THE DOH says that once a framework is in place and everything works right, then the country can expect about 125,000 medical tourists annually. That's assuming at least 10 percent of the present total bed capacity of each of the program's 17 "top facilities" (by DOH standards) will be foreigners.

If each visitor spends $1,000 each — a modest estimate, DOH says — that means at least $125 million a year going into local coffers. There would also be the employment needs that the industry is expected to generate: from doctors and nurses, to travel agents, telephone operators, and interpreters, to masseurs and spa therapists.

University of Asia and the Pacific Prof. Cherry Lyn Rodolfo, who co-wrote a forthcoming book on the trade and liberalization of health services in the country, says medical tourism could even stem the emigration of healthcare workers. With hospitals earning more, doctors and nurses will be better paid, she notes. More people may even be encouraged to take up medical and health sciences courses; except for nursing, the enrollment rate in these courses has been declining in the past five years, Rodolfo says.

Your health at your fingertips IT SOUNDS like something out of the brain of Amazon.com's Jeff Bezos, but it's as local as ampalaya tablets: an online shopping cart for such things as a heart transplant coupled with a yoga retreat. The first searchable online directory of medical doctors and dentists in the Philippines, Rx Pinoy features the cart in a special section that makes "shopping" for medical services much easier. This new feature is part of efforts under the country's medical tourism program to "cluster" services offered by the private sector. To start shopping, all one has to do is register online. The shopper's personalized page will then lead to the Medical Tourism Showroom, an automated travel planner where one can order a "package" that could be a mix of any of the four services: medical services; spa retreats; accommodation; concierge (services of an interpreter or caregiver); tourist destinations; and insurance packages. The medical-services section offers two choices: shop by provider (i.e. hospital) or shop by specialty (type of service). Only four medical-tourism hospitals are currently on the menu: St. Luke's Medical Center, Makati Medical Center, Metropolitan Medical Center, and World Citi Medical Center. A click on a hospital takes you to either to the health facility's website or to an information page that includes a list of medical and surgical packages. Metropolitan Medical Center, for example, offers a kidney transplant package for $18,941.75. The transplant is only $14,068, but the package covers operating room fees, medicines, hospital tests for screening the patient and the donor, a week's stay in a private room, and airport transfers. (In the United States, a kidney transplant operation could cost $150,000.) One could also opt to shop by specialty and choose packages from any of the 10 "specialty services," among them cosmetic and plastic surgery, cardiac procedure, executive check-up, ophthalmology, and even hair transplant service. There is also a "Specials" section devoted to slimming packages, one of which includes liposuction, several sessions of lipodissolve, other free medical procedures, a spa treatment, and a half-day tour around Manila — all for $3,685.96. But should these packages not suit the shopper, the "Match Me" option will allow Rx Pinoy to match her needs with her budget. Once all the shopper's choices are in the shopping cart, submitting the "order" is as easy as clicking on the checkout button. (Changing one's mind is allowed; simply unclick the order.) One then receives an emailed confirmation of the order. Rx Pinoy says it first has to review orders and check if the patient is suitable for the packages selected. A doctor will also offer suggestions. Once the type of treatment has been finalized, an advance payment to Rx Pinoy is required; the balance will be paid once the patient arrives in the Philippines. Rx Pinoy will coordinate airport pick-ups, hotel bookings, and meetings with the patient's doctors. After the treatment, and with the doctor's permission, the patient can then enjoy a stay in a beach resort or a visit to some of the country's cultural or heritage sites. — Avigail Olarte (Note: The official site for the Philippine Medical Tourism Program is philippinemedicaltourism.info. It was created to serve as a central clearinghouse of information for potential foreign patients. But the site is still incomplete, and at the moment leads the user to Rx Pinoy.)

"You create the opportunities locally and you create the opportunity to earn the dollar locally," she says. "At the same time, you keep your people here."

Then again, she says this may also cause an "internal brain drain," wherein rural doctors and health workers leave their barrios for dollar-earning hospitals in the city. She says, however, that these are "risks" that may not happen. At least, she points out, these issues are already being discussed. "It's up to us how we can manage or reduce these risks," she says.

Rodolfo agrees with Reganit that medical tourism could "improve the local healthcare situation." But that, she says, is hinged on the program proponents' ability to find "a mechanism where some of these earnings can be channeled back to the public health sector."

"We would not want to arrive at a situation where we're earning billions of dollars from medical tourism and the local healthcare budget is declining or the poor's access to health services is not improving," she says.

Which is exactly what Romualdez is afraid of. "We don't know if we'll actually gain from this," he says. "We cannot quantify, for example, how much money will come in and how much will be lost to incentives."

THE DOH says the government is still looking into fiscal and non-fiscal incentives it could offer to medical-tourism enterprises. But to Dr. Enrique Ona, the facility upgrade and improved services the medical-tourism program would make possible for his hospital are incentive enough.

Ona is the executive director of the National Kidney and Transplant Institute (NKTI) in Quezon City, one of the government hospitals included in the program. The sprawling, 266-bed NKTI is currently the only tertiary government hospital in the country that has an ISO global seal of quality standard. When Ona says the NKTI would be able to upgrade because of medical tourists, he means the hospital would be able to afford more improvements. Six years ago, the NKTI had already sunk in sizeable sums to spruce up its facilities-and has since been attracting patients from abroad.

"We practically service the renal care of the whole of Micronesia," says Ona. "Through our website, these patients saw our facilities and cheap rates and they decided to come." Other patients have flown in from Canada, Israel, several Arab states, the United Kingdom, and Australia.

The NKTI is best known for its transplant program for the kidney, liver, pancreas, stem cell, and bone marrow. But to many health activists, this specialization makes its inclusion in the medical-tourism scheme suspect.

Activists say a government-sanctioned program that encourages foreigners to have transplant operations here may not only mean Filipinos in need of the same organs would be pushed down the waiting list. Some of them say it could also lead to an organ-selling spree among the desperate poor who are hardly in perfect health themselves. For sure, the current "black market" rates for kidneys from live "donors" are already tempting: P75,000 to P150,000 each, of which P30,000 usually goes to a middleman. The Kidney Foundation of the Philippines, however, says the fair rate is actually P300,000, which covers costs for the screening process and the post-operative care of the donor for 10 years.

Ona admits there are moral and ethical issues involved with organ donations. He tries to explain the situation this way: Under the Filipino organ-donation program, the first option is always an organ from a relative. Next is from a deceased donor. The third and last option is from a living donor not related to the patient. Ona says they make sure the donor from this set understands that his or her organs are not being bought, although there would be what Ona calls a "gratitudinal gift" for donating.

At least the Kidney Foundation says it now has guidelines for its donor program to stop "profiteering clinics" from encouraging organ-selling. The DOH, for its part, wants all living, "non-related" donors to pass through the Foundation's screening process to ensure no one is just trying to make a buck.

Ona says that despite the medical-tourism program, Filipino patients will always be given priority in the organ transplant list. He adds that this is supported in part by DOH guidelines on transplant operations involving foreign patients. Ona also points out that under the Philippine Organ Donation Program, foreign and well-off Filipino patients are asked to donate to the Kidney Foundation to help those who cannot afford a transplant operation. The donations can run up to $12,000 (some P612,000) per foreign patient; a transplant operation costs from P500,000 to P1 million.

Hospital administrator Blesilda Gutierrez notes that the yearly government subsidy of P185 million for the NKTI's charity patients has barely increased since 2003. She also says that before 2005, NKTI had to use part of that subsidy for other operational expenses. But because of improved revenues — partly due to its modestly sized yet steady stream of foreign patients (109 in 2005 and 105 in 2004) — the hospital was able to spend more on its indigent patients last year, and even put into the charity pot 20 centavos for every peso it received from the government.