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CHAPTER 1

INTRODUCTION

1.1 INTRODUCTION

Tourism has emerged as a key sector of the world economy and has become a

major workforce in global trade. It has been making a revolutionary and significant

impact on the world economic scenario. Tourism has been identified as the major

export industry in the world (Gosh Viswanath, 1998). The multifaceted nature of this

industry makes it a catalyst to economic development and helps balanced regional

development. It is a low capital, labour intensive industry with economic multiplier

and offers and opportunity to earn foreign exchange at low social cost.

Tourism industry acts as a powerful agent of both economic and social

change. It stimulates employment and investment, modifies economic structure and

makes positive contributions towards balance of payments. The money spent by the

foreign tourists in a country is turned over several times. In the process, the total

income earned from tourism is a number of times more than the actual spending. The

multiplier effect of tourism receipts is completely recognized as spreading to

secondary and tertiary spheres of the economic activities of a nation. It encompasses

economic, social cultural, educational and political significance. Marketing and

promotion are of vital importance in tourism because of the competitive nature of the

industry both within and between the generating countries. Tourism creates direct,

indirect and induced employment. It produces a vast spectrum of employment form

highly qualified and trained managers of five-star hotels to room boys, sales girls, and

artisans. With its faster growth, new horizons of employment open up for the

unemployed and underemployed youth of the developing countries.

1.1.1 Economic Growth and Tourism

Tourism has been a major social phenomenon of the societies all along. It is

motivated by the natural urge of every human being for new experience, adventure,

education and entertainment. The motivations for tourism also include social,

religious and business interests. The increase of education has fostered a desire to

know more about different parts of the globe. The basic human thirst for new

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experience and knowledge has become stronger, as communication barriers are

getting overcome by technological advances. Progress in air transport and

development of tourist facilities have encouraged people to venture out to the foreign

lands.

Tourism‟s importance, as an instrument for economic development and

employment generation, particularly in remote and backward areas, has been well

recognized the world over. It is the largest service industry globally in terms of gross

revenue as well as foreign exchange earnings. Tourism can play an important and

effective role in achieving the growth with equity objectives which India has set for

itself. Tourism is one economic sector in India that has the potential to grow at a high

rate and can make sure consequential development of the infrastructure of the

destinations. It has the capacity to capitalize on the country‟s success in the services

sector and provide sustainable models of growth.

It has the potential to stimulate other economic sectors through its backward

and forward linkages and cross-sectoral synergies with sectors like agriculture,

horticulture, poultry, handicrafts, transport, construction, etc. Expenditure on tourism

induces a chain of transactions requiring supply of goods and services from these

related sectors. The consumption demand, emanating from tourist expenditure, also

induces more employment and generates a multiplier effect on the economy. As a

result, additional income and employment opportunities are generated through such

linkages. Thus, the growth of the tourism sector can lead to large scale employment

generation and poverty alleviation.

The growth in the tourism sector emerged as a very important contribution to

the national economy and contributed quite a lot for employment generation in

various tourism related activities. The not direct employment multiplier in the case of

tourism is fairly high and is estimated as 2.36 which implies that direct employment

of one person in the tourism sector creates employment to 1.36 persons in other

sectors of the economy due to linkages with tourism .These linkages are in the sectors

like agriculture horticulture, poultry, handicrafts, construction, sports etc. Further

these directly/indirectly employed following the development of tourism may also

need more goods & services as a result of such employment than what they would

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have demanded otherwise. Additional demand will thus generate more employment

and further multiplier effect will come into force through successive chain of

transactions. In fact investment in tourism has the potential to create more jobs

compared to many other sectors and all the more at a lower level of investment. The

labour/capital ratio is very favorable in tourism sector compared to many other

industries with 47.5 jobs for a million rupee investment as has been seen in the survey

conducted by the Ministry of Tourism (MoT), government of India (Kanjilal, 2006).

The economic benefits that flow into the economy through growth of tourism

in shape of increased national and State revenues, business receipts, employment,

wages and salary income, buoyancy in Central, State and local tax receipts can

contribute towards overall socio-economic improvement and accelerated growth in

the economy. Tourism is overwhelmingly an industry of Private sector service

providers, although the public sector has a significant role to play in infrastructure

areas either directly or through public–private partnerships (PPPs) approach. It is a

multi-sectoral activity characterized by multiple services provided by a range of

suppliers. It is quite similar to manufacturing industry, where the supply chain is as

important as the end product. The related sectors include airlines, surface transport,

hotels, basic infrastructure and facilitation systems, etc. Thus, the growth of tourism

cannot be attained unless the issues related to all the sectors are addressed

simultaneously.

Another important feature of the tourism industry, which is of particular

significance to India, is its contribution to national integration and preservation of

natural as well as cultural environments and enrichment of the social and cultural

lives of people. Over 382 million domestic tourists visiting different parts of the

country every year return with a better understanding of the people living in different

regions of the country. They have a better appreciation of the cultural diversity of

India. Tourism also encourages preservation of monuments and heritage properties

and helps the survival of arts forms, crafts and culture.

It is also important to note that tourism has become an instrument for

sustainable human development including:

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Poverty alleviation

Environmental regeneration

Job creation

Advancement of women and other disadvantaged groups.

1.1.2 Size of Global Tourism

According to the World Tourism Organisation (WTO), the year 2008 saw

more than 922 million international tourist arrivals, and the tourism receipts were of

the order of US $ 944 billion. The World Travel and Tourism Council (WTTC) for

2009 the contribution of the Travel & Tourism economy to total employment is

expected to rise from 219,810,000 jobs in 2009, 8.4% of total employment or in 1 in

every 11.8 jobs by 2019. Gross Domestic Product (GDP) is expected to rise from

9.4% (US$5, 474 billion) in 2009 to 9.5% (US$10, 478 billion) by 2019. However

Real GDP growth for the Travel & Tourism economy is to be -3.5% in 2009, down

from 1.0% in 2008, but to average 4.0% per annum over the coming 10 years with

export earnings from international visitors and tourism goods are to generate 10.9% of

total exports (US$1, 980 billion) in 2009, growing (in nominal terms) to US$4, 132

billion (9.8% of the total) in 2019. (World Travel & Tourism Council, 2009)

1.2 TOURISM IN INDIA

India as a tourist destination exercises immense attraction from various angles.

Tourism has emerged as a major industry of the Indian economy, contributing

substantially to foreign exchange earnings and serving as a potential generator of

employment opportunities. India is the largest democratic republic in the world with

immense possibilities of growth in the tourism sector, with its vast cultural and

religions heritage and varied natural attractions, but the country has only a meager

share in world tourism. It is a land of contrasts, that is, from tropics to snows. It

presents a diversity of rare natural and cultural endowments, which is the traditional

symbol of India, i.e. unity in diversity. India has God‟s plenty of natural beauty

ranging form the towering Himalayas in the north to the sun-kissed beaches of the

east and the breathtaking beauty of the west. Each area of the country offers a

different experience with its own specific festivals and culinary culture. India‟s rich

cultural heritage and glorious tradition are linked with the development of tourism in

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India. The great German scholar, Max Muller, observed: if we were to look over the

whole world to find out the country most richly endowed with all the wealth, power

and beauty that nature can bestow in some parts a very paradise on earth.

The best performing states of India include Uttaranchal, Rajasthan, Andhra

Pradesh, West Bengal, Karnataka, Uttar Pradesh, Orissa and Haryana. Even though

India‟s share in international tourism is less than 0.4 percent, the tourism sector alone

accounts for 5.8 percent of the total employment generated in India. Tourism

contributes 5.6 percent of the national income with in India (Anbalagan, M., Selvam,

V., Amudha, R. 2005). According to World Travel and Tourism Council, India will be

a tourism hotspot from 2009-2018, having the highest 10-year growth potential. The

Travel & Tourism Competitiveness Report 2007 ranked tourism in India 6th

in terms

of price competitiveness and 39th

in terms of safety and security. Despite short-and

medium-term setbacks, such as shortage of hotel rooms, tourism revenues are

expected to surge by 42% from 2007 to 2017. India‟s 5,000 years of history, its

length, breadth and the variety of geographic features make its tourism basket large

and varied. It presents heritage and cultural tourism along with medical, business and

sports tourism.

1.2.1 Size of India Tourism

There has been a remarkable growth over the years in foreign tourist arrival to

India due to the various efforts made, including promoting India through the

„Incredible India‟ campaign in overseas markets. This global campaign had attracted

the attention of tourism industry observers as well as tourists. Foreign tourist arrivals

(FTAs) in India increased from 2.65 million in 2000 to 5.58 million in 2010. The

foreign exchange earnings (FEE) from the tourism sector in 2010 were $ 14193

million, an increase of $10729 million over 2007 (Ministry of Tourism India, 2010).

The contribution of the Travel & Tourism economy to employment is

expected to rise from 31,105,000 jobs in 2009, 6.4% of total employment or 1 in

every 15.6 jobs to 40,037,000 jobs, 7.2% of total employment or 1 in every 13.8 jobs

by 2019. Real GDP growth for Travel & Tourism economy is expected to be 0.2% in

2009 and to average 7.7% per annum over the coming 10 years (World Travel &

Tourism Council, 2009).

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Table 1.1

Foreign Tourist Arrivals/FATs in India and Foreign Exchange Earnings/FEE in

US million Tourism in India, 2000-2010

Year

FTAs in

India (in

million)

Percentage (%)

change over the

previous year

FEE from Tourism

in India (in US

million)

Percentage(%) change

over the previous year

2000 2.65 6.7 3460 15.0

2001 2.54 -4.2 3198 -7.6

2002 2.38 -6.0 3103 -3.0

2003 2.73 14.3 4463 4.38

2004 3.46 26.8 6170 38.2

2005 3.92 13.3 7493 21.4

2006 4.45 13.5 8634 15.2

2007 5.08 14.3 10729 24.3

2008 5.28 4.0 11832 10.3

2009 5.17 -2.2 11394 -3.7

2010 5.58 8.1 14193 24.6

Source: (i) Bureau of immigration, Govt. of India,

(ii) Reserve Bank of India,

(iii) Ministry of Tourism Govt. of India,

Though the growth in tourism in India has been impressive, India‟s share in

global tourist arrivals and earnings is quite insignificant. India‟s rank in world tourist

arrivals in 2008 was 41. It is universally acknowledged that the tourism resources in

the country have the potential to generate significantly higher levels of demand from

the domestic and international markets, and, if exploited intelligently in a sustainable

manner, can prove to be the proverbial engine of growth for the economy.

1.2.2 Scope of Tourism in India

India has many tourist attractions that have healing abilities and are capable

of providing rewarding experiences of life. India has the Himalayan ranges in the

north, a long coastline surrounded by seas in the south. In addition, India is rich in

varied landscapes, enchanting historical sites and royal cities, clean beaches, serene

mountain retreats, rich cultures and festivities to enjoy and rejuvenate.

In any part of the year, India can offer a wide selection of destinations

and experiences. In summer, there are lovely retreats amidst the heady beauty in the

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Himalayas or the lush-heights of the western Ghats with cool trekking trails, tall

peaks, or stretches of white water for the adventure seekers. In the cool Indian

winter, cities come alive with cultural feasts of music and dance. The sun-clad

beaches are ideal locations for rejuvenation in the winter. The wild-life sanctuaries

with their abundance of flora and fauna provide delights to the mind and

rejuvenation to the body. Various tourism themes are being promoted in India,

which are described below:

Adventure Tourism: The country offers a wide range of adventure sports

for tourists. Trekking and skiing in the Himalayas; white water rafting on the rivers

such as Ganges and Beas; camel and jeep safaris in the deserts of Rajasthan,

paragliding in Himachal Pradesh, water-sports in Goa; Scuba diving in Andaman

and Lakshadweep islands are some of the options available to adventure seeking

tourists. Lakshadweep islands also offer excellent wind surfing and snorkelling in

the crystal clear waters of the lagoons.

Eco-Tourism: The Himalayan Range spread across five Indian states

providing widest monotonic geographical variety. Wide sweeping valleys and

deep gorges give way to thick deciduous forests and alpine meadows, undulating

tea gardens and slopes, bar narrow terraces, gently contoured hills, snow draped

peaks surrounded by a fluff of clouds, thundering rivers and deeply fissured

glaciers provide excellent locations for eco-tourism. In the southern part of India, the

south and eastern Ghats, especially the Nilgiri Ranges, have its own unique appeal

to eco-tourism.

Architectural Treasures: India has rich architecture traditions, which have

the beginning as old as 3rd millennium BC. Indian architectural tradition is the living

vital art of the various dynasties, which ruled over it. The Buddhist stupas (dates

back to 230-500 AD); Jain‟s sculpture at ancient Palitana, Ajanta, Ellora, and Mount

Abu; the Hindu temples with profuse carvings and Gopurams of the South India;

arches and domes, filigrees in architecture promoted by Mughals; presidency

towns built by modern rulers like British, French, Portuguese, are some of

the vital arts assimilating the influence of various dynasties that ruled over the

country.

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Sun and Sand – Coastal Tourism: India‟s coastal states such as Gujarat,

Masharashtra, Goa, Karnataka, Kerala, Tamil Nadu, Andhra Pradesh, West

Bengal and Orissa have a choice of beaches. Many breathtaking beaches

promise perfect escape to tranquility. While some of them are for quite beaches (like

Chorwad, Ahmedpur and Mandvi in Gujarat; Gopalpur in Orissa), the beaches in Goa

are popular for wind-surfing and yatching.

The Backwaters: Kerala is said to have sprung from the ocean. All along

the coast, these exotic backwaters, canals, lagoons and inlets create an intricate

maze that stretches for 1900 km. across the land. The serene villages in the

backwaters of Kerala are living portrait of Kerala‟s rural life.

Forts and Palaces: India‟s once famous princely kingdoms, which carried

feudal traditions, have built forts and palaces, some of which have been converted

into hotels now. Jaipur, Jodhpur, Jaisalmer, Bikaner in the state of Rajasthan;

Mysore in Karnataka; Mughals‟ forts in Northern India are some of the examples of

several fascinating forts and palaces.

Hill Delights: A journey through the hill resorts of India promises a deep and

refreshing communion with nature in its varying beauty. Lush river valleys

surrounded by snow-caped peaks, fruit-laiden orchards, gurgling streams and dense

forests evoke enchantment and delights of hilly regions. The misty dawn on

mountains creating magnificent landscapes extend to the entire north-eastern states,

whose natural beauty has earned the title „seven sisters.' Other hill states,

Himachal Pradesh and Jammu & Kashmir provides a breathtaking variety of the

Himalayan splendour. The Nilgiris in the South have the picturesque Anantagiri,

Udhagamandalam, Madikeri and Munnar. Mount Abu in Rajasthan, Panchgani in

Madhya Pradesh and Mahabaleshwar in Maharashtra are other hill regions with

tourist attractions.

The Deserts: The state of Rajasthan has the mystique of the desert with

sand dunes closer to the splendid cities of Jodhpur, Bikaner and Jaisalmer. The

royal edifices take the tourists to the magnificence of the bygone era. Turbaned

men with proud moustaches, and village girls in colourful attires and heavy jewellery

swaying in the desert sands to match with the enchanting rhythm and melodies, are

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other attractions of the deserts of India.

The Jungle: India is a land of wildlife providing delight for the natural

lovers. Total area of India‟s protected wildness is approximately 140,000 sq. km.

and constitutes 4 percent of the century‟s total land area. The country has

preserved vast tracts of forests and habitats in its nearly 100 national parks over 400

wildlife sanctuaries. India‟s climatic and geographic diversity makes it the home of

over 350 mammals and 1200 bird species, many of which are unique to the sub-

continent. The wildlife parks and sanctuaries, filled with varieties of tigers and

elephants, the peacocks and the rhinoceros, are fascinating diversity of terrain, flora

and fauna. In northern India, Corbett National Park and Dudhwa National Park in

Uttar Pradesh, Kanha National Park and Bandhavgarh National Park in Madhya

Pradesh and Rajasthan‟s Ranthambore National Park and Sariska Tiger Reserve,

are all the home of the magnificent predator-the tiger. These also have varieties of

deers, and a range of lesser cats, mammals and birds.

Island attractions: The Andaman and Nicobar, and Lakshadweep islands

are enriched with white and sandy beaches, crystal-clear water and picturesque coral

reefs. Sun-bathing in these islands along with snorkelling and scuba-diving are

tourist attractions.

Pilgrimage: India holds attractions, for pilgrim tourists of diverse religions,

where religion is considered more than the act of worship, but a way of life. For the

Hindus age-old cities of worship like Prayag (that provide holy confluence of

Ganga, Yamuna and Saraswati rivers); Puri (Jagannath temple); Konark (Sun

temple); Kanchipuram, Madurai, Tiruchirappalli and Kanniyakumari (Southern

Gopurams), provide peace and reverence. In addition, there are also religious

places that are carved with craftsmanship, at Belur and Halebid. In these temples,

the interior and exterior walls are decorated with intricately-carved deities stylized

motifs from nature and friezes depicting the life in the reign of the Hoysalas. There

are also worship places for the Muslims (Delhi - Jumma Masjid), Christians

(Churches in Goa and Kerala), Buddhists (Bodhgaya, Saranath, Kushinagar),

Sikhs (Golden Temple) and Jains (Sravanabelagola), that have tourist attractions.

North-East Region: Life moves at a serene pace in the north- eastern region

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of India with the „seven sister‟ states are generously blessed with the natural beauty.

The region is enriched with magnificent landscapes naturally created by

verdant valleys, emerald tea gardens, lush forests and tumultuous rivers. A misty-

dawn of the mountains, bronze sun-set across the expanse of the Brahmaputra,

and the clang of prayer bells at monasteries, provide healing to mental and

physical well-being of the visiting tourists.

In nut shell, India has many tourist attractions that have healing abilities

and are capable of providing rewarding experiences of life. India has the

Himalayan ranges in the north, and a long coastline surrounded by three seas

in the south. In addition, India is rich varied different landscapes, enchanting

historical sites and royal cities, clean beaches, serene mountain retreats, cultures

and festivities to enjoy and rejuvenate.

The above said tourism may be an added asset for attracting to promoting

health tourism in India.

1.3 CONCEPT OF HEALTH TOURISM

The wealth of a country is judged among other things by the health of its

citizens. Worldwide, countries are seeking to provide viable healthcare solutions to

its population. Improvement in healthcare in a society means more than the

availability of doctors or hospitals or medicines. Improvement in healthcare occurs

through promotion of health consciousness through a range of activities that would

suit to various sections of the society – children, youth and elders. In this

perspective, Indian traditional healthcare systems such as Ayurveda and Yoga, as

also the concept of spiritual healings are popular amongst both domestic and

international tourists.

It is generally considered that a person who travels from one region (or a

country) to another for the purpose of undertaking treatment is a healthcare

tourist. However, this definition excludes people who travel to another region (or a

country) to explore, enjoy and rejuvenate, either the body or the mind or both

without undergoing medical treatment. Flow of tourism is far higher in absolute

number as well as volume of business generated if the latter aspect is taken into

account. Tourism to, and associated activities to places like sea-side, mountains,

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river-beds, forests, plains, valleys, temples or historic monuments provide

rejuvenation to the body and mind and thereby bestow the overall well-being upon

the person involved with such activities.

In any part of the year, India can offer a wide selection of destinations

and experiences. In summer, there are lonely retreats in the Himalayas or the lush-

heights of the Western Ghats with cool trekking trails, tall peaks, or stretches of

white water for the adventure seekers. In the cool Indian winter, cities come alive

with cultural feasts of music and dance. The sun-claud beaches are ideal locations

for rejuvenation in the winter. The wild-life sanctuaries with their abundance of

flora and fauna provide delights to the mind and rejuvenation to the body.

Healthcare tourism, however, could be defined in a broader perspective.

Patients traveling abroad with the objective of overall wellness, without any urgent or

elective medical procedures, may also be covered under the healthcare tourism.

Healthcare tourism thus could become a common form of vacationing, and covers a

broad spectrum of healthcare services, mixing with leisure/relaxation, with the

overall objective of wellness and healthcare. The objective of the healthcare

tourism is to offer an opportunity to be away from the daily routine and come

into a different surrounding for relaxation. During the stay, the tourist receives an

orientation that will help improve life in terms of health and general well being. It is

like rejuvenation and cleansing process at all levels - physical, mental and emotional.

1.3.1 Features of Health Tourism

There are some distinguishing features of healthcare tourism which are

outlined below:

One of the important features of healthcare tourism is that it is not an

impulsive activity. However, packages are woven with attractive features to draw

the tourists. Another important feature of healthcare tourism is the willingness to

spend. While, the cost of packages is attractive to wealthier segments, this may not

be working in favour to attract patients from poorer countries. In such a scenario, the

non-availability of such facilities in the home country and the quality of services

provided in the host country play an important role.

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Healthcare tourism is also non-seasonal. This attribute can either be used

to buffer seasonal business for resorts and location- specific properties, or as the main

business itself. Some countries such as Thailand are promoting healthcare tourism

as main business for the properties developed for this purpose. In India, some of

the hospitals/healthcare centers in Kerala that provide Ayurvedic treatment adopt

this model of business. The non- requirement for custom-builds is a strong

characteristic in favour of the hotels. The patient and the family in this model stay in

hotels during pre-operative and to some extent during the post-operative periods.

Another important feature of healthcare tourism is that the average duration of

stay is longer as compared to the conventional corporate/holiday travel. Depending

upon the procedures and nature of treatment, the average stay of a healthcare tourist

ranges between two weeks to two months. For example, procedures as complex as

open-heart surgery, including post-operative care, involve a stay for at least two

weeks.

It has been reported that the persons who travel outside the country seeking

low cost healthcare are predominantly uninsured or underinsured population in

developed countries. In addition, the new trend is that the corporates in developed

countries are increasingly sending their employees to low cost healthcare destinations

to reduce the expenditure on healthcare for their employees.

Successful treatment associated with satisfactory services are considered as

important factors for getting repeat business, as healthcare tourism is not a one time

business. In conventional tourism, the satisfactory services alone are enough to get

repeat business.

The objective of this study is to explore antecedents to promoting health

tourism in India. Therefore, India can take strategies position to cater demand supply

goal in the international market by adopting right marketing strategies.

1.3.2 Definition and classification of health tourism

Medical Tourism and Healthcare Tourism are interchangeably, however

According to World Tourism Organization (WTO), “Tourism associated with

travel to health spas or resort destinations where the primary purpose is to improve the

traveler‟s physical well being through a process comprising physical exercises and

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therapy, dietary control, and medical services relevant to health maintenance” is

defined as Medical Tourism.

Health Tourism has three branches of different tourism

Medical Tourism

Wellness Tourism

Curative Tourism

Health tourism structure is shown in Figure 1.1 and 1.2

1.3.2.1 Medical Tourism

Figures 1.1 explain that Medical Tourism is the major branch of health

tourism. In this tourism surgical and non-surgical are consider major activities.

The focus of present study is on medical tourism. Therefore, concerti

definition of medical tourism is explained Para No. 1.5, Page No. 25.

1.3.2.2 Wellness Tourism

Wellness tourism in many ways, this is one of the most ancient forms of

tourism, if one considers the scrupulous attention paid to well-being by Romans and

Greeks, the quests for spiritual enlightenment of Mediaeval pilgrims, or the medical

seaside and spa tourism of the 18th

and 19th

century European élite. Arguably,

however, there has been an unprecedented intensification in the pursuit of wellness in

the history of tourism in recent years. The proliferation of wellness centres, holistic

retreats, spas, spiritual pilgrimages, complementary and alternative therapies is

unprecedented (House of Lords Report 2000).

Myers, Sweeney and Witmer (2005) define wellness as being „a way of life

oriented toward optimal health and well-being in which the body, mind, and spirit are

integrated by the individual to live more fully within the human and natural

community‟.

Adams (2003) refers to four main principles of wellness:

a) Wellness is multi-dimensional;

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b) Wellness research and practice should be oriented towards identifying causes

of wellness rather than causes of illness;

c) Wellness is about balance; and

d) Wellness is relative, subjective or perceptual.

The destination in wellness tourism is often an alternative space in which one can

engage in self analysis without the stresses and distractions of home. The addition of a

supportive, like-minded „community‟ can sometimes help to further encourage the

individual on a journey of self-discovery. However, for other wellness tourists, the

age old preoccupation with rest, relaxation and escapism reigns supreme. But

arguably all wellness tourists are self-aware, active seekers of enhanced well-being,

health and happiness.

1.3.2.3 Curative Tourism

Travel for treatment and recreation became one of the major purposes of

tourism. Curative tourism is not exclusive to those who have body disorders, but also

include others who want to relax, retrieve vitality and for mental, physical and

spiritual fitness.

The term curative tourism has not exactly been raised as an independent

concept; instead most of the research was mainly about health tourism. As a result,

many scholars have defined health tourism, which implies curative and/or medical

tourism in different ways. Abeles and Kipnis (1998:695) defined health as: A

condition of social, psychological and physical well-being and many different

avenues can be pursued so that this state is achieved. This definition emphasises a

balanced condition in the whole body, whether it is physical, psychological or

spiritual, and is matching the definition that is given by the World Health

Organisation (WTO), where health does not mean the absence of disease, instead it is

a balance in the whole body, physically, psychologically and spiritually

Suad Imran (in Jallad 1995: 12-13): Curative tourism is a temporary

movement, by which the tourist (patient) travels for the purpose of treatment, whether

it is medical or therapeutic in healing certain disease or for relaxation and physical up

keeping. This movement should be voluntary or by a doctor recommendation

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Fig 1.1

Health Tourism Structure (1)

Figure 1.2 shows classification of health tourism given by Jallad (2000:11-12)

distinguished between, medical tourism, curative tourism and wellness tourism as

follows:

A. Travel for the purpose of treatment of certain body ailment or for doing a

surgery under medical supervision in hospitals or medical centres, and then

the patient (tourist) may need to stay some period of time in spas for recovery

purposes. This type is called Medical Tourism.

B. Travel for the purpose of treatment of certain disease or for convalescence

under medical supervision, by using natural curative resources such as thermo-

mineral springs, salt lakes, mud and radioactive sand and climatic therapy.

This is called Curative Tourism.

C. Travel for the purpose relaxation, recreation, enjoyment, to escape a way

from daily tensions and for revitalisation in any health resort or spa without

medical supervision, and the tourist has no body ailments. This type of

tourism is called Wellness Tourism.

Health Care Tourism

Wellness Tourism Medical Tourism

Non-Cosmetic Surgery Cosmetic Surgery

Or

Elective surgery

Source: Caballero Danell & Mugomba, 2006

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Fig 1.2

Health Tourism Structure (2)

Source: Jallad, 2000

1.4 CROSS BROADER TRADE IN HEALTH TOURISM

Many countries probably did not think of health care as something that is

traded internationally. However, it is being increasingly offered cross-border in two

ways (fig. 1.3). Vast majority of cross border health care services are availed by the

patients from developed countries, by undertaking travel to the host countries, which

are increasingly developing countries. In such cases, the services are very

specialized and are either available at low cost or a decision to purchase the

Health Tourism

Wellness Tourism Curative Tourism Medical Tourism

Alternative Medical

& Treatment

Complementary Medicine

Medical Treatment

Surgery (Cosmetic and Non Cosmetic Surgery)

Dental

Reproductive Tourism

Fertility

Birth

Sex Change

Source: Jabbari, 2007

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service was taken after waiting for long period in home countries. This category of

trade in healthcare services also includes unplanned emergencies that may

occur when a foreigner falls sick or injured while traveling to other countries. In

such cases, neither the service nor the service provider crosses a border; instead, the

patient goes to where the service is available. Consequently, this is not typically

considered as trade in the way it is generally understood, although some suggest that

it should still be considered as trade in health care services.

Fig 1.3

Two Forms of Trade in Healthcare

Source: Export-Import Bank of India, Research

Another form of trade in healthcare services would be when the healthcare

services cross the border, the service provider as well as the patient stay wherever

they are. This type of cross border trade in healthcare services happens with the

advancement in communication technologies. The use of advanced diagnostic

testing technologies, satellite communication, tele-health consultation, and

the Internet may make it possible, and perhaps even desirable, for a patient from

one country to get the advice and expertise of highly regarded specialists in other

countries. In fact, there are examples of physicians being able to assist in

surgeries through satellite transmissions linking a doctor in one country with a

surgery being performed in another country. Such form of trade in healthcare

Patients travel Services

Across boarder are provided

To avail health- across

Care services boarder

Mode-1 Mode-2

Healthcare

Tourism

18

services are minuscule at present; however, with the advent of technology, trade in

health care services under this mode is likely to become increasingly common.

1.4.1 Background of the Health Tourism

Though the concept of healthcare tourism is thousands of years old, it has

got its prominence rather recently. In ancient Greece, pilgrims and patients came

from all over the Mediterranean to the sanctuary of the healing god, Asklepios, at

Epidaurus. In Roman Britain, patients took the waters at a shrine at Bath, a

practice that continued for 2,000 years.

Since 18th century, wealthy Europeans traveled to Spas in the Nile. In the

21st century, relatively low-cost air travel has facilitated the growth of the industry,

as traveling across continents has become affordable to even middle class

population. Currently, healthcare tourists are traveling in large numbers to countries

/ regions, where the quality of healthcare is at comparable standards and yet the cost is

significantly lower. Such healthcare destinations also offer numerous options for

touring, sight-seeing, shopping, exploring and even lounging of healthy diets. The

evolution of healthcare tourism in the world is depicted in Fig.1.4.

Fig. 1.4

Progress of Healthcare Tourism

Source: Export-Import Bank of India, Research

19

1.4.2 Tradable Healthcare Solution

There are two major types of healthcare solutions in the world (a)

traditional or indigenous system, and ( b) allopathic or modern healthcare

system. While the latter can be defined as „cosmopolitan‟, as they are

not limited to a region or territory, acceptance of the former as a valuable

healthcare solution is increasing all over the world. The renewed interest in

using traditional healthcare solutions is mainly due to the advantages of minimal

side effects and recognition of time-tested health solutions.

Fig. 1.5

Tradable Health care Solution

1.4.2.1 Traditional Therapies

In many countries, the citizens have varied health seeking behaviours with

the prevalence of multiplicity of medical or healing systems. Many of these systems

have evolved over a period of time, due to competitive environment and have gone

through changes in healing solutions. In a competitive environment, some of these

healing systems either may get absorbed by a dominant healing system or probably

die out. A healthcare system may thus be defined as „a pattern of social institutions

and cultural traditions that evolves from deliberate behaviour to enhance health‟. It

Healthcare

Solution

Traditional

Therapies

Faith/Spir

itual

Healing

Modern Health care

System/Medical

Tourism

20

should be, against this background, noted that every healing system is a service that

is being availed by a particular group of people. With the globalisation, the spread

of such systems is also faster with more number of people going for diverse

therapies that are originally unique to a country. When the end users move to

another region or territory, they may be called healthcare tourists. In the context of

India, notable traditional healthcare systems that are attracting international

travelers include Ayurveda and Yoga.

In India, in addition to existence of modern medicine, indigenous or

traditional medical practitioners continue to practice throughout the country.

Popular indigenous healthcare traditions include Ayurveda, Siddha, Unani,

Homeopathy, Naturopathy, and Yoga.

1.4.2.1.1 Ayurveda

The Ayurveda (meaning science of life) system deals with causes, symptoms,

diagnoses, and treatment based on all aspects of well-being (mental, physical, and

spiritual). These professionals, traditionally, have been inheriting the skills from

their ancestors. However, with the advent of education, a variety of institutions offer

training in indigenous medical practice.

1.4.2.1.2 Siddha

The Siddha system defines disease as the condition in which the normal

equilibrium of the five elements in human beings is lost resulting in different

forms of discomfort. The diagnostic methods in Siddha medical system are based

more on the clinical acumen of the physician after observation of the patient,

pulse and diagnosis and clinical history.

1.4.2.1.3 Yoga

Yoga is a science as well an art of healthy living physically, mentally,

morally and spiritually. Yoga is believed to be founded by saints and sages of India

several thousand years ago. Yoga has its origin in the Vedas, and its philosophy is

an art and science of living in tune with the universe. Yogis gave rational

interpretation of their experiences about Yoga and brought a practically sound and

scientifically prepared method within every one‟s reach.

21

1.4.2.1.4 Naturopathy

Naturopathy has several references in the Vedas and other ancient texts,

which indicate that these methods were widely practised in ancient India.

Naturopathy believes that all the diseases arise due to accumulation of morbid

matter in the body and if scope is given for its removal, it provides cure or

relief. It also believes that the human body possesses inherent self-constructing and

self-healing powers. Naturopathy differs slightly with other systems of medicine, as

it does not believe in the specific cause of disease and its specific treatment but

takes into account the totality of factors responsible for diseases such as one‟s un-

natural habits in living, thinking, working, sleeping, or relaxation, and the

environmental factors that disturbs the normal functioning of the body.

1.4.2.1.5 Unani

Unani system of medicine believes that the body is made up of four basic

elements viz., earth, air, water and fire, which have different temperaments i.e. cold,

hot, wet and dry. After mixing and interaction of four elements a new

compound having new temperament comes into existence i.e. hot-wet, hot-dry,

cold-wet and cold-dry. The body has simple and compound organs, which got their

nourishment through four humours, viz. blood, phlegm, yellow bile, black bile.

Unani system of medicine believes in promotion of health, prevention of diseases

and cure.

All these traditional healthcare systems are attracting national and

international patients, and generate tourism flows. In addition to such healthcare

systems, there are also faith/spiritual healers, who are largely present in rural parts of

India. Some spiritual leaders use one or more of the traditional therapies, viz,

Ayurveda, Yoga or Naturopathy as one of the healing modes to cure their clients.

Such spiritual leaders are attracting large gathering, especially international

travelers from various countries.

Both the Government of India and state governments have realized the

potential of attracting tourism leveraging traditional wellness systems of India.

Some state governments have been projecting their states as center for traditional

wellness systems (e.g. Kerala as Ayurveda hub and UP as Yoga hub). Some state

22

governments have announced tourism policy leveraging the potential of

traditional healthcare systems. The attempts by the state Governments to attract

tourists are not restricted to traditional medical systems, but also through leveraging

spiritual tourism/faith healing. For example, Andhra Pradesh has drawn up an action

plan to promote spiritual tourism, especially to attract German tourists,

combining visits to famous temples along with Yoga, meditation and Vedanta.

Similarly, Uttar Pradesh is promoting the state as Yoga hub, leveraging the

presence of religious circuits and being a land of Sadhus.

In addition to indigenous therapies/healthcare systems, there are also healing

solutions that are prevalent in different societies. One such healing solution popular

across the world is faith healing or spiritual healing.

1.4.2.2 Faith/Spiritual Healing

Faith healing refers to healing that is believed to have occurred supernaturally,

as a result of prayers or other forms, rather than through the use of medicines or

the involvement of physicians. Such healing services are often referred to as

miracles. Since such healing solutions are available only in some parts of the world, it

is important for people from other regions to travel for availing such healing

services.

The concept of spiritual tourism is not well defined. In a general context,

spiritual tourism can be interchanged with religious tourism. However, religious

tourism (pilgrimage) is one of the various forms spiritual tourism. It may be

mentioned that pilgrimage used to be one of the oldest forms of tourism flows all

over the world. Pilgrim centers such as Mecca, Jerusalem, temples in India are

attracting large flow of tourists since many years. Religious events such as Kumbha

Mela have also been traditionally attracting large number of tourists. Spiritual

tourism adds to this form of tourism by travelers who are looking for a meaning

while on vacation. Thus, spiritual tourism, in a broader context, also includes

availing of healthcare systems that are providing psychological peace, mental

strength, and inner-purity. Many concepts and solutions could be brought under this

umbrella, such as journeys to sacred places, Yoga / meditation camps, or even trips

focusing on astrology and mythology. However, in the context of popularity and

23

origin of India, we may mainly highlight Yoga as one such solution.

At present, spiritual tourism is one of the fastest growing segments in

the travel industry worldwide. The growing individualism in our society has

led to the growth of spiritual tourism. Fig. 1.6 explains the commonly used methods

of spiritual healing.

There are mainly non-economic dimensions in spiritual tourism. In general,

the faith healers do a free service with the objective of providing health for all;

however, a nominal fee is charged for undergoing a structured healing course. In

many cases, the healers keep a box to receive offerings, which shows that the fees

collected are not under compulsion.

Large number of tourists is traveling to destinations that offer spiritual

healthcare/faith healing. National governments are also promoting spiritual tourism

considering its potential. Government of Malaysia, through the Tourism Malaysia

promotes spiritual tourism with the existing tourism circuits of Hindu temples,

Chinese shrines, mosques, churches and gurdwaras.

Fig 1.6

Methods of Spiritual Healing

Source: Export-Import Bank of India, Research

24

Malaysia Tourism promotes religious festivals, such as Lantern festival of Chinese,

St. Anne‟s Feast celebrated by Christians and „Thaipusam‟ festival celebrated by

Hindus to attract large number of tourists from all over the world. Faith healing in

Nepal, a neighbouring country to India, dates back to the pre-historic times with the

Shamans using tantric spirits to heal the people. Philippines promotes spiritual

tourism and projects the country as „international Mecca of spiritual tourism‟.

1.4.2.3 Modern Health Care System/Medical Tourism

Medical Tourism, a term unknown until a few years ago, sounds paradoxical.

Indeed, it is hard to imagine stronger polarity between two areas of social life, than

that between tourism and hospitalization. Tourism, a voluntary leisureactivity often

perceived as a luminal reversal of everyday life (Graburn, 1977) and a time for

hedonistic pleasure, free from obligations and external constraints, stands in sharp

contrast to medical treatment and hospitalization. Two domains seem to be

fundamentally incompatible. While tourism is associated with freedom and pleasure,

hospital evokes images of constraints and sufferings. One does not visit a hospital

unless one needs to. As a travel writer noted: “the dentist chair and the antiseptic

smells of a hospital waiting room are synonymous with pain and a sense of

helplessness. They just don‟t blend with travel and vacations” (Ross, 2001). However,

during the last decade, the medical travel movement has accelerated sharply.

The present phase of modern medical travel is characterized by an industry

approach whereby uninsured and underinsured consumers from industrialized

countries seek first-class quality at developing country prices, a trend commonly

referred to as medical outsourcing. At the same time, the medical travel industry is

increasingly grounded in tourism. Well developed healthcare systems and advances in

technology have supported medical travel among Western countries for many years.

However, medical travel in Asia is relatively new, mostly emerging in the aftermath

of the Asian financial crisis in 1997. With the middle-class clientele in many countries

affected by the economic downturn, private hospitals were faced with a significant

drop in local business.

25

1.5 MEDICAL TOURISM

1.5.1 Definition

The term medical tourism has emerged from the practice of citizens of

developed countries traveling to developing countries around the world, to receive

a variety of medical services, mainly due to continually rising costs of the

same services and complicated procedures to avail such medical services in

their home countries. Thus, medical tourism can be defined as provision of „cost

effective‟ private medical care in collaboration with the tourism industry for

patients needing surgical and other forms of specialized treatment. Thus, patients

going to another country for either urgent or elective medical procedures could be

defined as medical tourists. This process is being facilitated by the corporate sector

involved in medical care as well as the tourism industry - both private and public.

Medical tourism or medical travel is the act of traveling to other countries to

obtain medical, dental, and surgical care. Almost two decades ago, Goodrich &

Goodrich (1987:217) defined health-care tourism as "the attempt on the part of a

tourist facility (for example a hotel) or destination to attract tourists by deliberately

promoting its health-care services and facilities, in addition to its regular tourist

amenities".

In 1999 a report, on regional healthcare, released by the European Union (EU)

tipped medical tourism to be a lucrative industry for Europe with the dominant market

operators cited as being Switzerland and Germany and the targeted consumers;

wealthy individuals from the Middle East and Eastern Europe. While the

fundamentals of the definition remain valid, a combination of leisure and health-care,

the facilities referred to 20 years ago generally included spas, resorts, hot springs,

were added to this definitions. This definition seems somewhat exclusive in that it

was for the select few i.e. those who could afford to engage in such leisure pursuits.

Such as Connell (2006:2) define medical tourism as a popular mass culture "where

people travel often-long distances to overseas destinations (India, Thailand, Malaysia)

to obtain medical, dental and surgical care while simultaneously being holidaymakers,

in a more conventional sense ...”.

26

Include some definition in meaning way, Medical Tourism: a global analysis

(2005), where medical tourism is described as any form of travel from one's normal

place of residence to a destination at which medical or surgical treatments is provided

or performed. The travel undertaken must involve more than one night away from the

country of residence. The focus of the second definition is on the nature of the

treatment provided and the destination without making reference to the simultaneous

pursuit of leisure.

Another definition of Medical tourism is occurs when international patients

travel across boundaries for their healthcare and medical needs (Monica, 2007).

Medical tourism can be broadly defined as provision of 'cost effective' private medical

care in collaboration with the tourism industry for patients needing surgical and other

forms of specialized treatment (India Medical Care, 2007).

The combination of medical and tourism seems to be a promising relatively

new Type of niche tourism. Medical tourism is where "tourists" primarily seek

medical treatment abroad and afterwards the more conventional form or tourism

experience related to leisure and relaxation in tourist places (Caballero et all, 2006). In

the past decades several Asia countries are dominate this industry but most countries

have sought to enter the market (Connell, 2006).

Nowadays medical tourism defined in many researches, as the act of traveling

to other countries to obtain medical, dental, and surgical care or where people travel

to other countries to obtain medical care maybe include complementary (alternative)

and traditional medicine like (spa water or climate ,black mud, stone ,sand, ... ). It also

includes medical services (inclusive of elective procedure and complex specialized

surgeries) like knee/hip replacement, heart surgery, dental procedures and different

cosmetic surgeries .Also Leisure aspect of traveling may be included on such medical

travel trips. On the other hand medical tourism is where the healthcare services are

sought and delivered outside of the home country of the customer, wherein the

provider and the customer use non-formal channels of communication-connection-

contract, with no or minimal regulatory or legal oversight to assure quality and with

limited formal recourse to reimbursement or redress.

27

Many countries have adopted a proactive approach for medical tourists and are

facilitating it as a revenue generating business. The Indian government has begun to

recognize the potential of tourism to Indian economy and has begun to invest in

tourism infrastructure (Diekmann, 2011).

1.5.2 Factor Supporting Medical Tourism in Developing Countries

In South Asia, South-East and East Asia. Asia represents the most potential

medical tourism market in the world. According to a recent article on

Hotelmarketing.com, Asia‟s medical tourism industry is expected to be worth at least

$4 billion by the year 2012. Currently, an estimated 1.32 million medical tourists

come to Asia from all over the world, including the U.S. and Europe (actually, quite a

bit of the current travel comes from within the Asian region itself) (Vequist, Valdez

and Morrison, 2009). India, with its low cost advantage and emergence of several

private players, represents the fastest growing Market. It is also crucial that the more

advanced developing countries open their market more significantly and provide

increased opportunities for this industry (IHT, 2007). The main Factors contributing

to this phenomenon include long waiting lists for surgery, costly health care in

industrialized countries, no or minimal insurance coverage in many developed

countries, anonymity and surprising by medicine surgery in other countries, powerful

communication between the various nations and states in the world, having natural

resources in many developing and Asian countries for offering complementary and

traditional medicine has led to the recent natural progression within health and

medical from developed counties to developing countries (Jabbari, 2007). Many

Asian countries involved after 1990 in the Asian economic crises and they need to

find economic diversification and solution for wake of this crisis (IHT, 2007). In the

recent decades Medical tourism is a fast growing industry in the Asian region and

many countries are actively promoting it and the others such as India have sough to

enter the market (Connell, 2006). According to Indian Cultural Heritage News (2007),

Indian medical facilities are unique in the regions that can providing a massive

potential for medical and health tourism and India can become a hub of medical

tourism in the region in future. The first and most important growth factor for medical

tourism in developing countries is the enormous costs of treatments and therapies in

28

the developed countries. Also Waiting times for procedures in industrialized nations

,Facilities in international travels, access to various air lines, establishing powerful

cultural and political communications between nations and states are the helpful

factors in developing medical tourism (Jabbarii, 2007).

Ecommerce, which is the cause of enhanced knowledge of people in IT

domain and created internet lines, is the first powerful communication factor between

the various nations and states in the world (Levett, 2005). Moreover, the traditional

methods and natural resources for therapy and treatment in developing Asian

countries, has led to attract many patient by different religions in the world and

caused to growth of this market for these countries (Huff-Rousselle et al, 1995).

Successful countries in this sector of tourism have recognized and examined existing

the potentials and planning appropriately of needs for other countries, especially

neighboring ones, and invested accordingly. Many Asian countries are rapidly-

growing practice of traveling to another country to obtain health care. Also India with

high potentiality for attract medical tourism have sought to enter this market.

The special geographical location of India, the history of medical sciences, the

availability of medical and Para medical teams/faculties, low-cost and high-quality

healthcare services, may led to high importance of medical tourism in economic and

medicine fields in India. It seems that medical tourism is the most growing sectors of

tourism in the resources, and many countries interested in developing tourism industry

have noticed this sector of tourism industry and are planning for this. This

international trade in medical services has huge economic potential for developing

countries and serious implications for health care across the globe (Karla et al., 2007).

1.5.3 Reasons for Medical Travel

There are several reasons for the increase in medical travel. First, the

demographics of the developed nations are causing a significant increase in demand

for health care. In Japan, the United States of America, the United Kingdom and

many other European nations, the proportion of the population older than 60 years, in

relation to the total population, is increasing rapidly. Similar trends are being seen in

many countries across the world. At the same time, life expectancy in most countries

has also increased steadily over the years; the combined result is significant strain on

29

national health-care systems. The inability of many health-care systems to deal with

the increase in demand does, in many cases, lead to compromised levels of service

and decreased access through long waiting lists and high costs. This drives many

individuals to seek alternatives to domestic health care. Such alternatives can be

found in the economically stratified global health-care marketplace (Turner, 2007),

which offers everything from cutting-edge surgical procedures such as organ

transplants to cosmetic procedures and wellness packages at a wide range of prices.

As is the case in many economic sectors, outsourcing to more affordable health

service provision abroad is increasing. Private health-care facilities in countries such

as India, Malaysia, Philippines, Singapore and Thailand are utilizing the prevailing

cost differentials, relative to countries such as Canada, the United Kingdom and the

United States of America, to attract international customers who have the financial

means to access medical care abroad. The cost of medical treatment of different

countries is shown in table 1.2

Table 1.2

Cost of Medical Procedure in Different Country

Medical

Procedure

USA Mexico Costa

Rica

India Thailand Korea

Angioplasty 57,000 17,100 14,000 10,000 9,000 21,600

Heart Bypass 144,000 21,100 26,000 10,000 26,000 26,000

Heart Valve

Replacement 170,000 31,000 31,000 3,000 24,000 38,000

Knee Replacement 50,000 11,50 12,000 9,000 14,000 19,800

Hip Resurfacing 30,000 31,400 13,000 10,000 18,000 22,900

Hip Replacement 43,000 13,800 13,000 10,000 16,000 18,450

Special Fusion 100,000 8,000 16,000 14,000 13,000 19,350

Face Lift 15,000 8,000 6,500 9,000 8,600 5,000

Breast Implants 10,000 9,000 4,000 6,500 5,700 13,600

Rhino Plasty 8,000 5,000 6,000 5,500 5,400 6,000

Lap Band/Bariatric 30,000 9,200 9,000 9,500 14,000 11,500

Above cost in US $*

Source: www. Inidahelathtourism.com

International accreditation and name recognition linked to quality care

provision are laying to rest many of the concerns individuals may have, regarding

professional competence, patient safety and quality in low-cost health care abroad.

Combined with inexpensive air travel, low-cost telecommunications, digitized patient

30

records, widespread access to information through the internet, and an increasingly

sophisticated medical travel industry to manage all these processes on the patient‟s

behalf, travelling abroad for medical treatment is an appealing alternative for

uninsured or underinsured individuals. The alternatives available through medical

travel are not only within the reach of individuals in developed countries but also to

the people from developing and least developed countries who have the financial

means to find sophisticated and affordable medical care in neighbouring countries

(UNESCAP, 2009). Improving patient safety, medication, infection prevention and

control, quality performance, and improvement and the environment of care is a

primary concern for hospitals and medical facilities involved in medical tourism

voluntarily seek JCI accreditation. In India Quality Council of India (QCI), an

organization of Government of India has set up National Accreditation Board for

Hospitals and Healthcare Providers (NABH). In a NABH accredited hospital, there is

strong focus on patient rights and benefits, patient safety, control and prevention of

infections in hospitals and practicing good patient care protocols like special care for

vulnerable groups, critically ill patients and better and controlled clinical outcome.

1.5.4 Meaning and Categories of Medical Tourists

The Medical Tourism industry is still across. Service providers are strategizing

to position their products for different targeted segments. Each such segment is being

labelled as medical tourist. In the earlier days of the medical tourism, the wealthy

people from developing and under-developed world travelled to developed countries

to avail quality medical facilities that were not available in their own countries. Rich

Indians travelled to US and UK for medical treatment. Recent years have witnessed a

reversal in this trend. People from developed countries are travelling to developing

countries offering comparable quality medical care. Reasons often cited are affordable

costs and medical services available without wait or with a short wait. There is a

growing demand for alternative therapies and therapies like Yoga and Tai chi that

border wellness and might extend into the realms of spirituality. Further there are

opportunities to combine medical treatment with leisure and vacationing. Erik Cohen

(2010) suggests a typology of medical tourists based on the extent to which medical

treatments play an important role in tourists‟ motivations for and conduct on the trips,

31

relative to vacationing. First is a Mere Tourists. This is an individual who does not

make any use of medical services while vacationing in the host country. Second type

is a Medicated Tourist who receives medical treatment for health problems

incidentally occurring while in host country. Medical Tourist Proper, the third type, is

an individual whose visit to the host country includes both tourism and medical

treatment (for matters unrelated to the trip). Tourists travelling to the host country

with the intention of receiving treatment while vacationing, as well as, those deciding

on such treatment once in the country will fall within this category. A Vacationing

Patient is an individual who visits the host country mainly to receive medical

treatment, but makes incidental use of vacationing opportunities, especially during the

convalescence period that follows the medical procedure. This is the fourth type.

Finally, a Mere Patient visits the host country solely to receive the medical treatment,

and does not make use of any vacationing opportunities (Fig.1.7)

Fig.1.7

Classification of Tourist

Mere Tourists Medicated Tourist Medical Tourist Proper

Vacationing Patient Mere Patient

Source: Erik Cohen, 2010

A McKinsey (Ehrbeck, Guevara, & Mango, 2008) article suggests that though

the market for medical travel has captured world‟s attention and imagination, it isn‟t

as large as reported. It further mentions that most medical travellers seek high quality

and faster service instead of lower cost. On the basis of quality of medical treatment,

authors segment buyers into 5 discrete types. The largest segment is 40 percent of all

medical travellers. They seek world‟s most advanced technologies. They are in search

for high quality medical care available anywhere in the world, giving little attention to

the proximity of potential destination or the cost of care. Example includes people

travelling to developed countries for treatment. Second segment comprises of 32

32

percent market, include patients who seek better care then they could find in their

home countries. They travel from under-developed and developing countries to

developed countries. In selecting the destination, these patients generally trade-off

perceived quality against burdens such as costs, distance and unfamiliar culture. The

third segment, about 15 percent of the market, comprises of the medical patients who

want quicker access to medically necessary procedure delayed by long wait times at

home for orthopaedic and cardiac complications. 9 percent of the travellers represent

the fourth segments that seek lower costs for medically necessary procedures. They

seek to save significant part of the cost of treatment. The choice of destination for

treatment is in accordance with the costs of treatment offered by the services

providers. The last category representing a meagre 4 percent of market comprises of

the patients seeking lower costs for discretionary procedures such as breast

augmentation and reduction, liposuction etc. This segment seeks smaller but

specialised service providers rather than larger multi-specialty hospital. (Fig.1.8)

Fig. 1.8 Medical Tourist Segment

40%

32%

15%

9%4%

Most advanced technology

Better quality care for medically necessary procedures

Quicker access for medically necessary procedures

Lower cost care for medically necessary procedures

Lower cost care for discretionary procedures

Source: Ehrbeck, Guevara and Mango, 2008.

33

Another report (UNESCAP, 2009) categorizes medical travellers on similar

lines into four categories. The first group includes patients from developed countries

who do not have, or have inadequate, health insurance coverage. Many of these

individuals come from Australia, Europe and Japan, a large number coming from the

United States of America. The second group includes individuals, also primarily from

developed countries such as Canada and the United Kingdom , who face long waiting

lists for non-elective surgery and other critical procedures. In the United Kingdom,

many individuals choose to pay for medical treatment abroad to avoid long waiting

lists even though the national health-care system, in spite of being overstretched,

ensures free treatment to all its citizens. The third group includes individuals looking

for affordable cosmetic procedures. Many of these individuals come from Australia,

Europe and Japan, with a significant number again coming from the United States of

America. For example, most health insurance in the United States of America covers

critical care, not cosmetic care and beauty treatments. The increased demand for

surgical procedures such as facelifts, hair transplants, dental treatment and

liposuction, as well as non-surgical procedures such as Botox and hair removal, and

the relatively high cost of these procedures is driving many individuals to find more

affordable alternatives abroad. The last segment of medical travellers includes

individuals seeking quality assured- often specialized- care that is unavailable or in

short supply in their own countries. A significant number comes from the Middle

East. This last group also includes an increasing number of medical travellers from

developing and least developed countries seeking better health-care infrastructure at

affordable prices in their own neighbourhood.

Fig. 1.9

Categorization of Tourist

Insurance Coverage Long waiting Period Unaffordable cosmetic Non-availability

in home county procedures or short supply

quality treatment

in home country

Under insured Not Insured

Source: UNESCAP, 2009

34

A Deloitte (Yap, Chen, & Nones, 2008) report segments medical tourists on

the basis of complexity of medical procedure/ treatment and the extent of follow-up

care needed after leaving the country where the treatment was received (See Figure

1.10).

Figure 1.10

Classification of Medical Tourists by Requirement for Follow-up Care vs.

Complexity of Treatment

Less invasive surgery

for example laparoscopic

procedures

More invasive/ complex

for example bypass,

transplant,

cancer treatment

Elective cosmetic

for example lasix, cosmetic,

etc.

More invasive surgery

for example hip or knee

replacement

Increasing complexity

Source: Yap, Chen, & Nones, 2008

Another research (Chen, Kuo, Chung, Chang, Su, & Yang, 2010) classifies

medical tourists segments on similar lines. First segment seeks low-risk procedures

with high price differential and long stay after retirement; second is the segment that

requires high-risk procedures with less attention to price difference. Third and last is

the group of medical tourists who seek banned procedures that are not allowed legally

in home countries of foreign patients, such as stem cell therapy. It is therefore often

difficult to define the market and determine the size. One, there is a large number of

expatriates who have been living in India for a long time. They might hold insurance

policies from the host country or might be covered by some other type of security.

Many of them are earning in India and therefore pay in Rupees like any other

domestic medical tourists. Many service providers tend to use a differential pricing

policy for international medical tourists. Many expatriates have friends and visitors

who register themselves as domestic patients. Similarly, there are many non-resident

Indians (NRIs) and persons of Indian origin (PIOs) who seek medical treatment as

domestic patients while on holiday back home. Further, nationals of neighbouring

Incr

easi

ng n

eed f

or

foll

ow

up c

are

35

countries with or without relatives in India also present themselves as resident

patients. Similarly there is a segment of tourists who give ayurveda, yoga and similar

therapies a try for sake of excitement rather than expressively requiring a medical

treatment(fig. 1.11). Further there are huge medical establishments who cater only to

affluent segments of Indians from other states. Examples are select hospitals in

Mumbai who cater to Gujratis, Marwaris and Parsis. They are reluctant to cater to

international tourists where they would have to undergo the hassle of accreditations,

documentation, etc. This is large domestic medical tourists segment that is not

accounted for in the definition of the market.

Fig. 1.11

Classification based on Perceived risk in Medical Treatment

Low risk procedure High risk procedures with Banned procedure

with high price differential less attention price difference in home country

Source: Chen, Kuo, Chung, Chang, Su, & Yang, 2010

1.6 MARKET DESCRIPTION OF MEDICAL TOURISM

1.6.1 Medical Tourism Market with other factor

The market description is based on an analysis made of the medical tourism

reality, what services operators offer how countries market their destinations and

package them with medical treatments, the social issues that have arisen and the

effects of the absence of a legal framework to keep up with the development of the

medical tourism niche market. The flow of health tourist also explains how

infrastructure in medical tourism destinations are changing in order to host tourists,

they are by giving special attention to the safety and technological requirements,

among other things, in an effort to compete against medical institutions in various

regions for the medical tourist's disposable income. The figure no. 1.12 provide a

better understanding of the current status of medical tourism and anticipated

developments, given by Caballero Danell & Mugomba, (2006) have developed a map

in order to document all Information collected for describe market descriptions.

36

Fig. 1.12

Market Description of Medical Tourism

Source: Caballero Danell & Mugomba, 2006

1.61.1 Product

Researchers within field of medical tourism predict and approximately 40

million global medical tourists in 2010 (Jeffery, 2006). While the medical tourism

package may generally be divided into two main elements: the medical procedure and

the holiday/leisure element there are ancillary elements that make the package

possible. An Indian corporate hospital websites indicates that the main consistent

elements are of a package are; medical treatment, personally tailored leisure packages

to aid healing, translators, luxury accommodation during the course of the treatment,

car rentals, visa and foreign exchange expertise, coordinators and emergency medical

assistance. The medical component of the medical tourism package may include any

one or more of the following services, which would be complemented by a leisure

component as well, either after or before the medical procedure.

Consumer

Benefit Branding

Legal

Framwork

Infrastructure

Target Market

Social Issues

Operators

Communication

Channel

Product

37

Table 1.3

Types of Services provided in Medical Tourism

Serious Illnesses Cosmetic Surgery

Plastic surgery

Skin Treatment

Health control check

Orthopaedic

Heart

Magnetic Resonance

Dialysis

Rheumatism

Psoriasis

Pain Management

Rehab

Neurology

Health Coaching

Health control

Balance week (stress treatment)

Private-coach week (work-out treatment)

Back in form (overweight)

Re-start program (serious lazy asses)

Stress treatment

Massage and Spa

Balanced diet – theory & practice

Skin Diseases

Teeth Surgery / Treatment Sight Treatment

Bleaching with laser

Teeth-coloured filling

Ceramic Inlays

Porcelain veneers

Crowns and Bridges

Implants

Gums Treatment

Dental Care (for adults and children)

Dental Surgery

Lasik surgery

Eye Diseases

1.6.1.2 Social Issues

Medical tourism yields many benefits for the economies of countries that

choose to partake in the tourism industry. Apart from being good for the country's

image, expenditures by in bound medical tourists contribute to national reserves of

foreign currency thus increasing the host countries national income which ideally is

re-invested into economy through the provision of public services. The rewards to the

tourist industry, and especially the hotel sector, are considerable because of the often

necessary stay required of the patient for recuperative purposes (Connell, 2006:8). As

a niche market within tourism the market description reveals while there are plenty of

economic gains.

38

There are some sentiments that what medical tourism comes down to is

subsidized MDC‟s (more developed countries) health care at LDC (less developed

countries) rates. Generally the key countries identified thus far in this research that

promote medical tourism are relatively less-developed such as India, Malaysia,

Thailand, South Africa, Mauritius, Mexico and Antigua. According to the World

Health Organisation (WHO) the ideal export strategy for health services in any

country must be based on the principle that the primary obligation of governments is

to provide universal coverage of health care to their local communities. Therefore the

development of an export strategy is secondary. The literature reviewed thus far does

not give any indication of whether medical tourism destinations offer adequate

national health care services for the locals. However there seems to be a uni-

directional medical tourism flow which the articles and sources researched thus far do

not dispute i.e. that people are moving from developed to less developed countries

seeking affordable medical treatment.

The impracticality of surgery follow-up due to the geographic distance once

the medical tourist leaves the host destination is another important issue as the risk of

surgery gone wrong and the inability to remedy it contributes to the other associated

risks of consuming medical tourism. Of growing concern is that if medical services

can be marketed like consumer goods such as cars, TV‟s and home appliances then

the ease of consuming a medical tourism package may result in individuals opting for

unnecessary surgery. This ease of obtaining medical treatment is of concern to some

health care experts as "The surgery may be too soon. This is one of the 'side-effects' of

having surgery too available,” (Nachammai, 2006:1).

In India, where medical tourism generates significant income for the country,

private corporations run the large specialist hospitals catering to tourists‟ medical

needs. The government subsidizes these corporations on the premise, ideally, that a

proportion of the revenue will revert back to finance the public sector but this hasn‟t

happened yet (Gupta, 2007). This revenue is meant to give the public sector the means

to improve the public service healthcare quality and ensure that the service will be

delivered at zero costs. Gupta (2007) explains that the more medical tourism develops

the higher the demand for professionals to work in the private medical care sector.

39

These professionals are lured from the public sector thus generating a shortage of

skilled specialists in the public hospitals. Nevertheless, the impacts of medical

tourism are not only negative. A positive outcome is the probable return of Indian

medical professionals, residing abroad, to India as medical tourism opens up new

employment possibilities in their country of origin (Ramesh, 2006).

1.6.1.3 Legal framework

Experiencing double-digit growth medical tourism is forecasted to grow to 40

million trips or account for 4% of the global tourism volume by 2010. However the

legal aspects of medical tourism are undefined at present. Given the anticipated

growth of the medical tourism niche market by the corporate sector this suggests a

need for the development of a framework of global standards or at least guiding

legislative framework. The following discussion highlights issues surrounding the

absence of a global legal framework.

All medical procedures performed abroad or at home carry an element of risk.

Even routine surgery may sometimes lead to medical complications. A patient may be

dissatisfied with the results of their surgery or medical treatment, and wish to seek

legal recourse. Currently there is no international governing regulation for medical

tourism. The regulation of goods and services has long since been the function of the

World Trade Organisation (WTO). Under the umbrella of GATS (General Agreement

on Trade of Services) there are four modes of supply of which „consumption abroad‟

is the most relevant mode to the subject of our research as it refers to the crossing of

geographic borders to obtain health services i.e. medical tourism (Smith, 2006).

In the United States (US) the lack of adequate health insurance, which affects

more than 43 million people, is one of the reasons motivating Americans to seek

surgery interventions abroad. Individuals without health insurance have great

difficulty accessing the health care system and frequently do not participate in

preventive care programs. When health problems arise they seek more affordable

medical treatment options abroad (SeattlePI.com). Adams (2005) in an article

appropriately titled Medical Tourism, affirms that part of the price that is paid for

surgery in the United States not only goes to tedious paperwork but also to pay all the

types of malpractice insurance doctors have to get in order to perform surgeries. The

40

cost of malpractice insurance in the US is USD 100,000 while the comparable

malpractice insurance in India is USD 4000. This is due to the affinity that Americans

seemingly have for taking legal action. In other countries the general practice is to use

disclaimers that the patient signs where he/she agrees not to sue the hospital or

doctors under certain conditions. While the disclaimer protects the medical tour

operators they leave the patients relatively vulnerable to unscrupulous medical

professionals. However it must be noted that it is in the best interest of the medical

tourism destinations to provide impeccable services as anything less would be

detrimental to their branding efforts.

As medical tourism increases worldwide, it is likely that an international

regulatory authority will come into being. Currently the consequences of this lack of

international agreements related to insurance coverage and payments for treatments

serve as a constraint in the medical tourism development. If an international legal

framework were to come into place then issues of jurisdiction between a patient's

home country and the country where the medical treatment was availed can be

resolved.

1.6.1.4 Consumer benefits

Untimely and rising medical care costs are the qualms that most would be

medical tourists have with the health services in their own countries and are thus

driving them to seek medical care abroad. A review of medical tourist packages and

medical tourist testimonials reveals that there are many incentives for engaging in

medical tourism. Perhaps the biggest incentive is there are no waiting queues for

treatment as the medical tourism operators and intermediaries are not only working to

deliver cost-effective procedures with leisure as an added feature but to provide the

procedures in a timely manner. Research indicates that surgery is 30% to 70% cheaper

than in the home country of the medical tourist. An indication of prices quoted on the

Global Health Tours website as at the time of our research ranged from US$69,000

(India) for bone marrow transplant as opposed to US$250,000 (USA), US$6,000

(India) for orthopaedic surgery as opposed to US$20,000(USA) or root canal

procedures performed by top dentists in both destinations; US$1,000 in the USA as

opposed to US$100 in India (Travelite India, 2006).

41

The temporary residences that patients and accompanying persons are placed

in during the stay of their visit is of 4 to 5 star luxury quality, with hospitals

resembling more luxury hotels than a general ward for post-op patients. After the

procedure there is the opportunity to engage in the more conventional forms of

tourism; as the destinations researched, are established and well-recognised leisure

travel destinations. Having surgery abroad also offers a degree of anonymity for those

wishing privacy from family and friends in their home countries. It also awards some

the opportunity to have medical procedures that may be legislated against in their

home countries.

1.6.1.5 Target Market

Previous studies on health-care tourism identify two types of marketing

segments; 1) health afflictions that prompt individuals to seek health-care tourism and

2) income levels (Goodrich & Goodrich, 1987). As a subset of health tourism this

may be applied to medical tourism as well. Perhaps most importantly the main

purpose of market segmentation is to distinguish between consumers seeking wellness

tourism (spa or the seemingly popular Ayurveda treatment from India) and those

seeking medical surgery (invasive surgery).

Within the framework of this study candidates for medical tourism are people

who have been waiting for surgery for a substantial period of time in their country of

residence, who either have deteriorating health afflictions that require immediate

attention or those who are simply tired of waiting. Today in many Western countries

the public health system is under attack for inadequate and untimely provision of

services as needed. The NHS (National Health Service) in Britain is currently

embroiled in conflict with health-related unions over mass retrenchment to remedy

budget deficits (BBC News, 2006). In the US there is currently a health care crisis in

California where the privatisation of the health care has resulted in sky rocketing costs

and 7 million people without health insurance and a reported 46 million people

nationwide without adequate health cover (The Mercury News, 2006). These are few

examples of systemic failures at national level that are in fact creating opportunities

for medical tourism destinations in other countries.

42

Demographics have also had an influence on the medical tourism target

market. The increasing pressure on national healthcare systems may also be attributed

to a change in the demographics of regional Western Europe and the USA. According

to findings by an independent industry analysis specialist firm, Datamonitor, aging

populations in the US and Western countries in general are putting a strain on heath

care systems; where in the US it is reported that an estimated 76 million baby

boomers will turn 65 years old in the next 10 years. One of the implications of this has

seen growth in outsourcing and off-shoring activities (Datamonitor, 2005).

In addition the target market also includes uninsured and under-insured

consumers seeking more affordable health treatment outside of their home country.

Almost all of the medical tour operators‟ websites analysed revealed that within the

testimonial section where past patients documented their experience of the medical

tourism package, the two most prominent factors motivating them to seek medical

services abroad were long waiting lists and the significant price differences (Globe

Health Tours, 2006).

In any industry, technology, manufacturing or service-based, sometimes

market forces will dictate market feasibility. Global issues today are examples of such

market forces that affect both conventional tourism patterns and the medical tourism

sector. As a consequence medical tourism is not immune either. Within conventional

tourism there is significant research and evidence that shows the impact on the

industry of wars, natural disasters, epidemics and other significant natural and man

made catastrophes. Post-2001, the Gulf region provides an example of a destination

whose target marketing strategy in terms of out-sourcing patients had to be re-

developed. In general, citizens of countries within the Gulf region are increasingly

more likely to encounter visa problems for travelling to the US for healthcare than

before. However this has proved to be a win-win situation for countries such as India,

Singapore and Thailand, tipped to be the emerging giants within the medical tourism

industry (The Hindu Business Line, 2004). Healthcare tourism planners in India,

according to a medical expert in India, should address two gaps; health insurance that

comes with contingency cover for foreign patients and a well-defined role for tour

43

operators, the former as discussed earlier under the social issues theme (The Hindu

Business Line, 2004).

Wellness tourism is more tailored for people seeking a form of relaxation or

stress relief at a spa or yoga retreats or suitably equipped wellness centres. This leads

us to what we consider an ideal illustration of the primary difference between medical

tourism and wellness tourism that reiterates the definition of medical tourism as

presented in the in this study. While a medical tourist product has two components,

the medical procedure and the leisure element, wellness packages are single units for

example a spa resort, a wellness clinic or a yoga retreat. The market review reveals

that the target marketing strategies destinations adopt to market the two entities as a

single package have to be complemented by an appropriately effective branding

campaign to over come some of the social issues by highlighting the benefits of

medical tourism. While prominent social issues have already been highlighted a

discussion of the various identified branding strategies within medical tourism is

necessary.

1.6.1.6 Branding

In this section the description of the observed branding strategies will be

supplemented by reviewed branding academic literature. The purpose of this is an

attempt to rationalize the varying strategies adopted by medical tourism destinations

or medical operators within destinations. Tourism research has shown that the tourism

product image, be it a destination, event or trip has become a key marketing concept

that has a bearing on the decision-making process for the consumer. In the case of

tourism-related travel, according to Hem and Iversen (2004) there is sufficient

evidence from past studies, which shows that perceptions of destinations and the

resulting purchases or travel decisions are positively correlated.

The concept of branding is defined as “a name, term, sign, symbol, design,

logo, slogan or a combination of these, and used to identify the goods or services of

one seller or group of sellers and to differentiate them from those of competitors”

(Doyle, 1998 as cited in Singh, 2004:94; Hem & Iversen, 2004:84). As an extension

of this destination branding, is the selection of a consistent element mix to identify

and distinguish the destination through positive image building (Hem & Iversen,

44

2004). While we agree with the provided definition of branding we find it somewhat

lacking for the purposes of this study. We propose another element; pre awareness of

the destination be it through 1) history; for example the historical connection between

India and Britain and the attendant ethnic migration of Indians to Britain, and the

reserve migration of Indian doctors armed with British medical qualifications and

contacts setting-up medical facilities in India, 2) familiarity with the destination

through previous visits or media representation, 3) or the close migratory patterns

between Mexico and North America or Asia as an established destination of Western

Europe holiday-makers.

As is common in many sun, sea and sand destinations the destination image

has emerged as a crucial marketing concept in the tourism industry (Echtner &

Ritchie, 1991, p. 4; Kim & Richardson, 2003 as cited Hem & Iversen, 2004).

Evidence of this differentiation can be found in the use of slogans. Within product

branding, slogans are short phrases that communicate descriptive or persuasive

information about a brand and they summarize the intent of a marketing campaign

thus contributing to brand equity. This argument for product branding through slogans

may also be ascribed to destination branding within medical tourism (Keller,

2003:204). A review of certain medical tourism destinations‟ slogan use suggests that

their function as a branding tool is twofold. Firstly, it is to re-iterate an existing brand

of the destination as a travel destination. Secondly, to engender an awareness of what

the destination‟s additional medical tourism product offering while simultaneously

differentiating the destination from competitors (Hem & Iversen, 2004).

According to Hem & Iversen (2004) the purchase of a destination mix

(geographic site, activities, duration etc) has an inherent uncertainty. The intangibility

of tourism service products disallows the consumer from conducting a trial run before

committing to the purchase. Within medical tourism this uncertainty may be further

exacerbated by the nature of the tourism product, a medical procedure. The

geographic discrepancy between the potential consumer and the host destination may

also lead to even higher uncertainty levels. Therefore, the decision involves greater

risk and extensive information search and depends on tourists‟ mental construct of

what a potential destination has to offer relative to their needs. Thus brands have to be

45

strong enough overcome this uncertainty by increasing customers‟ trust of the

invisible, enable them to better visualize and understand the intangible benefits of the

services (Singh, 2004).

Whatever the case may be the branding campaigns appear to be working as

Globe Health Tours (an American tour operator) claims that there is a wave of North

American and European patients heading to well-established medical tourist

destinations mainly India, Thailand and Singapore for top-class orthopaedic surgery,

plastic surgery, infertility treatment and cardiology that come much cheaper than in

their home country. Some medical tourism campaigns feed of existing knowledge of

the destination perhaps due to advances in other industries while for others history

may serve as a better platform. Whatever marketing platforms exist, as a typology of

tourism, branding is an important element of perception creation. With this

knowledge, tourism marketers today target the senses of would-be-tourists, creating

tantalizing images, which perhaps lead to the consumer subconsciously correlating a

positive perception of the destination product and ones own needs (Hem & Iversen,

2004).

1.6.1.7 Infrastructure

This not only refers to the actual construction of facilities, hotel/resort quality

hospitals, but also externalities within the medical tourism framework such as the

local community, medical advances in technology and intellectual capital. Research of

the niche market shows that there have been various strategies implemented within

the different medical tourism destinations in an effort to aid market development.

According to an Asian Wall Street journal article, Malaysia's government permitted

the promotion of hospitals and medical tourism packages overseas (Kilrich, 2004).

There are many other government initiatives that have been undertaken to facilitate

the development of medical tourism in various developing countries.

As mentioned earlier the evidence thus far reveals that tourism medical tourist

flows are predominately uni-directional, from more developed to less developed

nations. The medical tourism enterprises from destinations reviewed have, to some

extent, government involvement in the development of infrastructure for this tourism

typology. Be it through more efficient systems for processing incoming visas for

46

those seeking the product or providing marketing platforms to better enable the

medical tour operators to reach target markets. As a consequence perhaps it‟s the

scale of resources required to enter this niche market that prompts government

involvement. India is a prime example, where the Ministry of Health and Family

Welfare and the Ministry of Tourism have actively developed policies and

infrastructure tools to encourage the growth of the industry. The Incredible India

homepage (official) has links to health tourism sites. Other initiatives taken up by

governments include the health sector of Barbados where, a media article from 2005,

purported that the highly specialised Invitro Fertilisation programme currently being

developed will serve as a platform for medical tourism towards the Caribbean

destination in a effort to diversify the incoming tourist typologies.

In countries such as Oregon, the Netherlands, Sweden, New Zealand, Norway,

Denmark, Israel, Switzerland and the United Kingdom, “politicians and governments

in their role as policy makers or health funders, health insurers, and health

professionals are asking which health services should be publicly funded, for whom”

(Edgar, 2000:190). There is a general trend towards privatisation of healthcare, which

in turn leads to a reduction in subsidized healthcare. It is widely accepted that in any

economy the privatisation of health ideally leads to more efficient delivery of health

services however this is usually accompanied by an increase in average health costs as

mentioned under the target market theme the NHS (National Health Service) in the

UK. Nevertheless governments sometimes deem it is necessary to provide a

framework for the development of private health care in an attempt to ease the

demands on the public health systems and the national budget.

Another infrastructure issue is the absence of certified medical tourism

statistics. The absence of defined characteristics to collect statistics means that the

actual market size of medical tourism is unknown except for claims by governments

and medical groups about the annual medical tourists that visit their destination. India

has an annual Medical Tourism Expo and it has been predicted that medical tourism

will earn India as much as US$2 billion by 2012 (Connell, 2006:4). This serves as an

economic indication of the size of the medical tourism market. The implication of this

on our research is that while the are many articles that coin this niche the new tourism

47

with positive rapid growth perhaps it has always been around only now its become

publicised. The many different labels that can be loosely applied to this type of

tourism – well-being tourist, health tourist, surgery tourist, medical tourist and

cosmetic tourist among others also make it challenging to quantify and qualify the

niche market.

As a subset of tourism, observations reveal that for the medical tourism market

to grow an efficient logistics system is necessary to facilitate this predominantly

unidirectional flow. Targeted consumers must have easy access to the medical tourism

destination. Despite the strategies: branding, product, pricing among others, that a

medical destination may develop, our research reveals that all actions are futile if the

consumption of the service is anything but easy. For example if acquiring a visa for

the medical tourism destination requires going through many channels then would-be

medical tourists are better off on the waiting lists for surgery within their home

countries. Or if travel connections between the consumers‟ home market and the

medical tourism destination are such that the opportunity cost of foregoing medical

tourism is more favourable then the consumer is most likely not to engage in medical

tourism.

1.6.1.8 Distribution Channels

Within the tourism and hospitality industry, as modes of distribution, service

intermediaries have a number of standard functions which include: 1) making services

locally available when a geographic distance exists between the consumer and the

producer, 2) gathering the appropriate service components to make packages and

retailing them, 3) building relationships between the consumer and the producer and

4) to some extent co-producing the service (Bitner & Zeithaml, 2003). Interestingly,

according to Bitner & Zeithaml (2003) traditional service providers with a limited

distribution area such as doctors and dry cleaners, opt not to use distribution channels

as they directly distribute their services consumers. Therefore, with the rise of medical

tourism are doctors still defined as traditional service providers?

Danell, 2006 has developed model below to categorise specific channel

distribution such as the Internet and conducting a comparison between different

48

operators that use this channel as a primary marketing medium and possibly

benchmarking.

Fig. 1.13

The Medical Tourism Distribution Channel Model

Source: Mugomba & Caballero Danell, 2006

This model(fig.1.13 ) has to categories three identified channel distribution

modes that link the consumer to the destination; operators, representatives within

targeted consumer markets that are also referred to as intermediaries and word of

mouth. Only the first two channels have been explored as the sources used during our

study were secondary sources. Therefore no accounts by medical tourists were

included. A comparative discussion was made of the different operators' choice of

distribution media and also a look at the operations of intermediaries.

1.6.2 Competition

Thailand, Singapore, Malaysia, India and Philippines are the major

destinations in the Asian medical tourism market. Thailand is more popular among

Western European medical tourists for cosmetic surgery. Singapore and India

specialize in complex procedures with India having a cost advantage and Singapore a

Medical Tourism

Operators

Representatives in the

consumer‟s country

Word of mouth

Consumer

(Patient) Destination

Distribution Channel Model

49

technology advantage. Global economic downturn has resulted in decline in visitors‟

numbers in Singapore and the same holds true for medical tourists also. The health

care industry in Thailand has seen rapid growth in recent years, ahead of the country‟s

GDP. In Thailand, medical costs are lower than in Singapore and also, it is a much

more popular tourist destination. The cost of healthcare in Thailand is about five times

lesser than it is in the US. The government of Singapore has formed a collaboration of

industry and government representatives to create a medical hub in Singapore. The

Malaysian government is aggressively promoting medical tourism. It has extended the

visa period for health tourists from one month to six months. Major hospitals in

Malaysia are targeting new markets such as Vietnam and Cambodia.

Taiwan provides high- quality healthcare at very competitive prices but is a

slow starter. A liver transplant costs half as much in Taiwan as in Singapore. China is

a key target market for Taiwanese hospitals. The government has announced a $318

million project to help further developed countries medical services.

The Korean government is promoting the nation‟s growing medical tourism

industry and has set a target of 100,000 foreign patients by 2012. However, Korea is

considered to be a latecomer in medical tourism industry.

India is one of the lowest cost and highest quality of all medical tourism

destinations. It offers low- cost cardiovascular and orthopaedic procedures, at about

one- tenth the cost of similar surgeries in the US (Koncept Analytics, 2009).

1.6.3 Market Drivers

Over the years, the medical tourism industry has become quite large. In 2008

Deloitte estimated that the world medical tourism market in 2008 was around US$ 60

billion and that it is expected to grow to US$ 100 billion by 2010. It is also estimated

that around 6 million people a year worldwide will travel for medical care by 2010

(Herrick, 2008). Whereas at the beginning of the rise of the medical tourism industry

there were only a handful of hospitals and only about 4 or 5 countries promoting

themselves as medical tourism destinations, today there are hundreds of hospitals and

clinics and over thirty different countries promoting it (Edelheit, 2009).

50

On the demand side, factors contributing to the growth of medical tourism are

closely intertwined. Authors agree that rising health care costs in industrialized

countries coupled with the availability of high-quality medical services at

significantly lower prices in developing countries has become the primary incentive

for patients seeking treatments abroad. According to Deloitte (2008a), medical

services in India, Thailand and Singapore can be as low as 10% of those in the United

States. Other research indicates that surgery is 30% to 70% cheaper than in the home

country of the medical tourist (Caballero-Danell and Mugomba, 2007) and even 80%

in some cases (Herrick, 2007). For example, an open heart surgery may cost about

US$ 150 000 in the U.S. while in India‟s best hospitals the costs range between US$ 3

000 and US$ 10 000 (Connell, 2006). An MRI in Brazil, Costa Rica, India, Mexico,

Singapore or Thailand costs between US$ 200 to US$ 300, compared to over US$ 1

000 in the U.S (Herrick, 2008). According to prices quoted on the Global Health

Tours website, a bone marrow transplant and a root canal procedure in the U.S. cost

about US$ 250 000 and US$ 1 000 respectively, as opposed to US$ 69 000 and US$

100 in India (in Caballero-Danell and Mugomba, 2007). Mattoo and Rathindran

(2006) add that there is significant evidence that the upper-end of the quality

distribution of both professionals and hospitals in several advanced developing

countries lies well above the minimum acceptable standard in industrial countries.

Because of this, many medical tourism destinations are proud to offer “first-class

services at third-world prices.”

Rising incomes in industrialized countries have also fuelled the demand side

of medical tourism. Although medical procedures and treatments are considerably less

expensive in developing countries, a medical tourist needs to have enough disposable

income so as to be able to pay for the medical and traveling costs out-of-pocket, given

that most of these procedures are not covered by health insurance companies. Higher

incomes have also translated in the possibility of buying more wellness and

preventive medicine (Bookman and Bookman, 2007). According to Connell (2006)

medical tourism has been “particularly attractive to elites, even -perhaps especially- in

developing countries.” Nevertheless, other authors disagree claiming that what is

different about the current trend in medical tourism is that traveling to other countries

51

in search of medical care is no longer exclusive to elites paying premium prices

abroad, but is rather accessible to the mass population which now has the possibility

of medical care and leisure abroad at a cost-effective price (Caballero-Danell and

Mugomba, 2007). Horowitz, Rosensweig and Jones (2007) identify two types of

medical tourists in the United States: one group of patients is middle-class adults with

no health insurance or inadequate coverage; the other group is people searching for

treatments that are not covered by their health insurance such as cosmetic surgery,

fertility treatments and gender reassignment procedures. What is common in both

groups, however, is that they have enough resources to purchase healthcare in low-

cost medical tourism destinations but insufficient to afford the same services in their

home country.

The development and expansion of medical tourism has not only been

demand-led but has also resulted from the countries‟ ability of supplying high quality

medical services at significantly lower prices. Strong economic growth in developing

countries has provided the resources and opportunities to improve capacity and

infrastructure constraints that had hindered the development of this industry in the

past (Deloitte, 2008a). Horowitz, Rosensweig and Jones (2007) claim that it is due to

these advances that potential medical tourists today are able to compare prices and

arrange healthcare travel plans anywhere in the world. Similarly, Bookman and

Bookman (2007) point out that new telecommunications technologies such as

telediagnosis and teleanalysis have reduced geographical barriers and have facilitated

the cross-border trade in medical services. The Internet, as the most effective

communication channel for the medical tourism industry, has made possible, for

example, video-conferencing between patients and doctors as well as “real time”

guided tours of medical facilities (Caballero-Danell and Mugomba, 2007).

1.6.4 Customer Satisfaction

Customer satisfaction is a critical issue in the success of any business system,

traditional or innovative (Ho & Wu, 1999). Customer satisfaction, a business term, is

a measure of how products and services supplied by a company meet or surpass

customer expectation. Customer satisfaction is the ultimate result of meeting a

consumer‟s expectation from the performance of products. Most satisfied customers

52

normally have the intention to re-purchase the products if product performance meets

his or her expectation (Alam & Yasin, 2010).

Customer satisfaction is an abstract concept and the actual manifestation of the

state of satisfaction will vary from person to person and product/service to

product/service. The state of satisfaction depends on a number of psychological and

physical variables which correlate with satisfaction behaviours such as return and

recommend rate. The level of satisfaction can also vary depending on other factors

such as other products against which the customer can compare the organization's

products.

Customer satisfaction is defined as result of cognitive and effective evaluation,

where some comparison standard is compared to the actually perceived performance.

If the perceived performance is less than expected, customers will be dissatisfied. On

the other hand if the perceived performance exceeds expectations customer will be

satisfied (Kang, 2006).

Work done by Parasuraman, Zeithaml and Berry (1991) delivered

SERVQUAL- an instrument which provides the basis for the measurement of

customer satisfaction with a service by using the gap between the customer's

expectation of performance and their perceived experience of performance. This

provides the researcher with a satisfaction "gap" which is semi-quantitative in nature.

Cronin and Taylor extended the disconfirmation theory by combining the "gap"

described by Parasuraman, Zeithaml and Berry as two different measures (perception

and expectation) into a single measurement of performance relative to expectation.

1.7 MEDICAL TOURISM VALUE CHAIN

Acharyulu and Reddy (2004) (Fig. 1.14) conceptualised value chain for an

international patient as following:

Medical travel operators can be broadly classified into two groups. First, there

are medical service providers such as hospitals and clinics. Hospitals that actively

attract international patients are not involved only in the medical procedure itself, but

are, in many cases, also responsible for all patient logistics from arrival to departure.

Often the hospitals‟ involvement starts before arrival with the processing of the visa

requirements and ends only after departure with patient follow up.

53

Figure 1.14

Value Chain for International Medical Tourist

Adapted from Achayulu and Reddy (2004)

Source: Adapted from Achayulu and Reddy (2004)

The second group consists of medical travel facilitators who function like

agents and associated service providers. These are often smaller companies with just a

few people on their payroll and most of them have spread their risk by dealing with

hospitals and clinics in a number of different countries. Those medical travel agents

which are dealing exclusively with hospitals of only one country or region are

exposed to the same risks as the hospitals with which they work.

These facilitators offer global health-care options that will enable international

patients, primarily from source countries to access international health care at fraction

of the cost of domestic care or shorter wait time. By selling a type of medical value

travel, they focus particularly on the self-insured patient. Some companies charge

International

patient in need of health care

Airport pick-up transport,

receiving patient

Planned hospital accommodation

hotel hospital

Planned hospital

accommodation

hotel hospital

Information centre in the

country internet

Hospital

scheduling/patient care management/pre &post

operative care

Dropping at airport

Air ticket booking for air travel

Tourism plan recreation/

sightseeing visits

Flow on Information

Movement of patients

54

clients a flat rate commission or a percentage of the total cost of care. Others do not

directly charge customers, but are paid by the hospitals to which their clients travel

for treatment.

The companies typically provide experienced nurse care managers to assist

patients with pre and post procedure medical issues. They also help provide resources

for follow-up care upon the patient's return. Medical travel packages can include all

costs associated with medical care, air and ground transportation, hotel

accommodation, provision of a cell phone in the destination country for ease of

communication, practical assistance from a local company representative at the

health-care facility, travel arrangements for a companion, stays in nearby resorts

during the post-operative recovery period and vacation to tourist destinations.

For the purpose of this study a simple medical tourism value chain is

considered. It broadly comprises of three components/ stages (Keckley & Underwood,

2008) (See Figure 1.15).

Figure 1.15

Medical Tourism Value Chain

1.7.1 Pre Procedure Stage

In this first stage the tourist is typically engaged in navigating the process and

arriving at a decision to buy the procedure. A customer enters the procedure with

search of relevant information from various sources. However, given the complexity

many customers prefer to use services of an intermediary referred to as “medical

facilitator”. Prime responsibility of the medical facilitator is to seamlessly coordinate

the outbound medical tourism programme.

Medical facilitators are intermediaries that guide the use of medical tourism

for patients who find using their services more convenient and expedient than

organising various service providers on their own. They offer single window solutions

Pre procedure

stage

Procedure

stage

Post-procedure

stage

55

to the customers. They have experience in the medical tourism process and are able to

address any concerns or questions that patients might have. Facilitators also provide

assistance with logistics and travel arrangements. Patients may even be able to get

lower rates from medical facilitator than directly from clinical programmes abroad

(Keckley & Underwood, 2008). A medical tour operator is an important facilitator.

Literature has referred to four types of medical facilitators- Medical Travel

Planners, Travel Agencies, Hotel Groups and Provider Groups. Long before the actual

medical procedure/ treatment, a customer must decide about a number of key issues,

including the choice of facilitator, hospital, doctors, destination country, costs,

conveniences, risks, etc. not necessarily in that order. Pre procedure stage typically

ends with patient reaching the destination.

1.7.2 Procedure Stage

This is the key component of the medical tourism value chain. Procedure stage

begins with patient reaching the destination and hospitals/ service providers offering

pickup facilities followed by pre-counseling for treatment, necessary medical

examinations required before the medical procedure.

Medical procedure includes preparing for the procedure, organising a doctor

and Para medical team, operating theatre, procedure, prosthesis, medical supplies, etc.

1.7.3 Post Procedure Stage

Post procedure stage has two important components the post operative care

and follow-up care. The post operative care includes doctors‟ visits and monitoring

for complications, recuperation in hospital and physical therapy, medical supplies,

meals, post operative recuperation in destination country but outside the hospitals, etc.

An important concern of medical tourist is the follow up care facilities long after they

have left the country of treatment.

Normally there is a tie-up between the medical service providers and doctors

in the customers‟ country who are responsible for follow up on behalf of service

provider. After the post operative care when the tourist is fit to move around, he/ she

may demand post treatment leisure as a part of the package.

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1.8 SELECT COUNTRY EXPERIENCES

The joint initiatives of tourism and healthcare industries are reasons for

success in some countries. Government has taken initiatives to support the tourism

and healthcare industries in other countries by way of policy packages, aimed at

creation of infrastructure attracting healthcare tourists. Some countries are leveraging

its capabilities of offering traditional wellness systems, which becomes their unique

proposition and sharpen their competitiveness. In this section, such country

experiences are summed up for select countries.

1.8.1 Thailand

Tourism industry has been regarded in Thailand as one of the prime activity

that contributes to the national economic development. Thailand has been

highlighting elements such as Spas and alternative therapies in their promotional

strategies for several decades. However, since late 1990s, Thailand has been

emphasising the „state-of-the-art‟ hospitals and skilled medical professionals in their

promotional strategies. Healthcare tourism is positioned as an extension of its well-

known Spa and wellness treatment offerings. Many hospitals in Thailand have

installed technologically advanced equipments such as Gamma Knife Brain Surgery

equipments. Thailand has also been emphasising on associated services such as health

check-ups, optical services, dental services, rejuvenation and skin care, face lifting,

rhinoplasty, breast augmentation or reduction, fixing of ear and digital hearing aids.

In addition to having state-of-the-art hospitals and technologies, Thailand has

developed high professionalism in healthcare tourism in such a manner that many of

the hospitals are furnished like a hotel, and customers are treated as hotel guests rather

than patients. Hospitals provide ambulances or other such transports at airport for

transfer of patients as also the accompanying persons. With world-class medical

facilities and specialists, and warm hospitality of service staff, patients are attracted to

come to Thailand for vacationing and treatment.

The experiences of hospitality and tourism industry, particularly the travel

agents, have been successfully leveraged by the healthcare industry in Thailand.

Further, the innovative promotional strategies of the national carrier, Thai Airways

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International, have also helped in development of healthcare tourism industry in

Thailand.

Communication technology has also been leveraged by the healthcare tourism

industry in such a way that the patients can identify and select the hospital / doctor

suitable for the treatment, identify the favourable destination for holiday /

recuperation, seek online appointments for various healthcare services, and customise

the required packages with the travel / tourism operator. The hospitals are also

equipped with equipments for receiving patient history through satellite.

Major hospitals in Thailand have set-up recuperating facilities at tourist

centres such as Phuket or Chiang Mai. The city of Chiang Mai, in particular, is

branded as a healthcare destination with its blend of Spas and high-quality, low-cost

medical, dental and therapeutic services. The city has about 10 private hospitals with

over 2000 beds and 700 doctors, currently operating at 50% capacity on an annual

basis.

It may be mentioned that aggressive and collective marketing by all

stakeholders, including the Royal Government of Thailand, has positioned the country

in the global map of healthcare tourism. In the Marketing Plan (2005) of the Tourism

Authority of Thailand (TAT), healthcare tourism has been identified as a major

“Special Interest” tourism product to be promoted in all of its geographical markets.

TAT has been collaborating with the Ministries of Public Health and

Commerce (MOPH) to implement a national strategy to develop Thailand‟s potential

in the field of health and wellness. TAT has identified staff training and skill

development as a major requirement for development of healthcare tourism sector.

MOPH is collaborating with the Thai Spa Association to formulate procedures for

accreditation and certification, to ensure international quality standards.

Hospitals are encouraging the staff to develop their language skills targeting

the international patients. Many hospitals have staff with knowledge of Japanese,

Arabic and English to cater to the requirements of international patients.

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1.8.2 Singapore

Singapore has been considered as one of the successful countries in attracting

international tourists. The travel and tourism industry contributes significantly to

national economy. The healthcare market in Singapore is a mixed basket comprising

competent public and private sector service providers. Together, they provide quality

healthcare services, both for Singaporean and foreign patients. The trend in market

share of private and public sector healthcare services in Singapore (in terms of

workload and revenue based on inpatient discharges and day surgery) during 1993-

2002, indicates that the private sector market share has shrunk from 20% in 1993 to

16% in 2002 in terms of workload, and 43% in 1993 to 36% in 2002 in terms of

revenue. However, private sector has been contributing significantly to international

patients in Singapore. During the period 1993-2002, the share of private hospitals in

catering to foreign patients, both for day surgery as well as inpatient services,

remained around 80%.

Singapore on its records has several achievements in healthcare: these include

world‟s first successful peripheral blood stem cell transplant and cord blood transplant

from an unrelated donor; Asia‟s first unicompartmental arthroplasty; Southeast Asia‟s

first heart transplant using an Electronic Heart Assist (Left Ventricular Assist Device),

and first adult living donor liver transplant; successful separation of craniopagus

conjoined (joined at the head) twins from Nepal; and successful completion of „tooth-

in-eye‟ surgical procedure. Singapore has also significantly achieved quality and

technological ability in healthcare sector. It may be mentioned that the Centre for

Transfusion Medicine in Singapore is internationally reputed for its high standards of

blood safety practices and management of blood transfusion services.

Singapore projects itself as a destination for international tourists with its

highly developed transport and communication infrastructure, good living conditions,

orderly and tourist friendly environment, duty free shopping and variety of

recreational attractions. The Singapore Tourism Board (STB) is the national tourism

organisation responsible for planning, developing, marketing and administering the

tourism industry in the country. STB has three major departments to promote

Singapore as a healthcare hub, viz., Economic Medical Hub Department, Clinical

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Medical Hub Department, and Allied Health, Wellness and Complimentary Medicine

Department. STB is strategically promoting Spa tourism with the objective of

removing the negative connotation of “massage parlours”. The Government of

Singapore has classified Spas as a discrete licensing category.

Various government initiatives include providing a greater focus on clinical

research, medical staff recruitment, intensified marketing and closer cooperation

between the public and private sectors. Such initiatives later led to the formation of

Singapore Medicine, a multi-agency government initiative, aimed at making

Singapore as one of leading destinations for healthcare services in Asia. Singapore

Medicine serves as a gateway connecting international patients with the service

healthcare providers of Singapore.

The Government has enacted two major Acts, viz., the Medical (Therapy,

Education and Research) Act, 1972 (MTERA) and Human Organ Transplant Act,

1987 (HOTA), which facilitates easier transplantation surgeries in Singapore. All

citizens and permanent residents (excluding Muslims) are included in HOTA, for

organ donations, unless they register their objection. Foreigners visit Singapore to

undergo transplantation surgeries, as there are procedural delays in home countries.

Many healthcare establishments have set up international patient service

centres to exclusively serve the needs of international patients. These centres act as

one-stop service centres; patients can obtain information about the services offered by

various healthcare establishments and cost of treatments from such centres. Dedicated

staff at these centres assist in fixing appointments, take care of referrals and

admissions, organise visa, travel assistance, medical transportation and interpretation

services. The centres also provide information on accommodation for the

accompanying persons as also information on other tourist attractions.

1.8.3 Malaysia

Malaysia is another country in Asia strategically attracting international

tourists. Travel and tourism is one of the prime activities in Malaysia significantly

contributing to the national economic development. Malaysia aims to diversify the

economy and reduce the country‟s dependence on the manufacturing sector through

its wider policy to boost its service industries. Tourism has been identified as one of

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the key segments under the services sector. Within the tourism sector, healthcare

tourism was initially introduced in 1998 as one of the sustainable growth areas

following the Asian financial crisis. The Malaysian Government has set up a Medical

Tourism Committee with representation from the tourism ministry, Malaysian

Industrial Development Authority, Malaysian Airline System, industry associations,

including the Malaysian Association of Hotels, Malaysian Association of Tour and

Travel Agencies, Primary Care Doctors‟ Organisation of Malaysia, and the Malaysian

Medical Association. The code of ethics formulated by the Association of Private

Hospitals of Malaysia.

The Government also has announced „Fast Track Immigration Clearance‟ for

foreign patients provided that the relevant hospital informs either Malaysia Airport

Berhad at Kuala Lumpur International Airport or the immigration authorities, at any

point of entry to Malaysia, preferably three days in advance. The patient and

accompanying persons may also get extension of their stay on medical grounds from

the Malaysian Immigration Department under such fast track. Major thrust markets

for marketing healthcare services for Malaysia include Arab countries. The ethnic

community and cultural ties between the Gulf region and Malaysia make the region as

a natural target market for Malaysia. Tourists from Gulf region are reportedly availing

wellness and cosmetic related services while travelling to Malaysia.

Tourism Malaysia, the promotional arm of Ministry of Tourism, Government

of Malaysia participates in international travel marts and helps promote Malaysia as a

healthcare destination. Tourism Malaysia has over 30 branch offices and about 10

representative offices all over the world.

The Government is also encouraging multinational healthcare firms to invest

in Malaysia in order to encourage private sector participation in this sector.

Immigration conditions for entry of foreign medical specialists and supported clinical

research in health institutions are also relaxed to promote the emergence of clinical

centres of excellence. Tax incentives have been introduced to encourage hospitals to

upgrade their facilities to cater to the foreign patients.

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1.8.4 Philippines

Philippines is another country taking significant steps to cash-in on the

booming tourism industry, including healthcare tourism. Travel and tourism in

Philippines is significantly contributing to the national economic development.

Promotion of healthcare tourism received importance with the launch of „Philippines

Medical Tourism Programme‟ (PMTP), a private-public initiative, with the

involvement of industries such as wellness, Spa, health, tourism and retail business,

through Executive Order No. 372 by the President of Philippines in October 2004.

The Order created a public private partnership, which brings together relevant

government agencies and private sector representatives under a Task Force, which

formulates a development strategy for sub-sectors such as Medical and Surgical Care,

Traditional and Alternative Healthcare, and Health and Wellness Care (Spas).

Philippines has been projecting dentistry services, cosmetic surgery, eye-bag

removal, face-lift, nose lift, tummy tuck, enhancement of organs, non-surgical

specialties such as dermatology, family practice or internal medicine. Philippines has

also been projecting its advantages such as availability of welltrained competent

medical professionals, fluency in English, healthcare cost differential, technological

advances and a vibrant tourism sector with compassionate and caring professionals, in

its promotional programmes. The broad policy framework for development of

healthcare tourism under the National Tourism Strategy of Philippines include:

Broadening the marketability of the Philippines by promoting Spa and medical

tourism;

Contributing to regional development in terms of employment generation and

increase in local government revenue;

Increasing investments relative to health holiday activities;

Promoting and developing the country‟s thermal springs and other resources

for health tourism program.

The Government has included medical tourism in the Investments Priorities

Plan (2006), which outlines incentives for prospective investors in this Sector. The

IPP has also introduced the concept of „International Medical Zone‟ which will be a

notified area developed into a center for professional healthcare. The Department of

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Health plans to classify certain medical zones under medical tourism zones, which in

turn would be accredited by the Department of Tourism.

Incentives provided by the Government for development of Spa tourism and

medical tourism include reduced import tariff on select Spa / medical equipments and

tax holiday for hospitals.

1.8.5 China

Although statistics / information related to healthcare tourism in China is not

readily available, it is worthwhile to recognize the country‟s potential to offer

healthcare solutions to the world through outward flow of healthcare services.

Already the Traditional Chinese Medicine (TCM) is prevalent in many parts of the

world. Thus, the potential of TCM as a source for generating tourism may not be

restricted to tourism inflows into China alone, but also as outflow of services to other

countries. China has adopted diverse strategies to popularize TCM in several parts of

the world. These include integration of TCM into national healthcare system, setting

up of quality systems from production of raw materials to final products, setting up of

support institutions and adopting a science-based approach to promote in international

markets.

1.8.6 South Africa

Tourism is one of the important industries in the South African economy.

Traditionally, medical tourism in South Africa was largely for cosmetic and

reconstructive surgery, dental as well as orthopaedic surgery. However, the scope of

the medical tourism sector in South Africa has expanded to cover all medical and

surgical specialties as well as tertiary healthcare services, from simple procedures to

complex medical and surgical procedures. Number of tourism agencies have

enhanced their canvas to include medical tourism and formulated strategies to attract

international tourists. Packages have been woven to attract international tourists

which include providing professional services and hand-holding of international

tourists when necessary, providing information and advisory services to help identify

appropriate healthcare institutions and sightseeing places for recuperation.

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1.8.7 Jordan

According to industry estimates, the healthcare tourism in Jordan is estimated

to be generating approximately JOD 500 million per annum30. In terms of numbers

about 100,000 non-Jordanian Arab patients visited Jordan for healthcare purpose,

mainly for treatment such as coronary, kidney, brain and eye surgeries. Yemenis

constituted an estimated 30% of patients, followed by Libyans (25%), and Sudanese

(20%). Patients from countries such as Algeria, Tunisia, Iraq and Palestinians also

come for medical treatment in Jordan. It is estimated that Jordan has generated US $

600 million per annum as hospital fees from visiting healthcare patients alone.

Ministry of Health, Government of Jordan has set a plan to achieve US $ 1 billion

revenue per annum from healthcare tourism.

The Ministry of Health, Government of Jordan has formed a Committee

following the recommendations of Economic Consultative Council to establish links

with Arab countries to attract patients needing treatment. Around 60 private hospitals

in Jordan have formed an association, Private Hospital Association of Jordan.

Ministry of Health, Government of Jordan has set up Health Tourism Board, which

has set up promotional desks at various terminals of the Queen Alia International

Airport, to provide information and advisory services to the visiting Arab patients.

Tourism operators in Jordan have been projecting the Dead Sea coast as one of

the prime destinations for rejuvenation. Large volume of investment has happened in

this area to attract healthcare tourists. The main attraction of Dead Sea is its soothing,

abnormally salty water. The salt content of the water is 31.5% making the water so

buoyant that it is impossible for the visitor to sink. The water also contains 21

minerals including high levels of

magnesium, sodium, potassium, and bromine and 12 of these minerals are found in no

other body of water in the world.

Studies have shown that the combination of Dead Sea water and the rich black

mud found along the shoreline to have significant health benefits such as increasing

blood circulation, easing discomfort from arthritis, healing allergies, and revitalizing

skin. Visitors to the Dead Sea also take advantage of another nearby tourist spot,

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Hammamat Ma‟in (Ma‟in Hot Springs), located 264 meters below sea level, to enjoy

bath in mineral rich water.

1.8.8 Cuba

Health tourism in Cuba is well known among international communities in

view of the healthcare technologies treatment procedures developed by the

professionals in the country. Cuban healthcare institutions are offering treatments to

various health problems such as hypertension, pigmentary retinosis (or night

blindness), Parkinson‟s disease, psoriasis, deformities of the spinal column, bone

tumours, paralysis, and rheumatic diseases.

Cuba has a large network of hospitals equipped with latest technologies and

highly skilled professionals, some of them have specialised in giving unique

treatments. Besides, mineral springs and Spa centres are also being projected as

destinations for wellness in Cuba. It is reported that Cuba has over 30 mineral springs

with medicinal properties.

1.8.9 Inferences from Country Experiences

From the above analysis, it may be inferred that many of the competitor

countries in this arena are strengthening their capabilities in modern healthcare

systems. India, while strengthening its capabilities in modern healthcare systems, is

also leveraging its inherent strengths in traditional healthcare systems, such as

Ayurveda, Siddha, Yoga, Naturopathy, and faith-healing / Spiritualism. In addition,

India has diverse tourism destinations like the backwaters, architectural treasures,

forts and palaces, hills, springs, deserts and jungles, with wider themes, such as

adventure tourism, coastal tourism, eco-tourism, spiritual tourism, to cater to the

requirements of tourists to achieve a state of overall wellbeing. India also holds an

edge over competitor countries, as the country is enriched with techniques of

concentration, mind-control, natural resources, intellectual capital, cultural diversity

and tolerance. Thus, India is in an advantageous position vis-à-vis many of its

competitor countries.

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1.9 SUMMARY

This chapter expressed that tourism industry acts as a powerful agent of both

economic and social change. It stimulates employment and investment, modifies

economic structure and makes positive contributions towards balance of payments. It

has emerged as a major industry of the Indian economy, contributing substantially to

foreign exchange earnings and serving as a potential generator of employment

opportunities, because India as a tourist destination exercises immense attraction from

various angles, with its vast cultural and religious heritage and varied natural

attractions. Healthcare tourism thus could become a common form of vacationing,

and covers a broad spectrum of healthcare services, mixing with

leisure/relaxation, with the overall objective of wellness and healthcare. India has

great potential for health tourism. Health tourism has three branches. Medical tourism

is the major branch of the health tourism. For the purpose of medical travel is such as

cost effectiveness, not available in own country and waiting time.

Medical Tourism is the service industry so value chain is the very important

role in medical tourism specially for the point of view international level.