A by-product of globalisation, in short – the increasing economic integration and interdependence of nation states and regions – is the rapidly growing international market in health care services, products and consumers Stronger national interconnections have facilitated the free exchange of people, and products, yet at the same time the rise of cross-border movement presents fresh challenges for the governance and regulation of patient care , , .
The present review focuses on one growing dimension of health care globalisation – medical tourism, whereby consumers elect to travel across borders or to overseas destinations to receive their treatment. Whilst cross-border patient mobility is a relatively small proportion of all elective care its recent growth raises a number of important questions with regard to safeguarding the well-being of European patients. As this review suggests, there has been limited progress in answering the call to strengthen the flimsy evidence base to support the internationalisation of health provision .
Medical tourism has emerged from the broader notion of health tourism. Some researchers have considered health and medical tourism as a combined phenomenon but with different emphases. Carrera and Bridges  identify health tourism as “the organised travel outside one’s local environment for the maintenance, enhancement or restoration of an individual’s well-being in mind and body”. It encompasses medical tourism which is delimited to “organised travel outside one’s natural health care jurisdiction for the enhancement or restoration of the individual’s health through medical intervention”. Here medical tourism is therefore defined as a subset of patient mobility.
It is possible to identify five but not necessarily mutually exclusive categories of patient mobility , .
Temporary visitors abroad: greater mobility has meant a sharp increase in short-term tourist flows. People holidaying abroad utilise health services as a result of accident or illness. Citizens of the European Union may make use of the European Health Insurance Card for occasional or emergency treatment. Health services for tourists are also funded variously through private insurance and out-of-pocket expenses.
Long-term residents: later-life mobility also known as “retirement migration” has intensified as a result of increased wealth, open borders, and lower cost and ease of travel. There are increased flows of EU citizens choosing to retire elsewhere within the EU borders , as well as examples of increased European exchanges of working age citizens [also 8]. Such residents may receive health services funded variously by the country of residence, the country of origin, private insurance, and private contributions.
Common-borders: countries that share common-borders may collaborate in providing cross-national public funding for health care from providers across borders . Frequent cross-border flows for example take place between Belgium and her neighbouring countries.
Outsourced patients: are those opting to be sent abroad by health agencies via organisational cross-national purchasing agreements which are driven by long waiting lists and a lack of available specialists and specialist equipment in the home country. Typically patients travel relatively short distances and contracted services (both public and private) are subject to stringent safety audits, quality monitoring , , .
Medical tourists: finally, there are patients who are mobile through their own volition and this type of patient mobility forms the foci of this brief review.
Within the European context a medical tourist may be categorised in two ways. First, they are those citizens who use their European citizenship rights to avail themselves of medical surgery in another EU Member State and have their national purchaser reimburse the costs of their treatment. This is enabled because European citizens, under specific circumstances, have rights to receive medical surgery and services overseas. Such rights have been established by successive rulings of the European Court of Justice on private cases regarding consumption of health care in another EU Member State and reimbursement by the (national) purchasing body in the home country .1 There is however an ongoing confusion over patient rights to travel overseas for treatment, the need for authorisation, mechanisms and process of redress when something goes wrong.
Second, there are a group of European medical tourists who may be best categorised as consumers whom pay out-of-pocket to access a range of dental, cosmetic and elective surgery. These dual roles of citizen and consumer set Europe apart from their American counterparts where medical tourists are more accurately described as a consumer rather than a citizen given the emphasis in the United States on the purchase of insurance cover and the greater use of out-of-pocket payments. The boundary between the citizen and the consumer may shift as the result of policy development and decisions around eligibility and waiting times.
Beyond sharing a set of common drivers (e.g. preferences for immediate treatment, a willingness to travel, or a desire for privacy in receiving cosmetic care), differences across Europe with regard to underinsurance, service eligibility, and length of waiting lists are likely to shape the decisions of those considering obtaining treatment. Sensitivity to social context and legislation are important, as are issues of culture, history and geography. Findings of the Flash Barometer Survey  suggests 4% of European Union citizens received treatment in another EU member state, ranging from 3% in the UK to 20% in Luxembourg.
The review sought to identify the medical tourist literature for out-of-pocket payments, focusing wherever possible on evidence and experience pertaining to patients in mid-life and beyond. We searched two databases, OVIDSP, and Web of Science and SSI Proceedings. A search strategy was designed that incorporated a number of stages and elements. Designated search terms and databases were used. The search results obtained were then screened to determine which references were relevant to the review. A screening stage was undertaken which involved scanning the titles and the abstracts returned in the searches. The screening of abstracts and papers was guided by exclusion and inclusion criteria that aimed to identify relevant literature for out-of-pocket medical tourism and for European patients. Thus we sought to avoid a review that was heavily American in evidence or one that focussed on EU cross-border exchanges and allied forms of patient mobility.
Multiple searches were undertaken on each of the databases. An illustrative example of the generic terms used and items excluded from an OVIDSP search are provided in Table 1.
We also undertook searches on specific treatments likely to be of particular relevance to mid-life and later-life patients, including ‘hip resurfacing’ and ‘facelifts’. Additional Internet searches were undertaken using Google and Google Scholar. The searches were undertaken by one researcher, and both the screening of the abstracts and the full papers were undertaken by the same researcher. The conclusions drawn from the review are based upon an interpretation by the authors of the information data included in the publication of the studies.
The market for medical tourism
Despite increasing media interest and coverage , , , ,  hard empirical findings pertaining to out-of-pocket medical tourism are rare. Findings relating specifically to mid-life and ageing populations and medical tourism are non-existent. In light of this our narrative review seeks to draw attention to these, somewhat surprising, gaps in research evidence. Our review strengthens the call for more empirical research on the role, process and outcomes of medical tourism.