Private

Taibah University

Journal of Taibah University Medical Sciences (2014) 9(4), 257e262

Journal of Taibah University Medical Sciences

www.sciencedirect.com

Review Article

Kingdom of Saudi Arabia: A potential destination for medical

tourism

Shahzad Khan, MD a,* and Md. Shariful Alam, PhD b

a Wuhan University School of Medicine, Department of Pathophysiology, Wuhan, China

b School of Business and Economics, United International University, Dhaka, Bangladesh

Received 1 July 2013; revised 28 September 2013; accepted 5 January 2014; Available online 6 September 2014

*

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صخلملا

٣٧نمرثكأدوجوب،يملاعلاداصتقالايفًاماهًارصنعةيبطلاةحايسلاتحبصأ نإ.ماعلكورويرايلم٣٣نمرثكأتاداريإوةحصلابةلصتاذةلحرنويلم ةمدقتملاوةيمانلانادلبلايفرمتسمدايدزايفةيبطلاةياعرلاىلعلوصحللرفسلا ةديدجلاةينقتلاىلعلوصحللةيمانلانادلبلايفسانلاىعسيثيح،ءاوسلاىلع ةمدقتملانادلبلايفسانلاىعسيلباقملايفو،ةمدقتملانادلبلايفتاراهملاو راظتنالاةمئاقوفيلاكتلاعافتراببسبىرخأنكامأيفةيبطلاةياعرلاىلإةينغلا قوسلاىلعدنالياتو،ةروفاغنسو،ايزيلامو،دنهلانميهتو.مهنادلبيفةليوطلا يبديفةيحصلاةياعرلاةنيدمءانبعمةدحتملاةيبرعلاتارامإلاتبذج.ةيويسآلا ،طسوألاقرشلاو،يجيلخلانواعتلاسلجملودو،ةيبرغلالودلانمنئابزلا اذهيفةيبعشرثكألانادلبلانمةيدوعسلاةيبرعلاةكلمملاتسيل.ايقيرفألامشو ،ةحجانلاةيبطلاةحايسلاةعانصلةيساسألاتازيملارفوتنممغرلاىلع،لاجملا صاخيحصعاطقدوجوو،ًاديجًازيهجتةزهجمةثيدحتايفشتسمنماهيفامب ًاضيأيهو.ةرقتسمةيملسةئيبو،جراخلابنيبردتمونيصصختمءابطأو،زيمم ةكلمملاذخأتنأنكمي.مهمينيدزكرمومالسإللةسيئرلاةسدقملانكامألانطوم ةيبطلاةحايسلانيبعمجلالالخنمقوسلااذهيفةدايقلاةيدوعسلاةيبرعلا نكلو)ملاعلاناكسنم%٢٣(ملسمرايلم١٠٦ـلطقفسيل.ةينيدلاةحايسلاو لبقنمةيدوعسلاتايفشتسملانمديدعللثيدحلادامتعالارهظي.ملاعلاةيقبلاضيأ ةحايسلاعيجشتلمهمازتلاةيكيرمألاةدحتملاتايالولايفةيلودلاةكرتشملاةنجللا ةكلمملايفتاداريإلاةدايزيفةروثلبابلاةيبطلاةحايسلاحتفتنأنكمي.ةيبطلا .حيحصلكشبتريدأاماذإ،ةيدوعسلاةيبرعلا

;طسوألاقرشلا;ةينيدلاةحايسلا;ةيبطلاةحايسلا;داصتقالا:ةيحاتفملاتاملكلا ةيدوعسلاةيبرعلاةكلمملا

Corresponding address: PhD Scholar, Wuhan University School

Medicine, Department of Pathophysiology, Wuhan, China.

E-mail: [email protected], shahzadkhan571@gmail.

(S. Khan)

r review under responsibility of Taibah University.

Production and hosting by Elsevier

8-3612 � 2014 Taibah University. duction and hosting by Elsevier Ltd. This is an open access article und nc-nd/3.0/). p://dx.doi.org/10.1016/j.jtumed.2014.01.007

Abstract

To perform a comparative study of Medical tourism in

the Arab world with special reference to Saudi Arabia

and find ways to upgrade medical tourism in Saudi

Arabia. A comprehensive literature review and analysis

of statistical data from Saudi Ministry of Health is

performed.

With more than 37 million health-related trips and the

generation of more than £ 33 billion each year, medical

tourism has become an important element in the global

economy. Travelling abroad to seek medical care is

increasing steadily in both developing and developed

countries: people in developing countries seek new

technology and skills in developed countries, while

people in rich developed countries seek medical care

elsewhere because of high costs and long waiting lists

in their home countries. India, Malaysia, Singapore and

Thailand dominate the Asian market, and the United

Arab Emirates, with the construction of the Dubai

Health Care City, attracts clients from western, Gulf

Cooperation Council, Middle Eastern and North Afri-

can countries. Kingdom of Saudi Arabia is not one of

the most popular countries, even though it has all the

basic attributes for a successful medical tourism in-

dustry, including modern, well-equipped hospitals, a

well-established private health care sector, foreign-

trained doctors and specialists and a stable, peaceful

environment. It is also home to the main holy places of

Islam and an important religious center. Kingdom of

Saudi Arabia could take the lead in this market by

combining medical tourism with religious tourism, not

only for the 1.6 billion (23% of the world’s population)

Muslims but also for the rest of the world. Recent

accreditation of many Saudi hospitals by the Joint

er the CC BY-NC-ND license (http://creativecommons.org/licenses/

S. Khan and Md.S. Alam258

Commission International in the United States shows

their commitment to promoting medical tourism. If

properly managed, medical tourism could open the

door for an income generation revolution in Kingdom

of Saudi Arabia.

Keywords: Economy; Kingdom of Saudi Arabia; Medical

tourism; Middle East; Religious tourism

� 2014 Taibah University. Production and hosting by Elsevier Ltd. This is an open

access article under the CC BY-NC-ND license (http://

creativecommons.org/licenses/by-nc-nd/3.0/).

Table 1: Countries and numbers of hospitals with Joint Com-

mission International accreditation in August 2013.

Country Number of accredited

hospitals

Bahrain 1

Bangladesh 1

China 16

Egypt 3

Germany 3

Indonesia 5

Israel 7

Jordan 9

Kuwait 2

Lebanon 2

Malaysia 6

Qatar 5

Pakistan 1

Republic of Korea 13

Kingdom of Saudi Arabia 42

Singapore 14

Taiwan 12

Thailand 18

Turkey 39

United Arab Emirates 39

Introduction

Medical tourism is the practice of travelling to another

country with the purpose of obtaining health care, including elective surgery, dental treatment, reproductive treatment, organ transplant and medical check-ups. It is not the same as

“wellness tourism”, which involves visiting spas and under- taking homeopathic treatment and traditional therapies.

1

Carrera and Bridges 2

described health tourism as “the organized travel outside one’s local environment for the

maintenance, enhancement or restoration of an individual’s well-being in mind and body”.

The reasons for medical tourism include 3e5

: lack of

availability of a particular facility in the home country; health care in the home country too expensive

5 ; health

need or procedure not covered by health insurance in the

home country; desire to avoid long waiting lists controlled by the government

6e8 ; privacy and confidentiality in a far-

off setting (for e.g. plastic or cosmetic surgery, fertility treatment, gender assignment procedures and drug rehabil-

itation) 9 ; lack of availability of a specific diagnostic

manoeuvre in the home country, regardless of whether treatment is required; combining tourism with an elective

procedure (e.g. in Israel, people can have medical treatment and also visit some of the holiest places in the world)

10e12 ; annual or routine medical check-up for

healthy people 13 ; and screening for specific diseases in cases

of a family history. 14

Choice of a suitable country for medical tourism

When a person decides to undertake medical tourism, the first step is to select a destination. This depends primarily on

the availability of the desired facility, cost and technical excellence. A blind decision to select a more developed country for medical tourism is being replaced by local and

regional hubs or centres of medical tourism, which attract people from specific regions. Medical tour operators play an important role in choosing countries and may also persuade

people to go to specific hospitals and hotels with which they have business contracts.

7 As far as professional excellence is

concerned, the hospital chosen should be assessed and

accredited by a dependable, independent external accreditation body. In international health care accreditation, the quality of health care providers and programmes is ascertained globally. These bodies certify

not only hospital services but also a wide range of health

care programmes, including primary care, medical transport and ambulatory care. Accreditation Canada

(formerly known as the Canadian Council on Health Services Accreditation) is the oldest of such agencies. Others include the Joint Commission International based

in the USA, QHA Trent Accreditation in the United Kingdom, the Australian Council for Healthcare Standards and the Society for International Healthcare Accreditation.

Some hospitals have multiple international accreditations in order to attract people from many regions. Many countries are applying for international accreditations in order to boost their medical tourism industry. For

example, in 2007, at least 15 hospitals in India and 5 in Thailand had Joint Commission International accreditation, whereas there are now 20 hospitals in India

and 18 in Thailand, 15

to meet the growing demand. The accreditation is reviewed every 3 years. Table 1 lists the numbers of hospitals with accreditation by Joint

Commission International in August 2012. It should be noted that affiliation with a reputable agency

does not necessarily mean that a country or hospital will receive more clients; this also depends on tourism authorities,

who use their own tactics to attract patients, regardless of accreditation, such as by offering full services, including any bookings that patients and their families might require,

flights, car services, accommodation, clinic appointments, interpreters and recreational activities. Hospitals may also advertise themselves, and tour operators and hospitals may

have mutual agreements. Sometimes, the popularity of a region may influence the selection of destination. For example, although China has few accredited hospitals, it

attracts many patients from neighbouring countries such as Pakistan and Viet Nam, where people consider that China is more advanced than their own country. Regional or global impact is important and can sometimes surpass accredita-

tion. For example, Germany has few accredited hospitals but

Table 2: Gross health expenditure in Kingdom of Saudi Arabia,

2011.

Indicator 2011 value

Total health expenditure

(% gross domestic product)

4

General Government expenditure

on health (% total health expenditure)

69

Private expenditure on health

(% total health expenditure)

31

Total expenditure on health per

capita at purchasing power

parity (riyals per US$)

901

Total expenditure on health

(million riyals)

79 795

General government expenditure

on health (million riyals)

55 003

Private expenditure on health

(million riyals)

24 792

Medical tourism in Saudi Arabia 259

attracts many Gulf nationals to its health centres and specialist hospitals. The main reason is that it has an estab-

lished reputation for high standards of care and advanced medical treatment.

16

Economic value of medical tourism

Medical tourism is an important source of revenue: the report of the Tourism Research and Marketing Group shows

that 37 million health-related trips are taken each year, generating V33 billion.17 The economic value is not only in the direct health budget but also in indirect factors, as foreign patients are often accompanied by family members

or friends, who are likely to use facilities such as hotels, restaurants, tourist attractions and tour operators. The numbers of patients from richer nations going abroad for

medical treatment is substantial; according to a McKinsey report based mainly on US citizens, the figure is between 60 000 and 85 000 annually.

18 The annual number of

patients travelling from the United Kingdom for this purpose elsewhere in Europe and internationally is estimated by industry sources to be 50 000.

19

Regional examples show a similar trend. Currently, India,

Singapore and Thailand and, in the Gulf, Jordan and the United Arab Emirates (UAE) are paying greater attention to medical tourism, increasing their hold on the market in the

region. These countries find significant economic develop- ment potential in this emerging field. The Indian, Malaysian, Singaporean and Thai governments have all sought to pro-

mote their comparative advantages as medical tourism des- tinations at large international trade fairs, by advertising in the overseas press and providing official support as part of

their economic development and tourism policy. 20

For example, 150 000 medical tourists visited India in 2004, according to the Confederation of Indian Industries, and medical tourism may have brought in US$ 2 billion by the

end of 2012. 21

Medical tourism in the Arab region

The UAE has achieved notable successes in medical tourism and a documented increase in the number of patients coming from abroad to seek medical treatment. According to

newspaper reports, Dubai Health Care City showed a sharp growth in medical tourism during the past 3 years. Of 502 000 patients in 2011, about 15% were medical tourists, compared with 10% of 412 000 patients in 2010 and an estimated 5% of

231 000 patients in 2009. Each month, the City Hospital in Dubai receives 10e15 foreign patients, and Al Noor Hos- pital in Abu Dhabi receives 15% of patients from abroad.

The UAE has focused on becoming the hub among Gulf Cooperation Council countries and tries to divert the flow of foreign patients towards the UAE by continuous, efficient

advertisement, introducing legislation to facilitate the visa process, building infrastructure, hiring top-class foreign- trained doctors and staff from all over the world with

attractive packages and facilities, and international cooper- ation with medical tour operators.

22

Jordan has gained a reputation in the region for its commitment to offering services for medical tourism in an

emerging, strong medical services sector. 23 In 2005, nearly all

foreign patients coming to Jordan were from the Middle East, with the highest percentages arriving from Yemen (29%),

Libya (16%), Palestine (12%), Sudan (7%) and other countries in the Middle East and North Africa, i.e. mainly from neighbouring Arabic-speaking countries. According to

Jordan’s competitiveness report in 2010, medical tourism brings in a revenue of US$ 1 billion annually, with a steady increase of about 10% more foreign patients each year.

23

Medical tourism in Kingdom of Saudi Arabia: current

situation and future scope

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. It represents the largest economy in the region, with a national budget of US$ 144 billion and a surplus of US$ 20.4 billion. 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.

According to WHO, 24

total health expenditure as a percentage of gross domestic product was stable in 2009e 2011 (latest data available) at about 4.0%, at a total of

79.795 million Saudi Arabian riyals (Table 2). 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.

25 Fast-growing health needs in a

changing global economic situation demand new ways of health care financing, and medical tourism is a globally tested solution. The recent trend of obtaining accreditation from

the Joint Commission International resulted in more than 40 accredited hospitals by August 2012.

15 Although

accreditation is not designed to attract more patients from

abroad but rather to upgrade national health facilities, the authors believe that this will develop more trust among foreign patients choosing a hospital. Most doctors in Saudi hospitals have been trained in western countries with well-

S. Khan and Md.S. Alam260

known, trustworthy training systems, which may attract patients from abroad.

Merging religious and medical tourism

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 impor-

tant. Furthermore, during illness, people may have greater spiritual needs. Several studies have shown a potential impact of religious or spiritual activity on physical and

mental health. Most have shown that religious involvement and spirituality are associated with better health outcomes, including faster recovery, greater longevity, better coping

skills and feelings of optimism and hope, with reduced feel- ings of depression and anxiety.

26,27 The fact that Kingdom of

Saudi Arabia is home to the most important holy places of Islam makes religious tourism the backbone of Saudi

tourism. 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. Israel is a good example, as many medical tourists select Israel as a destination because of its attractive sites, such as the Dead

Sea. 13

Moreover, most Muslims believe that God 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.

28

Kingdom of Saudi Arabia’s achievements in health care

Kingdom of Saudi Arabia has made notable achieve- ments in some health care-related fields, which could lead the nation’s potential health-related progress. For example

Kingdom of Saudi Arabia has a well-developed organ transplant set up and has a good history of successful transplants (Table 3); however, many Saudis seek transplants

in other countries, underestimating their own capability. A recent study showed high mortality and morbidity rates in Saudi and Egyptian patients who received transplants in

China when compared with those transplanted in King Faisal Specialist Hospital and Research Centre during the same period.

29 As described earlier, Saudi hospitals are

equipped with well-trained professionals and the most

advanced technology, and this edge could be used to market medical tourism. The facilities include well-equipped critical

Table 3: Organs successfully transplanted in Kingdom of Saudi

Arabia, 1983e2009.

Transplanted organ Period Total

Lung 32

Cornea 1983e2008 18 225 Kidney 1979e2009 6 143

Heart valves 1986e2009 497

Heart 1986e2009 168

Liver 1990e2009 828

care units such as for burns, surgical intensive care, endos- copy, neurosurgery and general surgery. All these are

attractive reasons for the people of the region to select Kingdom of Saudi Arabia as their destination for meeting their health requirements. Neurological rehabilitation for the

handicapped, rehabilitation with both occupational therapy and physiotherapy and rehabilitation for people with neurological disorders due to stroke and cerebral palsy are

particularly suited for the Arab population of the region, who require not only professional and technological profi- ciency but also cultural and language similarities, which can hasten their recovery. Kingdom of Saudi Arabia’s capacity

can be judged from the fact that, in 1 year, 463 481 cases were treated in Ministry of Health hospitals and 949 876 cases in other Government sector hospitals, with physiotherapy,

speech therapy and various types of rehabilitation. 30

Moreover, 353 203 disabled children were successfully rehabilitated, including speech therapy, physiotherapy and

psychological consultations. 31

A successful record in surgery, especially for separating Siamese twins,

32 could be

a focus for medical tourism.

Barriers to medical tourism in Kingdom of Saudi Arabia

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 med-

ical 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.

33 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.

33 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.

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 in-

formation portals should be dedicated solely for this pur- pose, and a more efficient national health information system

34 should be set up, from which the international

community could also benefit.

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

Medical tourism in Saudi Arabia 261

burden of scheduling appointments, booking hotels and providing assistance in getting a medical visa.

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.

Suggested remedies

Identify specific areas for medical tourism

Although providing all types of medical services is a fascinating target, focussing 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, Israel on in-vitro fertilization, China on stem cell treatments, India on alter- native medicine, bone-marrow transplant, cardiac bypass

surgery and eye surgery. 35

Kingdom of Saudi Arabia must explore which field its hospitals should focus on.

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 Chi-

nese 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 adver-

tised, the entire Muslim world.

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.

More international cooperation

Cooperation with foreign governments and private bodies will have dual benefits, such as publicity at the cross-border level and, more importantly, direct access to Saudi health

facilities. The Ministry of Health has tried a number of strategies in this regard, including cooperation with the governments of Germany, the Netherlands and Thailand.

One possibility is operation of selected medical units or complete hospital systems by well-known foreign health care companies. Bearing in mind the pros and cons of this ap- proaches, the Ministry of Health has instituted a pilot system

for 31 public hospitals across the country, which are

continuously monitored. Expansion of the policy will de- pends on the outcome of this study.

34

Expanded use of Internet-based health information and E-

health

e-Health and electronic information systems are already functional in many Saudi hospitals, such as the King Faisal Specialist Hospital and Research Centre, the National Guard

Health Affairs and Medical Services of the Armed Forces. 36

The Ministry of Health understands the importance of E- health and undertook a 4 billion-riyal project between 2008

and 2011. 37

To emphasize the importance of e-health and to explore future strategies and infrastructure, a series of conferences on e-health is organized by the Saudi

Association for Health Informatics every 2 years (the latest one was in 2012).

38 Yet another success in bringing the

benefits of information technology to medical care is the

creation of ‘telecare’ systems to follow up patients with chronic diseases after discharge from hospital. A telecare system is already functioning in the country. For example, the telecare system for managing diabetes at the Saudi

National Guard Hospital in Riyadh is a web-based pro- gramme that allows diabetes patients to communicate online with their clinic in order to follow their blood sugar levels,

without having to visit the clinic. 39,40

This system would be of great benefit to foreign clients, who would feel secure and attached to the hospital even after discharge.

Conclusion

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 in-

dustry. 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.

Conflict of interest

The authors have no conflict of interest to declare.

References

1. Smith R, Martı́nez Álvarez M, Chanda R. Medical tourism: a

review of the literature and analysis of a role for bi-lateral trade.

Health Policy 2011; 103: 276e282.

2. Carrera PM, Bridges JF. Globalization and healthcare: under-

standing health and medical tourism. Expert Rev Pharmacoecon

Outcomes Res 2006; 6: 447e454.

3. Burkett L. Medical tourism. J Leg Med 2007; 28: 223e245.

4. Dunn P. Medical tourism takes fight. Hosp Health Netw 2007;

81: 40e42.

5. Milstein A, Smith M. America’s new refugeesdseeking afford-

able surgery offshore. N Engl J Med 2006; 355: 1637e1640.

S. Khan and Md.S. Alam262

6. Ramirez de Arellano AB. Patients without borders: the emer-

gence of medical tourism. Int J Health Serv 2007; 37: 193e198.

7. Turner L. Medical tourism: family medicine and international

health-related travel. Can Fam Physician 2007; 53: 1639e1641.

8. Snyder J, Crooks VA, Johnston R, Kingsbury P. What do we

know about Canadian involvement in medical tourism? A

scoping review. Open Med 2011; 5: e139ee148. 9. Horowitz MD, Rosensweig JA, Jones CA. Medical tourism:

globalization of the healthcare marketplace. Medscape Gen Med

2007; 9: 33.

10. Sukenik S, Abu-Shakra M, Kudish S, Flusser D. Dead Sea and

Tiberias as health resort areas for patients suffering from

different types of arthritis. Harefuah 2006; 145: 117e122.

11. Ingber A. Medicine is flourishing at the Dead Sea. Isr Med

Assoc J 2006; 8: 499e500.

12. Moses SW, David M, Goldhammer E, Tal A, Sukenik S. The

Dead Sea, a unique natural health resort. Isr Med Assoc J 2006;

8: 483e488. 13. O’Hagan HC. Medical tourists opting for sea, sand, sun and

surgery. Abu Dhabi: National Abu Dhabi Media Co; 2012.

14. Oh KM, Jun J, Zhou Q, Kreps G. Korean American women’s

perceptions about physical examinations and cancer screening

services offered in Korea: the influences of medical tourism

on Korean Americans. J Community Health; 2013 [Epub 2013/

12/11].

15. JCI accredited organizations. Oak Brook, Illinois: Joint Commis-

sion International; 2013.http://www.jointcommissioninternational.

org/jci-accredited-organizations/ [accessed 05.09.13].

16. Connell J. Medical tourism: sea, sun, sand and. surgery. Tourism Manage 2006; 27: 1093e1100.

17. Smith RD, Chanda R, Tangcharoensathien V. Trade in health-

related services. Lancet 2009; 373: 593e601.

18. Ehrbeck T, Guevara C, Mango PD. Mapping the market for

medical travel. McKinsey Q; May 2008.

19. Medical tourism survey. Churchgates, Herts: Intuition

Communication Ltd; 2007.http://www.treatmentabroad.com/

about/medical-tourism-survey/?locale¼en [accessed 09.03.13]. 20. Lunt N, Carrera P. Medical tourism: assessing the evidence on

treatment abroad. Maturitas 2010; 66: 27e32.

21. Chinai R, Goswami R. Medical visas mark growth of In-

dian medical tourism. Bull World Health Organ 2007; 85:

164e165.

22. Ismail M. Dubai Healthcare City to compete for foreign pa-

tients. The National. http://www.thenational.ae/news/uae-news/

tourism/dubai-healthcare-city-to-compete-for-foreign-patients;

18 February 2012 [accessed December 2013].

23. Jordan’s competitiveness report, chapter 6: medical tourism.

Amman: Ministry of Planning and International Cooperation;

2007.

24. NHA indicators. Geneva: World Health Organization;

2013.http://apps.who.int/nha/database/DataExplorer.aspx?

ws¼0&d¼1 [accessed 01.09.13]. 25. Al-Yousuf M, Akerele TM, Al-Mazrou YY. Organization of the

Saudi health system. East Mediterr Health J 2002; 8: 645e653.

26. Boelens PA, Reeves RR, Replogle WH, Koenig HG. The effect

of prayer on depression and anxiety: maintenance of positive

influence one year after prayer intervention. Int J Psychol Med

2012; 43: 85e98.

27. Allen RS, Harris GM, Crowther MR, Oliver JS, Cavanaugh R,

Phillips LL. Does religiousness and spirituality moderate the

relations between physical and mental health among aging

prisoners? Int J Geriatr Psychiatry 2013; 28: 710e717.

28. Hayden D. Spirituality in end-of-life care: attending the person

on their journey. Br J Community Nurs 2011; 16: 546.

29. Allam N, Al Saghier M, El Sheikh Y, Al Sofayan M, Khalaf H,

Al Sebayel M, et al. Clinical outcomes for Saudi and Egyptian

patients receiving deceased donor liver transplantation in

China. Am J Transplant 2010; 10: 1834e1841.

30. Usman NAA. Health statistical year book. Riyadh: Ministry of

Health; 2009 [Report No. 15/0588].

31. Services of rehabilitation center for disabled children by age.

Riyadh: Saudi Society of Caring Handicapped Children; 2009.

32. National guard health affairs. Wikimedia Foundation, Inc;

2013.http://en.wikipedia.org/wiki/National_Guard_Health_

Affairs#cite_note-2 [accessed 24.04.13].

33. Davis M. The global emergence of Saudi Arabia in medical

tourism. Raleigh, North Carolina: ArabMedicare.com; 2009.

http://www.arabmedicare.com/Medical_Tourism/news_Ziyad_

Bin_Mahfouz_Interview.htm [accessed 01.03.13].

34. Almalki M, Fitzgerald G, Clark M. Health care system in Saudi

Arabia: an overview. East Mediterr Health J 2011; 17: 784e793.

35. Medical tourism in India. Wikimedia Foundation, Inc;

2013.http://en.wikipedia.org/wiki/Medical_tourism_in_India

[accessed 01.03.13].

36. Altuwaijri MM. Electronic-health in Saudi Arabia. Just around

the corner? Saudi Med J 2008; 29: 171e178.

37. Mufti MH. Healthcare development strategies in the Kingdom of

Saudi Arabia. Berlin: Springer; 2000.

38. Riyadh Saudi Association for Health Informatics Conference

2009., http://www.saudiehealth.org/; 2012 [accessed 01.09.13].

39. Telecare for Managing Diabetes TeMaD. Riyadh: Ministry of

Health; 2013.http://eapps.ngha.med.sa/newapps/temad/user/

index.aspx [accessed 04.09.13].

40. Alkadi K, Roudsari A. TeMaD system: telecare for managing

diabetes in Saudi Arabia. Stud Health Technol Inform 2013; 183:

57e62.