With the increase in international movement of capital, inputs of production, consumer goods, and services, global trade in health commodities and services has grown rapidly. The nature and composition of international trade in health services is undergoing rapid transformations with technological developments in medicine and communications. Although flow of medical commodities was always important in international trade, in recent years movement of patients across borders has become increasingly significant. With increasing demand for medical care internationally, a number of countries have identified medical tourism as an important growth sector. For example, countries like Thailand, Singapore, India, Turkey, have adopted specific policies to encourage and subsidize international flow of patients. Wider diffusion of modern medical technology is increasing the competitiveness in this market, encouraging product differentiation across the countries. Early adopters of medical tourism (Thailand, Philippines, Singapore, and India) started with specialized services and then branched-out to provide more broad-based services but further expansion of the market is encouraging greater degree of specializations in advanced medical procedures and interventions. Aspiring medical service exporters are also trying to identify medical specializations in which they might have comparative advantage because of their geographic locations, economic structure and quality and efficiency of health care systems.
Medical Tourism takes place when individuals travel to another country with the primary intention of receiving medical treatments and services. There are a number of reasons why patients seek care internationally rather than obtaining the services in their own country of residence. The reasons may include non-availability of services locally, lack of insurance coverage, long waiting time, higher quality and lower cost in the destination countries, possibility of combining medical care with tourism, other factors related to personal taste and preferences. Depending on the type of care needed and the benefits and costs of accessing the services internationally, the trips may be short distance (for example, travel within Europe) or long or even intercontinental. The flow of patients is also not unidirectional from developed to developing countries; patients flow from one developed country to another, from developed to developing regions, between developing areas or from developing areas to developed economies.
The flow of patients to developed countries is not a new phenomenon. Richer and privileged patients from both developed and developing countries sought care in developed countries mainly because of perceived high quality of services. In the past, travelling overseas for medical care from developing countries was limited to high-income, politically connected individuals . Flow of patients between developed countries, mainly within the European Union  and between USA and Canada was also common . In recent years, the magnitude and direction of patient flow has changed drastically. Alsharif et al.  mentioned Middle Eastern countries like United Arab Emirates and Jordan as important destinations for patients from the region because of their relatively well-developed healthcare infrastructure. Ramirez  found similar flow to Mexico, Cuba, Panama and Costa Rica from the neighboring countries. A number of Southeast Asian countries like Thailand, Singapore, Malaysia and India in South Asia, have become important destinations for patients from both developed and developing countries .
Range of treatments available overseas include cosmetic and dental surgery; cardio, orthopedic and bariatric surgery; in-vitro fertilization (IVF) and related treatments; and organ transplantation and other general services . Medical travel decisions are affected by many factors like patient characteristics (insured or uninsured, socioeconomic situation, age and disabilities), medical care in the home country and in destination country (quality, cost, ease of access), existence of formal incentive mechanisms (encouraged by employers, insurance agencies, governments), type of medical care treatment being sought (cosmetic, elective, mandatory, emergency, highly specialized procedures, legally not allowed in home country), psychological factors associated with travel and obtaining care from unfamiliar cultural and social context, possibility of unexpected expenses, complications, malpractice, etc. For countries without universal medical insurance like United States, cost savings has been reported as one of the most important factors for seeking care internationally while in countries with national health programs outflows of patients are mainly for obtaining services not covered by the national program  or to avoid waiting line .
Lower transportation costs, instant electronic communication system, low time costs of travel have enabled many countries to enter the medical tourism market. Turkey is also taking advantage of this global change and has been encouraging foreign patients to seek care in Turkey. As a destination country, Turkey has become quite popular in recent years, probably due to the provision of quality services at a relatively low cost, low waiting time and good reputation of some specialized medical care facilities and professionals. With rapid expansion of medical tourism, competition among potential destination countries has also become more intense. Market competition has encouraged countries to become specialized in a few highly specific medical interventions and services. Although the degree of specialization of Turkish health system is still evolving, in-vitro fertilization has emerged as one of the important areas in which the country appears to have some comparative advantage over other medical care interventions. The purpose of this study is to better understand the factors associated with increased popularity of medical tourism in Turkey through a case study of in-vitro fertilization (IVF) treatment.
Size of medical tourism market
Despite the fact that international trade in medical services has been growing rapidly over the last few decades, data on medical tourism and number of medical tourists worldwide are not readily available. Although some numbers are referred to, these are not based on any systematic collection of data . Anecdotal evidences are often presented to indicate high rates of growth of medical tourism in India, Thailand and Mexico, but objective information is hard to come by. The Tourism Research and Marketing reported that the global medical tourism market had over 19 million trips in 2005 with a total monetary value of $20 billion. Since a number of countries were experiencing double-digit growth in 2005, the projection was that medical tourism will double in value by 2010 . Deloitte Medical Tourism Report estimated that approximately 750,000 Americans traveled outbound for medical care in 2007. Deloitte projected a 100 % annual rate of growth through 2010 . Among the OECD countries, the largest importer of medical care is Germany with US$1.5 billion in value while the United States is the largest exporter with US$2.3 billion in exports. Among the OECD countries, Turkey has become an important exporter of medical care (export value of US$409 million), third largest exporter after USA and Czech Republic . McKinsey report, on the other hand, estimated that the number of medical tourists from the USA was only 75,000 if service use by expatriates and emergency cases is excluded, asserting that “the market is much smaller than conventional wisdom suggests” .
In Turkey, medical tourism is considered an important growth sector and policy makers are eager to help expand this market. Ministry of Health medical tourism department reported that the number of medical tourists arriving Turkey increased from 74,093 in 2005 to 261,999 in 2011 . The Turkish data on medical tourists may also represent significant overestimation. It is interesting that the same report mentioned that the majority of foreign patients in Turkey were the patients who needed emergency care and therefore the number of “real” medical tourism patients (those who travel to Turkey primarily for seeking medical treatment) should be much smaller. It is also possible that patients misrepresent their medical care use as emergency type in order to be able to receive reimbursements from their home-country insurance agencies.
Specialization in medical tourism
As indicated above, with increasing competition in the medical tourism market, countries are trying to define their own areas of specializations to create differentiation and market segmentation. Countries tend to specialize in market niches on the basis of the resources they have, medical care infrastructure of the countries, levels of development of tourism and trade opportunities. Although some countries may decide to focus on general medical care services, differentiation allows countries to develop some market power in a highly competitive environment. The differentiations are often created by offering specialized medical care services, the services in which the countries show significant comparative advantage. Investments in these narrowly defined specializations allow the countries to become well-known as the preferred destination for those specific services.
Becoming recognized as the preferred destination for highly specialized medical care services creates the “reputation-effect”, which may become the catalyst for achieving higher market demand for other medical services as well. For example, Poland and Hungary started medical tourism with dental treatments because of their significant cost advantage over the neighboring countries . This initial specialization in dental care triggered development in other medical care fields and some of these Eastern European countries became well-known destinations for plastic surgery and other elective treatments. Similarly, Connell  reported that Thailand specialized in sex change surgery at the early stage but gradually became important destination for general medical care services, cosmetic surgery, heart surgery, etc. South Africa and Argentina also specialized in cosmetic surgery and attracted patients from their own geographic regions.
A number of countries have taken advantage of their special status as the centers of specific religion to become recognized as medical tourism destinations for people with the religious identity. Inhorn  mentioned that Iran and Lebanon have become destination for a significant number of Shiite population. Israel attracts many Jewish people from around the world . Travel for IVF or surrogacy to a number of Asian countries has become popular because of lower regulatory restrictions on surrogacy and sex-selection in addition to the price-advantage these countries offer .
Sometimes, focusing on particular treatment stems from destination countries’ location and for being a travel hub for regional countries with relatively low heath care quality. Accredited hospitals in Jordan and Turkey became specialized in state-of-the-art cancer treatments and attracted patients from the neighboring countries. Similarly, Indian hospitals became well-known in the diagnosis and treatment of cardiovascular diseases while Argentina became specialized in eye surgeries. Malta became a destination for hip and knee replacement. The ability of the destination countries in using trained medical professionals, modern technology and scientifically recognized methods has also attracted medical tourists . Once a country becomes well-known in the provision of specific medical services, economies of scale allows it to capture even a higher market share . The ability of countries to package medical services with general tourism improves cost-advantage for patients .
Medical tourism facilitators use the country-specific specializations for guiding their customers in the choice of countries and health care facilities. Medical tourism websites emphasize these specializations to encourage international travel for obtaining medical care. For example, medical tourism websites often mention India for orthopedic surgery (especially knee resurfacing) and cardiac surgery; Singapore for cancer treatment, spinal surgery, transplants, and Mexico for dental treatments. India, Thailand, Singapore and Malaysia have also become very successful in attracting long-distance medical tourists from developed countries to their JCI accredited hospitals . These hospitals are comparable to some of the best hospitals in the world .
Medical tourism, In-Vitro Fertilization (IVF) and Turkey as a destination country
In reproductive health area, the IVF technique has remained relatively unchanged over the last 30 years. Treatments start with the stimulation of ovaries in order to trigger production of large number of eggs, some of which can be retrieved. Retrieved eggs are placed in a tube for fertilization and sperm is introduced in the solution to get fertilized eggs. After 2–5 days, the fertilized embryos are transferred into the uterus of the mother-to-be with the help of a catheter .
It is estimated that at least 20,000 to 25,000 couples receive in-vitro fertilization (IVF) care each year from abroad . In a 2008 report, the fertility industry was seen as an important growth sector with additional revenue earning potential of $1-2 billion by 2012 . Turkey is ranked 7th in the global IVF market with more than 120 Assisted Reproduction Centers operating in the country. Total number of baby born with IVF in Turkey was 44,000 in 2010 .
Many of the IVF patients prefer to seek care from foreign countries for a number of reasons. Prohibitions, restrictions and regulations (e.g. restrictions on surrogacy, donor eggs, donor spermatozoa and age limitations), long waiting line for the service, high out-of-pocket cost and uncertainty about success of the treatment are considered the major reasons. In general, the IVF treatment is such that it rarely exposes the provider to malpractice risk and many providers are willing to participate in this service provision. Since the procedure does not make patients sick or require them to remain in the clinic or hospital for an extended period of time, patients can often combine obtaining IVF services with general tourism.
Although Turkey has become an important IVF medical tourism destination, interestingly, it is not because of its lower restrictions or prohibitions in terms of reproductive choices individuals face. For example, egg donation, surrogacy and sex selection are officially prohibited in Turkey . Therefore, international movement of patients to obtain IVF services from Turkey is probably related to factors like cost, quality and convenience of obtaining the services.
The possibility of adverse consequences on access to health care in the host country has been mentioned in the literature but IVF services should not lower availability of other general medical care services. Medical Tourism for IVF is unlikely to affect availability of medical personnel in other health care services and therefore will have little or no impact on availability of general health services for the population. With more than 120 IVF laboratories in the country, access to IVF services is also not a concern for Turkey. Even though making IVF services to foreign patients may increase the price of this service in the marketplace, it is unlikely to affect the out-of-pocket costs for Turkish patients. In Turkey, first and second cycles of IVF are paid by the governmental social security agency and increased market price may increase pressure on governmental budget but unlikely to affect costs paid by patients.
One potential issue working against continued expansion of medical tourism in Turkey is the political uncertainty and disruptions created by wars and conflicts in the Middle East. It is not clear how the volatile political environment will affect medical tourism. If the armed conflict becomes more widespread with spillover effects in Turkey, the perceived cost of obtaining services from Turkey may exceed the perceived benefits reducing the demand for medical tourism in Turkey.