Introduction

In 2005, nearly 374,000 travelers traveled to Singapore for medical treatment. Today, tourism has become one of the largest industries in the world. One of the sub-sectors of this industry that has brought a lot of financial flow is medical tourism. Numerous factors have led tourists to seek treatment abroad. This article introduces the medical tourism industry, and examines this market in countries active in this field. Medical tourism industry Today, attention to tourism and its positive effects has greatly increased. This industry plays a very important role in the social and economic well-being of host communities. According to the World Tourism and Travel Council, tourism is becoming the world's largest industry. The number of tourists and turnover of this industry has been growing during the years 1990 to 2010. The number of tourists has increased from nearly 270 million in 1990 to approximately 950 million in 2010. This industry has several functions, including the vital force for peace, social importance, economic importance, cultural richness, employment opportunities and educational purposes. One of the branches that has been welcomed by tourists in recent years is medical tourism. According to the definition of the World Tourism Organization (WHO), health and medical tourism refers to people traveling from their place of permanent residence to maintain, improve or regain physical and mental health for a period of more than 24 hours and less than a year. But in this context, the definition of "nomads" may be more accurate in expressing the concept of this type of tourism: Medical tourism is the sum of all relationships and phenomena that result in relocation of people in order to improve, stabilize and return the situation to its original state. Physical, mental and social use of health services and by those who do not live or work. The concept of medical tourism is not new, but its history dates back to thousands of years ago. That is, from the time when Greek pilgrims went to a sacred place called Epidoria in the Saronic Gulf to seek healing and healing from Asclepius, the god of health. There were also experienced people who treated the sick. People in Britain, during the Roman Empire for two thousand years, went to shrines where they bathed in holy water. In the 18th century, wealthy Europeans, especially Germans, tended to travel along the Nile for peace and health. Medical tourism can be categorized into different types. In one of the divisions, medical tourism is divided into three sections based on the cost and risks of surgery: Light treatments such as dentistry, facial beauty, ophthalmology and complete checkup Moderate treatments such as hair and cornea transplants, infertility treatments, beauty treatments in different areas of the body and angioplasty; heavy treatments such as internal surgeries such as organ transplants, cochlear implants, open heart surgery, spinal cord repair, bone marrow transplants, etc. In another division based on clients' interests, surgical expertise and length of treatment in this area into four sections of cosmetic surgery, hydrotherapy and health tourism, dental tourism and infertility tourism are divided. The link between health care and tourism is growing in such a way that the contradiction in the combination of the concept of leisure and pleasure and illness, suffering and treatment can be ignored. Medical tourism is in the role of marketing that has been formed by countless medical, economic, social forces and potential factors in this field. Many countries have succeeded in competing in the medical tourism market by offering a wide range of surgical, dental and medical services with comfortable and modern equipment.

Definition of medical Tourism   

Medical tourism refers to people traveling abroad to obtain medical treatment. In the past, this usually referred to those who traveled from less-developed countries to major medical centers in highly developed countries for treatment unavailable at home. However, in recent years it may equally refer to those from developed countries who travel to developing countries for lower-priced medical treatments. The motivation may be also for medical services unavailable or non-licensed in the home country: There are differences between the medical agencies world-wide, whether a drug is approved in their country or not. Even within Europe, although therapy protocols might be approved by the European Medical Agency (EMA), several countries have their own review organizations in order to evaluate whether the same therapy protocol would be "cost-effective", so that patients face differences in the therapy protocols, particularly in the access of these drugs, which might be partially explained by the financial strength of the particular Health System.

Health tourism

A combination of several factors has led to an upward trend in people's inclination to medical travel, including the high cost of living in industrialized countries, the facilitation of international travel, and the improvement of medical technology and standards in many countries around the world. One reason for the attraction to medical travel is its convenience compared to other countries. In some countries where the public health care system is common, it often takes a long time to meet the needs of citizens and patients have to wait a long time to be treated, conditions such as hip transplants that have to wait in line for a year or more in the UK and Canada. However, in Singapore, Thailand, the Philippines, or Bangalore, India, a patient can be cared for and treated one day after arrival. Reasons why people travel for treatment include the low cost of medical care, the search for a specialist and experienced doctor, the quality of care, safety, and the shorter waiting time for treatment. In Canada, the number of people waiting for treatment in 2005 was 782,936, a world record. The number in South Africa was less than a tenth lower than in the United States or Western Europe. The cost of a tooth in the United States is $ 5,500, in India and Bolivia it is $ 500, in the Philippines it is $ 200, and the cost of a knee transplant in Thailand with six days of physiotherapy is about one-fifth that in the United States, and LASIK's surgery costs 3,700. The dollar in the United States is estimated at $ 730 in many countries with a health tourism approach. In addition, while facial cosmetic procedures, which may cost around $ 20,000 in the United States, cost between $ 2,300 and $ 2,700 in countries such as South Africa, the Philippines, and Bolivia. Seekers of treatment and health from anywhere in the world can enter a country and receive medical services and care in areas such as cancer, neurological diseases, organ transplants, cosmetic surgeries and so on. Countries that mainly receive medical tourists include Brunei, Cuba, Hong Kong, Hungary, India, Jordan, Lithuania, Malaysia, the Philippines, Singapore, Thailand, and most recently the United Arab Emirates. Argentina, Bolivia, Brazil, Costa Rica, Mexico and Turkey

are also considered for beauty practices. In Europe, too, Belgium and Poland are engaged in the medical tourism business. Interestingly, the country of South Africa is trying to attract medical tourists with the poems "Facial surgery with wildlife". In a country like the United States, with all the quality and high-quality insurance services and treatments, doing business in the health tourism business is a risk. It is enough to cite an example to show the reason for this approach in the United States, and that was the change in the tendency of many patients in the Middle East in 2006 who preferred to go to Hong Kong and Singapore for their treatment.

Medical tourists travel to the four corners of the world for general checkups, ophthalmology, cosmetic services, dentistry, organ transplants, heart surgery, organ cell culture, artificial insemination and treatment of obesity (Fig. 1).

Figure 1. The flowchart of screening the eligible studies

The most common surgeries that are considered by medical tourists are: cosmetic surgery, dentistry (general restorations, cosmetics), cardiovascular (angioplasty and transplants), orthopedics (joint and spine, sports medicine), cancer, fertility, weight loss and gastric bypass, scanning, testing and health screening. Asian destinations are especially welcomed for bone defects and heart operations. India, Singapore and Thailand are well-known destinations in medical tourism that attract large numbers of foreign patients and earn a steady income from the services provided. These countries have vast modern medical facilities run by skilled physicians who provide a range of different services. The ability to provide services in medical tourism destinations depends on the level of development of the national economy. In terms of the characteristics of the economic environment and specialized responsibilities for paying premiums, the rate of medical services in some destinations is lower than others.

In addition, medical tourism facilitates access to resources and development in areas that previously lacked health benefits and can now provide medical benefits not only to foreign tourists but also to indigenous peoples. Numerous factors have played a role in attracting medical tourists, including flow of international patients, potential for cost savings, transparency and political stability, proper structure of the tourism industry, stable reputation for a particular advantage, history of achievements and inventions in the field of health, experienced employees in the field of health and appropriate technology in this sector is one of the effective factors in the potential of attracting medical tourists. The success of countries in attracting medical tourists offers many opportunities. The largest centers of medical tourism attraction are Brazil, Costa Rica, India, South Korea, Malaysia, Mexico, Singapore, Taiwan, Thailand, Turkey and the United States. In general, the tendency to use medical tourism services has different causes. One reason for the attraction to medical travel is its convenience compared to other countries. In some countries where the public health care system is common, it usually takes a long time to meet the needs of citizens and patients have to wait a long time to be treated, such as hip transplants, which in the UK and Canada have to wait in line for a year or more. But in Singapore, Thailand, the Philippines or India, a patient can be cared for and treated one day after arrival. Another reason why people travel for treatment is the low cost of medical care in other areas. The motto of this industry is to achieve first world health services at third world prices. As can be seen in Table 1, the cost of treatment in some countries active in the field of medical tourism has been considered. As can be seen, the level of treatment costs varies greatly between these countries, and patients are able to pay lower treatment costs while receiving high medical services. The medical tourism industry has been one of the sources of national economic development in many countries. An example of the use of this resource can be seen during the 90s. In countries across Asia and Latin America, the middle-income population declined sharply during these years. This has reduced demand for the private healthcare and medical markets and left the private sector facing serious health problems. In Thailand, for example, as the Thai baht depreciated, unemployment soared, the Thai stock market plummeted, and many Thai families lost their savings and could no longer afford their own private medical services. Following the crisis in the private sector of medical services, Thailand International Hospital and Bangkok Hospital Group were widely seeking to expand their international market. Governments in other countries, such as India, Thailand, Singapore, the Philippines, and Indonesia view medical tourism as an important source of economic and social development. Singaporean leaders believe that given the country's limited population, efforts are needed to attract foreign tourists in order to retain medical professionals and the private sector. India is one of the most popular destinations for medical tourists in the world. It is a world leader, especially in the field of heart surgery and bone, thigh and other medical transplants. No country in the field of medical tourism has been comparable to India during 2005 and 2006, and the Indian government and private sector are aware of the goal of promoting medical tourism services and turning the Indian subcontinent into a single hub. The cost of treatment in India is much lower than the cost of medical services in developed countries such as the United States and the United Kingdom. The country has one of the largest centers of cosmetic surgery, dentistry, bone marrow transplantation, cancer treatment, which is equipped with the latest electronic equipment and disease diagnosis. In Singapore, the quality of health care is excellent. Advanced research and international reputation in the field of medicine, safety, and trust are among the strengths of this industry in Singapore, which has made this country one of the main centers for attracting medical tourists. In 2005, nearly 374,000 people traveled to Singapore for medical treatment. Many patients from neighboring countries such as Malaysia and Indonesia have traveled to the country, and the number of tourists from India and China,

South Asia and the Middle East is also increasing. In late 2006, Singapore hospitals were certified by the U.S. Joint Commission International (JCI) and are still seeking similar certifications in European and Asian systems.

In Thailand, medical tourism is a growing part of the Thai tourism industry. The cost of treatment in Thai hospitals is very low compared to the United States, and at the same time nursing services and medical care are provided at a high level. Thai hospitals are ready to provide medical services to tourists and some of them provide translation services in 22 languages of the world in addition to English. The modern medical service system in Thailand is inspired by the American medical system, and the reason for this is the tendency of the Thai royal family to study citizens in prestigious American universities such as Harvard University. In addition to this favorable situation, the existence of some issues like the existence of some infectious diseases, has made American and European medical tourists less interested in traveling to this country. In general, medical tourism as one of the branches of the tourism industry has been followed by a large financial flow worldwide. Many countries have taken advantage of the opportunities that this branch of tourism provides for their economic development. In fact, countries with a high level of medical and care services have been able to take advantage of the economic opportunities created by this industry in the direction of their economic development.

Results

E Medical tourism has originated from a broader field of tourism, namely health tourism [14,15]. In medical texts and health studies, medical tourism is used as a general term that refers to a foreign trip to seek medical treatment and this trip is with or without tourism services [10]. Despite the clear definition of medical tourism, the statistics that are always reported include all foreigners receiving medical services in the host country. In other words, the statistics include people living in a foreign country, although they are not considered tourists, while various sources about the relative importance of receiving medical services during the trip to the host country by tourists are significantly different. Accordingly, a spectrum is presented to clarify the meaning of medical tourism (16). According to this spectrum, a "tourist" is a person who has no use of medical services while spending leisure time in the host country. "Medical tourist" is a person who receives medical services and tourism services in the host country. The tourist has been motivated to receive medical services in addition to leisure. "Patient for leisure" is a person who chooses the host country for the purpose of receiving medical services, but suddenly uses leisure services, especially during the recovery period and follow-up of a particular surgery or treatment. Finally, a "patient" is an individual who has chosen the host country only to receive medical services (Table 1).

Table 1. Results of search strategy in selected databases between 2011-2011 and identification of final articles

Motivations of medical tourists

Medical tourism has grown for a variety of reasons. Various studies indicate that the main reasons for the growth and development of the medical tourism industry include the following: a) Increasing the waiting list in developed countries [16-19]; b) increasing the rate of international exchanges, internet- with the development of communication network, new companies have been established as intermediaries between international patients and hospital network that provide basic information to patients; c) low services in developing countries [19-23]; d) modern technology and equipment adapted to new health services [24]. Bristow et al showed the cost and reputation of medical facilities and centers, accreditation of hospitals, reputation of doctors, opportunities after surgery (recovery period), culture of the country, dependence of facilities on hospitals in developed countries, the lack of some medical services in the country were among the factors which affects consumer behavior [25].

Ethical issues in medical tourism and its impact on the health system

Connell et al. see medical tourism as an element in the growth of the global tourism industry [1]. In this regard, they pointed to some issues such as the privatization of the health sector, the key role of technology and access to health resources to promote medical tourism [1]. In other words, medical tourism allows low-income countries to enter the global tourism industry and ensure their economic growth. These people believe that the development of medical tourism will ensure appropriate taxes and profits for industries and its income is a good subsidy for public health. Such a subsidy could lead to the payment of staff, staff training, development of equipment and facilities in the public health system. Medical tourism stimulates foreign direct investment in developing countries and thus provides the necessary development capital that benefits the country's population [28]. Based on the analysis of media discourses, the study shows a change in attitudes toward medical tourism, so the ethical dimensions of medical tourism in the field of infertility tourism and transplant tourism has surrendered to market logic [29]. According to these cases, the ethical issues of medical tourism based on different texts can be divided into two categories of ethical issues related to domestic patients and ethical issues of foreign patients: 1) ethical issues related to domestic patients, and 2) ethical issues related to foreign patients. As for the former, they include the areas in which medical services should be provided, while the country's domestic population suffers from illness or receives poor medical services. Medical tourism is a growing global industry that has significant impacts on the health system. The medical tourism industry is stimulating the faster growth of the private sector in leading countries in medical tourism such as Thailand and India by increasing the number of joint ventures [24]. Although such contributions help to improve facilities and introduce excellent management methods and information systems, earning more money through medical tourism can be an important issue for private hospitals to apply for more government subsidies over time. This leads to conditions in which joint-stock hospitals use government subsidies and funds, resulting in outflows from the government health system and the creation of two separate health departments (the stock sector and the public sector), which focus on advanced technologies and services are not needed by the wider community. In this two-part system, there may be a discussion of skimming cream, which means that people with less need but more pay, receive services (treatment) at the expense of the disabled and poor people [30]. Also, in the country, medical resources may be transferred from basic health services (improvement-infection control and healthy nutrition) to the provision of third-level care, which these services are not needed by the local population [31]. High shortage of skilled professionals in the health sector: Another issue is brain drain, which has led to the transfer of doctors and staff from a public hospital to a private hospital, as wages and working conditions are better than in the country [32]. Moreover, regarding irregular growth of the private sector, the government should play an important role in private sector law and regulation, but in India government intervention is minimal and there is no policy framework based on a specific set of rules and regulations for the private health sector. Enforcement and enforcement of existing laws is weak and many laws are not updated and are not sufficiently relevant to the situation. The government has no structured way to handle private sector issues. Private health institutions also show significant resistance to the adoption of specific principles, rules and regulations for professional manpower [30]. With respect to increased cost of medical procedures, in recent years, several studies have shown that medical costs have increased. This level of cost leads to inadequate and non-standard health and lack of health facilities and limited access of patients to the public health system and patients are forced to go to the private sector to receive services and for this purpose many of them are forced to sell their assets [20]. As for ethical issues related to foreign patients, in the medical tourism industry, there is a need for a series of regulations and reporting systems that evaluate the quality of care to compare indicators and facilitate accreditation and validation of certificates. However, there are no qualitative and safety data on infection rates for institutions and no reports of adverse events [14].

What is medical tourism? There are various definitions of medical tourism, sometimes referred to as health tourism or health tourism. WTO specifically defines health tourism as the use of services that improve or enhance one's health and morale, using mineral water, climate or medical interventions, and outdoors; it takes more than 24 hours from where you live. The category of health tourism goes beyond medical tourism. Hot and mineral waters and sludge treatment along with natural facilities are also included in health tourism. The global motto of health tourism is facilities and services at the level of first or advanced world countries and prices and costs at the level of developing countries and the third world. Health tourism has existed since ancient Greece and Rome and then spread to many European countries and other parts of the world. Since ancient times, people used to go to the river and mineral waters for spiritual relaxation and healing and warm waters have been associated with peace and rejuvenation of human body and mind. Users of such waters have been bathing in hot water for centuries and drinking water from mineral springs. In the UK, the development of seaside resorts is based on the belief that the use of seawater is beneficial in the treatment of disease. In Europe, many cities have been built around mineral springs and medical facilities. Examples can be found in the cities of Baden, Lassana, Moritz and Interlaken in Switzerland, Baden and Wiesbaden in Germany, Vienna in Austria and Budapest in Hungary. In these cities, people use mineral water to treat diseases such as rheumatism, skin infections and indigestion. In Europe, mineral springs and hydrotherapy clinics received serious attention in the late eighteenth century, and in addition to being equipped with appropriate equipment, the spaces around them were arranged to enjoy the tranquility and tranquility and natural landscapes. In such clinics, medical consulting teams are engaged in prescribing the duration and method of using each type of water to treat various diseases. References to such waters are often made by patients with skin disorders, rheumatic pains, arthritis, fatigue and excessive physical exhaustion, gout, inflammation of the vertebrae and spine. In the United States, people travel to mineral springs, resorts near the sea. The oldest area of American hot springs is Saratoga, which has been active for about 200 years as a commercial area in this area by providing suitable accommodation and hospitality facilities. Mineral springs near Philadelphia and Virginia can also be mentioned. To maximize the convenience of travel, facilities such as a library, theater, music hall and playground have been created to entertain tourists. So, today people travel to these areas not only for hydrotherapy but also to use a variety of social entertainment.

There is a lot of evidence and traces of the importance of mineral and warm waters for Iranians. In particular, the categories of Bu Ali Sina, which divide these areas into spiritual sanatoriums, healing springs and hot springs,