This is the Working Paper of my article which has just been accepted in the International Journal of Health Care Quality Assurance. It’s due to be published in Vol. 27, Issue 1. It should be in ”print” in January 2014 following sub-editing and page proofing. An Early Cite version will also go online sooner but I wanted to support open access by putting this final draft on Scribd.

Please Cite: Woodhead, A. (2014) ‘Scoping Medical Tourism and International Hospital Accreditation Growth’ , International Journal of Health Care Quality Assurance. Vol 27. No.1.

Correspondence: anthony.woodhead@gmail.com.

Scoping Medical Tourism and International Hospital Accreditation Growth

AbstractPurpose - Uwe Reinhardt stated medical tourism has the potential of doing to the US healthcare system what the Japanese auto industry did to American carmakers after products developed a reputation for value for money and reliability. Unlike cars however healthcare can seldom be ‘test-driven’. Quality is difficult to assess after an intervention (posteriori) therefore it is frequently evaluated via accreditation before an intervention (a priori). This paper scopes the growth in international accreditation and its relation to medical tourism markets.Method – Using self-reported data from Accreditation Canada, the Joint Commission International (JCI) and the Australian Council on Healthcare Standards (ACHS) this article examines how quickly has international accreditation been increasing, where has it been occurring and what providers have been accredited.Limitations – Whilst analysing which countries and regions where the most international accreditation has occurred gives some indication as to the location of the most active medical tourism markets it must be noted providers will not solely be providing care for medical tourists.Findings - Since January 2000 over 350 international hospitals have been accredited with the JCI’s total number nearly tripling from 2007-2011. The JCI was also found to have conducted most international accreditation at over 90%.Implications for research, practice and/or society – The article discusses that although receiving accreditation certainly will not mean mistakes will never happen, it does perhaps indicate accredited providers are more willing to learn from them, to varying degrees. It concludes that if a provider has been accredited by a large international accreditor then patients should gain some reassurance the care they receive is likely to a good standard.Value - The article however questions whether further international-accreditation commercialization will result in improved quality, arguing extended research is necessary to further assess accreditation of these growing markets.Keywords - Accreditation, Medical tourism, Private healthcare, Patient perceptionPaper type – General review.Acknowledgement - Dr Neil Lunt, Senior Lecturer in Social Policy and Public Management at the University of York, for his help and advice in compiling this article.

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IntroductionMedical tourism involves premeditated travel outside the natural boundaries within which individuals normally receive healthcare to improve or restore their health (Carrera and Bridges, 2006). The phenomenon is not new, archaeological evidence indicates people travelled for health cures from as early as the middle third millennium BC (Kevan, 1993). Contemporary medical tourism is however a globalisation product; it may be situated within larger international medical trade frameworks such as the World Trade Organisation (WTO) General Agreement on Trade in Services (GATS) model highlighted by Cattaneo (2009). Medical tourism falls within Mode 2 trade, consumption abroad.

Table I: GATS Health Trade Modes (adapted from Cattaneo, 2009, p.3)

Mode 1 Cross Boarder Supply Tele-medicine including virtual diagnostics and radiology over the Internet

Mode 2 Consumption Abroad Medical tourism and health tourism via voluntary trips

Mode 3 Commercial Presence Foreign participation and hospital/clinic ownership

Mode 4 Presence of Natural Persons

Healthcare personnel movement between countries

Medical tourism is not however the only Mode 2 consumption. Other patient mobility include: temporary visitor’s abroad; long-term residents; common-boarders and outsourced patients (Bertinato et al., 2005; Rosenmöller et al., 2006). Medical tourism typically involves out-of-pocket payments for treatments and mainly stems from an individual consumers choice to travel whether for cost, privacy, accessibility or availability of treatment (Lunt et al., 2011).

Following a systematic review Johnston et al., (2010) synthesis five themes concerning what is known about the effects of medical tourism upon destination and departure countries. First as a user of public health resource, such as redirecting them from public to private in destination countries and necessitating and increased need for follow-up care in departure countries. Second as offering solutions to problems, such as developing infrastructure in destination countries and reducing costs and waiting times in departure countries. Third as a revenue generating industry that results in net losses for departure countries. Fourth in setting standards of care, by seeking accreditation destination countries may develop increasingly Western-orientated standards of care. Conversely due to low labour costs in destination countries medical tourists could develop expectations that are unsustainable in departure countries such as high nurse-to-patient ratios. Fifth medical tourism can be seen as a cumulative source of inequality. Medical tourism may result in internal brain drains within destination countries as medical workers move from rural to urban and public to private sectors. Medical tourism may also contribute to a loss of impetus for reform in departure countries as simultaneously travelling abroad drains medical tourists’ finances.

However, as Johnston et al., (2010) highlight, little is currently known about the effects of medical tourism with respect to any of these themes. They identify only 6 empirical studies reporting on primary data and there is little academic work on medical tourism quality management. Statistics are also not collected in sufficient detail to be useful for assessing quality, especially treatment outcomes (Lunt and Carrera, 2010).

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When patients undertake medical travel they undoubtedly put a high degree of trust into unfamiliar hands and structures; however UK evidence suggests even when it is available patients do not readily use outcome data when deciding on private providers (Mannion and Davis, 2005). Research generally indicates a healthcare provider’s public image and reputation, regulated extensively through voice by the medical profession, has more effect on markets than consumer exit (Hibbard, as cited in Hamblin, 2008). No evidence explores whether patients are more discerning when travelling abroad.

Medical tourism markets have seen affiliation through franchising with well-known medical centres. For example The Cleveland Clinic owns facilities in Canada and Abu Dhabi (Cleveland Clinic, 2012). Such marketing tries to instil and profit from trust with other global brands. (Hooley et al., 2004) Accreditation can play an important signalling role and is often conducted by organisations from developed countries. There has recently been an increase in the provider accreditation in developing countries aimed at aiding medical tourism growth, which some governments, including India, Thailand, Singapore and Malaysia actively encourage (Shetty, 2010; Pocock and Phua 2011). Such accreditation also aims to ensure good quality health services for their own citizens. For example, though Dubai Health Care City (DHCC) was established to try and persuade Middle Eastern medical tourists to receive treatment in their region instead of traveling to Asia, it also hosts A&E departments, research units and teaching sections (Crone, 2008).

Quality in medical tourism Though low cost is an important trade-driver, it cannot be realised by sacrificing quality (Reinhardt, as cited by Horowitz, 2007). There is a gap in the literature regarding quality signals and accreditation, though there are many indicators against which healthcare quality can be assessed. Drawing on limited evidence, the following table exemplifies how medical tourism can relate to some healthcare quality indicators.

Table II: Key medical-tourism quality indicators

Access People travel to the places where treatments are readily available (Lunt and Carrera, 2010).

Accrediting Organisations and also individual practitioners, where it may be termed certification (Milstein and Smith, 2007; Mattoo and Rathindran, 2006).

Appropriateness Can impact negatively on appropriate care to the general population in provider countries (Lunt and Carrera, 2010).

Continuity of Care

Potentially a problem with acute medical tourism (Canales, Kasiske and Rosenberg, 2006).

Effectiveness The ‘cure’ factor, difficult to judge but important (Canales et al., 2006).

Efficiency Either technical, allocative or a mixture; people may travel to a developing country for low cost, high quality heart surgery (Mattoo and Rathindran, 2006).

Equality Under social health systems, care ultimately needs to be rationed. Medical tourism affects opportunity cost (Lunt and Carrera, 2010).

Equity Medical tourism can affect who has access (Lunt and Carrera, 2010).

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Responsiveness How quickly a provider advertises and offers new products to market can be important for long term commercial success (Karuppan, 2010).

Safety In modern medicine, there may be a trade-off between potential harm and benefit, particularly when surgery is conducted (Williams, 1995).

Satisfaction Includes socio-cultural aspects, climate, culture and cuisine (Connell, 2006).

Timeliness In social healthcare, waiting lists is rationing. People may travel abroad to avoid the queue (Lunt and Carrera, 2010).

Managing risk is pertinent to ensuring patient safety; however medical tourism frequently involves surgery, which by its nature carries an inherent risk. For example, Williams (1995) highlighted infection risks are a common potential danger that can be reduced with adequate infection control procedures and stresses the importance of following protocols and seeking consultation with consultant microbiologists if postoperative infection rates exceed acceptable limits. Connell (2006) and Herrick (2007) speculated that inherent risks are increased because flight is added into the equation shortly afterwards, increasing the potential for Deep Vein Thrombolytic Episodes. Deep Vein Thrombosis is a common complication following any operation; the chances of it occurring and leading to a pulmonary embolism increase from the tenth postoperative day (Williams, 1995b). Symptomless DVT occurs in up to 10% of long-haul travellers (Scurr et al., 2001). For those with additional risk factors (hormonal therapies, surgery, malignancy, immobilization, pregnancy, obesity, previous thrombosis and significant family history); the risk is significantly increased (Arya et al., 2002). Obesity can also cause additional problems from surgical and anaesthetic perspectives (Williams, 1995b).

There are no studies into the increased risks in specific procedures performed through medical tourism; for specific patient groups however, safety is called into question solely by an increased inherent risk, irrespective of how well the procedure is performed. One postulated example is when patients fly to receive gastric band surgery.

Medical tourism might also increase risk because procedure efficacy is reduced. There is however, little published outcome data for most medical treatment abroad. Canales et al., (2006) looked at ten kidney transplantations performed in several countries. Though they found kidney function and graft survival was generally good, they discuss problems regarding continuity of care, highlighting a high incidence of post-operative infection. The statistical significance of the reported increased infection rate was however undetermined.

Milstein and Smith (2007) attempted to evaluate Cardiac Surgery outcomes by analysing non-urgent 12 month Coronary Artery Bypass Graft (CABG) mortality rates. Though their limited findings indicate comparable rates in Thailand and India versus the US, the significance is unclear because the operation total is unknown. For CABG mortality to be a useful efficacy comparator the procedure must be performed frequently. Small sample with low event rates limit the statistical power of population based benchmarking. In a large US study Dimick et al., (2004) found that in six common surgical procedures, only CABG’s fitted both criteria, relatively high mortality rate and frequent performance. This was because from a cohort of 1036 hospitals 90% had caseloads of 219 or higher which were therefore great enough to detect doubling of mortality rates in comparison with the national benchmark with statistical significance. Caseloads were generally too low to establish significance with the other procedures.

Even when statistical significance data are published, it is important to ensure their reliability, ideally via independent audit. Though Mattoo and Rathindran (2006) reported the

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Apollo hospital chain in India has maintained a 99% success rate in more than 50,000 cardiac surgeries, performance on a par with US centres of excellence, Apollo’s audit trail is uncertain. Apollo (2010) state the number is 55,000 with a 99.6% success, making them one in only ten centres to achieve such volumes. If their longitudinal data could be assured then this would indicate that Apollo’s cardiac efficacy is indeed world-class.

Given such difficulties in evaluating efficacy, or indeed quality generally, after an intervention (posteriori) accreditation of the processes through which care is delivered become central to ensuring quality before an intervention (a priori). Although CABG mortality can help signal efficacy in other forms of Cardiac Surgery, (because it closely correlates with valve replacement morality rates for example), no single mortality measure is appropriate for every operation. Subsequently managers must rely on other indicators (Goodney et al., 2003).

Another quality indicator is satisfaction, though it has been used infrequently to date. Such data are commonly termed PROM’s (Patient Reported Outcome Measures). Studies indicate PROM’s have potential for improving quality (Maynard and Bloor, 2010). PROM’s data relating to medical tourism are limited. A McKinsey study by Ehrbeck et al., (2008) interviewed patients finding them largely satisfied with quality. This was also the only source identified that made any reference to providers’ accreditation-views, stating that whilst the JCI accredited nearly every provider they visited, providers were divided over whether this made patients more confident about the service quality.

This American orientated study is however not an academic source; omitting participant numbers or discussion of interview method, economic in its focus and unreferenced. This is typical of sources within much of the medical tourism literature. As Johnston et al., (2010 p.10) conclude, sources in general “revealed that initial estimates and ideas about medical tourism were heavily cited and recycled until they became treated as facts, both within and outside of scholarly publications.”

Medical tourism and market forcesMedical tourism is thought to be a $60 billion industry; however it is difficult to ascertain the medical tourism markets’ size and scope (Crone, 2008). Ehrbeck et al., (2008) estimate medical tourist numbers at 60-80,000. Youngman (2009) believes numbers could total five million overall; however his estimates include cross border travel, which will not always involve travel outside an individual’s natural environment. Recent articles in mainstream media tend to focus on ‘North-South’ travel, a definition given to indicate travel from more to less developed countries. Estimates however suggest as much as 70% of the industry involves ‘South-North’ Travel. ‘South-South’ trade is also thought to be increasing as governments in the UAE and Singapore for example are helping create regional centres of excellence that cater for medical tourists from neighbouring countries, exploiting economies of scale and scope both with respect to infrastructure and health technologies (Cattaneo, 2009).

Medical tourism involves advertising surgical procedures including Bariatric, Cardiac, Cosmetic, Ophthalmic and Orthopaedic Surgery; Dentistry and Organ Transplantation (Lunt and Carrera, 2010). Lunt and Carrera also suggest people commonly travel for interventions including IVF and Diagnostic Medicine. The latter often involving ‘high-tech’ health-checks frequently offered by private US healthcare providers (Quinn, 2010). Without price incentives, many medical tourism markets might be unsustainable. Cost drivers are difficult to ascertain however since Health is a service industry, with 70% of costs typically salaries, cost effective capitation is important for technical efficiency (Walshe and Smith, 2006). Horowitz (2007)

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argues in US healthcare that the bureaucratic documenting, analysing and reporting information, consumes unimaginable resources, resulting in increased prices, which must be passed on to the patient. US healthcare administration is certainly expensive, costing $465 vs. $172 per capita in the UK in 2006 (Peterson and Burton, 2007). However these costs have to be compared with total healthcare expenditure to be useful in accounting for the disparity - $6959 vs. $2996 per capita in the UK in 2006, (OECD, 2009). This indicates, in real terms, administration may account for too low a proportion of total spend to be useful in explaining large price differences.

It is possible that relative inefficiencies in exporter markets result in increased costs. Herrick (2007) suggests in many US states, Stark Laws, which prohibit kickbacks, prevent hospitals from structuring physician compensation to create financial incentives for efficient care; however foreign hospital managers have more freedom to employ doctors directly, such as in India, where doctors are contracted to work set hours for a fixed fee. In the UK however the effects of such pay for performance have been limited (Walshe and Smith, 2006). Whatever the reasons, such market forces should theoretically interact. However, medical tourism macro-level impacts are also not well studied. Cattaneo (2009), like Reinhardt (in Horowitz, 2007), suggests Mode 2 trade stimulates competition in national markets helping to ensure for technical efficiency. He highlighted that Oman alleviated some infrastructure and human resources constraints in the short term, before providing services locally. Interactions may not always be positive. Chinai and Goswami (2007) discussed the potential for negative impacts on allocative efficiency in India; suggesting inadequate regulation may result in an internal ‘brain-drain’, with healthcare professionals being lured from the public to private sector and away from rural areas, which require lower technology interventions as a priority. They argue that any generated income will not trickle down to public coffers unless national laws and regulations explicitly tax and channel revenue streams. Many governments however support the industry suggesting it helps raise all ships (Shetty, 2010; Pocock and Phua, 2011).

International accreditationSustainable markets also require consumer confidence. With medical tourism and healthcare in general this can be difficult to achieve because as health is an intangible product dominated by credence properties: ‘beyond the capabilities of the consumer to evaluate, even after consumption’ (Conway and Willcocks, 1997 p.133). Accreditation is an important form of external assessment that may be used to help instil confidence (Scrivens, 1997).

Accreditation can require a high level of technical capability (Walshe, 2009), which may be less evident within developing healthcare markets, where informal contexts dominate as managerial expertise are under-developed and leading physicians exert great influence over organisations, operating with less accountability (Bloom et al., 2008). Indeed Bukonda et al., (2003) questioned whether continued accreditation of hospitals in the developing world was an appropriate use of limited funds.

Some degree of accreditation in developing world countries occurs as a consequence of the way medical professionals are trained, many healthcare professionals who treat medical tourists are qualified to work in the US and Europe (Mattoo and Rathindran, 2006). The focus of this article however is on accreditation of process at the organisational level as opposed to professional certification.

Though some countries conduct their own hospital accreditation, this article investigates the three major schemes that operate internationally: Accreditation Canada (formally the Canadian Council on Health Services Accreditation, CCHSA); The Australian Council on

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Healthcare Standards International (ACHSI) and the Joint Commission International (JCI). All accredited by The International Society for Quality in Health Care (ISQua), which has enrolled members in over 70 countries (Greenfield and Braithwaite, 2008). The JCI is the largest accreditor. By late 2007 to early 2008, it had certified 100-120 facilities (Herrick, 2007; Horowitz et al., 2007; Carabello, 2008 and York, 2008). At 31st July, 2011 this number nearly tripled with total JCI accreditations standing at 329 in 42 countries. Also, according to their website, Accreditation Canada (2011) had accredited 21 hospitals in six countries whilst the ACHSI’s website (2011) lists ten Hong Kong hospitals they have accredited. The internet is a key medical tourism facilitator and all three organisations allow accredited facilities to display badges on their websites. These act like kite marks, aiming to reassure consumers about product safety whilst simultaneously promoting the organisations credentials. There is little information regarding website roles associated with the trade, how they are used or their impact. Though in seeking to increase awareness sites, whether unintentionally or deliberately, can create a perception that medical services are required by the consumer, thus helping motivate purchases through supply induced demand (Lunt et al., 2011).

Healthcare accreditation effect has however been investigated from broader perspectives. Greenfield and Braithwaite’s (2008) comprehensive systematic review reveals a complex picture; establishing consistency only with respect to accreditation positively promoting change and furthering professional development. Inconsistencies were found in relation to professions’ attitudes to accreditation’s organizational and financial impact, quality measures and program assessment. They conclude little correlation is found between quality measure and accreditation outcome. No difference was found between accredited and non-accredited hospitals regarding total medication errors (Barker et al., 2002). One study found accredited hospitals performed better over a range of quality indicators compared with non-accredited hospitals but stressed there was significant variation in accredited provider performance (Chen et al., 2003). Greenfield and Braithwaite (2008) discussed how accreditation can guide external stakeholders to assess safety and quality management in organisations; they believe accreditation’s financial cost is an under-researched area. Pomey et al., (2004) found doctors tend not to value accreditation programmes, feeling self-assessment is more appropriate; however nurses and health managers were more supportive. Mihalik et al., (2003) argued accreditation is an essential investment. Nandraj et al., (2001) looked at views regarding accreditation schemes in India, which officials were considering introducing, found hospital administrators, government officials, insurance representatives and doctors all in favour.

Hospital accreditation is commonly conducted against guidelines in detailed manuals. Smits et al., (2008) reviewed national manuals from the three major international accreditors finding the most common standard of accreditation across all manuals was quality, with the most common dimension being production related and the least common dimension being cultural and values. Goal attainment and adaption dimensions were again expressed to varying degrees. Smits et al., (2008) concluded the accreditation process took a normative stance since all manuals focus on accrediting from a top down perspective with ideas about what particular, or normal, procedures and outcomes are indicative of high quality practice.

Horowitz et al., (2007) questioned whether national and international accreditation standards were comparable, suggesting international standards might not be as high since the JCI produces a different manual for its international accreditation. However it is also possible that the JCI accreditors have slightly different aims when working abroad, possibly placing more emphasis on environmental dimensions to help ensure more appropriate health-system

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accreditation. Turner (2011) suggests medical tourism companies should also undergo accreditation and restrict care arrangements to internationally accredited facilities to help ensure quality.

Exploring medical tourism and accreditation This study scoped international hospital accreditation within the context of medical

tourism. It was hoped hinging the relatively well-grounded topic of accreditation to the lesser-researched medical tourism might allow ideas about quality assessment in medical tourism to gain some greater degree theoretical grounding. Initially three broad approaches were attempted: semi-structured interviewing, document analysis, and empirical evaluation.

All three major accreditors were approached for telephone interviews, only the JCI responded. Telephone interviews were rejected owing to busy travel schedules though two international accreditation directors did initially agree to answer a handful of questions via email. No responses were received to the questions posed, a spokesperson for the JCI did however state: Our sole mission is to help organizations worldwide increase patient safety and quality healthcare. How organizations choose to market the accreditations they receive from us is up to them.

Attempts were also made to source copies of the latest international accreditation manuals and conduct document analysis in concordance with the conceptual framework detailed in Smits et al., (2008). It only proved possible to review a revised ACHSI manual, ACHS: EQuiP 4 Hospital Accreditation Manual (2006) through personal contacts. As this study was unfunded it was not possible to purchase the latest international manuals from either the JCI or Accreditation Canada.

The 4th edition ACHS manual indicated its revision was influenced by the assessment of JCI and CCHSA manuals. The six functions present in the 3rd edition had been restructured into three topics: clinical, support and corporate. The manual explicitly stated it now aimed to be relevant to a range of provider types operating in a diverse health system by assessing appropriateness, though the ACHS considered this to be developmental criterion with performance against it not contributing toward accreditation until January 2011 (ACHS, 2006). Subsequently the culture and values dimension might now be considered present, where in the 3rd edition this dimension was considered quasi-absent by Smits et al., (2008).

Since interviewing and document analysis proved difficult it was decided to focus on empirical evaluation, making best use of publically available data. Although a number of authors had previously stated total numbers of JCI accredited facilities (see Herrick, 2007; Horowitz et al., 2007; Carabello, 2008 and York, 2008) none had analysed this to any great depth. It was realised since the JCI publishes all dates of accreditations the rate at which accreditation has been occurring at could be determined. Following discussion with a former tutor it was decided three useful questions could be examined using the data available. First, how quickly has international accreditation been increasing? Second, where has it been occurring and third what other providers have been accredited?

The data were predominately derived from empirical analysing dates, locations and organisations accredited and reaccredited by the JCI. More limited empirical analysis of Accreditation Canada and The ACHSI was also conducted as they provide publically accredited provider names though not accreditation dates. Data quality is mainly reliant on JCI self-reporting.

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Market growthAnalysing international accreditation growth rate can indicate how quickly medical tourism markets might be growing. Not all providers focus on providing care solely for medical tourists. As only JCI accreditation dates were determined, only increasing accreditation by the JCI is plotted. Figure 1 shows JCI accreditation has more than doubled every three years since 2001.

Figure 1: Cumulative JCI hospital accreditation.

Accredited countriesAnalysing which countries and regions where the most international accreditation has occurred might indicate where most active medical tourism markets are located. Providers will not solely be providing care for medical tourists but these are some countries where there has been activity around promoting medical tourism. The countries where accreditation has occurred was collated for the Accreditation Canada, ACHSI and the JCI. Some hospital groups were also accredited; e.g., Danish Hospitals Group had all six hospitals accredited and in Turkey five hospitals from Acibadem Group have been accredited. In total, the JCI has accredited over 50 hospitals from 17 groups in ten countries.

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Figure 2: Accredited Hospitals by Country

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Reaccreditation and diversification

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The JCI usually reaccredits organisations every three years, advising on its website that if accreditation has lapsed. The JCI have expanded their operational scope and started to accredit some organisations under different standards. Since 2004 they began to offer Ambulatory Care, Care Continuum, Medical Transport and Clinical Laboratory assessment, and Disease or Condition Specific Care Certificates (including Bone Marrow, Stroke, Oncology and Heart Services) in addition to their Hospital Accreditation programme. Accreditation Canada has also certified organisations other than hospitals, for example accrediting a primary health clinic in Kuwait and the Bermuda Hospitals Board. The ACHSI appears to only accredit international hospitals. Accreditation failure rates were undetermined for any accreditor.

DiscussionThe analysis supports the Herrick (2007), Horowitz et al., (2007), Carabello (2008) and York (2008) findings that the JCI had accredited 100-120 facilities by late 2007 to early 2008. The number has now nearly tripled, with the JCI accredited hospital total standing at 329 in 31 st July 2011. For all major international accreditors combined, accredited hospitals stands at 360, hence the JCI conducted 90% of international accreditation. Such growth is clearly indicates increasing healthcare-globalisation, perhaps also signalling maturation of some developing world health markets.

Middle Eastern countries, including Turkey, Saudi Arabia and the UAE have received most accreditations. The large amount of international accreditation in this region perhaps stems from Cattaneo’s (2009) suggestion that South-South trade is increasing as regional centres of health excellence are created. It is possible that network effects are occurring, with providers being more likely to be accredited if a close social or geographical neighbour is also accredited. Findings indicate that some provider-group accreditation has occurred. However it is also possible that informal ties help increase accreditation such as with senior management teams liaising to share best practice or with providers feeling they need accreditation to remain competitive in their market. As Crone (2008) indicates, the competition driver might be particularly pertinent in the Middle East, though further work is necessary to assess this. It would be useful to gauge what market saturation accreditation represents - total hospital per countries and bed numbers. It would also be helpful to conduct sub-group analysis, looking in more depth at how many accredited hospitals commonly cater for medical tourists in comparison to the total number of hospitals in any given country. Such work might indicate accreditation value within specific medical tourism markets.

Clearly not all international accreditation is being conducted to help facilitate medical tourism though. For some countries perhaps it is more viable to outsource accreditation to external providers who benefit from economies of scale. Also, since accreditation can require a high level of technical capability, (as Walshe (2009) highlights), Mode 3 trade could be occurring to fill skill gaps. It is interesting that most non-hospital accreditation conducted by the JCI (e.g., Disease Specific Care Certificates including Bone Marrow and Stroke) seem more focused on internal health issues than procedures that Lunt and Carrera (2010) suggest medical tourists typically travel for.

Perhaps in future, accreditors will begin to accredit facilitators who arrange care for medical tourists solely at accredited facilities, as Turner (2011) recommends. At present though, the worth international accreditation to medical tourism specifically and the developing world in general remains unclear. Bukonda et al., (2003) discussed how the accreditation costs for individual organisations was unsustainable in the developing world. However Mihalik et al.,

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(2003) believed accreditation to be an essential investment. This underlying tension lies at the heart of the value debate.

However there are possibly some instances where accreditation is being conducted more as a means to an end; a process predominately undertaken to gain a badge that helps providers advertise their quality credentials and compete in whatever health markets they operate. This stance could be contrasted with an alternative view of accreditation - being a continuous opportunity for learning, which leads to improving patient safety and healthcare quality. Neither is entirely mutually exclusive. The fact the latest ACHI manual analyses appropriateness, combined with some limited evidence of its revision being influenced by manuals from the two other major organisations, perhaps gives some credence to the view that the normative paradigm is being increasingly challenged.

Though Chen, et al., (2003) rightly caution, variation can be significant between different accredited providers, variation is common to all healthcare systems. Since they also found accredited hospitals performed better over several quality dimensions, receiving accreditation indicates, at the very least, organisations are willing to engage with quality improvement processes. Although this certainly does not mean mistakes will never happen, it perhaps shows they are more willing to learn from them, to varying degrees. Therefore if a provider has received accreditation from a large international accreditor, patients should gain some reassurance that the care they receive is likely to be a good standard. Bottom up approaches could help establish if this is indeed the case.

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