Medical tourism special insights with emphasis on the Gulf region by Prof. Tawfik A.M. Khoja

1. MBBS, DPHC, FRCGP, FFPH,FRCP
(UK)
Director General - GCC
International Medical Tourism Congress
Amman – Jordan, 12-13 Shaban 1436H / 30 – 31 May, 2015

2. 15/09/1436 Prof. Tawfik A. Khoja 2

3. The medical Tourism Industry
15/09/1436 Prof. Tawfik A. Khoja 3

4. Medical tourism is becoming
increasingly popular.
Medical tourism presents important
concerns and challenges as well as
potential opportunities.
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5. There is a compelling need for all
parties involved in healthcare to
become familiar with medical
tourism and to understand the
economic, social, political, and
medical forces that are driving
and shaping this phenomenon.
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6. The medical tourism
marketplace consists of a
growing number of
countries competing for
patients by offering a wide
variety of medical, surgical,
and dental services.
Medical Tourism Destinations
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7. Medical Tourism Destinations
Asia / Middle
East
The Americas Europe Africa Other
China Argentina Belgium South Africa Australia
India Brazil Czech Republic Tunisia Barbados
Jordan Canada Germany Cuba
Colombia Hungary Jamaica
Malaysia Costa Rica Hungary
Singapore Ecuador Latvia
South Korea Mexico Lithuania
Philippines United States Poland
Taiwan Portugal
Turkey Romania
United Arab
Emirates
Russia
spain
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8. Medical tourists are presently
traveling to faraway countries
for cosmetic surgery, dental
procedures, bariatric surgery,
assisted reproductive
technology, ophthalmologic
care, orthopaedic surgery,
cardiac surgery, organ and
cellular transplantation, gender
reassignment procedures, &
even executive health
evaluations.
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9. Several highly developed nations including
Belgium, Canada, Germany, and Italy are
attracting foreign patients under the banner of
medical tourism, offering sophisticated modern
care with careful attention to patient preference,
service, and satisfaction.
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For patients from countries where a
governmental healthcare system
controls access to services, the
major reason to choose offshore
medical care is to circumvent
delays associated with long waiting
lists.

10. National health programs do not typically pay for
cosmetic surgery and similar type services;
therefore, patients from Canada and the United
Kingdom desiring these procedures pursue
medical tourism for the same economic reasons
as those from the United States.
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Patients also travel to offshore
medical destinations to have
procedures that are not widely
available in their own
countries.

11. Some patients, particularly those
undergoing plastic surgery, sex
change procedures, and drug
rehabilitation, choose to go to medical
tourism destinations because they are
more confident that their privacy and
confidentiality will be protected in a
faraway setting.
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12. The insurance industry has
become an active participant in
medical tourism. In the USA, Blue
Cross Blue Shield sells insurance
policies that enable or encourage
patients to have expensive surgical
procedures at low-cost offshore
medical facilities.
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13. The informed patients shop outside the organized
medical system to find services that are
affordable, timely, or simply
available.
Physicians and
hospitals in medical
tourism destinations
recognize that they must
provide high-quality care
to develop a sustainable
competitive advantage in
the international marketplace.
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14. Medical tourism carries some risks that locally-
provided medical care does not.
Exposure to diseases without having built up
natural immunity can be a hazard for weakened
individuals, specifically with respect to
gastrointestinal diseases (e.g. Hepatitis A,
amoebic dysentery, paratyphoid) which could
weaken progress and expose the patient to
mosquito-transmitted diseases, influenza, and
tuberculosis.
Risks
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15. The quality of post-operative care can also
vary dramatically, depending on the hospital
and country, and may be different from US or
European standards. Also, traveling long
distances soon after surgery can increase the
risk of complications.
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Long flights and decreased mobility
associated with window seats can predispose
one towards developing deep vein thrombosis
and potentially a pulmonary embolism.

16. Also, health facilities treating medical
tourists may lack an adequate
complaints policy to deal
appropriately and fairly with
complaints made by dissatisfied
patients.
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17. Differences in healthcare provider
standards around the world have been
recognised by the World Health Organization,
and in 2004 it launched the World Alliance for
Patient Safety. This body assists hospitals and
government around the world in setting patient
safety policy and practices that can become
particularly relevant when providing medical
tourism services.
If there are complications, the patient may need to stay
in the foreign country for longer than planned or if they
have returned home, will not have easy access for follow
up care.
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18. Receiving medical care abroad may subject medical
tourists to unfamiliar legal issues.
The limited nature of litigation in various countries is
one reason for the lower cost of care overseas.
While some countries currently presenting themselves
as attractive medical tourism destinations provide some
form of legal remedies for medical malpractice, these
legal avenues may be unappealing to the medical
tourist.
Should problems arise, patients might not be covered by
adequate personal insurance or might be unable to seek
compensation via malpractice lawsuits.
Legal issues
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19. There can be major ethical issues around
medical tourism. For example, the illegal
purchase of organs and tissues for
transplantation had been methodically
documented and studied in countries such as
India, China, Colombia and the Philippines. The
Declaration of Istanbul distinguishes between
ethically problematic "transplant tourism" and
"travel for transplantation".
Ethical issues
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20. Medical tourism centered on new technologies,
such as stem cell treatments, is often
criticized on grounds of fraud, blatant lack of
scientific rationale and patient safety. However,
when pioneering advanced technologies, such
as providing 'unproven' therapies to patients
outside of regular clinical
trials, it is often challenging
to differentiate between
acceptable medical
innovation and
unacceptable patient
exploitation.
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21. Africa and the Middle East
Jordan
Jordan through their Private
Hospitals Association, managed
to attract 250,000 international
patients accompanied by more
than 500,000 companions in
2012, with a total revenues
exceeding 1B US$. Jordan won
the Medical Destination of the
year award in 2014 in the IMTJ
Medical Travel Awards.
Destinations
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22. Americas
Brazil
In Brazil, Albert Einstein Hospital in São Paulo
was the first JCI-accredited facility outside of
the US, and more than a dozen Brazilian medical
facilities have since been similarly accredited. B
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23. Canada
Canada has entered the
medical tourism field.
In comparison to US
health costs, medical
tourism patients can
save 30 to 60 percent on
health costs in Canada.
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24. Mexico
US doctors point out that the Mexican legal
system makes it almost impossible to sue
Mexican doctors for malpractice.
Some clinics may also offer alternative medicine
therapies that have been proven ineffective or
are banned in the United States.
The Mexican government has
shut down some of these
in recent times.
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25. United States
A McKinsey and Co. report from 2008 found that
between 60,000 to 85,000 medical tourists were
traveling to the United States for the purpose of
receiving in-patient medical care.
The same McKinsey study estimated that
750,000 American medical tourists traveled from
the United States to other
countries in 2007
(up from 500,000 in 2006).
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26. Hong Kong
All 12 of Hong Kong's private hospitals have
been surveyed and accredited by the UK's Trent
Accreditation Scheme since early 2001.
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27. India
Medical tourism is a growing sector in India.
India’s medical tourism sector is expected to
experience an annual growth rate of 30%,
making it a $2 billion industry by 2015.
An estimated 150,000 of these travel to India for
low-priced healthcare procedures every year.
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28. Singapore
Singapore has a dozen hospitals and
health centers with JCI accreditation.
In 1997 (published 2000), the World Health
Organization ranked Singapore's health
care system sixth best in the world and
the highest ranked system in Asia.
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29. Thailand
Thailand has 37 JCI-accredited hospitals.
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The Ministry of Public Health plays an important
role in developing healthcare to promote scientific
based education.
The Thai government has placed a more important
role in public health programs for its citizens.

30. France
British NHS patients have been offered
treatment in France to reduce waiting lists for
hip, knee and cataract surgery since 2002.
France is a popular tourist destination but also
ranked the world's leading health care system.
The French National Authority for Health (HAS)
issues high-level quality requirements for French
health care, with which clinics and hospitals must
comply in order to be accredited.
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31. Germany
Costs for medical treatment in
Germany are commonly 50% of those
in the USA.
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32. Price is not the only determining factor when it
comes to choosing a destination.
Networks, history and relationships may also
explain a great deal about the success of
particular destinations.
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The destinations of medical tourists are
typically based on geo-political factors.
Medical tourists from the Middle East typically
go to Germany and the UK due to existing ties,
while Hungary attracts medical tourists from
Western Europe owing to its proximity.

33. Dubai – UAE
Dubai is preparing to roll out medical tourism
packages covering procedures from spots
medicine to cosmetics surgery.
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Despite rapidly rising room rates across the
emirate, analytical believe the city’s health
offering will draw medical tourists from around
the world.

34. The Dubai Health Authority (DHA) will seek
applications which would hospitals in the
emirate to participate in medical tourism
packages recreational activities for
accompanying family members.
Medical tourism, which relies on affordable
quality treatment, is also dependent on ancillary
services such as hotels and recreational
infrastructure.
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35. While Dubai is becoming more expensive for hotel
guests, it is perceived as having an edge over other
medical tourism destinations such as Lebanon,
known as a cosmetic surgery hub. Bangkok or New
Delhi, in terms of security, shopping and leisure
activities.
“Dubai is counting on its brand and its additional
attractions plus the relatively shorter commuting
times from its core target markets”.
Dubai still appears competitive when compared
with more traditional medical tourism destinations
such as Switzerland, Germany and the UK.
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36. Still, the number of medical tourists to Dubai has
been rising despite the city becoming a more
expensive option.
In 2012, an estimated 107,500 medical tourists came
for treatment at Dubai’s 23 hospitals, five day
surgery facilities and 1,181 clinics.
The figure is growing at a compound annual growth
rate of 15 per cent, said DHA in February.
The top source markets include Russia, Qatar,
Kuwait, Saudi Arabia, the UK, India and Pakistan.
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37. Dubai is initially targeting wellness and
preventive care treatment, including
orthopaedic and sports medicine, plastic
surgery, ophthalmology, dental procedures and
full-body check-ups.
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“Dubai in general is attuned
to providing therapies in
beauty and often quick-fix
health issues such as gastric
banding and liposuction,

38. The making of a world-class healthcare
destination is complex.
We consider a variety of factors, including:
 Government and private sector investment in
healthcare infrastructure.
 Demonstrable commitment to international
accreditation, quality assurance, and
transparency of outcomes.
 International patient flow.
 Potential for cost savings on medical
procedures.
Why these destinations?
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39.  Political transparency and social stability.
 Excellent tourism infrastructure.
 Sustained reputation for clinical excellence.
 History of healthcare innovation and
achievement.
 Successful adoption of best practices and
state-of-the-art medical technology.
 Availability of internationally-trained,
experienced medical staff.
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40.  Cosmetic surgery
 Dentistry (general, restorative, cosmetic)
 Cardiovascular (angioplasty, CABG,
transplants)
 Orthopedics (joint and spine; sports
medicine)
 Cancer (often high-acuity or last resort)
 Reproductive (fertility, IVF, women's health)
 Weight loss (LAP-BAND, gastric bypass)
 Scans, tests, health screenings and second
opinions.
What are the top specialties for
medical travelers?
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41. Finding the answer to this question can be
challenging, as estimates and forecasts vary
widely among world's the top research firms.
Patients Beyond Borders' editors define a
medical traveler : as anyone who travels across
international borders for the purpose of
receiving medical care.
How big is the market?
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42. We believe the market size is USD 38.5 - 55
billion, based on approximately eleven million
cross-border patients worldwide spending an
average of USD 3,500-5,000 per visit, including
all medically-related costs, cross-border and
local transport, inpatient stay and
accommodations. We estimate some 1,200,000
Americans will travel outside the US for medical
care this year (2014).
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43. Yes…
The world population is aging and becoming more affluent at
rates that surpass the availability of quality healthcare
resources.
In addition, out-of-pocket medical costs of critical and
elective procedures continue to rise, while nations offering
universal care are faced with ever-increasing resource
burdens.
Patients are forcing to pursue cross-border healthcare
options either to save money or to avoid long waits for
treatment.
We estimate the worldwide medical tourism market is
growing at a rate of 15-25%, with rates highest in North,
Southeast and South Asia.
Is the market growing?
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44. Using US costs across a variety of specialties
and procedures as a benchmark, average range
of savings for the most-traveled destinations:
 Brazil: 20-30%
 Costa Rica: 45-65%
 India: 65-90%
 Malaysia: 65-80%
 Mexico: 40-65%
 Singapore: 25-40%
 South Korea: 30-45%
 Taiwan: 40-55%
 Thailand: 50-75%
 Turkey: 50-65%
How much can be saved?
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45. Countries & numbers of hospitals with Joint
Commission International accreditation in August 2013
Country
Number of accredited
hospitals
Bahrain 1
Jordan 9
Kuwait 2
Qatar 5
Kingdom of Saudi Arabia 42
United Arab Emirates 39
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46. Tourism is Kingdom of Saudi
Arabia's second largest source
of income after oil, generating
approximately US$ 13.8 billion
annually, and it is the third
largest source of employment.
Income from international
travel and tourism to Kingdom
of Saudi Arabia is predicted to
reach US$ 63.7 billion by 2019.
In Kingdom of Saudi Arabia,
religious tourism is the heart
and soul of all tourism.
Medical tourism in Kingdom of
Saudi Arabia
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47. Currently, Kingdom of Saudi Arabia is investing
intensively in its health system, most of the
financing coming from Government bodies,
which places a continuous strain on the
Government.
With 386 hospitals, 54 724 hospital beds and
55 000 physicians, a successful health care
infrastructure is well on its way to being fully
established.
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48. Most doctors in Saudi
hospitals have been trained in
western countries with well-
known, trustworthy training
systems, which may attract
patients from abroad.
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The recent trend of obtaining accreditation from the
Joint Commission International resulted in more than 40
accredited hospitals by August 2012. Although
accreditation is not designed to attract more patients
from abroad but rather to upgrade national health
facilities, this will develop more trust among foreign
patients choosing a hospital.

49. Surveys and research suggest that most foreign
patients coming to Kingdom of Saudi Arabia
have a spiritual life and regard their spiritual and
physical health as equally important.
Merging religious and medical
tourism
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With proper arrangements, patients (especially
those for elective surgery) could be offered
medical or surgical treatment packaged with
religious tourism, such as visits to holy places
for prayers or Umrah.

50. Moreover, All Muslims believe that ALLAH hears
their prayers and grants health in the holy
places, and they believe that spiritual activities
in the holy places boost their healing process.
Many old patients with terminal stage diseases
or geriatric problems would like to spend time in
the holy places during
treatment.
The spiritual
element is an essential
component of palliative
and end-of-life care.
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51. Underestimation of the country's potential
The authors consider that the main problem in
the emergence of Kingdom of Saudi Arabia as a
hub of medical tourism is that it is neglected by
the Government and the private sector, which
underestimate the importance of medical
tourism. Major medical tour operators are of the
opinion that Kingdom of Saudi Arabia has not
made a significant mark in the inbound medical
tourism business.
Barriers to medical tourism in
Kingdom of Saudi Arabia
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52. The authors suggest that the relevant authorities
should make a consolidated, joint effort to build a
long-term plan and infrastructure for medical
tourism.
Difficult documentation and visa processes
It is difficult to acquire a medical visa for a
number of reasons. A delay in acquiring a visa is
unfavourable in the case of medical ailments,
when one of the first priority of patients is early
diagnosis and treatment. This delay cannot be
reduced until the Government recognizes the
importance of medical tourism and makes special
arrangements and policies for this activity.
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53. Insufficient information
Although many milestones have been achieved
in the concept of E-health, special attention is
required for foreign patients intending to obtain
medical care in Kingdom of Saudi Arabia. This
includes clear-cut information from the medical
unit to which the patient wishes to go. Special
information portals should be dedicated solely
for this purpose, and a more efficient national
health information system should be set up,
from which the international community could
also benefit.
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54. Poor cooperation between medical tour
operators and medical units
Strong partnerships with medical tour operators
are of key importance, as these organizations
are not only specialized in travel services but
can also assist in related services before and
throughout a trip. Depending on the agreements
with medical units, they can take on most of the
burden of scheduling appointments, booking
hotels and providing assistance in getting a
medical visa.
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55. Inadequate marketing
As Kingdom of Saudi Arabia's neighbours are
emerging giants in medical tourism, Kingdom of
Saudi Arabia should undertake a well-planned,
continuous, worldwide publicity campaign
through sources such as the Internet, social
media and print and e-media.
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56. Identify specific areas for medical tourism
Although providing all types of medical services
is a fascinating target, focusing on a few areas
first and mastering them would be more
commercially practical in establishing a
position. For example, Thailand has focused on
gender defining and cosmetic surgery, China on
stem cell treatments, India on alternative
medicine, bone-marrow transplant, cardiac
bypass surgery and eye surgery. Kingdom of
Saudi Arabia must explore which field its
hospitals should focus on.
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57. Identify the target population
As mentioned earlier, certain populations are
attracted more to certain locations. This might
be due to a similar ethnic and racial
background: Taiwan attracts mainly Chinese
patients, Jordan mainly Arabs from the Middle
East and North Africa, and India and Pakistan
mainly South-East Asians. Kingdom of Saudi
Arabia has the edge, in that it can attract not
only patients from Gulf Cooperation Council,
Middle Eastern and North African countries but
also, if packaged with religious tourism and
wisely advertised, the entire Muslim world.
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58. Make policy and legal issues easy and
systematic
Legal regulations and laws related to medical
tourism, visa issuance, medical tour operators,
private sector involvement, health insurance,
medico-legal aspects of malpractice and related
issues should be revised and clear enough for
the convenience and safety of incoming
patients. The ministries of health, tourism and
information should initiate comprehensive,
multi-ministerial efforts.
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59. Kingdom of Saudi Arabia has good potential for
becoming a hub of medical tourism in the region. It
has most of the infrastructure and facilities with high
standards, many of which are already accredited
internationally. The unique position of the Kingdom
in religious and archaeological history and its
political stability give it advantages over competitors
in the field. Having learnt lessons from the
achievements of neighbouring countries, it is now
time that Kingdom of Saudi Arabia become
motivated and initiate a well-planned, long-term plan
for the medical tourism industry. The current era of
global economic turmoil is the right time to take
advantage of medical tourism and reduce the heavy
dependence of the country on oil.
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60. Today’s health challenges require a new
way of working based on :
- shared leadership;
- aligning root causes and
- strategy and measureable results.
It is believed that innovative
collaborations produce innovative
solutions for healthier communities.
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61. SUCCESS IS
COLLABORATION AMONG
COUNTREIS AND SHARING
Prof. Tawfik A. M. Khoja 61
LEADERSHIP & INNOVATION
IN MEDICAL TOURISM

62. Dr. Tawfik A. Khoja 62

63. Thank you for your
kind attention
‫ولكم‬ ‫لي‬ ‫سبحانه‬ ‫هللا‬ ً‫ا‬‫داعي‬
‫والرضوان‬ ‫والعافية‬ ‫الصحة‬ ‫بدوام‬