroad for cosmetic surgery. UK and Australian patients travelled for breast augmentation and uplift, tummy tucks, rhinoplasty and liposuction. Chinese patients travelling to South Korea access more expensive but high quality cosmetic surgery unavailable back home. UK patients in Spain are most usually already living in Southern Spain or Gibraltar so are not actually medical tourists. Everywhere the sample includes medical tourists, expatriates, local cross-border travellers and migrants returning home for treatment. For UK and Australian patients, cost is the biggest factor influencing decisions to travel abroad. Surgical quality, technique and technology (not cost) are the primary drivers for Chinese patients travelling to South Korea. UK and Chinese patients stay in their destinations for the shortest time possible to minimise costs (5-7 days average). Australian patients are more likely to combine surgery with a holiday and to stay longer in their destination country (10-15 days average). All patients put the quality of the surgeon as their primary reason for choosing a specific destination. The reputation of surgeons was judged mostly by personal recommendation, although Australian patients are more likely to consider surgical qualifications. The clinic and destination country is of secondary importance. Cosmetic surgery tourism agents are typically women and are often former patients. Agencies are largely unregulated and rarely consist of more than a single-person business. Most are working class with limited education and had often been beauticians or administrators. They have between one and thirty clients per month. Some require a fee from the patients; others take commission from hospitals and travel agencies. Better regulation is vital to protect patients. Surgeons and clinics should be accredited and inspected. The quality assurance of medical devices needs to be tightened. This regulation must be transnational not national. It is almost impossible to successfully sue across national borders. Patients should be very wary of clinics and surgeons that offer lifetime guarantees and other guarantees as many clinics close after a few years. Many clinics have no medical malpractice insurance cover, and refer claims to the surgeon who is often also uninsured. The report suggests patients should check if surgeons have professional liability insurance- but this is not practical as a condition precedent of such policies is that surgeons must not reveal their existence so if they reveal that detail it automatically invalidates the cover. Should anything go wrong during surgery, big hospitals often have better facilities than small clinics. Large hospitals have emergency departments and crash teams. In the event of cardiac arrest in a small clinic surgeons may have to call an ambulance and transfer the patient. Patients don’t always follow medical advice. Some patients drink alcohol soon after their surgery. Others fail to rest sufficiently. Some fail to take their prescribed medicine and some remove bandages or medical support garments too early. Language barriers and lack of geographical knowledge can make communication difficult. Patients sometimes travel to destinations that are not at all what they expected. They can be shocked by the poverty in their destination, get caught up political protests or even wars, or cause offence by failing to observe important religious or cultural customs. On a more local level many patients do not like the food in destination countries. Public hospitals back home are not equipped to deal with aftercare and although most complications are minor, healthcare systems are ill equipped to deal with them. Cosmetic surgery tourism is less risky than most people think but is never without risk.

The tiny Central American state of Belize is the only one that has English as the official language, and a population smaller than many British towns, but it now has a medical tourism association. The Belize Medical Tourism Association is open to healthcare and tourism professionals and institutions committed to providing specialized quality services to international medical travellers, while enjoying a unique tourism experience in Belize Within the next five years the BMTA seeks to be the official, self-sustainable, and inclusive association driven by Belizean stakeholders, made up of internationally accredited entities. Within ten years it seeks to position Belize as a leading regional destination for medical tourism. The reality is that the country has a population of 340,000 and depends heavily on the million tourists it gets, 60% of which are American. Once known as the British Honduras, it is on the North Eastern coast of Central America. Belize is bordered on the north by Mexico, to the south and west by Guatemala, and to the east by the Caribbean Sea. Its mainland is about 290 km long and 110 km wide. Belize has a diverse society, with many cultures and languages. Originally part of the British Empire, it became an independent Commonwealth realm in 1981, retaining Queen Elizabeth II as head of state. Most available medical procedures are cheaper in Belize than in the USA, but many locals head north into Mexico for treatment, where costs are lower, facilities are better and more procedures are available. Facilities, equipment and doctors in Belize are in extremely short supply, so the range of available treatments is limited at best. No local hospitals have international accreditation. Belizean doctors generally come from abroad, some as volunteers to help the locals, and the vast majority work in publicly funded clinics or hospitals with very little time and resources for special care. However there are a few doctors and dentists that run their own private practices, with some even advertising to foreigners. At present it gets a few American medical tourists a year, mostly for dental work, To expand medical tourism it will need outside investors to partner the few local private hospitals by expanding, updating and improving facilities. The limited state system will not get involved in medical tourism. Belize has a problem with violent crime, much of it drug-related, and the trafficking of narcotics to the US. Belize is on a US blacklist of countries considered to be major producers or transit routes for illegal drugs. The government sees the only way of making medical tourism work is to encourage overseas investors to set up in the country, preferably as partners to locals. But talks so far have failed as the investors want to have total control, and to fly in US doctors as need, which many local medical professionals oppose.