Maturitas 73 (2012) 300 304

Contents lists available at SciVerse ScienceDirect

Maturitas

jo ur n al hom ep age : www.elsev ier .com/

Review

Why do patients engage in medical tourism?

Vivien Rua Globalizationb Health Techn

a r t i c l

Article history:Received 23 AAccepted 25 A

Keywords:Medical tourisUnmet needMedical decisiChoiceHealth inform

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3001.1. The global market for health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3011.2. Fullling the (unmet) need for health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301

2. On the decision for medical tourism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3012.1. Should I stay or should I go? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3022.2.

3. . . .(Ex3.1.

4. ConclContrCompProveAcknoRefere

1. Introdu

In ordetourism offa patients ucial for info

CorresponE-mail add

pm.carrera@ya

0378-5122/$ http://dx.doi.oShopping for medical care abroad. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302pensive) deal? Confronting quality issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302Vetting providers of services abroad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302

uding remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302ibutors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303eting interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303nance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303wledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303nces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303

ction

r to take advantage of the opportunities medicalers as well as address and contain attendant threats,nderstanding of medical tourism is necessary and cru-rming a decision. This paper aims at extending current

ding author. Tel.: +31 53 489 5657; fax: +31 53 489 2159.resses: p.m.carrera@utwente.nl,hoo.com (P.M. Carrera).

knowledge on the increasingly popular and complex form ofaccessing and providing medical care, that is, medical tourism bydistinguishing the focal content of the decisions that patients make.Based on the existing literature, the paper proposes a theoreti-cal sequence of decision-making to engage in medical tourism,which includes considerations of the required treatments, locationof treatment, and the quality and safety issues that are attendantto seeking care. Correspondingly, it indicates improved ways toaccess health information online and refers to the current regu-latory mechanisms which impact on medical tourism.

see front matter 2012 Elsevier Ireland Ltd. All rights reserved.rg/10.1016/j.maturitas.2012.08.011nnelsa, P.M. Carrerab,

and Health Equity Research Unit, Institute of Population Health, University of Ottawa, 1 Stewart Street, Ottawa, ON K1N 6N5, Canadaology and Services Research Department, School of Management and Governance, University of Twente, PO Box 217, 7500 AE Enschede, The Netherlands

e i n f o

ugust 2012ugust 2012

m

on-making

ation

a b s t r a c t

Medical tourism is commonly perceived and popularly depicted as an economic issue, both at the systemand individual levels. The decision to engage in medical tourism, however, is more complex, driven bypatients unmet need, the nature of services sought and the manner by which treatment is accessed. Inorder to benecially employ the opportunities medical tourism offers, and address and contain possiblethreats and harms, an informed decision is crucial. This paper aims to enhance the current knowledgeon medical tourism by isolating the focal content of the decisions that patients make. Based on theexisting literature, it proposes a sequential decision-making process in opting for or against medical careabroad, and engaging in medical tourism, including considerations of the required treatments, locationof treatment, and quality and safety issues attendant to seeking care. Accordingly, it comments on theimperative of access to health information and the current regulatory environment which impact on thisincreasingly popular and complex form of accessing and providing medical care.

2012 Elsevier Ireland Ltd. All rights reserved.locate /matur i tas

V. Runnels, P.M. Carrera / Maturitas 73 (2012) 300 304 301

Source: Adapte

1.1. The glo

Medicalas an econoa major drtures beingcompanies elsewhere tto vote witcal touristspatients preing economadvanced e[4,5].

Among medical carby the Unitto US$660 mUnited StatUS$2.3 billiwith exporrespectivelytion of movalone, whildo not drive

1.2. Fulllin

At the hspur that dviduals for simplistic nthe individuover and abity for persassessmentsurgeries incoronary arthe develop

As illustbeyond thoavailable anmay be for

equence of a typical decision-making process to engage in medical tourism.

tically (i.e. resulting from lack of/insufcient health insur-overage) or rationed according to urgency (in the case ofly funded elective treatment), to one that does not resolveh problem but may improve an individuals sense of well-Fig. 1. Hierarchy of Health Care Needs.d from [10].

bal market for health care

tourism is commonly perceived and popularly depictedmic issue, with high costs of domestic health care beingiver of individual demand, and with these expendi-

a major driver on the supply side for countries andwho feel they can offer signicant cost advantageso large numbers of potential patients who are willingh their feet [1,2]. As such, although ows of medi-

are multidirectional [3], the direction of movement ofdominantly present as out of OECD countries to emerg-ies such as India, Malaysia and Thailand as patients ofconomies hedge the cost of medical services at home

OECD countries, for example, the largest importer ofe is Germany with US$1.5 billion in imports followeded States and the Netherlands with imports amounting

illion and USD$618 million, respectively [6]. That thees is the largest exporter of health care, reporting someon in exports followed by the Czech Republic and Turkeyts amounting to US$418 million and US$409 million,

[6], meanwhile, is further illustration that the direc-ement is not one-way and that wide price differentialse instrumental in the calculus for seeking care abroad,

Fig. 2. S

domesance cpublica healt medical tourism [3,4].

g the (unmet) need for health care

eart of the growth in medical tourism providing therives continued growth , is the unmet need of indi-health care [1,3]. The need for health care is neitheror binary. Decisions to engage in medical tourism atal level, may include considerations for the individualove a decision to purchase a good, service or commod-onal consumption and enjoyment, such as making an

of consequences for ones health and life. For example,cluding total hip replacement, total knee replacement,tery bypass graft, etc. are regarded as high risk as withment of antibiotic resistance [79].rated in Fig. 1, the hierarchy of health care needs goesse which are medically indicated for which funding isd not restricted [1012]. Consequently, the unmet needa medically necessary treatment which is inaccessible

being [3,13care systemnon-health

2. On the d

Identicmaking prodecisions retreatment (ties availabin the decisis determinthe extent alized. To ilas a (fertilito the numof treatmenthen fullls]. These needs are to be primarily met by the health; preventive health services may well be addressed by

care action.

ecision for medical tourism

ation of need is the rst step in a sequential decision-cess toward engaging in medical tourism: subsequentlate to the type of treatment sought and the location ofsee Fig. 2). Information about need, treatment modali-le and options for treatment abroad are core elementsion to seek treatment at home or abroad. While needed by the individual, the health care system inuencesto which a hierarchy of needs for health care is actu-lustrate, even as in vitro fertilization (IVF) is approvedty) treatment within a health care system, restrictionsber of covered treatments or the high market pricingts can lead to an unmet need, which medical tourism

in non-domestic locations [14,15]. In this regard, while

302 V. Runnels, P.M. Carrera / Maturitas 73 (2012) 300 304

need is independent of economic considerations (i.e. need existsonly where there is an effective service to improve health) to theextent that health care as a commodity is consumed to attain health,economic circumstances lead to needs not being met [11,16].

2.1. Should

The deciwho not onlmaking [17identicatioconsult a hthrough anof-mouth [decision to

Consultitreatment wfessional wof treatmenaspects of thare broughsystems thminimal, coprovision w

The procthe provisiotion takes pwithin and/the domestoutcomes fsuch, medicbut of the h

2.2. Shoppi

That thefeature of mand the conand havinging power epitomizes centered hemedical toutreatment a

Europeaauthority reing from dinsured patfor out-of-cprior to thetourism offcare system

Importinages of healThe export to turn excecare, unfortresulting frhealth care,repeat purcrepeat purc

Obtaininmedical toupose seriouof procedurreviewing t

of quality with regard to decision-making in medical tourism issomewhat beyond the scope of this paper, the matter of quality ofinformation pertaining to medical tourism decision-making will bediscussed in the remaining part of the paper.

(Exp

make cle

ed exendse theationible urgerndatian Mns toe of tereandinial th

not nal ialityERNt estation

tting

lity and

InteInterbodi

in sessmg [36ses, h

optthanf 25

ited bces, a

caree sinitatioe loc.

s woare rmon

als, t (35)t notienccredxt be

clud

dical phe

env I stay or should I go?

sion-making model postulated here considers a patienty wishes to be informed but also is involved in decision-,18]. The rst decision point in the process is then of a treatment option which leads the patient toealth professional locally or abroad, either directly or

intermediary, medical concierge, broker or by word-1921]. Which option is selected inuences the nalseek medical care, domestically or otherwise [22,23].ng a local health professional may likely result in localhile consulting an intermediary or foreign health pro-

ill expand the individuals options regarding locationt. The latter make manifest the latent consumeriste patient-doctor interaction as nancial considerations

t up [24,25]. For patients who come from health careat are publicly funded or where the private sector isnsideration of the direct and indirect costs of serviceill be made alongside quality.ess of engaging in medical tourism does not end withn of health care abroad considering that full recupera-lace back at home even though initial recovery happensor outside the health facility abroad. This implies thatic health care system (primarily) deals with any adverseollowing any temporary exit of patients [2628]. Asal tourism is not just an issue of the individual patientealth care system as a whole.

ng for medical care abroad. . .

patient is sovereign throughout the process is a keyedical tourism. By gathering information on the needcomitant medical treatment that will satisfy as such,

control over decision making and exercising purchas-to access a range of treatments, the medical touristthe empowered patient touted as critical to a patient-alth care system [2426]. To be sure though, not allrists end up footing the bill or paying the full price ofbroad.n legislation holds that the national purchaser or healthimburses for the treatment of the patient abroad result-elays in treatment domestically [13,27]. In Canada,ients may receive reimbursement from the public purseountry care but are generally required to seek approval

delivery of treatment abroad [28]. Be as it may, medicalers relief for the individual patient and also for healths [3,26].g medical services can be a means of overcoming short-th resources and dealing with stretched health budgets.of medical care, in the meantime, offers the opportunityss capacity into productive use. The market for medicalunately, is far from the perfect, frictionless ideal [29,30]om the search, experience and credence attributes of

that is, features that can be evaluated by the senses, byhases and that cannot be perfectly evaluated even withhase, respectively [31].g from the decision-making process of engaging inrism, medical tourism is rife with issues of quality thats threats to the safety of the patient such that the typee and choice of provider need to be considered whenhe risk of care abroad [7,32]. Whereas surveying issues

3. . . .

To requirereportand frito guidinformof credafter sommeAmericSurgeooutsid

Whin defepotentshouldthat siglish quas DISCsupporinform

3.1. Ve

QuaknownCanadadards These Qualitycare astraininprocestend torather

As oaccredResourhealthincreasaccredtals arEurope

It iwhich count ahospitArabiaing thaan inpaever, athe ne

4. Con

Medrivenforeignensive) deal? Confronting quality issues

informed decisions on medical treatment, patientsar, appropriate information, and often rely on theperiences of third parties as well as advice from family

[13,22]. Increasingly, patients carry out online researchir decisions to consume health care. Unfortunately, the

highway, that is, the Internet, is no foolproof sourceinformation (p. 64 [19]). The promise of sun and seay may put in abeyance the medical professionals rec-on prompting medical professional groups such as theedical Association and the American Society of Plastic

issue guidelines for individuals considering treatmenthe U.S. [32,33].s the guidelines as well as regulations are unequivocalg the interests of their members or constituents, thereats to patients safety and welfare are serious andbe taken lightly [34]. Even if not perfect, mechanismsf not to ensure quality, exist to guide decisions. To estab-

health information online there are rating tools such [20,29]. Quality labels such as HONcode certicationablishing the reliability of information and quality of

on treatment choices online [20,35].

providers of services abroad

of hospital care can be compared through commonly regarded accreditation systems such as Accreditationrnational, the Australian Council on Healthcare Stan-national and the Joint Commission International (JCI).es are all recognized by the International Society forHealth Care (ISQua) which accredits external healthent organizations, their standards, and their surveyor]. Given the high costs associated with accreditationospitals that place value in international accreditation

for accreditation from one of the accreditation bodies multiple accreditations.

May 2012, a total of 370 international hospitals werey JCI, the international division of the Joint Commission

US-based afliate of the Joint Commission that certies facilities in the United States, reecting a double-digitce 2010, and indicating its standing in the market forn of hospitals [37]. Two-thirds of JCI-accredited hospi-ated in Asia while a little over one-fth are located in

rth noting that while Thailand, India and Singapore,egarded as destination countries for medical tourism,g the countries with the most number of JCI-accredited

heir numbers pale in comparison to Turkey (40), Saudi and United Arab Emirates (33) (see Fig. 3). Consider-t all dental and cosmetic surgeries are carried out ont basis for which accreditation is chiey designed, how-itation through the proper national agency would be

st source of guidance on quality of medical care.

ing remarks

tourism is more than an economic issue or a price-nomenon given the nature of services sought and theironment in which treatment is delivered [5,15,29]. That

V. Runnels, P.M. Carrera / Maturitas 73 (2012) 300 304 303

Source: [35].

patients sehealth is coas such, resiveness of unmet needing to EasteUS or West

Consideengaging ina concertedpolicy-makand welfare[34,28]. Direncouraginfor making than can brsystem thaton medical

Of coursachieving dof resourceseration of toffers, advageneral anddence on thand providi

Contributo

PMC conthe initial tributed to of the nal

Competing

The auth

Provenanc

Not com

Acknowled

A prelimUniversity, of the EuroSweden, 30

acknowledge feedback from the participants to the conference andthank Dr. Neil Lunt as well for discussions and collaboration of pre-vious work on medical tourism and comments on an earlier versionof this paper.

nces

t N, Caturitaith R,

liter1;103rera Pdical t6;6(4

pkins at is 0;31(nels Vrism1;8(1anizance 2iciesalendetheticagi Krism: ctive &

arasistancical, a602

Instiportra.ibm.cessedn S, Ge servdicineds B. atmenier ARers n1;23(orn Mility hropoyer A8;24:er RBnt decitney. Zeits8;102d BJ, ntierst N, Consumond

ding mgh J, CisionsusineFig. 3. Top 10 countries with JCI accredited hospitals.

ek access to care abroad says something about hownstrued and how domestic health care is regarded and,ects to a certain extent on the performance and respon-domestic health care systems [26,28]. This, is driven by(s) of medical tourists, be they Western Europeans y-rn Europe or Southeast Asia, or Asians traveling to theern Europe for treatment.ring that the sequential decision-making process of

medical tourism is strewn with concerns of quality, effort involving professionals, regulators as well asers should be undertaken in order to protect the safety

of individuals who avail of such a temporary exit optionecting patients toward sound health information andg them to be critical of information are important stepsinformed decisions. This requires developing a systeming medical tourism to account as well as an accounting

would support the development of an evidence basedtourism [2,27].e, where patient involvement is regarded as crucial inesired health outcomes and promoting the efcient use, medical tourism should be welcome [3,25]. In consid-he challenges and opportunities that medical tourismncing scholarship on the globalization of health care in

of medical tourism in particular, calls for empirical evi-is increasingly popular and complex form of accessingng medical care.

rs

tributed to the conceptualization of the paper, writingdrafts and approval of the nal submission. VR con-the review, completion of the nal draft and approvalsubmission.

Refere

[1] LunMa

[2] Smthe201

[3] Carme200

[4] Howh201

[5] Runtou201

[6] Orgglapol

[7] MeAes

[8] Miytoutru

[9] Kumreslog597

[10] IBMA 935[ac

[12] AllicarMe

[13] Hintre

[14] Spesum201

[15] InhfertAnt

[16] Cul199

[17] Debme

[18] Whing200

[19] FrieFro

[20] Lunof c

[21] Ormrea

[22] Sindecof B interest

ors declare no conict of interest.

e and peer review

missioned, externally peer reviewed.

gements

inary version of this paper developed at HeidelbergGermany was presented during the 20th Conferencepean Association for Research on Services, Goteborg,

September2 October 2010. The authors would like to

[23] Ye BH, Qnese me11257.

[24] Hibbard Jvation mand cons

[25] Tu HT, Memptor? org/cgi/re

[26] Bridges Jhougen KDiego, US

[27] Carrera Pfor a kno66984.

[28] Runnels out-of-coUnpublisrrera P. Medical tourism: assessing the evidence on treatment abroad.s 2010;66:2732.

Martnez lvarez M, Chanda R. Medical tourism: a review ofature and analysis of a role for bi-lateral trade. Health Policy(23):27682., Bridges JFP. Globalization and healthcare: understanding health andourism. Expert Review of Pharmacoeconomics & Outcomes Research):44754.L, Labont R, Runnels V, Packer C. Medical tourism today:

the state of existing knowledge? Journal of Public Health Policy2):18598., Turner L. Bioethics and transnational medical travel: India, medical

and the globalisation of healthcare. Indian Journal of Medical Ethics):424.tion for Economic Cooperation and Development. Health at a009: OECD indicators; 2009, http://www.oecd.org/health/healthnddata/44117530.pdfz MM, Alizadeh K. Complications from international surgery tourism.

Surgery Journal 2011;31:6947., Auberson D, Patel AJ, Malata CM. The unwritten price of cosmetican observational study and cost analysis. Journal of Plastic, Recons-

Aesthetic Surgery 2012;65(1):228.amy K, Toleman MA, Walsh TR, et al. Emergence of a new antibiotice mechanism in India, Pakistan, and the UK: a molecular, bio-nd epidemiological study. Lancet Infectious Diseases 2010;10(9):.tute for Business Value. Health Care 2015: Winwin or loselose?it and a path to successful transformation; 2006, http://www-com/services/us/gbs/bus/html/healtcare-2015-win-win.html

25.05.12].rignon M, Le Grand J. Subjective unmet need and utilization of healthices in Canada: what are the equity implications? Social Science and

2010;70(3):46572.Premier not alone in venturing south of the 49th parallel for medicalt. Canadian Medical Association Journal 2010;182:E2556.. Brokers, consumers and the Internet: how North American con-avigate their infertility journeys. Reproductive Biomedicine Online5):5929.C, Shrivastav P, Patrizio P. Assisted reproductive technologies andtourism: examples from global Dubai and the Ivy League. Medicallogy 2012;31(3):24965.J. Need is a consensus possible? Journal of Medical Ethics7780., Kraetschmer N, Irvine J. What role do patients wish to play in treat-ision making? Archives of Internal Medicine 1996;156:141420.

SN. Whose decision is it? The microstructure of medical decision mak-chrift fr Evidenz, Fortbildung und Qualitt im Gesundheitswesen:4235.Harris DM. Managing healthcare services in the global marketplace.

of Health Services Management 2007;24(2):318.arrera P. Advice for prospective medical tourists: systematic reviewer sites. Tourism Review 2011;66(1/2):5767.

M, Sothern M. You, too, can be an international medical traveler:edical travel guidebooks. Health & Place 2012;18(5):93541.

uttler L, Silvers JB. Toward understanding consumers role in medical for emerging treatments: issues, framework and hypothesis. Journalss Research 2004;57:105465.iu HZ, Yuen PP. Motivations and experiences of mainland Chi-dical tourists in Hong Kong. Tourism Management 2011;32(5):

H, Stockard J, Mahoney ER, Tusler M. Development of the patient acti-easure (PAM): conceptualizing and measuring activation in patientsumers. Health Services Research 2004;39(4):100526.ay JH. Self-pay markets in health care: consumer nirvana or caveatHealth Affairs 2007;26(2):w21726, http://content.healthaffairs.print/26/2/w217

, Loukanova S, Carrera P. Empowerment and health care. In: Heggen-, Quah S, editors. International encyclopedia of public health. SanA: Academic Press; 2008. p. 1728., Lunt N. A European perspective on medical tourism: the needwledge base. International Journal of Health Services 2010;40(3):

V, Packer C. Travelling for healthcare from Canada: an overview ofuntry care funded by provincial/territorial health insurance plans.hed paper.

304 V. Runnels, P.M. Carrera / Maturitas 73 (2012) 300 304

[29] Cortez N. Patients without borders: the emerging global market for patientsand the evolution of modern health care. Indiana Law Journal 2008;83(71):71132.

[30] Connell J. Contemporary medical tourism: conceptualisation, culture andcommodication. Tourism Management June 15, 2012. Available from:http://www.sciencedirect.com/science/article/pii/S0261517712000970[accessed 01.07.12].

[31] Hurley J. The normative economics of health and health care. In: Handbook ofhealth economics. North Holland: Amsterdam; 2000. pp. 55118.

[32] American Medical Association. New AMA guidelines on medical tourism.Chicago, IL: AMA; 2008. Available at: http://www.ama-assn.org/ama1/pub/upload/mm/31/medicaltourism.pdf [accessed 25.05.12].

[33] American Society of Plastic Surgeons. Cosmetic Surgery Tourism BriengPaper; 2010, http://www.plasticsurgery.org/News-and-Resources/Brieng-Papers/Cosmetic-Surgery-Tourism.html [accessed 25.05.12].

[34] Fitzgerald R. Medical regulation in the telemedicine era. Lancet2008;372(9652):17956.

[35] Legido-Quigley H, McKee M, Walshe K. How can quality of health care be safe-guarded across the European Union? British Medical Journal 2008;336:9203.

[36] International Society for Quality in Health Care. http://www.isqua.org/accreditations.htm [accessed 25.05.12].

[37] Joint Commission International. http://www.jointcommissioninternational.org/JCI-Accredited-Organizations/ [accessed 25.05.12].

Why do patients engage in medical tourism?1 Introduction1.1 The global market for health care1.2 Fulfilling the (unmet) need for health care

2 On the decision for medical tourism2.1 Should I stay or should I go?2.2 Shopping for medical care abroad

3 (Expensive) deal? Confronting quality issues3.1 Vetting providers of services abroad

4 Concluding remarksContributorsCompeting interestProvenance and peer reviewAcknowledgementsReferences