e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 255 H. Omer Tontus Public Hospital Administration of Turkey, Emergency Health Services and Foreign Health Departments Saniye Nebioglu Public Hospital Administration of Turkey, Healthcare Services Department Drivers of Healthcare Globalisation and Their Effects on Medical Tourism Globalisation has intensified in many parts of the world, becoming an important challenge for public health institutions and policymakers. Although many studies have been conducted on the role of globalization in healthcare, no consensus has been reached on its effects. In this commentary, we attempt to evaluate the drivers of healthcare globalization and their effect on medical tourism destination selection. The focus of the commentary is the effects of globalization on patients, whose primary purpose is to travel for planned treatment for health reasons. People from developed countries look for alternative healthcare services and travel to developing countries for cost-effective medical care. Factors which foster medical tourism include demographic changes, remodeling of the healthcare industry, modern technological changes and advanced medical practices, including cost and quality considerations. This commentary presents a list of key factors related to globalization and their effects on medical tourism. Key words: Globalisation, Medical Tourism, Drivers, Factors H. Omer Tontus Public Hospitals Administration of Turkey, Emergency Health Services and Foreign Health Departments Ministry of Health Bilkent Kampus Ankara, Turkey Phone: [90] 532 175 2828 Email: otontus@hotmail.co.uk Saniye Nebioglu Public Hospitals Administration of Turkey, Healthcare Services Department Ministry of Health Bilkent Kampus Ankara, Turkey Phone: [90] 542 557 5272 Email: saniyet@googlemail.com http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 256 Introduction In this commentary, we attempt to evaluate the drivers of healthcare globalization and their effects on medical tourism and destination selection of medical travellers. During international travel to obtain medical service, the travel “only” part of the trip is termed “medical travel”, when the person arrives at the destination they become a “medical tourist”, and all activities (medical services, hospitality, traditional cultural tourism etc.) during this trip are called “Medical Tourism” (Jagyasi, 2008). The private healthcare sector and governments in both developing and developed countries have been instrumental in supporting medical tourism as a potential source of revenue from service export (Lunt et al, 2011). As a concept, medical tourism conveys both the “willingness to travel (patients)” and “willingness to treat (doctors/hospitals)” as core processes within the new health travel-related emerging global market. It captures the healthcare sector element, as well as the wider economic impact of travel, insurance and hospitality sectors (Lunt et al, 2011). Economic changes and new industrial sectors have been the primary driving factors behind the process of globalization for over half a century. Economic globalization has been characterized by an impressive increase in the volume of international flows. Cross-border business has grown at a remarkable pace at nearly 9% per year, in the last decade of the 20th century. In the same period, service sectors grew continuously and accounted for nearly 19% at the beginning of the 21st century (WTO, 2000). Globalisation is influenced by various factors such as political changes, technological developments, economic growth-related pressures and increasing environmental and socio- cultural concerns (Woodward et al, 2001). All driving forces stimulate increasing cross- border flows to the manufacturing and service sectors. The practice of medical tourism is becoming progressively popular nowadays, owing to the preference of patients and payers to reduce costs, shorten waiting times and access better quality of treatment (Kumar et al, 2012). http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 257 Main Drivers of Medical Tourism The medical tourism sector is expanding rapidly, and people from developed countries as well as investors from all over the world are aware of its future dimensions. Countries such as Thailand, India, Turkey, Malaysia, Costa Rica and Mexico, with some others, have flourishing medical tourism sectors and are attracting medical travellers by the hordes. Medical tourism is an expectation-driven sector, which is influenced by the complex interaction between medical, economic, social and political forces. Naturally, individuals who are looking for cross-border medical treatment expect similar or better quality of healthcare services (compared to those available in their own countries) without waiting time. The important factors that influence people’s decision to become medical travelers are better- personalized care, better hospitality, best hospital design, latest medicines, up-to-date technology, easy transportation, and security. Such additional benefits for patients facilitate their decision to become medical tourists. Table.1 shows intrinsic and extrinsic drivers which are related to medical tourism. Table 1. Intrinsic and extrinsic factors in healthcare tourism Intrinsic (Repulsive/Pushing) Factors Push from the home country Extrinsic (Attractive/Pulling) Factors Pull by the destination country  Demographic changes  High cost of healthcare services  Poor quality of healthcare services  Prohibited health services (circumvention)  Long waiting lists  Problems on access to care  Inadequate insurance coverage  Increased out-of-pocket payments for healthcare  Health system  International agreements  Diaspora effect  Cheaper healthcare service  No or short waiting list  Short distance from home country (short flying time)  High-quality health services and up-to-date technology  Accredited healthcare provider and reputation of service providers (hospital or doctor)  Ease of access to care  Better transportation opportunities  Organized facilitators  Cultural closeness and similarities  Simplified visa formalities  Communication without language barrier  Opportunity to visit their homeland  Destination facts (touristic attractions, historical places)  Social media and networking  International agreements  Diaspora effect http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 258 Globalisation has intensified in different countries of the world and has become one of the most important challenges for public health institutions and policymakers (McMichael & Beaglehole, 2000). Although many studies have been conducted on the role of globalization in healthcare, no consensus has been reached on how it affects the health of populations (Woodward et al, 2001). The following are the main drivers of medical tourism as a result of healthcare globalization: 1) Demographic changes: One of the latest reports from the United Nations reveals that the proportion of 65+-year-old people in the populations of developed countries will jump from 17% today to 24% by 2035 (Euromonitor International, 2017). The median age of the global population was 29.6 years in 2015, up from 27.5 years a decade earlier. From 2005 to 2015, average life expectancy increased by 3 years and reached 72 years (Euromonitor International, 2017). In the last decade, the percentage of people aged over 60 years rose from 10% to 12% globally, and this percentage is expected to rise further to 13% by 2020. In the United States, as of 2010, the ‘baby boomer’ generation has retired, thereby resulting in greater demand for more sophisticated health care. Many US healthcare providers and hospitals are already overwhelmed by the number of patients and the increased demand from baby boomers. Cross-border healthcare providers are also manoeuvring to handle a portion of the demands of this group. 2) Cost: A direct relationship exists between the health status of the population and the household income. Further, direct and indirect links exist between economic globalization and the determinants of health (Woodward et al, 2001). As a common feature of medical travel, it is associated with the patients’ financial ability to make such a voyage. Economic globalization and cost-cutting policies in the healthcare sector have a direct impact on population health. Owing to the effects of economic changes, especially on cost of living and http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 259 accompanying limited health insurance policies, individuals are seeking access to better- priced health care. Among the developed countries, the US and South Africa do not have national healthcare systems. In the US healthcare system, private health insurance is provided by employers with individual complementarity. In most cases, these insurance plans perform poorly in cost/benefit measures. Although the US is a leading country vis-a-vis treatment modalities, healthcare services and health technology worldwide, Americans pay at least twice for such services, compared to the citizens of many other developed countries. This condition puts a heavy pressure on healthcare financing bodies as well as on insurance companies, healthcare providers, and individuals. Since 2007, citizens of developed countries have been affected by a global economic recession. Prices of medical procedures have dramatically risen. As the economic recession continues to burden people financially, the interest of people in medical tourism is increasing (Rollyson, 2010), as a natural corollary. Patients who need medical support have started searching for more affordable medical care at the best price and with acceptable quality. Emerging economies such as India, Turkey, Malaysia, Thailand, and Mexico, have lower living costs; standards of living and salary rates in these countries are far lower than those in developed countries, which is also reflected in prices of healthcare services. Most of the developing countries have modern facilities and provide better priced (even half-priced) healthcare services than developed countries. 3) Quality: The growth and emergence of any industry, including medical tourism, is directly related to its technological and scientific development. For best medical practice to be conducted most effectively, facilities must be structured in accordance with the latest technological developments in developing countries to support medical tourism. Best http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 260 healthcare services can be delivered effectively through the latest technological developments. This approach includes transportation and communication technologies. The quality of healthcare services in the medical sector in developing countries has improved through the use of the latest technology. Developing countries have modern facilities along with Western-trained health personnel, who provide medical treatment for half of the treatment costs in developed countries. Also, many medical service providers obtain their accreditation certificates from JCI, QHA-Trent, Accreditation Canada or other relevant independent bodies. Accreditation with global standards extends an assurance of quality in procedures and services. This encourages patients and insurance companies to seek care from accredited healthcare institutions, regardless of their location (Rollyson, 2010). International accreditation standards are focused on patient care services. A basic requirement is to establish a protocol for continuity of health care, by taking appropriate measures on discharge, dispatch, follow-up, and transfer of patients (Mestrovic, 2014). Western-educated professionals, contemporarily- planned hospitals/clinics, and accredited procedures/services, along with other aspects of the medical tourism sector, lead to high quality. Therefore, patients prefer this type of centres to obtain treatment. Patients and insurers know that JCI-accredited hospitals in different countries all over the world are operated according to the same exacting standards as US hospitals. The global mobilization of healthcare services is synchronised with the expectation that health services will be validated through standardization of quality (accreditation) and safety measurement systems (Schroth & Khawaja, 2007). Most of the hospitals decide to formalize their international patient management services through the creation of a dedicated international office. These offices deal with issues other than medical services, such as financial, facilitation, cultural and language services. Quality management in such settings could be seen as the professionalization of the medical tourism sector (Mainil et al, 2012). http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 261 4) Insurance business: The insurance business all over the world is globalising. In the private healthcare sector, insurance companies serve as intermediaries that pay healthcare providers on behalf of healthcare consumers. Patients or employers pay premiums to insurance companies to obtain health coverage within a time frame. In some countries, the government takes a small amount of money from individual salaries to provide health insurance. Both private insurance companies and social insurance systems send many patients to healthcare providers, so they extract large ‘volume discounts’ for medical services and they determine the price. The same situation happens in the medical tourism sector. It is natural for insurance companies to use the disparities of prices for medical procedures to their advantage even overseas. Insurers enter into contracts with international service providers for services at very low prices, including foreign hospitals and doctors, to reduce the cost of the individuals that they insure. American healthcare providers charge at least twice for similar services compared to healthcare providers’ charges of many other developed or developing countries. This condition puts a heavy pressure on healthcare financing bodies as well as on insurance companies, healthcare providers, and individuals. This promotes and supports medical tourism as a key driver. 5) Access to care: For patients from countries where governmental healthcare system or private insurance companies control access to services, the major reasons to choose cross- border medical care are to circumvent delays associated with waiting lists or high prices (Horowitz et al, 2007). National health care programmes do not typically pay for cosmetic surgery, dental surgery and similar services; therefore, patients from the US, Canada, and the UK who desire these procedures pursue medical tourism for economic reasons. Patients also travel to medical destinations to have procedures that are not widely available in their own http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 262 countries, such as stem cell therapy, which may be unavailable or restricted in their countries (Horowitz et al, 2007). Circumvention medical tourism occurs when patients travel cross-border to get healthcare services that are “illegal” or “unapproved” in their own countries. In some cases, circumvention medical tourists may be travelling to unproven medical interventions. Circumvention tourism also has the potential to slow the process of research, as patients go abroad for interventions and opt out of domestic scientific trials. Strict regulations and restrictions on certain procedures such as D&C, organ transplantation, surrogacy, IVF with gender selection etc. have resulted in circumvention medical tourism as an opportunity for access to forbidden care. As an example; High Intensity Focused Ultrasound (HIFU) treatment for prostate cancer, which is approved in Canada and the EU but not the US. HIFU treatment is performed in the Bahamas by US-based surgeons and this represents an important opportunity for patients seeking such a treatment modality (SFU, 2015). For patients, barriers to accessing health care in their own countries can motivate medical tourism. Accessible health care in foreign countries also pushes medical travel. 6) Waiting time/list: Waiting times in many developed countries, especially those with national healthcare or social insurance systems, are often long and also costly for some surgical procedures. In medical tourism destinations, the waiting time is minimal, compared with the patients’ own country in elective surgeries such as hip replacement, cholecystectomy and prostatectomy. Developing countries which have medical tourism-targeted policies typically have shorter waiting periods for most of the medical procedures, including appointments, surgical operations or check-ups. When efficiency and shorter waiting times are combined, countries such as India, Thailand, South Africa, Turkey, Malaysia, Mexico, Singapore and Hungary attract patients from the US and the UK. For example, the waiting time for by-pass surgery or hip replacement surgery in Turkey is only two days. However, in http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 263 the UK, the waiting time for cataract eye surgery may be as long as two years; but this surgery is available without waiting time in many developing countries such as Thailand, India, and Malaysia. Medical tourism is promoted as a solution to the high price of medical care, as well as treatment delays in the USA. In the UK and some other publicly funded healthcare driven countries, medical brokerages attract people tired of waiting for knee and hip joint replacement surgeries, cataract surgery and other similar procedures (Turner, 2010). 7) Other drivers of healthcare globalisation • Sense and sensibility: Unfortunately, healthcare services have missed their humanitarian values and become a wild professional business with exclusively commercial motives. In most cases, the industry has lost the sensitivity of personal caring and interaction between patients and practitioners. Nowadays in busy clinics, a patient is seen as a number rather than as a social individual, and the success rate of clinics or physicians is measured by the income provided to the institution. Many patients feel that surgeons in developed countries are not reachable. Medical tourists who receive treatment abroad share their experiences of personal service and the feeling of connection with the healthcare professionals who supervised their treatment (Rollyson, 2010). Patients prefer to have physicians whom they can contact with any questions about their clinical situations. • Diaspora: A number of studies have been conducted on a group of medical tourists categorised as diaspora travellers. Reports describe this condition in relation to Mexico, China, Korea, and India, with recent migrants returning to their countries of origin to access healthcare services (Lunt et al, 2014). Turkey too has a large diasporic population in Europe, and so do countries such as Germany, the Netherlands, France, and Belgium. Some government and medical companies have targeted this group of people and created special http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 264 programmes for those who have cultural and social similarities or family roots in a medical destination. This group of people is often first- or second-generation immigrants. Diasporic populations targeted by medical tourism programmes are expected to become more prominent in the next decade. Managing diaspora patients is easy because they travel towards a familiar environment including language and socio-cultural life (Munro, 2012). Furthermore, most developed nations have large first- and second-generation immigrant populations. This group of people is predisposed to return to their countries of origin for healthcare (Rollyson, 2010). Patients and their relatives prefer their countries of origin because of better communication and the opportunity to visit their relatives at the same time. The medical diaspora has contributed significantly to the medical tourism industry and is becoming increasingly prominent. • Medical tourism facilitators are usually organizations operated by medical or tourism sector professionals with technical and medical knowledge. These facilitators usually work with physicians, surgeons, and other medical staff on the basis of the analysis of medical documentation and consultations of patients. They decide which clinic or medical department or hospital is appropriate for future medical tourists. Most of the facilitators have contracts or agreements with healthcare providers in their targeted market countries. They know the capability and quality as well as the rates charged by targeted health service providers. Their services usually include all arrangements of a patient’s journey from door to door, including independent arbitration between patient and clinic (HOPE, 2015), should it become necessary. • Visa formalities: The medical travel market is promising. A medical visa is an authentication issued to an individual and set in the patient’s travel permit. Patients and relatives are approved to enter the country for a particular length of time and for the purpose of healthcare services. For example, patients flying to India for medical treatment can receive http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 265 a visa only for treatment in reputed or accredited hospitals. Up to two attendants who are blood relatives are permitted to go with the patient. Countries such as Germany, USA, UK, Turkey, Malaysia, and India offer quicker and easier travel permit (entry visa) for the patient with certain medical conditions. This encourages medical tourists, but may lead to illegal immigration, as some people pretend to be a patient to get the visa to enter a targeted country. • Better transportation opportunities: Geographical distance, travel time, ease of reaching the destination and location of health care providers are key factors in medical tourism. Patients are not willing to experience long-haul indirect flights, tiresome traffic between the airport and the hospital, complicated visa procedures and problematic customs processes. Nowadays, cheaper ticket prices and regular flight schedules provide a faster connection between countries, thereby fostering medical tourism. • Better communication opportunities: Language barriers are a very important disadvantage for medical professionals as well as patients. Hospitals, facilitators, and governmental organizations must provide a solution for better communication in the patients' mother tongue. • Social media and networking: Stories and news on similar health services at low prices easily spread globally through social networks. Sharing experiences on social media is a powerful marketing tool. Thus, medical travelers are similar to global ‘ambassadors’ for the destination country and healthcare providers. A large number of websites are advertising healthcare for patients who would like to travel for health reasons. Web search is one of the major tools for gathering information on medical tourism, and it might continue to grow in importance. Word-of-mouth (WOM) is one of the most valuable forms of experience sharing. Because of that, WOM or eWOM (web/social media based WOM) marketing can be encouraged through different activities set up by related organizations, or by having http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 266 opportunities to encourage consumer-to-consumer and consumer-to-marketer communications. • Destination facts: The destination’s image, reputation, climate, tourist attractions, infrastructure and historical background are factors that influence the perception of patients. These factors have a key role in the patients’ decision making about countries and hospitals. The websites play a big role in providing this kind of information. Tourism Ministries or other related state organizations and NGOs have to should pay attention to provide the best information. • Health System: The health status of the population and its distribution throughout the country is directly related to the healthcare system of that country and the health risks faced by the population. The home country’s health system plays a significant role in the development of contemporary patient mobility. The concept of medical travel is different in the EU from that in the US. The EU provides healthcare to patients in a controlled manner, based on social rights. This is revolutionary and historical epoch-making changes on patient mobility, which began as a result of individuals contesting their right to receive health care in any EU state and ended in an EU directive on patient rights (Council of the European Union, 2011). • International agreements: Some countries send their experts to other countries for medical procedures or educational purpose. This is an important marketing opportunity for medical tourism destinations. Also, accepting medical students or postgraduate residents from other countries gives opportunities for future collaboration, when they return to their homeland. For example, Turkey has been accepting students from the Balkan countries and from many African countries for almost 30 years, depending on agreements. When students return to their homeland, their medical teachers are available to them as consultants in case http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 267 expert opinion is needed. Further, if the patient needs to be referred to a cross-border country, their own medical school takes the priority. Turkey has also signed international agreements with many countries to accept patients for certain medical procedures such as oncological or cardiovascular surgeries. Recommendations The results of the present analysis have a number of practical implications for those who are directly or indirectly engaged in attracting medical tourists, such as physicians, hospital managers, consultants, investors, Ministry of Health, Ministry of Tourism, Ministry of Economics and third-party initiatives. • Governments of developing countries should enact legislation encouraging medical tourism and should require medical-tourism service agencies to obtain a license. • Related state organizations could impose recordkeeping requirements, thereby using the licensing scheme to monitor foreign providers through the licensees. This can be achieved through accreditation programs such as JCI. • Health insurance plans must meet the standards of the Health Insurance Portability and Accountability Act (HIPAA), even if the patient prefers and receives medical care outside the country. • Patients should determine if medical tourism is appropriate for their specific situation, taking into account the burden of travel and the distance from family, friends and other people's support system. • Patients should ensure that the foreign healthcare provider’s quality is accredited and that the physicians have the requisite credentials, even if the travel plan is being coordinated by a facilitator. • Professionals and related authorities should confirm that the staff of the service provider are well trained and can speak adequate English with simultaneous translation http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 268 opportunities. • Hospitals should ensure that dedicated information desks for International patients are available to bestow personal attention on medical tourists. 
 • To promote medical tourism, travel and tourism agencies should engage with healthcare providers under the control of responsible state organizations. Conclusion International rules related to medical tourism need to be developed, implemented and monitored. However, the potential effects of medical tourism on the healthcare sector and other related sectors should not be ignored. This condition demonstrates the need to assess the full health impact of international agreements to be formulated. Educated consumers, a growing middle class, well-trained physicians, high-technology healthcare institutions and struggling public healthcare systems are some of the forces behind the demand for medical tourism. New healthcare and globalized economic policies are unable to meet the needs and expectations of patients, thereby forcing the globalization of healthcare. Evidently, medical tourism is an emerging multi-dimensional sector with effects on the healthcare system of developed and developing countries. Consequently, medical tourism, which refers to the cross-border mobilization of healthcare services, is operating with the expectation that healthcare services will be validated through accreditation of quality and safety measurement systems with proven standards. The growth of this sector depends on local government bodies, policies, the power of private healthcare sector, airlines, travel agents, medical tourism facilitators and hotels working together, as well as government-supported marketing to promote medical tourism. This sector has significant impacts on doctors, patients, employers, insurance companies, the transportation sector, healthcare providers and policymakers (Khan, 2010). In their conference paper, Kumar et al noticed eleven independent factors for Malaysia: ‘Functions of http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 269 Responsible State Organizations’, ‘Functions of Health Centers’, ‘Cooperation of Responsible Organizations’, ‘Diversity and Variance of Medical Services’, ‘Quality of Medical Services’, ‘Pricing of Medical Services’, ‘Advertising the Medical Services’, ‘Geography’, ‘Security’, ‘As an Islamic State’ and ‘Attractions of Medical Tourism Issues’ (Kumar et al, 2012). In her paper, Bennie (2014) noted that price/cost transparency and demonstrated savings, accreditation by the JCI or its equivalent, board-certified physicians in the related fields, and an ability and willingness to collaborate with domestic doctors to coordinate before and after trip care are essential for medical tourism. According to Jagyasi (2008), there are five key drivers of medical tourism, including technological improvements, the cost of the care, the emergence of the new consumer needs, the opportunity to engage in attractive tourism, and demographic drivers such as an aging population. Gill and Singh (2011) found five important factors that affect the choice of destination: “(1) medical facilities and services”, “(2) local primary doctor’s recommendation”, and “(3) governmental policies and laws” were among the most important choices. The two choices that were relatively important were “(4) hotels and food quality” and “ (5) general tourism resource” of the target destination. Patients are traveling beyond borders in search of affordable and timely healthcare services. Many medical tourism facilitating companies are now involved in organizing and arranging health services. Despite the rapid growth of the medical tourism industry, there are a few standards to ensure that these businesses provide high quality and competent international healthcare (Turner, 2011). This commentary has explored as much information as possible to present an overall view of the key factors that influence medical tourism. Studies on healthcare tourism have attracted close scrutiny (primarily associated with their qualitative methodology) (Lunt et al, 2016; Connell, 2013). Most of the information on http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 15, No. 2-3, 2018 http://ertr.tamu.edu 270 medical tourism is Web-based or published in magazines. Also, many academic journals have published studies or reports of quantitative findings on medical tourism (Lunt et al, 2016). Today, reforms related to the healthcare system are ongoing in many countries. Thus, the evaluations presented in this commentary are valuable for those who work in all stages of the reform process. In a global manner, the volume of medical travel and its service-related economic dimensions are still limited, compared to the total health expenditure. Currently, issues of cross-border social security, the cross-border mobility of patients and services are of special relevance for tourist regions, regions attracting retired persons, and both sides’ border zones neighborhoods. However, the question of how and which economic and political dynamics will shape cross-border patients’ mobility remains open. 
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