KONSEP

KEPARIWISATAAN

I WAYAN SUARDANA

Tourism

Tourism

Tourism provides a wide range of economic opportunities, especially for

developing and least developed countries:
Transport, communications, infrastructure, education, security, health,
immigration, customs, accommodation, agriculture and creative
industries

The typical visitor journey

A simplified Tourism Value Chain

(ex. Uganda)
Accommodation

SCTD Tourism Services Portfolio

Tourism for Development
Integrated Tourism Development
The SCTD provides specialized tourism assistance aimed to
maximize tourisms capacity to support countries in reaching
their development goals, while preserving their cultural and
environmental assets. The Services Portfolio on Tourism for
Development compiles the services available to LDCs and
developing countries.
Areas of
Implementing
intervention
agencies
The Services
Portfolio
makes available
over 50 types
of services
BBuilding
good governance
and sustainability
in
UNWTO
1
organized
around four pillars:
tourism
ITC
UNDP
Promoting investment in the tourism economy
2
UNEP
ILO
Fostering the poverty reduction impact of
UNESCO
3
tourism
UNIDO
UNCTAD
WTO
Encouraging human resources development
4

3. Fostering the poverty reduction impact

of tourism
Reducing poverty by developing value-chain linkages
between the tourism industry and local producers of
goods and services
A. Rationale for working on business linkages for
poverty reduction
-. 90% of DTIS linked to tourism state the creation of business linkages as key
challenge.
-. Increasing interest by hotel chains, restaurants and tour operators to invest
more in local sourcing.
-. Limited capacities and skills of entrepreneurs to meet quality requirements of
hotels, restaurants and tour operators.
B. Objective of joint support
-. Maximise the tourism industrys positive impact on local producers and
service providers & entrepreneurs (e.g. agro-food, creative industries,
services).

3. Fostering the poverty reduction impact

of tourism
Applying an integrated approach to developing sustainable
& inclusive business linkages
A.
In-depth feasibility assessment identifying
products and services currently sourced from abroad by
the tourism industry that could potentially be met by
local supply.
B. Facilitate stakeholder meetings to identify business
opportunities for the tourism
industry and how a demand-driven approach can
link them with local producers.
C. Enhance supply capacity, consistency and quality
characteristics of local products
and services to meet demand requirements of
tourism industry and their customers.

Assessment of Tourism Value Chain & Service providers

Accommodation

Pro-poor income mapping

WsP: woman a significant proportion

WiM: Women in majority
EM: Ethnic minority

Pengertian Pariwisata
Sejarah Perjalanan Manusia
Tolak dimulainya perjalanan untuk tujuan perdagangan: bangsa
Sumeria di Babylonia (4000 SM).
Traveller pertama: Marcopolo telah menjelajahi jalan raya dari benua
Eropa ke Tiongkok dan kembali ke Venesia (1254-1374)
Abad 14, 14 Juni 1324, Ibnu Batuta. Perjalanan dari Afrika Utara
menuju Mekkah dan Madinah. The First Traveller of Islam. Berjalan
kaki 79.000 mil (7 tahun).
Travel Agent Pertama di Dunia
Kemajuan dalam bidang transportasi abad XIX.
Thomas Cook, lahir 22 November 1818 di Melbourne, Debishre
(Inggris), dianggap orang pertama yang menjalankan profesi Travell
Agent.
Permulaan Angkutan Wisata
Kocs pertama kali diperkenalkan pada abad ke 15. Alat angkut dari
Hongaria.
Kocs adalah suatu gerobak tertutup dengan 4 roda.
Sekarang dikenal dengan Choach untuk angkutan wisata sering
digunakan untuk dari dan ke airport.

Dasar Pengertian Pariwisata (2)

Pariwisata sebagai Disiplin Ilmu
Ilmu tersendiri pertama diajarkan di kota Dubrounik
(Yugoslavia) tahun 1920.
Tahun 1930, di Swiss diajarkan sebagai mata pelajaran
pada berbagai sekolah tinggi dagang. (Bern University
dan St. Gallen University sejak tahun 1914).
Tahun 1962, konggres di Madrid. Organisasi seperti
AIEST (Association DExperst Scientifiquis Du
Tourisme), AIT (Alliance Internationale Tourisme), dan
IUTO secara resmi mengakui Ilmu Pariwisata sebagai
cabang ilmu pengetahuan yang berdiri sendiri. AIEST
berkedudukan di Bern, Swiss.

Dasar Pengertian Pariwisata (3)

Pengertian-Pengertian
PARIWISATA

Suatu proses kepergian sementara dari

seseorang atau lebih menuju tempat lain diluar
tempat tinggalnya.
Dorongan kepergian: kepentingan politik,
ekonomi, sosial, kebudayaan, agama, kesehatan,
maupun hal lain seperti karena sekedar ingin
tahu, menambah pengalaman ataupun untuk
belajar.
Pariwisata = Perjalanan Wisata

Dasar Pengertian Pariwisata (4)

WISATAWAN (TOURIST)

Seseorang atau kelompok orang yang melakukan suatu

perjalanan wisata, jika lama tinggalnya sekurang-kurangnya 24
jam di daerah atau negara yang dikunjungi.
Pesiar (leasure), untuk keperluan rekreasi, liburan, kesehatan,
studi, keagamaan dan olah raga.
Hubungan Dagang, sanak saudara, handai taulan, konferensi,
misi, dan sebagainya.

Kurang dari 24 jam disebut pelancong (excursionist). IUOTO

(The International Union of Official Travel Organization)
menggunakan batasan mengenai wisatawan secara umum:
Pengunjung (visitor), yaitu setiap orang yang datang ke suatu
negara atau tempat tinggal lain dan biasanya dengan maksud
apapun kecuali untuk melakukan pekerjaan yang menerima
upah.

Dasar Pengertian Pariwisata (5)

PASPOR dan VISA

Paspor, suatu keterangan yang dikeluarkan oleh

pemerintah untuk seorang wisatawan/warga negara yang
akan mengadakan perjalanan ke luar negeri, yang
pembuatannya diurus oleh kantor migrasi di negara yang
bersangkutan.
Visa, surat keterangan ijin tinggal di suatu negara yang akan
dituju oleh wisatawan. Surat keterangan itu diperoleh dari
Kantor Kedutaan Besar suatu negara yang menjadi tujuan
wisata.

Visa Diplomatik, visa yang diberikan kepada orang asing

pemegang paspor diplomatik yang hendak bepergian ke
Indonesia dengan tugas diplomatik
Visa Dinas, visa yang diberikan kepada orang asing pemegang
paspor dinas yang hendak bepergian ke Indonesia untuk
menjalankan tugas resmi dari pemerintah negara lain atau
diutus oleh PBB, dengan tugas yang tidak bersifat diplomatik.

Dasar Pengertian Pariwisata (6)

Visa Biasa, jenis visa ini dikelompokkan berdasarkan

maksud:
Visa Transit, visa yang dapat diberikan kepada orang
asing yang dalam perjalanannya perlu singgah di
Indonesia untuk pindah kapal laut/udara guna meneruskan
perjalanannya. Paling lama 5 hari.
Visa Kunjungan, visa yang diberikan kepada orang asing
yang bermaksud berkunjung ke Indonesia dengan tujuan
wisata, usaha, atau kunjungan sosial budaya lainnya yang
tidak untuk bermaksud berdiam atau berdiam sementara.
Paling lama 3 bulan.
Visa Berdiam Sementara, visa yang diberikan kepada
orang asing yang bermaksud untuk berdiam sementara di
Indonesia dengan tujuan bekerja, mengikuti latihan,
melakukan penelitian ilmiah menurut peraturan yang
berlaku.

Dasar Pengertian Pariwisata (7)

Wisata Alam
Bentuk kegiatan wisata yang memanfaatkan potensi
sumber daya alam dan lingkungan.
Obyek Wisata Alam
Sumber daya alam yang berpotensi dan berdaya tarik
bagi wisatawan serta yang ditujukan untuk pembinaan
cinta alam, baik dalam kegiatan alam maupun setelah
pembudidayaan.
Kegiatan Wisata Alam
Kegiatan rekreasi dan pariwisata, pendidikan,
penelitian, kebudayaan dan cinta alam yang dilakukan
di alam obyek wisata.
Konservasi
Pengelolaan dan pemanfaatan sumber daya alam
secara bijaksana berdasarkan prinsip kelestarian.

Dasar Pengertian Pariwisata (8)

Konservasi Sumber Daya Alam (Hayati)

Pengelolaan sumber daya alam (hayati) yang
pemanfaatannya secara bijaksana danmenjamin
kesinambungan persediaan dengan tetap memelihara
dan meningkatkan kualitas nilai dan keragamannya.
Sumber Daya Alam Hayati
Unsur unsur hayati dalam alam bersama sama
dengan unsur hayati secara keseluruhan yang
membentuk ekosistem.
Ekosistem Sumber Daya Alam Hayati
Sistem hubungan timbal balik antara unsur dalam
alam baik hayati maupun non-hayati yang saling
tergantung dan saling mempengaruhi.

Dasar Pengertian Pariwisata (9)

Kawasan Pelestarian Alam

Kawasan Wisata Alam

Kawasan dengan ciri khas tertentu, baik di darat maupun di

perairan yang mempunyai fungsi perlindungan sistem
penyangga kehidupan; pengawetan keragaman jenis tumbuhan
serta satwa dan pelestarian pemanfaatan sumber daya alam
dan ekosistem.
Kawasan dengan ciri khas tertentu, baik di darat maupun di
perairan, dengan mempunyai fungsi pokok sebagai kawasan
pengawetan keragaman jenis tumbuhan dan satwa beserta
ekosistem.

Cagar Alam

Kawasan suaka alam yang mempunyai ciri berupa tumbuhan,

satwa dan ekosistem yang khas dengan perkembangannya
diserahkan kepada alam.

Dasar Pengertian Pariwisata (10)

Suaka Margasatwa
Kawasan suaka alam yang mempunyai ciri khas
berupa keragaman dan atau keunikan jenis satwa
yang kelangsungan hidupnya dapat dilakukan untuk
pembinaan terhadap habitatnya.
Taman Nasional
Kawasan pelestarian alam yang dikelola dengan
sistem zonasi yang terdiri atas zona inti dan zona lain
yang dimanfaatkan untuk tujuan ilmu pengetahuan,
pariwisata, rekreasi, dan pendidikan.
Hutan Wisata
Kawasan hutan yang disebabkan keadaan dan sifat
wilayahnya yang perlu dibina dan dipertahankan
sebagai hutan dengan maksud untuk pengembangan
pendidikan/penyuluhan, rekreasi dan olahraga.

Dasar Pengertian Pariwisata (11)

Taman Wisata
Hutan wisata yang memiliki keindahan alam baik
keindahan tumbuhan, satwa maupun keindahan yang
mempunyai corak khas untuk dimanfaatkan bagi
kepentingan rekreasi.
Taman Buru
Hutan wisata yang didalamnya terdapat satwa buru
yang memungkinkan untuk diselenggarakannya
perburuan secara teratur bagi kepentingan rekreasi.
Taman Hutan Raya
Kawasan pelestarian alam yang terutama
dimanfaatkan untuk lokasi tumbuhan/satwa, baik yang
asli maupun bukan, untuk tujuan pengetahuan,
pendidikan dan pelatihan, budaya, pariwisata dan
rekreasi.

Dasar Pengertian Pariwisata (12)

Taman Laut
Wilayah lautan yang mempunyai keindahan dan
keunikan yang khas yang khusus digunakan sebagai
kawasan konservasi laut, untuk dibina dan dipelihara
guna perlindungan plasma, rekreasi, pariwisata,
pendidikan dan kebudayaan.
Contoh:
Taman Nasional Bali Barat di Bali
Taman Nasional Penelokan di Bali
Taman Nasional Komodo di NTT
Taman Laut Bunaken di Sulawesi Utara
Taman Laut Menjangan di Bali
Taman Buru Daratan Bena di Pulau Sumbawa, NTB
Taman Buru Tambira Selatan di Pulau Sumbawa

Dasar Pengertian Pariwisata (13)

BIRO PERJALANAN WISATA

Perusahaan yang menyelenggarakan kegiatan paket wisata

dan agen perjalanan.
Kegiatan usaha biro perjalanan wisata:

Menyusun dan menjual paket wisata luar negeri atas dasar

permintaan.
Menyelenggarakan atau menjual pelayaran wisata (cruise).
Menyusun dan menjual paket wisata dalam negeri kepada
umum atau atas dasar permintaan.
Menyelenggarakan pemanduan wisata.
Menyediakan fasilitas untuk wisatawan.
Menjual tiket/karcis sarana angkutan, dan lain-lain.
Mengadakan pemesanan sarana wisata.
Mengurus dokumen-dokumen perjalanan sesuai dengan
peraturan yang berlaku.

Dasar Pengertian Pariwisata (14)

AGEN PERJALANAN WISATA
Perusahaan yang melakukan kegiatan penjualan tiket
(karcis), sarana angkutan, dan lain-lain serta
pemesanan sarana wisata.
Kegiatan APW:
Menjual tiket, dan lain-lain
Mengadakan pemesanan sarana wisata
Mengurus dokumen-dokumen perjalanan sesuai
dengan peraturan yang berlaku.
BPW dan APW dibawah ASITA (Association of The

Indonesian Tours and Travel Agencies).

Dasar Pengertian Pariwisata (15)

Cabang Biro Perjalanan Umum

Satuan-satuan usaha dari suatu Biro Perjalanan Umum

Wisata yang berkedudukan di tempat yang sama atau
ditempat lain yang memberikan pelayanan yang
berhubungan dengan perjalanan umum.
Industri-industri dalam Kepariwisataan
Pengakutan
Akomodasi
Segala sesuatu yang menarik wisatawan untuk berkunjung
sesuai sifat kegiatan perusahaan perjalanan dibagi menjadi:

Wholesaler adalah perusahaan perjalanan yang menyusun

acara perjalanan wisata secara menyeluruh atau secara khusus
menjual paket perjalanan wisata kepada Retail Travel Agent.
Retailer atau Retailer Travel Agent adalah biro perjalanan yang
menjual perjalanan wisata secara langsung kepada wisatawan.

Heritage tourism

Literary tourism:
Haworth and the Brontes

Television tourism: Goathland and Heartbeat

The World Health Organization's

ranking
of the world's health systems

4 ANCAMAN WISATA KESEHATAN

DI INDONESIA
Unfinished
Unfinished agenda
agenda (yang
(yang tidak
tidak pernah
pernah selesai
selesai diatasi):
diatasi):

diare,
diare, demam
demam berdarah
berdarah (DBD),
(DBD), gizi
gizi kurang,
kurang, penyakit
penyakit yg
yg
menyerang
menyerang penduduk
penduduk miskin.
miskin.
Re-emerging
Re-emerging Diseases
Diseases (penyakit
(penyakit yang
yang diperkirakan
diperkirakan
turun
turun prevalensinya,
prevalensinya, justru
justru kini
kini meningkat
meningkat kembali)
kembali)
seperti
seperti TB
TB Paru,
Paru, dan
dan Malaria.
Malaria.
New-emerging
New-emerging Diseases
Diseases (penyakit-penyakit
(penyakit-penyakit baru):
baru):
SARS,
SARS, HIV/AIDS,
HIV/AIDS, Flu
Flu Burung,
Burung, penyakit
penyakit akibat
akibat
kecelakaan
kecelakaan
lalu
lalu
lintas,
lintas,
kecanduan
kecanduan
alkohol,
alkohol,
ketergantungan
ketergantungan narkoba,
narkoba, dan
dan penyakit
penyakit apa
apa lagi?
lagi?
Seringnya
Seringnya terjadi
terjadi bencana
bencana (disaster)
(disaster) baik
baik alamiah
alamiah
(gempa,
(gempa, banjir,
banjir, gunung
gunung meletus,
meletus, dsb)
dsb) maupun
maupun buatan
buatan
yang
yang berdampak
berdampak terhadap
terhadap kesehatan
kesehatan masyarakat.
masyarakat.
9/13/16

abidin-seminar kualitas dokter/drg

9/13/16

promkes

MEDICAL TOURISM

Source: http://english.busan.go.kr/06residents/08_03_01.jsp

Medical Tourism
Replacement of patients from their home countries to
the different countries basically for the purpose of
treatment.
Medical tourism could include recreation and
relaxation activities as well as treatment.
Medical Tourism creates approximately US$60 billion
to the world economy.
India, Thailand, Taiwan, Turkey and some developing
countries have done the great progress in medical
tourism industry

09.11.2012

Source: http://english.busan.go.kr/06residents/08_03_01.jsp

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Why medical tourism?

Lower cost
Better access to healthcare
High quality First World Treatment at Third World

Costs
Long waiting time (Canada & UK)
Lack of healthcare coverage
Medical procedures not provided (U.S - Stem Cell) or
restrained in home country
Privacy particularly for some cosmetic procedures
Exotic locations and travel mystique
09.11.2012

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Medical & Dental Procedures*

Cardiology

Gastroenterol

Orthopedics

ogy
Pain

Cardiothoracic

Management

General
CyberKnife

Surgery

Pediatrics

(cancer)
Gynecology
Dental
Infertility

Plastic

and
Reconstructive
Surgery

Detox/Rehab
Internal
ENT

Urology

Male/Female

Medicine
Vascular

Executive

Neurosurgery

Health Physicals

Weight

Oncology

(selective)

09.11.2012
*

Lazzaro, V. (2009). U.S. & International Medical Tourism University of California - Irvine

Loss/Obesity
Surgery

Drivers
Improvements in Technology
and Transportation

Cost
Differences

Globalization
of Healthcare

3
4

Medical
Tourism

Qualified Human
Resources

Quality
Network

Increasing
Healthcare
Expenditure

Regulations

6
Accredited Healthcare
09.11.2012
Organizations
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Challenges

Selection of physician

Communication Issues
Follow-up difficulties and
complication risk

Critical issues
for medical
tourists

Legal resource and

malpractice law

09.11.2012

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09.11.2012

Advantages and Disadvantages for MT

destination
Advantages
Shows the leverage effect for the economy.
Contribute to the related industries.
Acquisition of advanced technology and powerful
infrastructure.
Improve public healthcare sector as well as
private sectors.
Increase employment

Disadvantages
Low physician to patients ratio for local people
Domestic brain drain from public to private sector

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Accreditation
Joint Commission International conducts the

accreditation process of public and private health

organizations from different countries and
provides international standards .
About 550 foreign hospitals accredited from 52

countries by JCI.
There are also some other accreditation

organizations.
09.11.2012

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High-Quality Healthcare Services and Accreditation of

Healthcare Organizations
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Countries

Number of
Accredited
Organizations

Austria
Bahamas
Bahrain
Bangladesh
Barbados
Belgium
Bermuda
Brazil
Chile
China
Colombia
Costa Rica
Czech Republic
Denmark
Ecuador
Egypt
Ethiopia
Germany
Greece
India
Indonesia
Ireland
Israel

4
1
1
1
1
1
1
43
2
20
2
3
4
15
1
3
1
5
1
20
5
23
8

Italy
Japan

21
4

09.11.2012

Countries

Number of
Accredited
Organizations

27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48

Kazakhstan
Kuwait
Lebanon
Malaysia
Mexico
Nicaragua
Nigeria
Oman
Pakistan
Panama
Philippines
Portugal
Qatar
Russian Federation
Saudi Arabia
Singapore
Slovenia
South Korea
Spain
Switzerland
Taiwan
Thailand

1
2
2
8
9
1
1
2
1
2
4
12
10
1
50
21
2
33
21
1
22
35

49

Turkey

48

50
51

United Arab Emirates

Viet Nam

57
1

Total health expenditure as a share of GDP, 2009 (or

nearest year)
Public

% of GDP

Residual

Private

Total

20

18 17.4
16

14

12

10

12.0 11.8

11.6 11.511.4 11.4

11.0 10.9

10.3

10.1 10.0 9.8

9.7 9.6 9.6 9.6 9.5 9.5 9.5
9.3 9.2 9.1
9.0

8.7 8.5 8.5

8.4 8.2

7.9 7.8
7.4 7.4
7.0 6.9

6.4

6.1

5.4
4.6

4.2

4
2.4
2

09.11.2012
Source: OECD Health Data
2011

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Health insurance coverage of OECD Countries

for a core set of services, 2009

Primary priv ate health c ov erage

Total public cov erage

Percentage of total population

09.11.2012

Source: OECD Health Data 2011

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Medical Tourism
Destinations

09.11.2012

Source: Grail Research, 2009

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Waiting time of four weeks or more for a

specialist appointment

09.11.2012

Source: Commonwealth Fund International Health Policy Surveys

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Waiting time of four months or more for

elective surgery
%
50

2001-02

2007

2010

41
38

40
33
30 27 27
25
20

2005

30
26

22 23 21
21
1918 20

18

13
10

88

67

5
0

09.11.2012

Source: Commonwealth Fund International Health Policy Surveys

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Legal Issues
Indonesia un supports medical tourism via

governmental regulations and incentives.

The European Union accepted the Directive

on the Application of Patients Rights in

Cross-border Healthcare that facilitates the
mobility of patient among the member
countries in 2011 and it will be effective by 25
October 2013 within the member countries.
09.11.2012

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US

Price Statistics for

Selected Countries
TURKE
Y

IRELA
ND

THAILA
ND

GERMA
NY

TAIWA
N

SINGAP
ORE

INDI
A

ISRAE
L

ENGLA
ND

SWITZERLA
ND

Heart Bypass
(CABG)
Heart Valve
Replacement
Hip
Replacement

129.7
50

11.37515.000

26.50027.500

11.000

17.335

18.900

30.00033.000

8.66
6

30.00
0

27.770

44.596

58.25
0

16.950

N/A

10.000

N/A

27.500

12.500

11.7
50

25.00
0

25.000

47.794

45.00
0

10.750

19.50021.000

11.00014.000

11.644

7.500

10.725

7.00
0

17.15
0

15.840

19.899

Knee
Replacement

40.00
0

11.200

19.50021.000

10.500

11.781

8.000

9.350

7.83
3

12.95
0

20.600

20.432

Spinal Fusion

62.00
0

7.125

24.75025.900

7.000

13.50015.000

5.900

9.000

12.0
00

18.00
0

32.400

30.915

Liposuction

9.000

3.333

1.200

4.376

4.000

3.000

2.50
0

N/A

4.950

7.551

Bone Marrow
Transplantati
on

300.0
00

40.00070.000

50.00060.000

250.000

50.00060.000

250.000

40.0
00

90.00
0

250.000

200.000

Gamma Knife

40.00
0

8.676

Cyber Knife

12.00
0

Hysterectomy
(Vaginal)
Source:

20.00
0

250.00
0

16.65020.000

22.00025.000
13.5
00

12.500
7.000

10.0005.200
11.500 09.11.2012

5.5007.00

2.700

9.00010.500

4.25
0

10.100

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Opportunities
Large

pool of doctors, nurses & paramedics

(Potential to educate its human resources)
Increasing number of accredited health
organizations
Highly skilled experts
Possess English speaking skills
Collaboration with international well-known
organizations such as Johns Hopkins
Medicine and Harvard Medical School
Governmental and regulatory support
Geographical superiority and transportation
easiness
09.11.2012

Company Logo

Medical Tourism
Or, for the politically correct..

Case .
Elderly man, osteoarthritic knee not severe

enough to warrant joint replacement, advised to

maximize non surgical therapy
TKA done in India at a JCI accredited institution

Mycobacterium fortuitum joint infection 3 months post

op

Required 4 surgical procedures

Debridement & salvage procedure, two stage
revision, open Bx
Cost: > $140,000 vs patient costs for surgery in India
- $8,600
Cost of arthroplasty in Australia: ~ $15,000
Frequency of infections post total knee

arthroplasty: 1-2%
Frequency of infection post arthroplasty tourism:

Whats the evidence?

Data is limited
Largely anecdotal reports
Few case series or studies mostly in transplant
field
Data is subject to bias
Health care providers at destination are motivated
to emphasize good outcomes to protect
commercial interests
Health care providers at home are more likely to
see / report poor outcomes than good ones
Follow-up is limited
Patients stays at providing institution are brief f/u
variable
Procedures are done in a variety of locations
Patients return home to many different locations

Definitions / Scope
Medical tourism usual use
Travel to a foreign country (especially
exotic locations) to obtain medical
care
Medical tourism less common

uses

Physicians

engaging in unapproved
medical activities while travelling to
remote locations for tourism
(impromptu roadside clinics)
Medical students / physicians

Terminology
Alternate terms
Health tourism
Medical journeys
Global healthcare / Cross border healthcare
Medical value travel
More specific terms
Surgical tourism
Transplant tourism
Reproductive tourism
Dental tourism
Suicide / Euthanasia tourism

Medical Tourism: not a new

phenomenon
Renowned centres / physicians have always

attracted patients from afar

Healing shrines
Spas
Pilgrimages

Wealthy citizens of countries with limited

health resources travelling to access care /

expertise that cannot be obtained locally
Desperate patients with incurable conditions
seeking miracle cures

So, whats new?

Average citizens
Range of procedures available
Third world / emerging economies destinations
Development of an industry catering to medical

tourists

Travel agencies and brokers

Journals
Conferences

Systematic government support of industry

Insurance company promotion of medical

tourism

Why do countries promote medical

tourism?
Money!
Boost tourism revenues
Generate foreign exchange
Increase gross domestic product
Improve medical services

Upgrade services / resources available to

citizens
Stem brain drain to other countries

Why do patients want medical

tourism?

Lower cost
Timely alleviation of pain and

disability
Access to innovative procedures
Exotic locations and travel
mystique
Privacy particularly for some
cosmetic procedures

Issues
Clinical / Medical
Financial
Ethical
Legal

Clinical Decision Making in Medical

Tourism
How does the commoditization of care affect

clinical decision making?

Potential predisposition to recommend surgical /

more complex procedures over conservative Rx
Potential risk of minimizing risks to avoid losing a
client
Potential risk of focus on visible signs of quality /
luxury over medical quality assurance
Are patients overly optimistic about potential
benefits, and under-informed / inadequately aware
of potential risks?
Once patients have paid a broker fee, are they
pre-disposed to opt for surgery even if this is not

Other Clinical concerns

Are innovative techniques evidence based?
Are providers properly trained and accredited?
Are medical quality standards comparable to

home?
Complication rates? late complication rates
usually unknown
Infection control / MDR pathogens

Exposure to exotic / opportunistic pathogens

Ethical issues
Islands of excellence in a sea of medical

neglect
Infrastructure priorities may be focused on
industry rather than local needs
Infrastructure costs may be passed on to
local population in form of increased taxes or
reduced services
Emphasis on high tech care at the expense of
appropriate technology
Brain drain from public to private sector
Special issues pertaining to transplant

Financial / Resource issues

Potential plus for uninsured patients /

procedures
Potential undesirable results

Cost of complications is carried by home country

Impact on local resources if outsourcing becomes a
major source of care

Potential for decreased access to specialized services

Decreased training resources
Development of transplant programs stunted in countries
where transplant tourism is a major method of obtaining
transplantation

Coercive use of medical tourism by insurance

companies
Potential shortage of nurses / physicians if foreign

Legal Issues Medical

standards

Canadians protected against substandard care

by:
Professional licensing & credentialing
Institutional policies
Legal remedies

Care provided in other countries may not meet

Canadian legal standards

Disclosure of risks, benefits, alternatives
Certification of professionals training, expertise
Access to legal remedies
Limitations of liability awards

Legal Issues Liability

Brokers require clients to sign waivers absolving

them of any liability for medical negligence,

substandard care.
Clients may be unable to bring a case against

care providers in the Canadian courts

Recourse to legal remedy in country of care is

variable & complex

Legal Issues Transplantation

In some countries it is illegal to:
Sell / Buy organs for transplant

Provide transplants to foreigners

India / Pakistan
South Africa
China

To enter the country (as a foreigner) for the

purpose of obtaining an organ donation

Justifications
Consumer choice
Global competition in health care
Supply and demand pressures on costs / prices
Increased GDP for countries
Bystander benefits

Decreased wait times when patients remove

themselves from wait lists by going out of country
Economic and social spin off benefits to
communities in host countries employment,
better quality health care

What actually happens?

Does medical tourism raise the quality of care

and accessibility to care for the local

population?
Does medical tourism widen the gap between

rich and poor and decrease access to care for

the local population?

Either is possible..

Bumrumgrad Hospital Bangkok

554 beds, 2,600 staff
International patients from 150 countries
Foreign patients = 50% clientele
2003 1 million patients overall
2005 55,000 American patients
First hospital in Asia to receive JCI accreditation
Provides services in 26 languages
Expansion plans in other Asian and Middle

Eastern countries

Thailand
Private health care in Bangkok has more
Gamma knife
Mamography services
CT scans
..

Does

than all of England!

that translate into improved

access for local Thais?

India
Medical tourism is a key industry
Government subsidies, fiscal Incentives and
tax breaks
2003: Finance minister called for India to

become a global health destination

Promoted measures to improve infrastructure
to support the industry
Ministry of tourism promotes 45 centres of
excellence: cardiac surgery, minimally
invasive surgery, oncology, orthopedics and
joint replacement, and holistic care

The context of medical tourism in

India
Great divide between facilities focusing on

medical tourism and those providing health care

to the average Indian
The potential for health tourism to translate into

benefits for the local population seems to be

limited to increasing the wealth of the rich and
has done little to improve health care for the
average Indian.

Bulletin of the World Health Organization. March 2007, 85 (3)

164-165

The context of medical tourism in

India
WHO 2003 data: health expenditure
Private expenditure 75% of total
Public expenditure 25% of total

Addressed health needs of the majority of Indias

population

Health care facilities serving the Indian poor

<50% have a labour room or laboratory

<20% have a phone line
<33% adequately stocked with essential drugs
Shortages of physicians and other health care
workers
Corruption and lack of funds

Medical Tourism in Canada

15 medical tourism companies
1 each in Manitoba and Alberta
3 each in Ontario and Quebec
7 in British Columbia
And other agencies providing medical tourism
services in additional to traditional travel services
Clients are sent to a wide range of countries:

Argentina, Brazil, China, Costa Rica, Cuba,

France, Germany, India, Malaysia, Mexico,
Pakistan, Poland, Russia, Singapore, South Africa,
Sri Lanka, Thailand, Tunisia, Turkey, UAE, US

Medical Tourism
Brokers / Medical Tourism agencies
Middlemen

Find hospitals, physicians

Arrange transfer of information
Buy tickets / arrange flights
Reserve hotels
Arrange sightseeing

Do not verify credentials or licensing of facilities or

physicians
Make money from hotel commissions and
kickbacks
No licensing requirements for brokers and
agencies

Early developments in USA for licensing

Transplantation
Tourism

Tissue and Organ Transplantation

Cyclosporine and newer

immunosuppressants opened the door to

transplant tourism
WHO estimates that 10% transplants
worldwide involve developed world recipients
travelling to resource limited countries to
purchase organs
Why?

Wait times due to organ shortages

Eligibility patients declined for transplant in home
country are often readily accepted for transplant in
a for profit system
Non evidenced based transplants
Fetal tissue / cell transplants

Ethical issues transplant

tourism
Source of transplanted organs
Potential for coerced organ donation
Involuntary donations executed prisoners,
kidnappings
Transplant flow is overwhelmingly.
South to north
Female to male
Black / brown to white
Poor to financially secure
Association with organized crime
India, Brazil and other areas

Recipient Risks
Commercial influences on medical decision

making

Inappropriate transplantation

Poor donor recipient matching - to reduce wait

times

need for more intense immune suppression risk

OIs, toxicity

Exposure to drug resistant bacteria,

opportunistic infections, blood borne pathogens

Lack of continuity of care

Pre-transplant work-up and decision making through

long term care post transplant

Recipient Risks
Poor donor recipient matching intense

immune suppression exposes recipients to

increased risks
Increased risk of rejection
Increased risk of infection
Increased cancer risk
Increased risk of graft failure

Due to rejection, drug toxicity, infection

Renal Transplant Favourable

Outcomes

Morad et al 2000
515 Malaysian patients transplanted in
China or India

>90% graft and patient survival

Sever et al 1997
540 Saudi patients transplanted in India
96% graft survival
89% patient survival
Similar results to those transplanted in
Saudi Arabia

Renal Transplant - Inferior

Outcomes
Kennedy et al 2005
16 Australian patients
66% graft survival
85% patient survival

Sever et al 2001
Turkish patients
84% graft survival
patient survival similar to locally
transplanted patients

Canadian experience
Canadian data - 1998-2005
20 transplanted abroad - unrelated donors
22 transplants

South Asia (12), East Asia (5), Middle East (4),

SE Asia (1)
..compared

to

175 living biologically related donors

transplanted in Canada
75 living emotionally related donors
transplanted in Canada

Canadian experience - 2
33% - no records, 77% - incomplete records
1/3 hospitalized on return, primarily for sepsis
Hospital stays of 4-113 days (mean 19 +/- 36)
Complications:
27% systemic sepsis
52% opportunistic infections

23% CMV
9% fungal infections
14% tuberculosis

5% cerebral and spinal abscesses

25% wound infections
38% pyelonephritis (incl. MDR E coli)
10% each: allograph nephrectomy, wound dehiscence,
lymphocele
5% each: obstructive hydronephrosis, urine leak,

Compared to Canadian
Transplants.
Inferior graft survival at 3 years
98% biologically related donors
86% emotionally related donors
62% transplanted abroad
Patient survival at 3 years

100% for those transplanted in Canada

82% for transplant tourists

Donor Risks
Exploitation
Inadequate informed consent process

Donors treated as organ sources not patients

Safeguards ensuring free and fully informed consent are
weakest in countries where most transplants occur

Brokers target poor, disadvantaged

Diminished health status post donation leads

to further economic disadvantage that is

sustained over the long term
Stigma

Kidney sellers in Iran suffered extreme shame in

their community

Kidney sellers - India

305 kidney sellers in Chennai, India
71% females, at least 2 coerced by husbands
70% sold through a middleman, 30% sold direct to
clinic
Almost all sold their kidneys to pay off debt
47 - spouse had also sold a kidney
Economic outcomes

On average brokers and clinics promised ~1/3

more than they actually paid.
Average payment = $1070

Kidney sellers - India

Local conditions - significant improvements in

economic status over the last 10 years

Poverty decreased by 50% since 1988

Per capita income increased by 37% over 10 years

Most kidney sellers reported worsened economic

status

Average family income declined from $660 at time of

sale to $420 at time of survey
Percentage of participants below the poverty line
increased from 54% to 71%
Of those who sold a kidney to pay off debts, 74% were
still in debt
Increased time since selling a kidney associated with
greater decline in economic status

Kidney sellers - India

Health consequences (5 point likert scale)
13% no change in health status
38% reported 1-2 point decline in health status
48% reported a 3-4 point decline
50% had persistent pain at nephrectomy site
33% had persistent back pain
79% would not recommend selling a kidney to
others

Kidney sellers - India

Nephrectomy was associated with decline in

both economic and health status

Economic decline persisted and worsened
with increasing time since transplant
Health decline may have contributed to
economic worsening through decreased
fitness
Most sellers would not recommend it to
others - ?was informed consent adequate

Risk free donation?

Transplant surgeons have disseminated an

untested hypothesis of risk-free live

donation in the absence of any published
longitudinal studies of the effects of
nephrectomy among the urban poor
anywhere in the world. Live donors from
shantytowns, inner cities, or prisons face
extraordinary threats to their health and
personal security through violence, injury, and
infectious disease that can all too readily
compromise the kidney of last resort.
Nancy Scheper-Hughes

Stem cell transplants China

Tiantan Puhua Stem Cell Centre

Applies stem cell treatments to a wide range of
neurologic disorders

Unique stem cell treatments

Stroke, Parkinson's, cerebral palsy, hereditary

degenerative conditions
Self stem cell activation and proliferation program
Stem cell delivery by lumbar puncture or
stereotactically
Use of autologous bone marrow stem cells (to boost
the immune system) and fetal stem cells in combination

Claim a high level of recovery

Efficacy?
We are not aware of any double blind,

placebo controlled trials showing benefit and

safety of stem cell transplants
Improvements often slight / transient

come back for another treatment cycle

Long term follow-up is very limited

patients dont have time to wait
Treatments accompanied by intensive

physiotherapy / occupational therapy /

massage / accupuncture / Chinese traditional
therapy to:

promote improved mobility and function

stimulate the new cells into becoming functional
helps the cells migrate into the correct area

Solid Organ Transplants China

1 million Chinese awaiting transplant
Paying foreigners given priority (transplants at

military hospitals)
Organs derived from executed prisoners
# organs transplanted exceeds number of reported
executions by 41,500 (2000-2005)
Organ procurement takes weeks (vs. 2.5 years in
most countries)
Research by David Kilgour and David Matas
(Canada) documents evidence that Falun Gong
practitioners under detention are being used as organ
sources
China has indicated that it will ban sale of organs
from living donors and require consent from prisoners

Bottom line
Medical tourism is a reality and a growth

industry
Both risks and benefits exist
Difficult to determine the extent of risks
Quality of care is variable

Buyer beware

Many ethical issues

Travel clinic has a role in preparing medical

tourists for travel

What is the role

of the Travel
Health Provider?

What is the role of travel

clinic?
Provide usual general pre-travel advice
Vaccinations
Malaria prophylaxis
Pre-travel counselling
Make traveller aware of key issues in medical

tourism

Effects of commoditization of care on medical

decision making

Consider potential risks specific to medical

tourism

Buyer Beware
Joint Commission International accredits hospitals (US

standards)

List of accredited hospitals easily accessible on line

http://www.jointcommissioninternational.com

Trent International Accreditation Scheme

UK accreditation scheme
Beginning to accredit overseas institutions
Accreditation standards adjusted to reflect local standards
and culture
Local staff conduct accreditations
No inspections
Healthcare Tourism International
www.healthcaretrip.org
New, non profit US group, accredits non clinical aspects
of medical tourism

Providing Advice
Consider the potential for legal complications
Be aware of legal restrictions
May require special visa if travel is specifically for
medical care
Consider the what ifs
Will there be recourse to compensation if problems
occur?
What if there are complications? Who pays for
extended hospital stays? Additional surgery?
Specific medical tourism health risks
Avoid sunburn increased scar pigmentation
Infection multidrug resistant or unusual pathogens
Thromboembolic disease
Complications of early air travel post op - patients are
typically sent home 10-14 days post op

Anecdotal reports of patients being sent home within 2-3

Possible Outcomes
Quality, evidence based medical care
Appropriate indications
Well trained, experienced practitioners
Substandard care
Staff / hospital credentials
Unnecessary surgical procedures
Poor infection control procedures
Medically questionable procedures
Unproven efficacy for indication
Fraudulent care
Fake transplants / procedures
Fake credentials

Israel
2001 MOH regulation allowed reimbursement

for kidney transplants done abroad.

Increased competition between brokers

Local physicians with little knowledge of
transplantation medical advisors

Non-selective referral
Increased referral of older, less fit, highly
sensitized patients
Less selective choice of facilities
Downstream effects..

Israel
Complications
Patients required to return to Israel, presenting on
arrival with complications and no medical
information
Reduced imperative to develop national

donor programs

No increase in donor rates over 10 years

Poor access for non kidney transplants

2006 New MOH regulation to limit referrals

abroad to situations where absence of organ

trafficking could be guaranteed, increase
donations locally

Israel
>150 Israelis obtain transplants abroad/yr
50% transplanted prior to dialysis
Alternate route to obtain organs low donor

rates in Israel
Ministry of Health gains by saving expense of
dialysis
Health insurance agencies gain by selling
high priced policies covering transplants
abroad
Donors living related / paid unrelated
donors from Israel (travel with patient to

Transplant outcomes
Outcomes of United States Residents who

Undergo Kidney Transplantation Overseas:

Canales et al, Transplant Tourism

10 kidney transplant patients (Sept 02 July 06)

Transplanted in Pakistan (8), China (1), Iran (1)

Mean age: 36.8 years
Follow-up period: 0.4-3.7 years (mean 2.0)
6 serious post op (in 3 months) infections in 4 patients
1 death
1 graft failure due to acute rejection
Graft survival and function generally good
High incidence of post transplant infection
Inadequate communication of information
immunosuppressive regimens and perioperative information

Specific cases
One patient presented to emergency on

arrival in US with wound infection

Spent 2 months in hospital

Acinetobacter bacteremia
Aspergillus CNS infection
Died 4 months post transplant

Two patients diagnosed with urosepsis on

arrival home
One patient had a seizure immediately prior
to discharge in Pakistan, treated and allowed
to fly home, second seizure on arrival

Cyclosporine toxicity

Israel - complications post

transplant
3 cases of aspergillosis
2 cases of mucormycosis
1 case of severe hepatitis C

Kidney Transplants - India

India dubbed warehouse for kidneys and

the great organ bazaar

150,000 Indians need transplants annually

Only 3,500 actually performed

Sale of organs illegal Criminal act for foreigners to go to India to

obtain transplants

Kidney Transplants - India

Kidneygate - Illegal transplant ring
400-500 transplants done over past 9 years
Located in residential home in wealthy suburb of
Delhi
Donors

Recipients

Voluntary, paid donations, impoverished people

from slums
Migrant workers kidnapped / held at gunpoint /
drugged
Wealthy Indians, Americans, Europeans, Middle
Easterners

Culprits

Ayurvedic doctor Amit Kumar no MD degree

Kidney transplant - India

So with all the bad press .you would think it

would be difficult to access organ transplants

in India, right?
Numerous websites offering surgery in India
Some note the possibility of bringing a
potential donor
Small print What if you have not donor.

Kidney Sellers - Pakistan

239 kidney sellers
M:F ratio 3.5:1
90% illiterate
69% bonded labourers
93% sold kidney for debt repayment
19% repaying debts of parents, uncles,
grandparents
5% coerced by landlords to repay debts

Kidney Sellers - Paksitan

Promised payment: $1146 - $2950 (mean

$1737 +/- 262)

Actual payment: $819 - $1803 (mean $1377
+/- 196)
No sellers received promised amount
Deductions for hospital stay and travel
88% had no economic improvement
98% had worsened health status

Surgery

USA USD

India USD

BMTx

400,000

30,000

Liver Tx

500,000

40,000

CABG

50,000

5,000

Neuro-surgery

29,000

8,000

Knee surgery

16,000

4,500

Statistics
$60 billion / yr industry*
USA 2006: > million people travelled overseas

for care
Thailand 2006: 36.4 million baht (USD: 1.15
million)
Israel 2006: $40 million, 15,000 health tourists
Singapore 2005: 374,000 health tourists
India: 2005: >150,000 medical tourists
Costa Rica 1993: (CMAJ)

14% tourists came for medical reasons

10% of hospital beds in 1 private hospital occupied
by foreigners

*Crone, Academic Medicine, Vol 83, No 2, Feb 2008, 117-121

The Transplant Map

India, Pakistan
Turkey
Romania
Moldova
China
Philippines
Egypt

UAE / Oman
130 patients traveled to Mumbai for transplant
Poor donor-recipient matching

18.5% mortality (vs < 2% for other transplant pts)

Suspected high level of immunosupression

to compensate for poor matching
increased risk of infectious complications
and death
8 deaths in the immediate post-operative period
16 deaths in the first 3 months post-operatively
24 patients died within 1 year of transplant,
1 patient died after the first year

56% of deaths due to infection

UAE / Oman
Blood and body fluid borne pathogens
3 new diagnoses of hepatitis B
4 new diagnoses of HIV - previously screened
negative
Inappropriate transplant decisions
7 patients transplanted despite having been found
ineligible for transplant in home country
1 patient suspected to have AIDS and advised against
transplant but went to Mumbai and transplanted within
2 weeks, HIV confirmed on return

Stem Cell Transplants China

Parkinsons:
Human retinal epithelial cells from adults
No immunosuppression required
Cells injected stereotactically into putamen
Daily cocktail of drugs to fertilize the area

Stem cell activation and proliferation treatment (to

enhance the bodys own neural stem cells)

~20 patients treated

No published RCTs

Stem Cell Transplants China

Stroke
self stem cell activation and proliferation
50 patients treated
Minor to significant improvements
Cerebral plasy, Degenerative neurologic

disorders, Epilepsy, Brain infections

Neural (fetal) stem cells

Bone marrow stem cells (autologous)

Recommended because the immune system is weak

Both types of cells delivered by lumbar puncture

cells are said to flow through the CSF into the
brain

Thrombosis
DVT PE risk
Post operative period = increased risk for
DVTs / PE

Decreased mobility
Hypercoagulability

High risk: orthopaedic / joint replacement

surgery
Prolonged air travel

Convergence of risks

Economy class syndrome

Early post-op travel

Data?

Thank You !