Medical Tourism in India: Growth or Dilemma

Abstract

This study highlights the major trust areas, where the medical tourists are considering India as the country of choice. This study revolves around highlighting the reasons for which medical tourists recognize India as the perfect destination. The study investigates the framework of Medical Tourism in India, as the platform for medical tourists who seek low cost treatments with less waiting time. The study also revolves around identifying the core competencies of Indian Medical Tourism market, which makes it as the strategic thrust for the future growth drivers of the healthcare industry. The study is based upon the data collected through primary research, as well as secondary research from hospitals website, India's Ministry of Health website and from the website of National Association of Health Tourism.

Headnote

Abstract. This study highlights the major trust areas, where the medical tourists are considering India as the country of choice. This study revolves around highlighting the reasons for which medical tourists recognize India as the perfect destination. The study investigates the framework of Medical Tourism in India, as the platform for medical tourists who seek low cost treatments with less waiting time. The study also revolves around identifying the core competencies of Indian Medical Tourism market, which makes it as the strategic thrust for the future growth drivers of the healthcare industry. The study is based upon the data collected through primary research, as well as secondary research from hospitals website, India's Ministry of Health website and from the website of National Association of Health Tourism.

Keywords: medical tourism, medical visa, medical tourists, foreign patients, health tourism.

Introduction

Technology has made trans-border medical treatment a reality. Today, outsourcing of activities such as diagnostics services, clinical research, medical transcription, lab testing, licensing, clinical trials, drug trials and telemedicine to countries like India, China, Korea, Japan has become easier with knowledge process outsourcing businesses. This process has uplifted these nations and makes them part of the global village in the knowledge economy, The competition for opportunities is not limited to local or regional but is a global phenomenon. Health & Medical tourism is perceived to be one of the fastest growing segments in marketing 'Destination Incredible India' today. The Indian healthcare market is Rs 15 billion and growing at over 30% every year; the size of the medical tourism industry stands at Rs 12-15 billion (Express Healthcare Newspaper). While this area has so far been relatively unexplored, we now find that not only the ministry of tourism and the Government of India, but also various state tourism boards are all promoting health and medical tourism as a segment with tremendous potential for future growth.

This accelerating growth in the medical tourism industry has occurred because healthcare costs in developing Asian countries are a fraction of similar service costs in the United States or the United Kingdom, even though the quality of doctors and medical equipment is comparable to the best in the world. An economic incentive, which exists for residents of Western countries to travel outside their countries to seek elective, as well as non-elective medical services, is the major reason for this booming growth. A CII-McKinsey study on healthcare states that medical tourism alone can contribute Rs 50-100 billion additional revenue for up market tertiary hospitals by 2012, and will account for 3-5% of the total healthcare delivery market.

Emergence of medical tourism in Asia

Medical tourism (MT) refers to movement of consumer (patients) to a country providing the services for diagnosis & treatment. During the past few years, the number of people going out of their home country to consume health services has significantly increased. Today, developing nations in Asia including Singapore, Thailand, Malaysia, India offer all medical services which were once available only in Europe and the US. This offers a tremendous potential for developing countries because of their low cost advantage. The advantages that feature India as a potential earner from medical tourism include improvement in the export earning and healthcare infrastructure. No doubt that many countries like Malaysia, Singapore, South Africa, Cuba, Jordan and Lithuania along with India are fighting for a share of the MT market.

In order to realize the full potential of the industry, it is imperative for these countries to develop a strategic plan for coordinating various industry players, medical practitioners, private hospitals, policy makers, hotels, patient transportation services, and tour operators. In this, funding devoted to improving service quality as well as using more rigorous medical and para professional trainings, purchasing most modern equipment and upgrading infrastructure standards have resulted in greatly improved healthcare metrics. Many hospitals who embarked on ambitious improvement projects have now earned accreditation from international agencies, such as the Joint Commission International (2011).

According to GATS (General Agreement on Trade and Services), medical tourism is the second mode of trade in health services. Customers (patients) leave their home country to obtain health care services with high quality and affordable prices. Medical tourism occurs when international patients travel across boundaries for their healthcare and medical needs. It can be defined as provision of cost effective private medical care in collaboration with the tourism industry for patients needing surgical and other forms of specialized treatment.

The four main countries involved in this trade are India, Singapore, Thailand and Malaysia. Most of the medical tourists come from within Asia (Newman, 2006). MT can contribute Rs 50-100 billion additional revenue for up-market tertiary hospitals in 10 years and will account for 3-5% of the total healthcare delivery market, says the Confederation of Indian Industry (CII) (McKinsey, 2002). There is little data available on the actual number of people travelling to use medical services across South-East Asia. According to the tourism authority of Thailand, 600,000 foreigners sought treatment in Thailand and generated 20 billion Thai baht in revenues ($0.5 billion) in 2004. According to the Singapore Tourism Board overseas visitors surveys, approximately 150,000 foreign patients sought healthcare in Singapore in 2000, spending about 345 million Singapore dollars ($220 million). In Malaysia, the industry was estimated to be worth RM 60 million ($16 million) with over 100,000 medical tourists (Whittaker, 2008).

Reasons for the increase of the medical tourism in Asian countries

National Health Services (NHS) in UK is identifying one of the reasons for the boon during their pilot project. The situation of medical treatment in European countries was so dismal that in 2002, the NHS started a pilot scheme for 'overseas treatment' to see if surgery services abroad could be bought to shorten the waiting lists. The project focused mainly on facilities available in the European Union. Meanwhile, many British patients take the initiative to seek their own treatment abroad without waiting for the NHS to sort out its problems. Healthcare insurers in the developed countries are aware of the fact that the option of medical treatment in countries like India could help them reduce premiums and offer options to people who are currently uninsured. Over the next few years, insurance firms are expected to provide a fillip to the medical tourism business in India.

Medical tourism in India

The MT sector in India is expected to experience an annual growth rate of 30%, which makes $2 billion industry by 2015. As medical treatment costs of the developed world - and the US is leading the way - more and more people from the West find the prospect of international travel for medical care are increasingly appealing. US corporations and insurance providers have moved to provide extra incentives for their employees or customers to go abroad for medical care, in an effort to arrest spiraling US health care costs. These incentives include waiving deductibles and copayments when covered employees use medical tourism.

Indian hospitals have also realized the potential of this niche market and have begun to tailor their services for foreign visitors. Visitors, especially from the West and the Middle-East, find Indian hospitals as an affordable and a viable option rather than grappling with health insurance and national medical systems in their native lands. It is estimated that 150,000 people travel to India for low-cost health care procedures annually.

In India government's commitment to provide comprehensive healthcare, irrespective of their paying capacity, as part of its welfare policies, was given up after 30 years of independence when the Sixth Plan opened up medical care to the voluntary and private sectors. The rapid growth of the private sector over the 1980s, and the emergence of a corporate health sector in the 1990s was a part of conscious policy that chose to promote these segments. This was done through shifting subsidies in terms of cheap land, concessions for equipment and drug import, placing these institutions on government panels and making them a part of government insurance schemes in addition to providing trained personnel and expert physicians through state-supported medical education (Baru, 2000). The Eighth and Ninth Five-Year Plans emphasized primary healthcare for the underprivileged and the importance of involving the private, corporate and voluntary sectors in provisioning of medical care. The Ninth Plan also talked of alternative financing, thereby bringing in the policy of opening up healthcare to private insurance (Government of India 1992, 1997). Thus, the business interests of those other than professional providers of care found a place in the articulation of the plan as well as health policy (Government of India, 2002). The introduction of user fee in the public sector further undermined the principle of equity. The poor were "targeted for services" in family planning and primary level care (Government of India, 1997). The more complicated and expensive technologies were restricted to tertiary level institutions, and thereby became less accessible to the poor and lower middle classes. The national and international pressures for privatization, however, were too strong to pay attention to these aberrations.

The acceptance of the new economic policy and within it, of the health sector reforms by 1992 legitimized cutbacks in public sector investments in health as well as the commodification of health services (Baru & Nundy, 2008). These shifts in policy gradually led to India's acceptance of the economic principle advocated by the Commission of Macroeconomics and Health that investment in health was a route to economic development (World Health Organization, 2001). The climax was reached when the National Health Policy proclaimed urban medical institutions as service production units at par with production units, and therefore, important sources of foreign exchange earnings (Government of India, 2002).

Indian medical tourism process

The typical process is as follows: the person seeking medical treatment abroad contacts a medical tourism provider. The provider usually requires the patient to deliver a medical report, including the nature of ailment, local doctor's opinion, medical history, and diagnosis, and may request additional information. Certified physicians or consultants then advise on the medical treatment. The approximate expenditure, choice of hospitals and tourist destinations, and duration of stay, etc. are discussed. After signing consent bonds and agreements, the patient is given recommendation letters for a medical visa, to be procured from the concerned embassy. The patient travels to the destination country, where the medical tourism provider assigns a case executive, who takes care of the patient's accommodation, treatment and any other form of care. Once the treatment is done, the patient can remain in the tourist destination or return home.

Treatment availed by medical tourists

India is known as the state of art facilities for test tube babies and is popular for surrogacy services (Qadeer & John, 2009). Other than these, India offers hi-tech cardiac, pediatric, dental, cosmetic and orthopedic surgical services, as well as traditional healing systems. The medical tourism definitely does not cater to emergency services. The services provided are largely knee joint replacement, hip replacement (mostly orthopedic), bone marrow transplant, bypass surgery, breast lump removal, hemorrhoidectomy, cataract surgery and cosmetic surgery, etc. Hospitals also advertise for preventive health checkups for family members accompanying the patients in addition to alternate medicine services (Peacock, 2009).

Public and private hospitals practicing medical tourism in India

India is serving to the patients flying from neighboring countries like Bangladesh, Nepal, Pakistan and Sri Lanka that lack such facilities. These patients were initially targeting only teaching hospitals like the All India Institute of Medical Sciences (AIIMs) due to low cost treatment options. Patients from Pakistan, especially children with heart afflictions, have been regularly coming to Hyderabad and Bangalore corporate hospitals. Today patients prefer both public and private hospitals for treatment options.

Government's teaching hospitals are being encouraged to promote MT by strengthening their private facilities. Private hospitals are advertising their services on the web and the Ministry of Tourism has put up its own list of mostly private and one or two public hospitals as destinations for MT in the major cities of India. These hospitals are destination for patients from neighboring countries as well as from the Gulf countries, and a few nonresident Indians (NRIs) from the US (Dogra, 2003). The major service providers in Indian medical tourism are the Apollo Hospitals, Escorts Hospital, Fortis Hospitals, Breach Candy, Hinduja, Mumbai's Asian Heart Institute, Arvind Eye Hospitals, Manipal Hospitals, Mallya Hospital, Shankara Nethralaya, etc. AIIMs, a public-sector hospital is also in the fray. In terms of locations, Delhi, Chennai, Bangalore and Mumbai cater to the largest number of health tourists and are fast emerging as medical tourism hubs. It also visualizes high-end healthcare services through Indian BPO firms like Hinduja TMT, Apollo Heart Street, Comat Technologies, Datamatics and Lapiz that work in the areas of claim adjudication, billing and coding, transcriptions and form processing. One-stop centers in key international markets to facilitate patient flow and stream lining immigration for healthcare are envisaged. In India, private hospitals are trying to attract patients on their own and by showcasing Indian healthcare overseas through CII-IHCF led overseas missions. Developed nations will benefit majorly as costs and waiting time come down for a significant chunk of their population. India benefits through medical tourism as it brings in revenues and provides the right spur to improve the overall healthcare sector.

Strategies adopted by the medical tourism sector in India

Health and medical tourism is perceived to be one of the fastest growing segments in marketing shows 'Destination Incredible India' today. While this area has so far been relatively unexplored, we now find that not only the ministry of tourism, Government of India, but also various state tourism boards are all promoting health and medical tourism as a segment with tremendous potential for future growth.

The price differential between hospitals in Europe or North America and hospitals in India represents a primary motivating factor for medical tourism. Under the same umbrella of being treated, tourists/patients also enjoy a good relaxing time by indulging themselves in recreational activities like yoga, meditation, medicated spas, Ayurvedic massages, etc. Yet another motivating factor is the less waiting time for medical services. In countries such as the United Kingdom and Canada, patients are often required to wait a long time before they can undergo a surgery or other medical procedures. In contrast, patients face minimal waiting times for similar services in Indian hospitals.

Product strategy

India has a number of hospitals offering world class treatments in nearly every medical sector such as cardiology and cardiothoracic surgery, joint replacement, orthopedic surgery, gastroenterology, ophthalmology, transplants and urology to name a few. Well-trained medical staff with international board certification (US, UK, Australia, Germany, Japan) are considered as a valuable asset of the companies and used as an important tool to promote healthcare services. Moreover, the cutting-edge technology and equipment available made by each hospital is also used as one of the major products in this industry. Another marketing strategy used by service providers is to create more value through services. Superior value-added services have been created to differentiate themselves from their increasing competitors, growing its efficiency, creating convenience for the patients, and developing and strengthening the customer relationships. These nonmedical care services are services such as on-line service for medical arrangement, travel arrangement, interpreter services in many languages , luxury service apartments for patients' relatives adjacent to the hospital, hotel selection and reservation, sightseeing tour services, medical transportation both on land and air, one-to-one nursing care service, etc.

Pricing strategy

India's healthcare service providers have a competitive advantage among their competitors due to their high standard of medical treatments and services offered to patients at a very competitive price. In India, complicated medical procedures are being done only at one tenth of the cost in industrialized countries but in terms of infrastructure facilities such as roads, sanitation, power backups, accommodations, and public utility services much more is needed for the country to become a medical tourism destination.

Place strategy

Internet is the main means for disseminating information related to medical and non-medical care services offered by each of healthcare service providers. It is the most effective and inexpensive way to reach the product to its target customers directly, and at the same time helping patients acquire correct and valuable information allowing them to make an informed decision. Informative online marketing of each service provider creates awareness of the medical treatments available and reassures potential patients. Interactive communication, treatments description, presentation of services and facilities, quality assurance other concierge services were also presented on the websites to attract patients who are on medical traveling program. All healthcare service providers generally benefit from the help of specialized agents in promoting their medical tourism. These agents provide information and recommend the patients regarding their treatments to the hospitals. They work as a center cooperating between patients and hospitals for screening cases, sending all the necessary medical reports of the patients to the hospitals. At the same time, agents have the responsibility of advertising and doing marketing in those countries for healthcare service providers, spreading word of mouth advertising of service assurance and reliability.

Promotion strategy

Most healthcare service providers in India, particularly big private hospitals, participate in travel markets, travel fairs, trade fair, exhibitions, seminars, conferences, and advertise in travel magazines with the support from the government. In addition, other informative materials such as brochures, booklets, video-ads, paper bags and t-shirt with logos are also used to create awareness of the available healthcare services as well. Moreover, some healthcare service providers in India build up cooperation with local institutes, universities, medical schools in other countries to establish collaboration in education, exchange of knowledge and training as well as to promote their alternative healthcare services. Healthcare service providers use advertising about medical and non-medical services in both local and international media. Articles, video, news related to their high quality and standard of medical treatments and services, health issues, latest medical technology equipment, quality assurance/ awards/ accreditation are available on their own websites and also to the international media. These help to create awareness of the available alternative medical treatments, as well as to build up a positive image of the high quality and international standard of medical care in India.

People strategy

Another strategy that Indian healthcare service providers may use to attract the international patients for their low cost treatments in India, as well as to get the medical services is by promoting its well-trained medical specialists who have qualified from well-known overseas institutes. It is well acknowledged that having specialized and qualified doctors and staffs gives a competitive advantage for hospitals. However, shortage of doctors and trained medical staff is treated as the major concern in medical tourism in India. Moreover, due to the misunderstanding of the patients' culture, personnel is still considered as problem for medical tourism business in India.

Process strategy

International patients who seek medical treatments are mostly concerned with the quality of treatments and also want that the service providers preferably be accredited by a recognized international organization that audits medical quality. India has a large pool of doctors, nurses and paramedics with required specialization and expertise and the language advantage (English speaking skills). The medical education system caters to the ever-increasing demand for the delivery of the quality health care services all over the country. The Joint Commission International (JCI) recognizes and accredits that the standard of the hospital meets or exceeds the standard of medical facilities as compared to the west. India is a popular destination for medical tourists.

Physical evidence

In India, big hospitals like Apollo Hospitals, Escorts Hospital, Wockhardt Hospitals, Breach Candy Hospitals Lilavati Hospital, Manipal Hospitals, Mallya Hospital, AMRI Hospitals, etc. have a good ambience in their infrastructures with spacious, luxury rooms and excellent amenities, same as that of a five star hotel for patients and relatives, and are equipped with cutting-edge technology. This is a competitive advantage of India in order to gain the confidence and build up the trust of international patients, making a decision to choose India as their preferred choice.

Salient feature of medical tourism sector in India

India has been chosen as a destination for medical treatments because of its infrastructure and technology which is similar with the standards in the USA and Europe. Apart from these factors, the competitive prices and the rich cultural heritage of India, where the patient after recurring can visit the pilgrimage destinations, are also important reasons for the preference of tourists. India is preferred not only for cardiac surgeries but also for surgery of hip replacements, organ transplants, surrogacy & IVF treatments, bariatric surgeries, cosmetic, dental surgery and vision correction etc. Major reasons for India as the preferred destination are:

* Clinical outcomes being on par with the world's best centers.

* Internationally qualified and experienced doctors.

* Technology edge.

* Competitive costs - 1/5th to 1/10th of costs in the west.

* Quality of service.

* No waiting time.

* Patient-centric care.

* In all surgical areas Indian healthcare excels

* Exotic experience, increasing popularity as a tourist destination.

* Eastern healthcare wisdom along with the expertise of western medicine.

* Accreditation norms to be adopted by all major hospitals.

* Hospitals are conformed to a code of ethics.

* Provision of a uniform price band for major specialties especially for health insurance majors.

* Handling of medico-legal issues.

Benefits reaped

Medical tourism has yielded financial benefits to the country, as well as has helped India to expose its skilled medical expertise to the world. It has been seen that the healthcare tourism market in India can touch Rs 100 billion or upwards of $2 billion, catering to 350,000 foreign patients or more in 2012. Though India has emerged as one of the top-ten global destinations for medical tourism, it lags behind Thailand, Singapore and, to an extent, Malaysia. The biggest gain to the country from medical tourism will be the push it will give to achieve international standards. Leading hospitals that conform to such standards will also open a door for successful NRI doctors to return to India and work under conditions they are used to as more hospitals become world-class and repositories of the highest skills, it will lead to quality improvement down the line.

Challenges faced by medical tourism sector in India

Lack of public transportation facilities for patients, power supply issue along with pure drinking water supply at public places is the major challenge faced by medical tourists. Hospitals have observed poor hygiene awareness amongst medical attendants, unhygienic food handling, and lack of proper hospitality services, heterogeneous pricing of services.

The government can play a vital part to upgrade the medical tourism sector by improvising the area of medical visas, better language translator facility as every hospital does not have language translators, giving rise to communication gaps. Air lift facilities for patients and quality accreditations to Indian hospitals and service providers would be needed.

Suggestions

The following suggestions lay down the future path for India to achieve leadership position in medical tourism. These suggestions largely draw from the discussions with various stakeholders, as well as observing the other countries' medical tourism conditions.

Role of government

The government of India must act as a regulator to institute a uniform grading and accreditation system for hospitals to build consumers' trust. It also acts as a facilitator to encourage private investment in medical infrastructure and policy-making for improving medical tourism. The government should actively promote FDI (Foreign direct investment) in healthcare sector as well as also enacts conducive fiscal policies - providing low interest rate loans, reducing import/excise duty for medical equipment It also facilitates clearances and certification like medical registration number, anti-pollution certificate etc. The government should reduce barriers in getting medical visa and institute visa-on-arrival for patients and also can create medical attachés to Indian embassies that promote health services to prospective Indian visitors.

Medical visas

A simplified system of getting medical visas should be developed in order to make travel across borders smoother. Visas can be extended depending on the condition of the patients. The procedures for obtaining medical visa, the subsequent registration and visa extension procedures are complicated and time consuming. There is a need to simplify and speed up these procedures to make India a more attractive medical tourism destination.

Holistic medical and diagnostic centers within the corporate hospitals

Most of the big tertiary hospitals are opening up holistic centers within the premises, with yoga and meditation programs long with naturopathy, herbal medicine, and acupuncture and homeopathy departments. The claim is that these enhance treatment. However, these services are charged for and add to additional revenues. The hospitals have small spaces for the relatives to pray in, thereby wedding science with religion and traditional with modern medical practices.

Setting up of national level bodies

To market India's specialized healthcare products in the world and also address the various issues confronting the corporate healthcare sector, leading private hospitals across the country are planning to set up a national-level body on the lines of National Association of Software and Service Companies (NASSCOM), the apex body of software companies in the country. It is therefore essential to form an apex body for health tourism - National Association of Health Tourism (NHAT).

Integrate vertically

Various added services might be offered to patients. For example, hospitals may have kiosks at airports, offer airport pickups, bank transactions, or tieups with airlines for tickets and may help facilitate medical visas by the government. With more Arab patients coming in, some hospitals may hire Arabic interpreters, stocked up on prayer rugs and opened up a kitchen serving special food in corporate hospitals in India.

Joint ventures / Alliances

To counter increasing competition in medical tourism sector, Indian hospitals should tie-up with foreign institutions for assured supply of medical tourists. Specifically they may tie-ups with capacity constrained hospitals and insurance providers. For example, Mohali's Fortis Hospital has entered into a mutual referral arrangement with the Partners Healthcare System, which has hospitals like Brigham Women's Hospital and Massachusetts Hospital in Boston under its umbrella, to bring patients from the US. The Apollo group has also tied up with hospitals in Mauritius, Tanzania, Bangladesh and Yemen. In addition, it runs a hospital in Sri Lanka, and manages a hospital in Dubai.

As a part of this policy of promoting public and private initiatives, the Indian travel industry and tour operators have also designed packages that include air travel, hotel accommodation, and surgery expenses, claiming savings. They may also operate jointly to facilitate travel for medical services. Other than the central government's list of hospitals for medical tourism on the web, medical tourism may also get promoted through popular magazines, tourist guidebooks, business magazines and journals on tourism. Textual and video testimonies of cured foreign patients and administrators describing the excellence of the treatment, the low cost, the professional approach, the technical expertise, the affectionate and caring doctors and staff, and the cutting edge technology are all displayed on hospital web sites as evidence of efficiency.

Conclusion

India is in an advantageous position to tap the global opportunities in the medical tourism sector. The government's role is crucial for the development of medical tourism sector. The government should take steps as a regulator and also as a facilitator of private investment in healthcare. Mechanisms need to beset to enable quicker visa grants to foreign tourists for medical purposes where patients can contact the Immigration Department at any point of entry for quick clearance. Tax incentives to service providers, import duty reduction on medical equipment, committees to promote and foster medical tourism are some of the initiatives that can be undertaken. There is also a need to develop supporting infrastructure such as transport services to facilitate tourism in India. The tourism, health, information and communication departments need to work in tandem for efficient patient care.

This paper has recommended some of the medical tourism strategies for further promoting medical tourism in India. These include building and promoting the image of India as high quality medical tourism destination, creating and promoting new combination of medical tourism products, keeping up the high standard of quality treatments at a reasonable price, providing informative online and offline materials and make them available to the potential customers. Also attaining the accreditation/standard to reassure the quality of treatments as well as emphasizing on the needs and demands of the existing target markets must be incorporated.

References

References

Baru, R.V., and Nundy, M. (2008). Blurring of Boundaries: Public-Private Partnerships in Health Services in India. Economic & Political Weekly, 43(4), 62-71.

Brady, C.J. (2007). Offshore Gambling: Medical Outsourcing versus ERISA's Fiduciary Duty Requirement. Washington and Lee Law Review, 64(3), 1073-1114.

McKinsey (2002). Health Care in India: The Road Ahead. New Delhi: CII, McKinsey and Company and Indian Healthcare Federation.

Dogra, S. (2003). Can Delhi Be a Successful Model for Medical Tourism?. Express Healthcare Management. Retrieved from http://www. expresshealthcaremgmt.com/20030915/focus01.

Government of India (1992). Eighth Five-Year Plan 1992-97. New Delhi: Planning Commission.

Government of India (1997). Ninth Five-Year Plan 1997-2002. New Delhi: Planning Commission.

Government of India (2002). National Health Policy. New Delhi: Ministry of Health and Family Welfare.

Government of India (2008). Eleventh Five-Year Plan 2007-12. New Delhi: Planning Commission.

Government of India (2009). The National Health Bill. Working Draft Version January 2009. New Delhi: Ministry of Health and Family Welfare.

Harrick, D.M. (2007). Medical Tourism: Global Competition in Health Care. NCPA, Policy report No. 304. Dallas, Texas: National Centre for Policy Analysis.

Jones, C.A., and Keith, L.G. (2006). Medical tourism and reproductive outsourcing: the dawning of a new paradigm for healthcare. International Journal of Fertility and Women's Medicine, 51(6), 251-255

Laws, E. (1996). Health tourism: A business opportunity approach. In S. Clift and S.J. Page (Eds.) Health and the International Tourist (pp.199-214). London: Routledge.

McKennis, A.T. (1999). Caring for the Islamic Patient. AORNJournal, 69(6), 1185-1196.

Qadeer, I., and John, M.E. (2009). The business and ethics of surrogacy. Economic & Political Weekly, 44(2), 10-12.

Whittaker, A. (2008). Pleasure and Pain: Medical Travel in Asia. Global Public Health, 3(3), 271-290.

World Health Organisation (2001). Macroeconomics and Health: Investing in Health for Economic Development. Report of the Commission on Macroeconomics and Health, Geneva.

Received: February 3, 2015

Accepted for publication: December 17, 2015