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UNIVERSITI TUN HUSSEIN ONN MALAYSIA
STATUS CONFIRMATION FOR MASTER`S THESIS
DEVELOPMENT OF A HOLISTIC INTERNET MARKETING STRATEGY
FRAMEWORK (IMSF) IN PROMOTING MEDICAL TOURISM INDUSTRY
(MTI) IN MALAYSIA
ACADEMIC SESSION : 2015/2016
I, WONG LAI YOONG, agree to allow this Master`s Thesis to be kept at the Library under the
following terms:
1. This Master`s Thesis is the property of Universiti Tun Hussein Onn Malaysia.
2. The library has the righ to make copies for educational purposes only.
3. The library is allowed to make copies of this report for educational exchange between higher
educational institutions.
4. ** Please Mark (√)
CONFIDENTIAL (Contains information of high security or of great
importance to Malaysia as STIPULATED under the
OFFICIAL SECRET ACT 1972)
RESTRICTED (Contains restricted information as determined by the
organization/ institution where research was conducted)
FREE ACCESS
Approved by,
(WRITER`S SIGNATURE) (SUPERVISOR`S SIGNATURE)
Permanent Address: DR. NORALFISHAH BINTI SULAIMAN
NO 348, LORONG 22,
AULONG BARU ,
34 000, TAIPING, PERAK.
Date : ___________________________ Date: ____________________________
NOTE:
** If this Master`s Thesis is classified as CONFIDENTIAL or RESTRICTED,
please attach the letter from the relevant authority/organization stating reasons
and duration for such classifications.
This thesis has been examined on date December 14, 2015 and is sufficient in
fulfilling the scope and quality for the purpose of awarding the Degree of Master of
Science in Real Estate and Facilities Management.
Chairperson:
PROF. MADYA DR. NOR HAZANA BTE ABDULLAH
Faculty of Technology Management and Business
University of Tun Hussein Onn Malaysia
Assistant Chairperson:
DR. MOHD HAFIZAL BIN ISHAK
Faculty of Technology Management and Business
University of Tun Hussein Onn Malaysia
Examiners:
DR.MOHD LIZAM BIN MOHD DIAH
Faculty of Technology Management and Business
University of Tun Hussein Onn Malaysia
DR. SHAFIE BIN MOHAMED ZABRI
Faculty of Technology Management and Business
University of Tun Hussein Onn Malaysia
DR. NORBAYA BTE AB RAHIM
Faculty of Architecture, Planning and Surveying
University of Teknologi Mara (UiTM)
DEVELOPMENT OF A HOLISTIC INTERNET MARKETING STRATEGY
FRAMEWORK (IMSF) IN PROMOTING MEDICAL TOURISM INDUSTRY
(MTI) IN MALAYSIA
WONG LAI YOONG
A thesis submitted in fulfilment of the requirement for the award of the Degree of
Master of Science in Real Estate and Facilities Management
Faculty of Technology Management and Business
Universiti Tun Hussein Onn Malaysia
JANUARY 2016
ii
DECLARATION
I hereby declare that the work in this thesis is my own except for quotations and
summaries which have been duly acknowledge.
Student : ................................................................
WONG LAI YOONG
Date : ................................................................
Supervisor : ...............................................................
DR. NORALFISHAH BINTI SULAIMAN
iii
DEDICATION
The precious help and invaluable support of family, supervisor, lecturers and friends
must be fully appreciated, especially to:
My beloved parent,
Madam Chong Kian Chew & Mr. Wong Weng One
My grandma,
Madam Yew Ah Lin
My uncle and aunty,
Chong Seng Heng & Wong Mee Chee
Wong Beng Soon & Wong Mei Yan
My lovely siblings,
Yee Ling, Yew Wah, Yeet Kheng, Lai Phing & Yee May
My internal and external panels,
and my dearest friends, especially
Tan Swee Hong, Lai Mei Chien
iv
ACKNOWLEDGEMENT
The MofREFM process over the past two years has been a challenging but a rewarding
journey, and it would not have been possible without the support and guidance of a
number of people.
First and foremost, words cannot express how appreciative I am of my MOTHER,
Kian Chew and FATHER, Weng One, for their encouragement, sacrifices and patience
made during the journey. Their endless love kept the candle of hope alight inside me
at the most difficult times and hardships. My thanks also go to my UNCLE, Seng Heng
and AUNTY, Mee Chee, who gave me emotional support and encouraged me in
countless ways during the journey.
Further, special thanks to my SUPERVISOR, Dr. Noralfishah Sulaiman, whose
guidance and support directed me throughout all the stages of the journey. I am deeply
indebted to my PANELS, Dr. Mohd Lizam for his astute intellectual guidance and
assistance in sharing valuable ideas during the theoretical stages of this research, and
Dr. Shafie Mohamed Zabri and Dr. Norbaya Ab Rahim (UiTM), for his/her concern
and constructive feedback; things would have been a lot more difficult without you.
I would also like to thank Ms. Shobena (Executive of Public Relations & Marketing,
Malaysia Healthcare Travel Council), Mr. Tarmizi (Senior Executive of International
Marketing, Prince Court Medical Centre), Dr. Jeremy Low (Director of Business
Development & Marketing, Penang Adventist Hospital), Puan Norhaslina (Senior
Manager, Marketing & Business Development, Pantai Hospital Kuala Lumpur), and
Mr. Eric Beh (Head of Services, Public Relations & Marketing), who have been so
generous in sharing their knowledge and experience with me for this research. My
appreciation and special thanks also goes to the Universiti Tun Hussein Onn Malaysia
(UTHM) and MyBrain 15 for the provision of scholarship and financial support
throughout the Master programme.
v
ABSTRACT
Previous studies found that Healthcare Information (HI) asymmetry or doctor-patient
knowledge gap is identified as one of the problems causes the Malaysia’s Medical
Tourism (MT) industry less efficient. This study is then seeking to promote and
introduce MT in Malaysia by using Internet as one of the marketing strategies at the
national level. Two research instruments were used in this study known as (1) Content
Analysis of 63 Medical Tourism Websites (MTwebs) and (2) Semi-structured Expert
Interview with Malaysian Healthcare Travel Council (MHTC) and four Medical
Tourism Hospitals (MThops). Qualitative data for this study were analysed by using
content analysis, code frequency analysis and NVivo 10, as Computer-Aided
Qualitative Data Analysis Software (CAQDAS). The outcome from this study shows
that there are 5 criteria and 21 child nodes emerged from the analytical analysis, known
as (1) Price; (2) Destination; (3) Healthcare Services; (4) Hospital Accreditation; and
(5) International Patient Tourists (IPTs) Healthcare Services. Findings also indicated
that 34 out of 63 MTwebs were commercial-based websites which revealed that the HI
provided through these MTwebs were more towards promotional ends rather than
helps to inform International Patient Tourists (IPTs) regarding potential risks inherent
(travel risk and surgical risk) while seeking cross-border MT. On top of that, the
hierarchy of the results also indicated that healthcare services, price and IPTs
healthcare services were more significant than destination and hospital accreditation
in designing the best MTwebs. Finally, a holistic Internet Marketing Strategy
Framework (IMSF) named as “4A’s Model” is proposed as a marketing benchmark
for MThops to promote their cross-border healthcare services to the IPTs across the
globe.
.
vi
ABSTRAK
Kajian terdahulu mendapati asimetri Maklumat Kesihatan (MK) atau jurang ilmu
antara doktor-pesakit dikenalpasti sebagai salah satu masalah yang menyebabkan
industri Pelancongan Perubatan (PP) di Malaysia menjadi kurang cekap. Justeru,
kajian ini dilaksanakan bagi mempromosi dan memperkenalkan PP di Malaysia
menggunakan Internet sebagai salah satu dari strategi pemasaran PP diperingkat
nasional. Dua instrumen kajian telah digunakan bagi kajian ini yang dikenali sebagai
(1) Analisa Kandungan terhadap 63 laman web PP (MTwebs) dan (2) Temubual
Separa-berstruktur bersama pihak Majlis Pelancongan Kesihatan Malaysia (MPKM)
dan empat wakil dari Hospital Pelancongan Perubatan (MThops). Data-data kualitatif
bagi kajian ini telah dianalisa menguunakan analisa kandungan, analisa kod kekerapan
berbantukan NVivo 10.0 sebagai Perisian Data Analisa Kualitatif Berbantukan
Komputer (CAQDAS). Kajian ini mendapati bahawa terdapat 5 kriteria dan 21 nod
yang telah dikenalpasti daripada analisis analitikal, iaitu (1) Harga; (2) Destinasi; (3)
Perkhidmatan rawatan perubatan; (4) Akreditasi hospital; dan (5) Perkhidmatan
rawatan perubatan bagi pelancong perubatan antarabangsa. Penemuan kajian turut
mendedahkan bahawa 34 dari 63 MTwebs adalah laman web yang bersifat komersial
dimana MK yang disediakan adalah bersifat promosi berbanding bersifat memberikan
maklumat kepada Pelancong Perubatan Antarabangsa (IPTs) berhubung potensi risiko
utama (risiko pelancongan dan risiko pembedahan) ketika mendapatkan rawatan PP di
luar negara. Selain itu, hirarki penemuan kajian mendapati bahawa perkhidmatan
rawatan perubatan, harga dan perkhidmatan rawatan perubatan IPTs adalah dilihat
paling penting berbanding destinasi dan akreditasi hospital dalam merekabentuk
MTwebs yang terbaik. Diakhir kajian, Rangka kerja Holistik Strategi Pemasaran
Internet (RHSPI) yang dinamakan sebagai “4A’s Model” telah dicadangkan sebagai
penanda aras pemasaran dan garis panduan kepada MThops bagi mempromosikan
perkhidmatan kesihatan melepasi sempadan kepada IPTs diperingkat global.
vii
CONTENTS
TITLE
i
DECLARATION
ii
DEDICATION
iii
ACKNOWLEDGEMENT iv
ABSTRACT
v
ABSTRAK
vi
CONTENTS
vii
LIST OF TABLES
xii
LIST OF FIGURES
xv
LIST OF SYMBOLS AND ABBREVIATIONS
xvii
LIST OF APPENDICES
xxi
CHAPTER 1 INTRODUCTION
1
1.1 Preamble
1
1.2 Research Background
2
1.3 Research Problem
4
1.4 Research Aim
7
1.5 Research Questions
7
1.6 Research Objectives
7
1.7 Scope of Study
7
1.8 Significance of Research
8
viii
1.9 Thesis Structure
9
1.10 Research Framework
11
1.11 Conclusion
12
CHAPTER 2 LITERATURE REVIEW
13
2.1 Introduction
13
2.2 Medical Tourism
14
2.2.1 Definition
14
2.2.2 Medical Tourism System
18
2.2.3 Evolution of Medical Tourism
21
2.2.4 Medical Tourism in Malaysia
24
2.3 International Patient Tourists
27
2.3.1 Definition
27
2.3.2 Characteristics of International Patient
Tourists
28
2.3.3 International Patient Tourists Market Size
31
2.4 Healthcare Marketing
33
2.4.1 Hospitality Management Philosophies
34
2.4.2 Medical Tourism Service Triangle
37
2.4.3 Types of Healthcare Marketing Strategies
40
2.5 Internet Marketing
44
2.5.1 Internet Marketing Strategies
47
2.5.2 Typology of Medical Tourism Websites
48
2.5.3 Functionality of Medical Tourism
Websites
50
2.6 The Healthcare Marketing Mix 56
ix
2.7 Criteria of Medical Tourism Websites
61
2.7.1 Price
62
2.7.2 Destination
66
2.7.3 Healthcare Services
70
2.7.4 Hospital Accreditation
73
2.7.5 International Patient Tourists (IPTs)
Healthcare Services
77
2.8 Proposed Internet Marketing Strategy Framework
(IMSF)
79
2.9 Summary of the Chapter 84
CHAPTER 3 RESEARCH METHODOLOGY
86
3.1 Introduction
86
3.2 Research Philosophy
86
3.2.1 What is Research?
86
3.2.2 Why Healthcare Marketing Research?
87
3.3 Research Design
88
3.3.1 Reason for Choosing Qualitative Approach
91
3.4 Data Collection
92
3.4.1 Primary Data
92
3.4.2 Secondary Data
93
3.5 Data Analysis
97
3.5.1 Content Analysis
97
3.5.2 Code Frequency Analysis
98
3.5.3 Computer Aided Qualitative Data Analysis
98
3.6 Conclusion
102
x
CHAPTER 4 DATA ANALYSIS AND DISCUSSION
103
4.1 Introduction
103
4.2 General Information on Medical Tourism
Websites
104
4.2.1 Typology of Medical Tourism Websites
104
4.2.2 General Information
105
4.2.3 Contact Information
105
4.2.4 Medical and Wellness Services
Information
106
4.2.5 Room Facilities Information
107
4.2.6 Interactivity of the Medical Tourism
Websites
108
4.2.7 Websites Language Assistance
109
4.3 Discussion on Research Question (1)
110
4.4 Discussion on Research Question (2)
113
4.4.1 Price
113
4.4.2 Destination
118
4.4.3 Healthcare Services
120
4.4.4 Hospital Accreditation
125
4.4.5 International Patient Tourists (IPTs)
Healthcare Services
128
4.5 Discussion on Research Question (3)
131
4.6 Conclusion
136
CHAPTER 5 CONCLUSION AND RECOMMENDATIONS
138
5.1 Introduction
138
5.2 Market Trends of Malaysia Medical Tourism
138
5.3 International Patient Tourists
140
xi
5.4 Healthcare Marketing
140
5.5 Research Findings for Research Objective (1)
141
5.6 Research Findings for Research Objective (2)
143
5.7 Research Findings for Research Objective (3)
146
5.8 Limitation of the Study
147
5.9 Research Contribution 147
5.10 Recommendations for Future Research
150
5.11 Conclusion
150
REFERENCES
152
APPENDICES
183
xii
LIST OF TABLES
TABLE TITLE PAGE
1.1 Significant Seven Criteria for International Patient Tourists
2
2.1 Various Terminologies of Medical Tourism
14
2.2 Definitions of Health Tourism
15
2.3 Definitions of Medial Tourism
16
2.4 Definitions of Wellness Tourism
17
2.5 Factors of Medical Tourist Destination Region Component
20
2.6 Evolution of Medical Tourism Industry in Southeast Asia
Region
22
2.7 Malaysia Hospital Healthcare Facilities in 2011
25
2.8 Actual International Patient Tourists
27
2.9 Characteristics of International Patient Tourists
29
2.10 Medical Travellers by Source and Destination
31
2.11 Hospitality Management Orientations
35
2.12 Types of Healthcare Marketing Strategies
41
2.13 Internet Marketing Strategies
47
2.14 The Proposed Extensions of Healthcare Marketing Mix
59
2.15 Average Medical Tourism Expenditure in 2012
63
2.16 Ranking for Value for Money
64
2.17 Medical Procedures Price in Selected Countries
65
2.18 Major Medical Tourism Destination Region 67
xiii
2.19 Destination Attributes
68
2.20 State-of-Art Health and Services
70
2.21 Major Healthcare Services Offered
72
2.22 The Differences in Accreditation and Certification
74
2.23 Types of Accreditation and Certification
75
2.24 Number of JCI Accredited Hospital in Asian Countries
77
2.25 Tourism-related Services in Medical Tourism
78
2.26 The Differences between Conceptual and Theoretical
Framework
80
3.1 List of Medical Tourism Hospitals
95
3.2 The Function of Computer Program in Qualitative Content
Analysis
98
3.3 Nodes and Codes in Criteria of Medical Tourism Websites
100
4.1 Information List on Chosen Respondents
103
4.2 General Information
105
4.3 Contact Information
106
4.4 Medical and Wellness Services Information
107
4.5 Room Facilities Information
108
4.6 Interactivity of Medical Tourism Websites
109
4.7 Matrix Analysis of Expert Interview
111
4.8 Criteria 1. Price
114
4.9 Average Room Rates in Medical Tourism Hospitals
115
4.10 Criteria 2. Destination
118
4.11 Criteria 3. Healthcare Services
121
4.12 Types of Health Screening Assessment
123
4.13 Criteria 4. Hospital Accreditation
125
xiv
4.14 Criteria 5. International Patient Tourists (IPTs) Healthcare
Services
129
5.1 Checklist of Medical Tourism Websites (MTwebs) Content
148
xv
LIST OF FIGURES
FIGURE TITLE
PAGE
1.1 Medical Tourism Receipts in Malaysia
3
1.2 Research Framework
11
2.1 Medical Tourism System
19
2.2 Modes of Supply of Trade in Health Services
23
2.3 International Patient Tourists Market Share in 2011
32
2.4 Medical Tourism Service Triangle
38
2.5 Demographic Distribution of Southeast Asian Internet
Audiences
43
2.6 Activities Undertaken by Web-based Health Information
Seekers
46
2.7 Typology of Medical Tourism Websites
49
2.8 Functionality of Medical Tourism Websites
51
2.9 Healthcare Marketing Mix (7P’s)
56
2.10 Criteria of Medical Tourism Websites
62
2.11 Average Range of Cost Saving for International Patient
Tourists
66
2.12 Healthcare Services and Medical Travelling
71
2.13 Proposed Conceptual Framework for Internet Marketing
Strategy Framework (IMSF)
82
3.1 Sampling Presentation of the Research
90
3.2 Nodes and Codes in Criteria of MTwebs using NVivo 10
101
xvi
4.1 Typology of Medical Tourism Websites
104
4.2 Languages Assistance
110
4.3 Internet Marketing Strategies
111
4.4 Hierarchy of the Criteria of Medical Tourism Websites
132
4.5 Internet Marketing Strategy Framework (IMSF)
135
xvii
LIST OF SYMBOLS AND ABBREVIATIONS
AMA American Marketing Association
3T MRI 3 Tesla Magnetom Trio Magnetic Resonance Imaging
APHM Association of Private Hospitals of Malaysia
CA Content Analysis
CABG Corony Artery Bypass Graft
CAQDAS Computer-Aided Qualitative Data Analysis Software
CT scan Computed Tomography Scan
DMT Domestic Medical Tourism
ENT Ear, Nose and Throat
et al and other people
F&B Food and Beverage
FAQs Frequently Asked Questions
GATS General Agreement of Trade in Services
GCP Good Clinical Practice
GDP Gross Domestic Product
H Medical Tourism Hospitals’ Code
HACCP Hazard Analysis Critical Control Points
HI Healthcare Information
HIPAA Health Insurance Portability and Accountability Act
HM Healthcare Marketing
xviii
HPH Health Promoting Hospital Network
HT Health Tourism
IM Internet Marketing
IMS Integrated Management System
IMSF Internet Marketing Strategy Framework
IMTJ International Medical Travel Journal
IPTs International Patient Tourists
ISO International Standards Organisation
ISQua International Society for Quality in Healthcare
IT Information Technology
JCI Joint Commission International Accreditation
KTM Keratapi Tanah Melayu (Malaysian Railway)
M1 Respondent (Malaysia Healthcare Travel Council)
MGCC Malaysian-German Chamber of Commerce & Industry
MHSP Man Health Screening Package
MHTC Malaysia Healthcare Travel Council
MMA Malaysian Medical Association
MMC Mahkota Medical Centre
MofREFM Master of Science in Real Estate and Facilities Management
MoH Ministry of Health Malaysia
MRI Magnetic Resonance Imaging
MSQH Malaysian Society for Quality in Health
MT Medical Tourism
MTDR Medical Tourist Destination Region
MTGR Medical Tourism Generating Region
xix
MThops Medical Tourism Hospitals
MTI Medical Tourism Industry
MTP Medical Tourism Programme
MTS Medical Tourism System
MTwebs Medical Tourism Websites
n Number of sampling
NGO Non-Governmental Organisation
NHS National Health Services
NKEAs National Key Economic Areas
O&G Obstetrics and Gynaecology
PAH Penang Adventist Hospital
PCMC Prince Court Medical Centre
PET Positron Emission Tomography
PHKL Pantai Hospital Kuala Lumpur
PPC Pay-per-click
PVG Patient and Visitors Guide
R1 Respondent 1
R2 Respondent 2
R3 Respondent 3
R4 Respondent 4
RDF Resource Description Framework
RO1 Research Objective 1
RO2 Research Objective 2
RO3 Research Objective 3
RQ1 Research Question 1
xx
RQ2 Research Question 2
RQ3 Research Question 3
SEO Search Engine Optimisation
SIRIM Standards and Industrial Research Institute of Malaysia
SME Small and Medium-sized enterprise
TV Television
UCSF University of California San Francisco
UK United Kingdom
US United States
VISA Visitors International Stay Admission
WHO World Health Organisation
WHSP Women Health Screening Package
WMSP Well Man Screening Package
WT Wellness Tourism
WWSP Well Women Screening Package
XML Extensible Markup Language
xxi
LIST OF APPENDICES
A Letter for Data Collection
B Questionnaire Survey
C Participating Medical Tourism Hospitals in Malaysia
D Data collection of Expert Interviews
E Data Collection of Medical Tourism Websites (MTwebs)
F List of Publications
CHAPTER 1
INTRODUCTION
1.1 Preamble
The worldwide Health Tourism (HT) industry is not a new phenomenon and it has
been recorded since Neolithic and Bronze ages in Europe when people travelled to
visit mineral and hot springs (Paffhausen et al., 2010). Medical Tourism (MT) takes
place when individuals opt to travel internationally with the primary intention of
obtaining medical treatment while simultaneously being holiday makers (Connell,
2006; Lunt & Carrera, 2011). In recent years, MT which indicates the combination of
medicinal service and tourism, is gaining popularity worldwide as an innovative
tourism program (Min, 2013).
In Southeast Asia, Medical Tourism Industry (MTI) is expanding rapidly and
emerging as a lucrative business opportunity (Chee, 2007; Herberholz & Supakankunti,
2012; Tullao et al., 2012). Due to this promising opportunity, many ASEAN countries
(e.g. Singapore and Thailand) are promoting tourist destinations by combining high-
quality healthcare services at competitive prices with attractive tourism packages
(Connell, 2006; Dahlui & Aziz, 2012; Lončarić, Bašan & Jurković, 2013).
Why do people travel out of the country for healthcare? Chee (2007) addressed
that relaxation factor served as a motivator for the middle and upper-class International
Patient Tourists (IPTs) of developing countries making decision about MT in the
foreign land. These push and pull factors include lower treatment cost (Paffhausen et
al., 2010; Singh & Gill, 2011); high-quality healthcare services (Tawil, 2011; Bruce,
2013); shorter waiting times (Jeffreys, 2011; Woodman, 2015) and Internet-based
marketing by providers (Turner, 2011; Hanefeld et al., 2013; Osman, 2014). Despite
there are many factors, which may influence IPTs decision making on choice of
healthcare destination, Pollard (2012) and Teoh (2014) summarised that there are
seven significant criteria for an IPT to make informed choices as shown in Table 1.1.
2
Table 1.1: Significant Seven Criteria for International Patient Tourists (Pollard, 2012; Teoh, 2014)
Criteria Description
(1) Geographical
proximity
Travel time, travel convenience such as ease of airport access and
barriers to entry.
(2) Cultural proximity Language, religion, food, customs and practices.
(3) Destination image Perceptions and positive impression of destination, e.g. product image,
destination branding and accommodation services.
(4) Destination
infrastructure
Services and facilities which are available at the destination such as
treatment services, clinic or hospital level, role of medical travel
facilitators, range and quality of accommodation available.
(5) Destination
environment
Factors that may enhance attractiveness for IPTs, e.g. cultural heritage
attraction, climate, geographic origin and price.
(6) Risk and reward Medical outcome, safety, track record and guarantee.
(7) Price
Cost of treatment, cost of travel to destination, cost of stay
(accommodation and living costs for IPTs and companions), cost of
insurance such as the specialist medical travel insurance and medical
complication insurance.
1.2 Research Background
As a component of healthcare sector, MT services include a variety of elements such
as hospital facility services; hotel and accommodations to the IPTs; food and beverage
and excellent wide range of tourism support facilities services (Ko, 2011). As indicated
by Dahlui & Aziz (2012), given the potential economic gain from MT, the Malaysian
government has made aggressive efforts to market MT abroad and promote awareness
of Malaysia as a healthcare destination. According to Kweon & Kim (2013), the
Malaysian government create a high added value through MT by combining traditional
medical therapies with tourism as an alternative way to promote MTI at the national
level.
MT under the National Key Economic Areas (NKEAs) in 10th Malaysia Plan
(a medium-term spending plan from 2011 to 2015) becomes the key money spinner
for Malaysia (Dahlui & Aziz, 2012; Australian Government Trade Commission, 2014).
A survey reported that IPTs arrivals increased by 14.6 percent from 671,727 in 2012
to 770,134 in 2013 (Malaysia Healthcare Travel Council (MHTC), 2014). Furthermore,
the revenue from MT also grew from RM 594 million in 2012 to RM 688 million in
2013, see Figure 1.1.
3
Figure 1.1: Medical Tourism Receipts in Malaysia (Hilmi, 2013;Suleiman, 2013; MHTC, 2014; MToday News Online, 2014)
According to statistics taken from Teo (2013) and Orissa International Online
(2013), popular MT destinations with strong IPT attractions include Penang and Klang
Valley with each state contributes 49 percent and 21 percent respectively of the total
revenue generated from MT in 2011. Teoh (2014) and Yap (2014) indicated that most
IPTs come from neighbouring countries with less developed healthcare infrastructure
like Indonesia (72 percent), Singapore (10 percent) and Japan (5 percent). The higher
treatment costs in Singapore and unstable political scene in Thailand are the main
factors cause Malaysia becomes a preferred destination for these IPTs (Dahlui & Aziz,
2012).
As explained by Wickramasinghe et al. (2013) and Cooper (2015), the
Malaysian government are actively carrying out promotional activities to outsource
Malaysian healthcare facilities and healthcare services abroad. Concepts such as the
4Ps (Product, Price, Place and Promotion); service marketing mix and MT theories
have become increasingly significant strategies to create competitive advantages in
MTI (Hudson, 2008; Tracy, 2010; Pollard, 2012; Venkatesh, 2012).
Specifically, the Internet has been used as an effective mechanism to facilitate
electronic communications between IPTs and Medical Tourism Hospitals (MThops)
(Baker et al., 2003; Crooks et al., 2010; Lunt et al., 2010; Lunt & Carrera, 2011).
According to Medical Tourism Association (2009) and Manaf et al. (2010), 49 percent
of IPTs found out about healthcare services in a foreign country from the Internet. It
is not surprising that there is an increasing number of Medical Tourism Websites
2007 2008 2009 2010 2011 2012 2013
International Patient Tourists 341,288 374,063 336,225 392,956 583,296 671,727 770,134
RM million 253 299 288 378 511 594 688
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
0
100
200
300
400
500
600
700
800
Rev
enu
e
Arr
iva
ls o
f H
ealt
h T
rav
elle
r (
per
son
)
4
(MTwebs) as a mode of marketing communication to introduce and to promote a
health-related product, and services include medical procedures, hotels, airlines,
transportation arrangements and insurances to the IPTs (Turner, 2007; Lunt et al., 2010;
Tatnall, 2010; Crook et al., 2011; Watson & Stolley, 2012).
According to Lee & Kozar (2006), there is a significance relationship between
MTwebs quality, preference and business performance. Lončarić et al. (2013) added
that high-quality MTwebs would attract more attention and visits from IPTs by
implying that their healthcare services and healthcare products are of high-quality,
further higher the likelihood of increase business performance.
Hence, there is a need to conduct a research that looks into the Internet
marketing strategies which may strengthen or weaken a choice of MT destination
toward the IPTs. The development of a conceptual framework for the Internet
Marketing Strategy Framework (IMSF) to be suggested is named as "4A's Model":
Affordability, Accessibility, Availability and Accreditation.
Healthcare affordability is the ability of a person to pay for healthcare service
costs (Axene, 2003; Goudge et al., 2009; Pollard, 2012). Accessibility refers to the
ease with which an individual can obtain needed healthcare services such as
geographical accessibility (Paez et al., 2010; World Health Organisation (WHO),
2014). Meanwhile availability reflects to adequate supply of healthcare services,
utilisation of health facilities or outcome of healthcare services (Gulliford et al., 2002;
WHO, 2014). Accreditation refers to the self-assessment, which assesses the
performance of MThop towards high-quality healthcare services (Agarwal, 2010;
Jaafaripooyan, et al., 2011). This 4A's Model will be further explained in Chapter 2.
1.3 Research Problem
Healthcare Information (HI) means any information, either oral or recorded in any
form or medium, that for staying well; preventing and managing disease; and making
other decisions related to medical and healthcare (Rippen & Risk, 2000; Stewart, 2013;
Health Insurance Portability and Accountability Act, 2014). Undoubtedly, the
development of the information society has been driven by technology (Barr, 1985;
Khalil, 2001). The Internet therefore has become an important source of information
for consumers in merchandise, services, travel or health (Lončarić et al., 2013). As
5
cited by Singh (2014), the Internet has facilitated MT growth by providing an effective
networking between IPTs and MThops.
As of 2012, Malaysia has 18.6 million the Internet users regardless of locations
(Malaysian Communications and Multimedia Commission, 2013; Malaysia Asia
Online, 2013). The survey found that 94.3 percent of the Internet users are Malaysian
while 5.7 percent are of other nationalities (Malaysian Communications and
Multimedia Commission, 2013). It is known that the Malaysian Internet users spend
nearly 20 hours per week online (Ariffin, 2011; Malaysian Communications and
Multimedia Commission, 2013; Inthiran et al., 2013). Previous survey reported that
64.3 percent of rural women in Malaysia seeking HI through online (Bakar, 2011). As
indicated by Khalil (2001) and Fox & Duggan (2013), there is a current shift towards
giving IPTs more responsibility for their healthcare decisions and now many of them
switch their way of seeking online HI virtually.
Patrick & Koss (1995) and Khalil (2001) defined consumer of HI as "any
information that enables individuals to understand and make health-related decisions
for themselves or their families". Khalil (2001) itemised consumer HI, to cover (1)
information supporting individual and community-based health promotion and
enhancement; (2) self-care; (3) shared (professional-patient) decision making; (4)
patient education and rehabilitation; (5) using the healthcare system and selecting
insurance or a MThop; and (6) peer group support. The use of the Internet has been
benefiting IPTs to search online HI, compare medical costs and making decision
before use or purchase the health-related product and service (Cline & Haynes, 2001;
Khalil, 2001; Lunt et al., 2010; Lunt & Carrera, 2011).
In Malaysia's healthcare sector, according to Abdullah (2005) and Lum (2010),
IPTs as consumers of healthcare do not have adequate knowledge to access factors that
are associated with quality care, patient’s rights and have difficulty in judging the
quality and the appropriateness of healthcare they received. As explained by Abdullah
(2005); Chee & Barraclough (2007); Lum (2010) and Quek (2014), a major reason is
the asymmetry of HI gap between the MThops and IPTs. For instance, Chee &
Barraclough (2007); Lum (2010) and Quek (2014) stated that there is no relevant
information on hospital charges and no laws regulating patients’ rights (Lum, 2010) in
Malaysia private MThops.
6
As indicated by Chee & Barraclough (2007); Lum (2010) and Quek (2014),
there is imperfect information since IPTs have limited understanding of what will or
will not restore health, while the MThops has much better information on what the IPT
requires and usually has influence over what is supplied and consumed. In economics
and contract theory, information asymmetry deals with the study of decisions in
transactions where one party has more or better information than the others. The
imbalance of power in transaction can lead to market failures in MTI (Abdullah, 2005;
Vadaketh, 2014).
Bringgs (2006) indicated that there are between ten and twenty thousand
health-related websites available on the Internet. However, less than half of the online
HI has been reviewed by doctors. In addition, online HI is a secondary data and it is
relied on another person's interpretation of data. According to Lambert (2010), 60
percent of HI available through online is incorrect, only 40 percent website offers
correct information. As cited by Ibraghimova (2006) and Crooks et al. (2011), there is
still a paucity of knowledge about the dissemination, content and reception of
promotional materials through MTwebs strategies. Another issue that the MTwebs has
is the trust and mistrust of online health websites (Bringgs, 2006). Besides, the
majority of MTwebs contents are unclear, incomplete and misleading (Ibraghimova,
2006).
There is a limited number of studies that looks into the asymmetry of HI gap
between the MThops and IPTs or doctor-patient knowledge gap using MTwebs
marketing. To date, most of the studies that were conducted have paid particular
attention to MThops based in countries such as the western countries like US, Canada
and Australia (Laing et al., 2010; Lunt & Carrera, 2011; Turner, 2010) and Thailand
(Connell, 2006; Cohen, 2008; Whittaker & Chee, 2014) where none of these studies
was conducted in Malaysia.
Therefore, in this study, the HI asymmetry or doctor-patient knowledge gap is
identified as one of the problems causes the healthcare market failure. Hence, due to
this deficiency which leads to a gap in literature review, therefore the researcher seeks
to promote further understanding of MT in Malaysia using the Internet marketing
strategy at a nation's level. The establishment of new knowledge and practical
contributions in this research area is a very important value for Malaysia MTI.
7
1.4 Research Aim
The objective of this study is to develop a holistic Internet Marketing Strategy
Framework (IMSF) for MThops in Malaysia. Given the pivotal role of MTwebs for
gaining access to HI and advertising international healthcare, a systematic review of
MTwebs will provide a detailed account of quality of HI content and presentation.
1.5 Research Questions
In accordance to the discussed problem statement, the research inquiries of the study
are as follows:
(1) What are the Internet marketing strategies available in attracting International
Patient Tourists (IPTs) to Malaysia?
(2) What are the criteria of Medical Tourism Websites (MTwebs) provided by
Medical Tourism Hospitals (MThops) in Malaysia?
(3) What is the holistic Internet Marketing Strategy Framework (IMSF) for
Medical Tourism Programme (MTP) in Malaysia?
1.6 Research Objectives
There are three objectives in this study:
(1) To investigate the Internet marketing strategies available in attracting
International Patient Tourists (IPTs) to Malaysia.
(2) To evaluate criteria of Medical Tourism Websites (MTwebs) provided by
Medical Tourism Hospitals (MThops) in Malaysia.
(3) To propose a holistic Internet Marketing Strategy Framework (IMSF) for
Medical Tourism Programme (MTP) in Malaysia.
1.7 Scope of Study
This study is conducted in order to explore and investigate all the Internet marketing
techniques and practices in MTwebs thoroughly. In addition, it is trying to understand
the mechanism of the Internet marketing strategies, which is focusing on 63 MTwebs
under the Malaysia Healthcare Travel Council (MHTC) portal website. Respondents
8
involved to facilitate this study consists of four private MThops and governing body
in Malaysia.
This study is only limited to MThops that are engaged with the Medical
Tourism programme (MTP). Wellness MThops are not included in this study. There
are several limitations involve in this study. Firstly, a total of 63 MTwebs being studied
are restricted to English language-based websites. Secondly, the respondents in this
study are only of the expert from private sector in Malaysia where MThops have
acquired Joint Commission International (JCI) or Malaysian Society for Quality in
Health (MSQH) accreditation.
1.8 Significance of Research
In light of this review, this study is worth to be carried out in order to provide a better
guideline to marketing MT component using the Internet strategy. Besides, a detailed
and reliable online HI displays on MTwebs can benefits the following stakeholders.
(1) Public and Private Medical Tourism Hospitals (MThops)
Findings from this study would be shared and be suggested to the MThops
in order to allow them to promote and introduce their healthcare facilities
and services via an appropriate Internet marketing strategy. Moreover, it
also allows them to offer a seamless combination of complicated arrangements
within the MT support system such as insurance and documentation, travel-
related assistance for IPTs and One-Stop solution in healthcare services.
(2) International Patient Tourists (IPTs)
The IPTs, the uninsured IPTs, particularly those with reported chronic
conditions and individuals with longer travel times for their usual source of
care are more likely to use the Internet for health-related communication
(Bundorf et al., 2006). This study can act as a reference to the IPTs for
seeking HI online before or after visiting to a foreign country in order to obtain
healthcare facilities and healthcare services. Thus, many IPTs would easily
receive the HI needed guided by the suggested research framework.
9
(3) Physicians and Medical Trainees
E-health is an emerging field in the intersection of medical informatics,
clinical practice and business referring to health services and information
delivered through the Internet (Eysenbach, 2001). This study is expected to
benefit medical students, physician and doctors to exchange clinical
information and understanding the needs of the IPTs.
(4) Academics
This study reveals the growth of global MTI MThops all around the world is
increasing as well as its international marketing activities. Therefore, this
study would act as references to the postgraduates, lecturers and researchers
in their future studies as well.
1.9 Thesis Structure
There are five (5) chapters in this thesis, and each chapter discusses a specific aspect
of this study.
(1) Chapter 1: Introduction
The first chapter explains and discusses the problem and issues that occur in
the emergence of web-based HI in the globalisation of health and MT sector.
It covers research background, problem statement, research questions,
research objectives, scope of study, significant of study and the elements of
research framework.
(2) Chapter 2: Literature Review
Chapter 2 expresses overview of MT in Malaysia and other countries, various
Internet marketing strategies in healthcare services, previous theoretical or
conceptual frameworks, research findings and contribution, which related to e-
health trend in MTI. This chapter also clarifies the definition of concepts and
terminologies, history of MT and all other data associated with this topic.
10
(3) Chapter 3: Research Methodology
Chapter 3 covers the initial stage of the research process until the final stage
of the study. This includes research method selection and techniques designed
in collecting and processing the primary and secondary data through expert
interviews and content analysis of MTwebs in Malaysia.
(4) Chapter 4: Data Analysis and Discussion
Chapter 4 is a crucial chapter for this study. Qualitative data collection will
be analysed in this chapter. Computer Aided Qualitative Data Analysis
Software (CAQDAS) such as NVivo 10 is used to analyse the secondary data
to obtain the accurate finding. On top of that, primary data is collected
through the expert interviews designed.
(5) Chapter 5: Conclusion and Recommendations
Chapter 5 is the final part of this study. In this chapter, outcomes from data
analysis are summarised and concluded. Recommendations and suggestions
for the future research opportunities are also elaborated in this chapter.
11
1.10 Research Framework
Figure 1.2: Research Framework (Researcher’s study, 2015)
TITLE
Development of A Holistic Internet Marketing Strategy Framework (IMSF) In Promoting
Medical Tourism Industry (MTI) In Malaysia
To investigate the Internet
marketing strategies
available in attracting
International Patient Tourists
(IPTs) to Malaysia.
To evaluate criteria of
Medical Tourism Websites
(MTwebs) provided by
Medical Tourism Hospitals
(MThops) in Malaysia.
To propose a holistic
Internet Marketing Strategy
Framework (IMSF) for
Medical Tourism
Programme (MTP) in
Malaysia.
RESEARCH SCOPE
A total of 63 Medical Tourism Websites (MTwebs) and expert interviews with
respective bodies were conducted
RESEARCH METHODOLOGY
DATA COLLECTION
RESULT AND FINDING OF RESEARCH
RESEARCH OBJECTIVE 1 RESEARCH OBJECTIVE 2 RESEARCH OBJECTIVE 3
RESEARCH QUESTION 1
What are the Internet
marketing strategies
available in attracting
International Patient Tourists
(IPTs) to Malaysia?
RESEARCH QUESTION 2 RESEARCH QUESTION 3
What are the criteria of
Medical Tourism Websites
(MTwebs) provided by
Medical Tourism Hospitals
(MThops) in Malaysia?
What is the holistic Internet
Marketing Strategy
Framework (IMSF) for
Medical Tourism
Programme (MTP) in
Malaysia?
PRIMARY DATA SECONDARY DATA
EXPERT INTERVIEW
(1) Malaysia Healthcare Travel Council
(2) Four MThops
CONTENT ANALYSIS
63 MTwebs under Malaysia Healthcare
Travel Council portal website
CONCLUSION AND RECOMMENDATION
DATA ANALYSIS
12
Figure 1.2 explains the research process of the study. According to Sulaiman
(2011), a research process framework portrays the whole process involved in carrying
the research. It started with research background and research problem, followed by
identification of research objectives and scope of study. Definitions, key terms and
terminology related to this research will be defined in literature review chapter. In data
collection and analysis stage, primary and secondary data will be obtained through
expert interview and content analysis of MTwebs. The data collected then will be
analysed using NVivo 10, a Computer Aided Qualitatice Data Analysis (CAQDAS)
software.
1.11 Conclusion
Chapter 1 is an important chapter to summarise important points throughout the whole
thesis. This chapter explained and distinguished essential segments of research process
which covering the Research Problem, Issues that occur in Malaysia’s healthcare
industry, Justification for this research topic, the Significance of this research to the
Malaysia government, MThops and IPTs as well as researchers.
CHAPTER 2
LITERATURE REVIEW
2.1 Introduction
A review of the literature indicates that Health Tourism (HT) is not a new concept. It
has emerged due to the need of adapting the changing lifestyle and habits in HT (Manaf,
2010). The impact of globalisation in healthcare has paralleled with emerging trends
towards the increased reliance upon indivisualiased healthcare provision and IPT led
access to health-related websites (Craigie et al., 2002; Lunt et al., 2010). The Internet
as a key driver in the MT phenomenon has been opening up to a new demand and need
for healthcare consumers to access HI and efforts on advertising from anywhere in the
world, including information about international and cross-border provision of
healthcare services (Lunt et al., 2010; Lunt et al., 2011).
Healthcare in Malaysia consists of two main categories which are Medical
Tourism (MT) and wellness programme (Ministry of Tourism Malaysia, 2014). This
study is focusing on MT because Malaysia is ranked among the top choices in the
region for providing MT internationally (Bakhtiar, 2009; Puzi, 2012; Karen, 2013).
Thus, this chapter covers relevant review of literatures for this particular study. It is
structured and organised as follows:
(1) An overview of theoretical, propositions on marketing concept in healthcare
industry, and the Internet marketing;
(2) A review of the Internet Marketing Mix and the development of a conceptual
framework for this particular study.
14
2.2 Medical Tourism (MT)
2.2.1 Definition
Previous literature reveals that there are various terminologies which are given to
Medical Tourism (MT). However, when and where the terms of MT itself originated
is actually unknown (Connell, 2011; Munro, 2012). As the definition and concept of
MT in healthcare sector still ambiguous, General Agreement of Trade in Services
(GATS) has classified MT as an economic activity that involves trade in services from
two distinct sectors, healthcare and tourism. Unfortunately, Paffhausen et al. (2010)
claimed the kind of treatment encompasses in MT still make the definition unclear due
to several conditions as below.
(1) Does the term involved only specific medical intervention?
(2) Does it include elective as well as essential surgery?
(3) Do spa, relaxation, alternative and rehabilitation treatments qualify as part of
the healthcare services offered to medical tourists?
Hence, it can be said that there is no standards of MT terminology applied
consistently across the world. In addition to this, the interchangeable used of MT
terminologies may be confusing to some IPTs, government, MThops and countries
(Connell, 2011; Crooks et al., 2010; Munro, 2012). See Table 2.1.
Table 2.1: Various Terminologies of Medical Tourism (Bookman & Bookman, 2007; Connell, 2011; Hjalagar & Konu, 2010; Munro, 2012)
Medical Tourism (MT) Terminology
(1) Contraception tourism
(2) Cosmeceuticals
(combination of term "cosmetics" and "pharmaceuticals")
(3) Detox tourism
(4) Health travel
(5) Health tourism
(6) Medical travel
(7) Medical outsourcing
(8) Organ transplant tourism
(9) Pregnancy tourism
(10) Pharmaceutical tourism
(11) Spa tourism
(12) Toothache tourism
(13) Ultimately death tourism
(14) Wellness tourism
15
In academic literature, MT definition has been ignited from a tourism
management perspective, analysing pull and push factors in health perspective
(Henderson, 2004; Garcia-Altes, 2005; Connell, 2006; Smith et al., 2009; Lee, Sridhar
& Patel, 2009; Heung et al., 2010). Additionally, conceptual frameworks in the legal
literature which focus on intervention in health systems, IPT’s liability issues and
potential impact on health systems in specific countries like India and US are also
contributed toward the construction of MT definition and concept (Forgione & Smith,
2006; Atun et al., 2009; Cohen, 2010; Hazarika, 2010; Leng, 2010).
In this view, it can be seen that MT is not only been perceived as limited to few
specific treatments in healthcare services (Paffhausen et al., 2010). It also takes into
account the nature of health systems or depends on the act of travelling abroad and
health seeking behaviour of people who make health decision and choice (Pocock &
Phua, 2011; Munro, 2012). In this case, in order to have an appropriate definition of
MT there are three epistemological constructs being used in this study as shown in
Tables 2.2, 2.3 and 2.4. Under the umbrella term named as HT, these definitions are
viewed from two perspectives named as Medical Tourism (MT) and Wellness Tourism
(WT). Tables 2.2, 2.3 and 2.4 differentiate these interchangeable terms according to
IPTs travel motivation and health seeking behaviour.
Table 2.2: Definitions of Health Tourism (HT) (Researcher’s study, 2015)
Authors Years Topics Definitions
Goodrich 1993 HT
management
HT is defined as the deliberate attempt on the part of a
tourist facility (e.g. hotel) or destination to attract IPTs
by deliberately promoting its healthcare services and
facilities, in addition to its regular tourist amenities.
Bennett, King
& Milner
2004 Vacation
marketing
Any pleasure-oriented tourism which involves an
element of stress relief could be considered to be a
form of HT.
Caballero-
Danell &
Mugomba
2007 MT marketing HT encompasses all treatment that enhance a state of
well-being, both internally and externally, from spa
and relaxation treatments, cosmetic surgery to elective
surgery and essential surgery which include essential
procedures such as heart transplant or hip implants to
remedy and injury or treat an illness.
Joppe & Choi 2010 Spa holiday in
Canada
HT is used to describe someone who has one or more
medical conditions that would make her or him travel
abroad to experience therapies in order to improve her
or his health or well-being.
…Continue to the next page
16
Table 2.2: Definitions of Health Tourism (HT) (Researcher’s study, 2015)
Continued…
Authors Years Topics Definitions
Stanciulescu 2010 Destination in
health and WT
Provision of health facilities utilising the natural
resources of the country, in particular, mineral water
and climate. HT refers to those IPTs with medical
conditions who would travel to experience healing
therapies.
Musa 2013 MT marketing Travel to a destination and all the activities involved
to host the tourist, who travels with the main purpose
to attain a balance state of body, mind and well-being.
Table 2.3: Definitions of Medial Tourism (MT) (Researcher’s study, 2015)
Authors Years Topics Definitions
Connell 2006 Tourism
management
MT is defined as a new form of niche tourism where
people travel long distances overseas to obtain medical
care while simultaneously being holidaymaker.
Kazemi 2007 MT marketing MT is described as any form of travel from one's
normal place of residence to a destination at which
medical or surgical treatment is provided. The travel
undertaken must involve more than one night away
from the country of residence.
De Arellano 2007 Healthcare
services
marketing
Travel with the express purpose of obtaining
healthcare services abroad, which are typically paid
for out-of-pocket.
Keckley &
Underwood
2008 MT
consumers in
search of
value
It is a process of leaving home abroad for economical
treatments, well-being and recuperation of acceptable
quality with the help of a tourism support system.
These support systems include transportation services
(airlines, cruise ships, tour buses), hospital services
(hotel, resorts) and entertainment venues (amusement
parks, casinos, shopping malls, music and sport
venues, theatres).
Additionally, the medical destination is an
exotic resort halfway into the world, a neighbouring
country or a healthcare facility several hours away in
another province.
Hopkins et al. 2010 MT and
Health policy
system
Cross-border healthcare motivated by lower cost,
avoidance of long wait times or services not available
in one's own country.
Spece 2010 Conflicts of
broker`s fees
The MT market involves uninsured or underinsured
IPTs who are seeking a specific surgery or treatment
abroad.
Global Spa
Summit LLC
2011 Global
healthcare and
MT
People who are sick and travel to a different place to
receive treatment for a disease, ailment or condition,
generally seeking lower cost of care, high quality of
care, better access to care than they could receive at
home.
…Continue to the next page
17
Table 2.3: Definitions of Medial Tourism (MT) (Researcher’s study, 2015)
Continued…
Authors Years Topics Definitions
Pocock &
Phua
2011 MT and health
policy system
MT as a subset of HT whose involves the organised
travel outside from local environment for the
maintenance, enhancement or restoration of the
individual’s well-being in mind and body.
Musa 2013 MT marketing It can be defined as all activities related to traveling
and hosting an IPT who stays at least one night at the
destination region, for maintaining, improving or
restoring health through medical intervention with the
application of biomedical procedures to the IPT.
Table 2.4: Definitions of Wellness Tourism (WT) (Researcher’s study, 2015)
Authors Years Topics Definitions
Smith &
Puczkó
2009 Health and WT
marketing
WT includes a high focus in facilities for medical
treatment as well as pure leisure and relaxation sites.
Stanciulescu 2010 Destination in
health and WT
marketing
WT is about a balanced state of body, spirit and mind,
including such holistic aspects as self-responsibility,
physical fitness, healthy nutrition, relaxation, mental
activity and environmental sensitivity as
fundamentals elements.
Wellness is also be viewed as a way of life,
which aims to create a fit body, soul and mind through
acquired knowledge and positive interventions. A
person who seeks a wellness travel experience, is
generally healthy to start with and seeks therapies to
maintain his or her well-being.
Priszinger,
Formadi &
Mayer
2010 Health related
WT marketing
WT integrates body, mind and spirit. Generally, it
relates to the physical condition of a person's aim to
achieve a good health condition and minimise the risk
of illness.
Hjalager &
Konu
2010 Cosmeceuticals
in WT
Wellness experiences are not a matter of intangible
procedures and services. It is assisted by a large
number of auxiliary remedies and depends on the
interaction between the staff and the customers in the
wellness facilities.
Azman &
Chan
2010 Health and WT
management
A way of life that an individual creates to achieve his
or her highest potential for well-being, consists of
action that the individual able to control (how they
exercise, eat, manage stress and perceive the
environment) and achieving a high-level wellness
involves continual striving for a more healthful way
of living.
Joppe & Choi
Global Spa
Summit LLC
2010
2011
Spa tourism
Global health
and MT
management
The concept of wellness emphasizes personal
responsibility for making lifestyle choices and self-
care decisions that will improve the quality of life.
People who engage in WT are generally healthy, but
seek therapies to maintain this state of well-being.
18
In brief, Healthcare Tourism (HT) can be viewed from two different
perspectives, medical and wellness. Medical Tourism (MT) is used to describe the
health practice of IPTs or individuals who are sick travelling internationally with the
purpose to obtain healthcare services, typically paid from out-of-pocket. Meanwhile,
Wellness Tourism (MT) refers to IPTs who travel abroad to enhance and maintain their
state of well-being.
2.2.2 Medical Tourism System
General System Theory was originated in the natural sciences research sphere. The
theory requires a researcher to understand sets of objects, the relationships between
those studied objects, and the relationship between sets of objects and their
environments (Corlett, 2001; Ghosh, Siddique & Gabby, 2003). The Austrian biologist,
Bertalanffy created this theory in 1934, and it has been widely applied to the study of
organisations and human services since then (Corlett, 2001; Ko, 2011; Sauber & Vetter,
2013; Johnston, 2014). In the late 1920s, Bertalanffy wrote:
Since the fundamental character of the living thing is its organisation, the customary
investigation of the single parts and processes cannot provide a complete explanation of the
vital phenomena. This investigation gives us no information about the coordination of parts
and processes. Thus the chief task of biology must be to discover the laws of biological systems
(at all levels of organization). We believe that the attempts to find a foundation for theoretical
biology point at a fundamental change in the world picture. This view, considered as a method
of investigation, we shall call “organismic biology” and as an attempt at an explanation, “the
system theory of the organism” (7, pp.64 ff., 190, 46, condensed).
Bertalanffy (1972)
Tamas (2000) and Sauber & Vetter (2013) defined the word system as “a set
of elements in interaction with each other”. These elements could be a group of things
(forest, rock, animal or anything else), social groups, personality or technological
devices (Needham, 1993; Tamas, 2000). According to Ko (2011), a system is “a
collection of groups of various fields that are mutually related to their efforts to
achieve a common goal”. Lundvall (2010) and Mitchell (2014) added that system
theory studies the structure and properties of systems in terms of relationships, and
clearly define complex phenomena (Ko, 2011).
19
Indeed, as healthcare sector is regarded as a very complex industry which
encompasses various MT industries, these industries have a similar system in this
particular system theory. As a component of healthcare sector, MT services include a
variety of elements such as hospital facilities services; ambulatory healthcare services;
medical equipment and supplies manufacturing; medi-resort services to the IPTs; food
and beverage and excellent wide range of tourism support facilities (Sacramento
Regional Research Institute, 2005; Ko, 2011). In healthcare, Leiper’s Tourism System
(1995 & 2004) and Bertanlanffy’s System Theory (1972) were taken as a foundation
for Medical Tourism System (MTS) within the same phenomenon (Ko, 2011).
MTS has a capability to understand the roles, mutual connections and
relationships among the various suppliers, MThops and IPTs involve in the MTI
(Morrison, 2009; Ko, 2011). In the context of MT, MTS consists of four interrelated
elements: IPTs, Medical Tourist Generating Region (MTGR), Medical Tourist
Destination Region (MTDR), and MT industries, see Figure 2.1 (Ko, 2011).
Figure 2.1: Medical Tourism System (Ko, 2011)
Marketing
Other external circumstances: tourism experience, environmental changes, exchange rates,
visa policies, labour markets, openness towards foreigners and outbreaks of diseases.
Insurance Companies
Health insurance and travel
insurance
Employers/ Labour
unions/ Travel agencies
Transport services used to send their IPTs for overseas
treatment.
MTGR: IPT's origin country
Types of IPTs
G1 - Major surgery G2 - Minor surgery
G3 - Cosmetic surgery
G4 - Diagnostic service G5 - Alternative therapy
treatment
G6 - Lifestyle/ Wellbeing
MT
Ag
enci
es
(tra
vel
ag
enci
es o
r M
Tho
ps)
MTDR: country that provide healthcare
services
MT
Ag
enci
es
(tra
vel
ag
enci
es o
r M
Tho
ps)
Hotels, food and
beverage
Hospital facilities/
Healthcare services
Government and
social factors
Tourism support
facilities/ services
Type of MT services
Departure
Arrival
20
The diagram in Figure 2.1 is designed to explain the mutual roles and
relationships among the four components of the MTS, further express the services and
their suppliers according to the routes of the IPTs. According to Ko’s MTS model
(2011), there are six categories of IPTs, from Group 1 to Group 6 in the MTGR, and
IPT is the most basic component of this system. IPT can travel to MTDR in personally,
by medical tourist agency or insurers (only specific for US and Canada) via paid for
out-of-pocket or cover by health insurance.
In MTGR and MTDR, IPTs, insurer corporations, MThops and MT travel
agencies play an important role in stimulating the MTI. There are largely four types of
MT services provided by the MTDR country that are known as (1) Hospital facility
and related services; (2) Accommodation/Food and Beverage (F&B) services, (3)
Tourism support facilities services, and (4) Government and social factors. See Table
2.5. Each of this MTDR service component may strengthen or weaken the preferences
of IPTs (Ko, 2011).
Table 2.5: Factors of Medical Tourist Destination Region Component (Ko, 2011)
MT Service Component International Patient Tourists (IPTs) Preferences
(1) Medical facilities and
services circle
Medical costs; Availability of medical staff; Availability of medical
training (medical school, nursing programs); English commonly
spoken among medical staff; Hospital facilities (capacity,
accreditation, licensure of staff, specialisations); Staff (patient ratio,
ambulance service); Equipment available for rental (oxygen,
wheelchair, etc.); Private nurses available for hire; Medications
(availability, safety of medication quality, parallels to US medication);
Indigenous disease threats; Privately operated facilities; Operation of
aftercare facilities; Ease of medical records transfers back to the home
country.
(2) Hotel and F&B circle Lodging costs; Food and beverage costs; Number of 3/4/5 stars rating
rooms availability; Hospitality labour availability; Hospitality training
availability; Hospitality financial inducements for labour; English
commonly spoken among hospitality staff; Availability of potable
water in facilities; Reliability of electricity in facilities; Licensure and
regulation for: F&B operations, hotel accommodations, spa facilities;
Dietary accommodations available (gluten free, low sodium, doctor
prescribed); Internet availability; Hotel accommodation (disability and
special service accommodations, private baths, elevators, 24-hour
room services availability, proximity to hospitals, heat water or air);
Value for services provided ratio; Presence of spa services: (a) Medical
personnel associated with spa (b) Spa treatments (c) Traditional
treatments, e.g. acupuncture (d) Instruction in relaxation, diet or
wellness, e.g. tai chi, yoga, nutrition (e) Diagnostic services (f)
Exercise/workout facilities.
...Continue to the next page
21
Table 2.5: Factors of Medical Tourist Destination Region Component (Ko, 2011)
...Continued
MT Service Component International Patient Tourists (IPTs) Preferences
(3) Tourism support
facilities and services
circle
General labour costs; Commonality of English spoken and written;
Availability of educated translators; Airport (direct service from major
cities, airline's servicing area, airfare rates, frequency of flights); Local
transportation: (a) Availability of taxi, buses and other public transport
in hospital/hotel areas (b) Safety of available transport options (c)
Accommodation for disable available; Reliability of infrastructure
(electric service, public services, Waste Management); Safety from
crime; Local political stability; Distribution of service for: cell phones,
the Internet, ease of limited mobility maneuverability (wheel chair,
friendly pedestrian); Weather appeal for vacation and for recovery;
Destination appeal (city offerings, relaxation, education, culture,
sightseeing, traditional medicine as supplement/ alternative);
Receptivity by local to IPTs; Current awareness of locale by the IPTs.
(4) Governmental and
social factors circle
Political stability of the country; Stability of labour force; Currency
fluctuations; Access to money/credit; Safety of the country; Respect of
individual rights (culture of tolerance, gender equality, protection of
disable, freedom from unreasonable arrest); Legal system: (a)
Established laws (b) Evenness of enforcement (c) Ownership rights (d)
Legal resources (e) Protection of IPTs (f) Malpractice recognised (g)
Accounting and financial disclosure (h) Tax system (I) recognition of
patents, intellectual property rights; Ease of access: (a) Need for visa
by residents of target markets (b) Visa access (c) Visa processing time;
Type of market/economic model (capitalism, privatisation, regulation/
deregulation of areas impacting healthcare and tourism); Cultural
strain: (a) Likeness of source and host country culture (b) Host
country's citizen attitudes toward the source country.
In brief, MTS presents a systematic and comprehensive MT phenomenon that
occurs between consumer and supplier at each phase of a medical trip. This model
considers IPTs as consumer in the umbrella of MTGR. Meanwhile MTDR can be
referred to as the four types of services to be offered to the potential IPTs. As indicated
by Ko (2011), MTS is not only study the relationship between suppliers and IPTs, it is
also used to describe the geographical nature between two countries or cities: MTGR
and MTDR. Therefore, MTS can be used as a basis of the theoretical framework in
this study in a way to identify the target market in MTGR. The marketing strategies
then will be identified for attracting IPTs on the part of MTDR.
2.2.3 Evolution of Medical Tourism
Since ancient history, people have been traveling great distances to seek treatment for
illness and disease (Bookman & Bookman, 2007; Horowitz, Rosensweig & Jones,
2007; Medical Tourism News & Information Online, 2008; Yap & Yong, 2012). The
evolution of MT is shown in Table 2.6. Spa tourism became one of the earliest forms
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of HT during 18th and 19th centuries in Europe (Tawil, 2011). In the late 19th century,
IPTs from less-developed countries started travelling to medical centres in Europe and
the US for more affordable healthcare option that was not available in their home
countries (Horowitz et al., 2007).
Table 2.6: Evolution of Medical Tourism Industry in Southeast Asia Region (Yap & Yong, 2012)
Timeline History and Evolution of Medical Tourism
4,000 B.C The Sumerians built facilities around natural hot springs.
300 B.C The Greeks had their Asclepia temples based on the original complex in Epiduria
providing hot baths, gymnasiums and temples besides their curative services.
1248 The Mansuri hospital was opened in Cairo, and it was most advanced and largest
hospital built then with travellers all over the realm coming to seek cure.
16th -18th
century
Healthcare travel received resurgence in Europe and the UK as the elite
rediscovered Roman baths, and destinations grew around spas in location like Bath,
Baden-Baden, St. Moritz and Ville d’Eaux.
1980 -1990 The growth of tooth tourism as IPTs looking for affordable dental care or
procedures travelled to Central American countries for treatment, which was not
covered by their health insurance schemes.
Pre-1997 The US and Europe dominated in terms of technology and expertise as well as mind
share as centres of excellence for healthcare. Singapore was by default a medical
hub in Asia due to state of relatively advanced economic development. IPTs
traveled for high-end healthcare services which they could not obtain at home
geographies.
1997-2001 Era of the Asian economic crisis
Tough local economic situations compelled local government, e.g. Thailand and
healthcare industry players to source for alternative or foreign business revenue.
Competitive pricing becomes a factor in the healthcare travel equation.
2001-2006 9/11 and the Middle East boom
Rise in demand for elective and cosmetic surgery in the region. Emergence of Asian
destinations, e.g. Thailand, India, Malaysia, etc. as legitimate medical destinations
for IPTs from the west.
Present Rise of Asia and the emerging markets
Rapid rate development both a boon and a bane to the state of healthcare for nations
in the region. In countries where the maturity of the healthcare sector has managed
to keep up with the overall growth picture, they are able to offer world-class
healthcare expertise with no technology or quality gap at relatively competitive
prices versus the western world (supply), but for countries whose healthcare system
have not managed to keep pace, exists a growing market of IPTs whom are able to
afford and demand healthcare services but are not able to obtain them within home
geographies (demand).
Future state It is postulated that success in the industry for regional players can be distilled down
to the constituents of quality (the end-to-end IPT experience), accessibility
(connectivity and convenience) and product or service focus (best market segment
fit).
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It was not until 1973 that International Union of Travel Officials was first
categorised HT as a commercial activity (Paffhausen et al., 2010). As a form of
international trade in services, MT falls under Mode 2 of the General Agreement of
Trade in Services (GATS) (Drager & Vieira, 2002; Paffhausen et al., 2010; Herberholz
& Supakankunti, 2012). GATS distinguishes four modes of supply of trade in
healthcare services which can be traded as shown in Figure 2.2 (Paffhausen et al.,
2010; Herberholz & Supakankunti, 2012). According to Carrera & Bridges (2006) and
Pocock & Phua (2011), Mode 1 is regarded as a remote service provision such as
telemedicine, diagnostics and medical transcriptions. Meanwhile, Mode 2 involves the
movement of persons to a country where the services are provided, while Mode 3
regards to foreign ownership of healthcare facilities; and Mode 4 is about movement
of healthcare professionals.
Figure 2.2: Modes of Supply of Trade in Health Services
(Drager & Vieira, 2002; Paffhausen et al., 2010; Herberholz & Supakankunti, 2012)
Trade in Healthcare Services
Mode 2
Consumption of
health services abroad
Mode 3
Commercial
presence
Mode 4
Movement of
medical personnel
Mode 1
Cross-border supply
Shipment of
laboratory samples, diagnosis and
clinical
consultation via mail or electronic
delivery
(e.g. telemedicine)
Medical
tourism
Educational
services
provided to foreign
students
Foreign investment in the health
services sector in
another country, establishment of
hospitals, clinics,
etc.
Movement of health personnel:
includes both
temporary and permanent flows.
from the territory of one Member into the territory of any other Member.
in the territory of one Member to the service consumer of any other Member.
Mode
by a service supplier of one Member, through commercial presence, in the territory
of any other Member.
by a service supplier of one Member, through the presence of natural persons of a
Member in the territory of any other Member.
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2.2.4 Medical Tourism in Malaysia
According to Chee & Barraclough (2007) and Shah (2008), Malaysia’s healthcare is
under the control of Ministry of Health Malaysia (MoH). Malaysia healthcare system
is a mixed public-private in a provision of healthcare services (Chen & Tsai, 2007;
Jackson, 2009) whereas the private MThops are the main focus of the current initiative
to offer healthcare services to IPTs (Health Tourism Online, 2013).
Under the 9th and 10th Malaysia Plan, Malaysia Healthcare Travel Council
(MHTC) was established to promote healthcare within Malaysia for IPTs and
dedicated to advance the sector's delivery system and infrastructure (MoH, 2010).
According to Ministry of Tourism Malaysia (2014), HT in Malaysia consists of two
main categories, which are MT and wellness programme. Pharmaceutical, medical
technology products and elderly care (healthcare services, including health travel,
specialist care centers and care of seniors) have been identified as three healthcare sub-
sectors under the NKEA program for healthcare (Malaysian-German Chamber of
Commerce & Industry (MGCC), 2012; MoH, 2014).
According to the Medical Act 1971 (Act 50), every medical practitioner is
required to perform three years of service with public hospital to overcome the
shortage of medical practitioner in the country. However, Malaysian medical
specialists and officers above the age of 45 and working abroad have been exempted
from this rule as an incentive to attract them to return and serve the country (Shah,
2008).
According to Manaf (2010) and Selangor State Investment Centre (2013), other
supportive policies and incentives for MT programme in Malaysia, including:
(1) exemptions from income and withholding tax for 10 years from the
commencement of operations before the end of 2015 as well as unrestricted
employment of foreign knowledge workers;
(2) 100 percent income tax exemption on revenues generated from IPTs, apart
from granting visa-on-arrival to IPTs with a recommendation from
participating MThops, and
(3) 100 percent tax allowance on capital expenditure for medical equipment.