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The purpose of this paper is a discussion of some major concepts and operational definitions involved in tourism statistics within Regulation 692/2011, with a cross-country comparison and an in-depth look at the Italian case. Data and information are derived from main documents of major international and national institutions and Eurostat metadata. Both demand-side and supply-side data sources on tourism are discussed. The work highlights the main differences in the data production processes of different EU countries, although they follow the same regulation. The main critical points are: the definition of usual environment and survey design for the demand-side data, as well as the statistical unit for the supply-side data, which does not coincide with that used in structural business statistics. The analysis is limited to those EU countries with complete available Eurostat metadata. Moreover, only household surveys relating to trips and vacations are considered for demand-side data (border surveys are not treated). The main contribution is concerned with the description of the current situation in the production of tourism statistics, by looking and their comparability for cross-country analyses and at the possibility of their integration and reconciliation in the perspective of building a system of tourism statistics.

Since the global economic and financial crisis of 2008, tourism has taken up a central position in the recovery of Spain's severely damaged economy. If the first years after the recession signaled a considerable decline of the tourism sector, the later years in which those countries with the highest numbers of outgoing tourists to Spain had recovered, consolidated the tourism sector as one of the principal drivers of economic development. Testament to this are its contribution to a growing Gross Domestic Product (GDP) and decreasing unemployment, and its ability to stabilize the country's balance of payments. On the other hand, tourism has also proven to be a complex economic sector, in which various factors have come together in different forms. Faced with the impossibility to consider every single one of these factors, this study has limited itself to researching those indicators that shape the international character of Spain's cultural tourism sector, and subsequently determining how this sector performed from a macroeconomic perspective. The outcome of this study is to detect patterns that may allow for the development of more effective means for managing cultural tourism. The descriptive analysis of official cultural and tourism statistical data, and the synthetic representation of the results in various tables and graphs indicate that cultural tourism, at least in terms of international tourist arrivals, has indeed remained stable throughout the crisis, even though it has not grown significantly ever since.

This report serves as a record of the insightful discussions and valuable contributions made over the course of a two-day Workshop on \"Tourism Data Sharing, Governance and Integration\". The workshop was co-organised by the Directorate-General for Structural Reform Support (DG REFORM), through the TAIEX instrument, and the OECD. Experts from around the world gathered in Brussels and online to explore the opportunities and challenges to strengthen the evidence-base for tourism policy and decision-making.

In this paper, we address the issues of shortage and maldistribution of health personnel in southeast Asia in the context of the international trade in health services. Although there is no shortage of health workers in the region overall, when analysed separately, five low-income countries have some deficit. All countries in southeast Asia face problems of maldistribution of health workers, and rural areas are often understaffed. Despite a high capacity for medical and nursing training in both public and private facilities, there is weak coordination between production of health workers and capacity for employment. Regional experiences and policy responses to address these challenges can be used to inform future policy in the region and elsewhere. A distinctive feature of southeast Asia is its engagement in international trade in health services. Singapore and Malaysia import health workers to meet domestic demand and to provide services to international patients. Thailand attracts many foreign patients for health services. This situation has resulted in the so-called brain drain of highly specialised staff from public medical schools to the private hospitals. The Philippines and Indonesia are the main exporters of doctors and nurses in the region. Agreements about mutual recognition of professional qualifications for three groups of health workers under the Association of Southeast Asian Nations Framework Agreement on Services could result in increased movement within the region in the future. To ensure that vital human resources for health are available to meet the needs of the populations that they serve, migration management and retention strategies need to be integrated into ongoing efforts to strengthen health systems in southeast Asia. There is also a need for improved dialogue between the health and trade sectors on how to balance economic opportunities associated with trade in health services with domestic health needs and equity issues.

With China’s sustained economic development and constant increase in national income, Chinese nationals’ tourism consumption rate increases. As a major Chinese economic development engine, the domestic tourism industry has entered a transition period operation pattern featured by diversified products. Among them, as a new hot spot of the tourism industry in China, ecological tourism has enjoyed rapid development, with great potential. Thus, the ecological value evaluation of forest ecological tourism demonstration areas is very important to the domestic tourism industry. In this paper, we propose some Dombi Heronian mean operators with interval-valued intuitionistic fuzzy numbers (IVIFNs). Then, two MADM (multiple attribute decision making) methods are proposed based on IVIFWDHM (interval-valued intuitionistic fuzzy weighted Dombi Heronian mean) and IVIFWDGHM (interval-valued intuitionistic weighted Dombi geometric Heronian mean) operators. Finally, we gave an experimental case for evaluating the ecological value of forest ecological tourism demonstration area to show the proposed decision methods.

To systematically review the literature on women's experiences traveling for abortion and assess how this concept has been explored and operationalized, with a focus on travel distance, cost, delays, and other barriers to receiving services. Increasing limitations on abortion providers and access to care have increased the necessity of travel for abortion services around the world. No systematic examination of women's experiences traveling for abortion has been conducted; this mixed-methods review provides a summary of the qualitative and quantitative literature on this topic. A systematic search was conducted using PubMed, Embase, Web of Science, Popline, and Google Scholar in July 2016 and updated in March 2017 (PROSPERO registration # CRD42016046007). We included original research studies that described women's experiences traveling for abortion. Two reviewers independently performed article screening, data extraction and determination of final inclusion for analysis. Critical appraisal was conducted using CASP, STROBE, and MMAT checklists. We included 59 publications: 46 quantitative studies, 12 qualitative studies, and 1 mixed-methods study. Most studies were published in the last five years, relied on data from the US, and discussed travel as a secondary outcome of interest. In quantitative studies, travel was primarily conceptualized and measured as road or straight-line distance to abortion provider, though some studies also incorporated measures of burdens related to travel, such as financial cost, childcare needs, and unwanted disclosure of their abortion status to others. Qualitative studies explored regional disparities in access to abortion care, with a focus on the burdens related to travel, the impact of travel on abortion method choice, and women's reasons for travel. Studies generally were of high quality, though many studies lacked information on participant recruitment or consideration of potential biases. Standardized measurements of travel, including burdens associated with travel and more nuanced considerations of travel costs, should be implemented in order to facilitate comparison across studies. More research is needed to explore and accurately capture different dimensions of the burden of travel for abortion services on women's lives.

PurposeOur goal was to present the experience of bariatric surgeons with medical tourism on a global scale.Materials and MethodsAn online-based survey was sent to bariatric surgeons worldwide regarding surgeon’s country of practice, number and types of bariatric procedures performed, number of tourists treated, their countries of origin, reasons for travel, follow-up, and complications.ResultsNinety-three responders performed 18,001 procedures in 2017. Sixty-four of those 93 responders operated on foreign patients performing a total of 3740 operations for them. The majority of the responders practice in India (n = 11, 17%), Mexico (n = 10, 16%), and Turkey (n = 6, 9%). Mexico dominated the number of bariatric surgeries for tourists with 2557 procedures performed in 2017. The most frequent procedures provided were laparoscopic sleeve gastrectomy (LSG) provided by 89.1% of the respondents, laparoscopic Roux-en-Y gastric bypass (40.6% of respondents), and one anastomosis gastric bypass (37.5% of respondents).ConclusionAt least 2% of worldwide bariatric procedures are provided for medical tourists. Countries such as Mexico, Lebanon, and Romania dominate as providers for patients mainly from the USA, UK, and Germany. The lack of affordable bariatric healthcare and long waiting lists are some of the reasons for patients choosing bariatric tourism.

Background Many ethnic minorities in Hong Kong seek medical tourism after encountering inequalities in access to local healthcare because of language barriers and cultural-religious differences. The present study explored the ethnic minorities’ lived experiences of medical tourism and issues arising from cross-border health-seeking relevant to this specific population. Methods Qualitative in-depth interviews with 25 ethnic minority informants from five South Asian countries in 2019. Results The 19 informants out of the 25 have sought assistance from their international networks for home remedies, medical advice and treatments of traditional/Western medicines, for they are more costly or unavailable in Hong Kong and for issues related to racial discrimination, language barriers, transnationalism engagement, cultural insensitivity, and dissatisfaction with healthcare services in Hong Kong. Discussion Medical tourism can relieve the host country’s caring responsibilities from healthcare services, so the government might no longer be hard-pressed to fix the failing healthcare system. Consequently, it could cause public health concerns, such as having patients bear the risks of exposure to new pathogens, the extra cost from postoperative complications, gaps in medical documentation and continuum of care, etc. It also triggers global inequities in health care, exacerbating unequal distribution of resources among the affordable and non-affordable groups. Conclusion Ethnic minorities in Hong Kong sought cross-border healthcare because of structural and cultural-religious issues. The surge of medical tourism from rich and developed countries to poor and developing countries may infringe upon the rights of residents in destination countries. To mitigate such negative impacts, policymakers of host countries should improve hospital infrastructure, as well as train and recruit more culturally sensitive healthcare workers to promote universal health coverage. Healthcare professionals should also strive to enhance their cultural competence to foster effective intercultural communication for ethnic minority groups.

Background The popularity of cosmetic tourism may increase unnecessary risks for patients as postoperative care is variable. However, little is known about the current trends and public perception of this growing phenomenon. This study compares interest in cosmetic tourism in popular medical tourism destinations relative to the US. Methods Google Trends was queried from October 2017 to September 2023, examining trends over the full period and dissecting changes between 2017–2020 and 2020–2023. Search volume data were retrieved for the top international countries and the US for each of the top five cosmetic procedures, according to the ISAPS 2022 Global Survey. A p value < 0.05 was used for statistical significance. Results Searches for liposuction, blepharoplasty, breast augmentation, mastopexy, and abdominoplasty were compared between the US, Mexico, Turkey, Thailand, and Colombia. Google Trends data mirrored the prevalence of the two most common procedures, liposuction, and breast augmentation. Differences in interest regarding liposuction were greatest in Mexico, Thailand, and Turkey compared to the US ( p  < 0.05). Medical tourism for blepharoplasty had the highest search interest scores for Turkey and Thailand from 2017 to 2023 ( p  < 0.05). Significant differences were also consistent across all time intervals for breast augmentation, mastopexy, and abdominoplasty, with higher interest in Mexico and Turkey ( p  < 0.05). Conclusions Google Trends analysis serves as an insightful tool for understanding cosmetic tourism. Changing trends bring the potential to assess worldwide versus country-specific procedure interest. These observed trends may foreshadow future international aesthetic procedure trends. No Level Assigned This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

Background The Jordanian healthcare system has evolved over the past decades expanding its services, technological, and educational resources. A comprehensive view of this system is lacking. The objective of this report is to describe the structure of the Jordanian healthcare system, the challenges facing it, and the current and recommended health policies. Materials and methods This study reviewed the current status of the Jordanian healthcare system. The following parameters were analyzed: health indicators, infrastructure, human resources, insurance system, pharmaceutical expense, health education system, and medical tourism. Data were collected from various relevant official institutions and related published literature. Results Jordan has a young population with a median age of 23.8 years. Life expectancy is 78.8 years for females and 77.0 years for males. The Jordanian healthcare system is divided into three major categories: (1) Governmental Insurance (i.e., the Ministry of Health (MOH), the Royal Medical Services (RMS) and semi-governmental insurance); (2) Private Insurance; and (3) Refugee Insurance, including the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and the United Nations High Commissioner for Refugees (NHUR). The Governmental Insurance covers 64.30% of the total population. Health expenditure is 6.37% of the gross domestic product (GDP). Pharmaceutical expenses make up 26.6% of the total national healthcare budget. Human resource assessment shows a high ratio of medical staff per 10.000 inhabitants, especially concerning physicians (31.7), dentists (7.9), and pharmacists (15.1). However, the ratio of nursing staff per 10.000 inhabitants is considered low (37.5). The Hospital bed/1000 population ratio is also relatively low (1.4). Healthcare accreditation is implemented through the Joint Commission International (JCI) accreditation which was achieved by 7 hospitals and by the National Health Care Accreditation Certificate (HCAC) achieved by 17 hospitals and 42 primary healthcare centers. Postgraduate medical education covers almost all medical and surgical fields. Medical tourism is currently well-established. Conclusions Assessment of the Jordanian healthcare system shows high ratios of physicians, dentists, and pharmacists but a low ratio of nursing staff per 10.000 inhabitants. The hospital bed/1000 population ratio is also relatively low. Pharmaceutical expenses are significantly high and medical tourism is well-developed.