1. CHAPTER ONE: INTRODUCTION
‘The Ministry of Health and Family Welfare (MHFW) launches an E-Marketing campaign that will promote India as a quality Healthcare destination for persons across the globe and also increase the average time they stay in India. This will help other tourism related service industries, such as hotels, spas, and restaurants. On the whole, it will benefit the tourism industry and follow the Indian government’s strategy of promoting India as the ‘Medical Hub of Asia’.’ ‘ (Ministry of Indian Tourism, 2015)
The purpose behind the conduction of this empirical study is to analyse the levels of satisfaction of the foreign patients in the multi-speciality hospitals of India which is chosen as their medical tourism destination. These levels are given ranking based on their importance of quality healthcare standards that the hospitals should focus on. The research is mainly focus on the patients influencing behaviour, decision making process and the experiential values. For the development of the effective framework for the medical tourism which is largely a consumer driven trend, a hypothetical analysis is done in order to understand the motivational factors of the patients. This section of study will give an overview of the empirical research’s attainment, types of medical tourism, aims and objectives that are considered for the study and summarises the different stages of research study.
1.1 RESEARCH BACKGROUND
Medical tourism is a term that is used when a patient going to a different country for either urgent or elective medical procedures (Connell, 2011).It provides an opportunity for the patients who wanted to receive a quality healthcare in anywhere of the world within their personal budgets (Cortez, 2013).The rise in market value for medical tourism can be due to increased healthcare costs in well developed countries, cross border training and widespread air travel (Connell, 2011).For the patients who are travelling to developing countries for medical services from high industrialised nations can be primarily because of attractive low cost (Business Insider, 2014).Mc Kinsey & Company estimated the gross revenues of medical tourism in the world had reached more than $120 billion in 2014 from $80 billion in 2012[See figure 1]
Figure 1 . Medical Tourism Industry Revenues World Wide Analysis (billions of U.S. dollars)
Source (Mc Kinsey & company, 2014)
The popular hospitals which are known for their international standards are in Bumrungrad in Thailand and Apollo and Fortis hospitals in India, report revenue growth of about 20 percent to 25 percent annually (Mc Kinsey & company, 2014).McKinsey & Company report estimates that Indian medical tourism alone will grow to $7.3 billion by 2016 and Singapore hopes to treat 1 million foreign patients that year (McKinsey and the Confederation of Indian Industry, 2014). Currently the medical tourism is expanding worldwide, it involves about 50 countries in all continents and Asian countries like India, Singapore and Thailand are clearly in the lead (Horowitz, 2014).These three countries, which combined comprised about 90% of the medical tourism market share in Asia in 2014, have invested heavily in their health-care infrastructures to meet the increased demand for accredited medical care through first-class facilities, medical tourism is an opportunity for patients to travel for medical care and take advantage of reduced costs and wait times (health, 2014).The medical tourism is divided into three categories according to world health organisation : outbound implies travelling from India to other countries, inbound means travelling to India from other countries and intra-bound implies within the home country (domestic).
Table 1: Types of medical tourism (Chinai, 2013)
OUTBOUND MEDICAL TOURISM (World Health Organization, 2013)
Patients travelling from home country to
other countries to receive medical care (World Health Organization, 2013).
INBOUND MEDICAL TOURISM (World Health Organization, 2013)
Patients from other countries travelling to
India to receive medical care (World Health Organization, 2013)
INTRABOUND MEDICAL TOURISM
(DOMESTIC) (World Health Organization, 2013)
Patients travelling within home country
to receive medical care outside their
geographic area, typically to a Centre of
Excellence in another state/region (World Health Organization, 2013)
Source adopted from. Bulletin of the World Health Organization. 85 (3), p161- 244.
1.2. MEDICAL TOURISM SCENARIO IN INDIA
India has been the most attractive destination for the visitors around the globe (Kaur, 2014). This is because of the heritage attraction of the country and growing medical care facilities in India (Cati, 2014).According to the estimation of the Price Water House Coopers projects the Indian Health care sector can be worth about $90 billion by 2016 (Cohen, 2013).Medical tourism is a developing concept and this sector is growing rapidly in countries like India which stands second in world’s healthcare economical standards (Kaur, 2014).Indian Brand equity Foundation (IBEF) suggests that the Indian health care sector can be expected to become a US$ 280 billion industry by 2020 with an expenditure to grow 14 percent annually (Indian Institute of Tourism and Travel Management, 2011).India offers other services like yoga, meditation and Ayurveda which are equivalently becoming popular as a non- surgical treatment for various ailments among the foreign patients (Kaur, 2014).Health care turned out to be the prominent and largest service sector with presumed GDP to be spent of 12 percent by 2016 from 8 percent in 2011 (Deloitte Development LLC , 2015). Table 2 depicts the percentage of foreign tourist arrivals (FTAs) in India for medical treatment from the year 2011 to 2014 which focuses primarily on Middle East, Japan, ASEAN (Association of South east Asian Nations), USA, Australia and then comes with Nigerian and African countries due to the affordable and inexpensive costs of medical services when compared with costs in United States it is approximately 30% to 70% lower in price, and also the proportion of the population older than 60 years compared to the total population is increasing finely(the Richest, 2015) .The highest percentage of FTA’s for medical treatment to India was in year 2012 followed by 2014 (Indian Institute of Tourism and Travel Management (IITTM), 2014).
Table 2: Foreign Tourists Arrivals in India for medical treatment (2011-2014)
Year No. FTAs in India
Percentage of FTA for
Estimated Revenue(dollars) Medical tourists by nationality
2011 5167699 2.2 69,690 1. Middle East.
3.ASEAN(Association of south east Asian Nations)
2012 5775692 2.7 78740 1. Middle East.
3.ASEAN(Association of south east Asian Nations)
2013 6309222 2.6 87560 1. Japan
2014 6577745 3.0 95,509-1,21090 1.Nigeria
3. Middle East.
Source adopted from India Tourism Statistics 2011, 2012, 2013 and 2014, Available at http://www.tourism.gov.in (Medical Tourism Association, 2014).
The following graph represents the growth of medical tourists and future prediction can have a substantial increase from 13% to 24 %( 2013-2020) from South Indian management report 2014 from
Figure 2. Number of Medical Tourists Arrivals and Future Forecast in India
Source (Medical Tourism Association, 2014) South Indian Management Report 2014.
Figure 3 depicts the citizens of other countries visiting India had tremendously increased who are arriving mainly from Maldives (59% of 50,000 visitors), Afghanistan(16% of 95000 visitors), Oman (11% of 500000 visitors) and UAE with 8% of 41000 visitors (Saxena, 2014).
Figure 3 Medical Tourists Arrivals in India Country wise Statistics
Source adopted from (Saxena, 2014) Renub research of Medical Tourism Arrivals to India
1.3.MEDICAL TOURISM IN HYDERABAD
Medical tourism at hospitals in Hyderabad combines care for health with international tourism. The primary reason behind the attainment of popularity is better healthcare services at an affordable budget (Snyder, 2014).Hospitals in Hyderabad can provide internationally accredited medical facilities using the latest technologies. The international patients can have significant cost savings compared to domestic private healthcare (US/Middle east countries).Besides medical treatment costs in India, especially India are lower by at least 60-80% when compared to similar procedures in North America and the UK (Goutam, 2013a).Below table represents the cost effectiveness for attracting more foreigners for complicated procedures in healthcare adopted from (Mckinsey, 2014).The following figure illustrates the percentage of Foreign patients arrivals to Hyderabad compared with other states which has the highest rate of 45% and then following by Chennai with 43%.(Ministry of Tourism, Indian tourism Statistics 2014).
Figure-4 Graph indicating the percentage of FTA’s in the states of India
(Source adopted from (Ministry of HomeAffairs, Government of India, 2014))
Table 3. Cost comparison: Procedure charges in USA and Hyderabad (Mckinsey, 2014)
Procedure United States(in dollars) Hyderabad(in dollars)
Bone Marrow Transplant 2,50,000 69,000
Liver Transplant 3,00,000 69,000
Heart Surgery 30,000 8,000
Orthopaedic surgery 20,000 6,000
(Source adopted from Health care India by Mc Kinsey, 2014)
1.3.1. Role of Government in Promoting Medical Tourism in India and Hyderabad
Indian Government has undertaken various measures to promote India as a global health destination. The Indian Ministry of Tourism (MoT) has started a new category of visas for medical tourists called the ‘M’ or medical visas (Peacock, 2014). The Union MoT has also included Medical Tourism under the Marketing Development Assistance (MDA) Scheme. The MoT provides financial assistance under MDA to the following approved Medical Tourism Service Providers: (Sharma, 2013)
‘ Representatives of Hospitals accredited by Joint Commission International (JCI) and the National Accreditation Board of Hospitals and Healthcare Services (NABH).
‘ Medical Tourism facilitators (travel agents/tour operators) approved by Ministry of medical Tourism of India (Sharma, 2013)
1.4 Overall Research Aims and Objectives
‘ The Overall aim of the empirical research study is designed to determine the effective factors for attracting medical tourism to India in a variety of aspect such as proper function of related organization, proper marketing Mix according to special circumstances of India by concentrating on the factors such as quality of health care, safety and follow-up after and before the treatment offered. To gain much deeper understanding , the two main aspects of consumer experience ,’quality of care’ and ‘identification of gaps in the services with respect to the views of customer expectations’ are to be critically analysed. At the end of the study, for the formulation of effective framework make recommendations to address concerns of medical tourists (on the basis of data collected).Furthermore, in the context of customer satisfaction, the main objectives of the research study are :
Research Objective One – To critically analyse the key factors involved in patient satisfaction levels for their visits to the multi speciality Hospitals.
Research Objective Two – To identify the gaps in service (as experienced by tourists against expectations) which includes cost of treatment, Quality and Waiting time.
Research Objective Three – To critically evaluate the bottle necks of the medical tourism industry in Hyderabad with respect to Multi speciality hospitals that includes International accreditation of the hospitals in order to target US and UK which appear to be niche markets, Language related problems to non-English speaking patients, issues related to food and accommodation.
Research Objective Four – To formulate a framework for the kind of medical treatment that is mostly preferred by the Foreign people to take in India.
1.5. Dissertation Outline
This sensible research was conducted with a series of various stages. However, the main approach of the project is presented in the form of subsequent phases. To add up, these subsequent phases are connected to the overall aims and objectives of this research study (Douglas, 2011).Table 4 depicts the contents of the chapters and gives an overview of the main structure of this dissertation.
Table 4 : Overview and structure of the Dissertation
Chapters of Research Critical Analysis of each Chapter
Source adopted from (Douglas, 2011) and compiled by the researcher.
2. CHAPTER TWO : LITERATURE REVIEW
This part of the dissertation will explain the critical review of the literature with a comprehensive look on the key issues encompassing the medical tourism experience with the Foreign patients visiting India to get the treatment and services by exploring their decision making process and experiential values specially for Quality of the treatment, Clinical infrastructure of the hospitals(Such as Accreditation), Waiting time and connectivity from the home country. The study in the literature review emphasises on the objective one and gives a theoretical view on the objectives two and three.
2.2.Research Background on Medical tourism
Medical tourism or medical travel is the act of travelling to other countries to obtain medical, dental, and surgical care. Goodrich & Goodrich (2011:217) defined health-care tourism as ‘the attempt or the effort which is a part of a tourist facility or destination to attract tourists by deliberately promoting its health-care services and prerequisites, in corporation to its regular tourist provisions’ (Goodrich, 2011).
2.2.2.Emergence of medical tourism globally and in India
The history of medical tourism asserted that during the ancient times, people travelled round the world for medical purposes (Connell, 2011).The concept of Medical Tourism had been traced back to the Early Romans and Egyptians who used hot springs and baths to improve their health from illness (Leahy, 2010). During 4000 BC, the Sumerians formulated the earliest known healthcare complexes that were incorporated around hot springs and baths. These medical care amenities encompassed with magnificent elevated temples with flowing hot water pools. Prior research conducted by (Connell, 2011) stated that the history of medical tourism dates back to its first registered case when the Egyptian settlers travelled from the Mediterranean to a small territory in the Saronic Gulf known as Epidauria (Connell, 2011).This small territory was the sanctuary of Sekhmet which was considered to be sacred place and known as the healing God (Cooperman.S, 2011).Thus, it is evident from the ancient history that Epidauria is the original destination for medical tourism.
Asia was also been in the history for the evidence of medical tourism with traces found in India and Japan (de Arellano, 2011). Yoga and Ayurvedic medicine were most popular in India as early as 5000 years ago, where in constant flow of medical voyagers and spiritual students flocked to India to seek the benefits of these alternative-healing methods (Frochot, 2010).Japan’s affluence of mineral springs known as onsen have also been favourite health retreats for therapeutic properties for centuries. These springs are known for healing wounds (Connell, 2011).In the mid16th century, the wealthy and the noble of Europe rediscovered Roman baths and flocked to tourist towns with spas like St. Mortiz, Ville d’Eaux (Frochot, 2010), Baden Baden, Aachen and Bath in England (Al-Sabbahy, 2012).
Bath or Aquae Sulis enjoyed royal patronage and was famous throughout the known world which resulted to be the centre of fashionable wellness and became a playground for the rich and famous (Al-Sabbahy, 2012).According to the research conducted by Ajzen (2009), reveals that the England during 18th century saw a boom of dedicated spa towns and sanatoriums catering to those who could afford to make the trip (Ajzen, 2009). These places were almost always centered on natural hot springs, as the carbonated water is assumed to treat all kinds of diseases, from gout to bronchitis (Alleman, 2010).
With the increase of the cost of healthcare services in the 1980sand 1990s, American patients started considering offshore alternatives, in the same way as dental care services in Central America. Whilst US doctors were alarmed at the idea of seeking medical care in foreign hospitals amid these periods, Cuba started programs attracting foreigners for eye surgeries, heart and cosmetic procedures (Cortez, 2013).
The medical tourism industry has continued to emerge in recent years in which surgical procedures in developing countries were well known as the medical service costs are charged at significantly cheaper price than in the patient’s country of origin (Glinos, 2013).Americans and the Europeans for instance frequently travel to Thailand and India for heart and knee replacement surgery which costs only a fraction of the same medical treatment in the Europe and United States (Cohen, 2013).
According to World Health Organisation report in 2013 (World Health Organization, 2013), the Joint Commission International was formed to check and investigate international healthcare facilities for conformance to international standards due to the emergence of health providers around the world (Hall, 2011). Consequently, countries like India, Singapore and Thailand became legitimate medical tourism destinations due to JCI accreditation which is considered as the gold standard in global health care . Based on the report (World Health Organization, 2013),the medical tourism continued its massive growth with as many as 185,000 US,UK Citizens will be travelling to destinations in Asia and Latin America in the end of 2015. As per the Mc Kinsey and Company report 2015,Worldwide medical tourists continue to travel abroad to get medical treatment overseas due to the economic savings advantage and currently, several foreign tourists combine their medical treatment with a relaxing holiday vacation (Brotman, 2013), (Mc Kinsey& Company, 2015). As globalization in health care market continue to grow, the medical tourism trend is set to be a booming industry (Peacock, 2014).
2.2.3.Medical Tourism in Various Countries Worldwide
Globalisation has a tremendous impact on the healthcare market sector (Lunt, 2010).With the persistent increase of the medical care costs and long waiting periods in the USA, Europe and other affluent nations (Kubendran, 2012) in the world, the development of medical tourism has created scope for the patients to obtain medical care facilities outside their home country (Chinai, 2013).
The following gives an outline on the background, growth and current trends of
medical tourism in various countries around the globe ( New Delhi: RNCOS Industry, 2014)
1. United States of America
The United States of America is considered to have one of the most technologically advanced medical health care. The American healthcare system is the most expensive system in the world (Marlowe, 2011). The Deloitte Centre for health solutions report 2015 states that the inbound medical tourism to the United States is approximately $5 billion or 400,000 patients annually (Deloitte Development LLC, 2015).The international patients come from the countries like North America, the Caribbean, Europe and the Middle East(ASEAN) (Mc Kinsey& Company, 2015). These patients are wealthy people traveling to the United States in search for high technology medical care (Deloitte Development LLC, 2015). An article in (Forbes, 2014)mentioned that the availability of advanced medical technology and sophisticated training of physicians is the driving motivators for growth of foreigners traveling to the United States for health care.
The prolonged U.S. recession has had a predominant impact on patients’ ability to afford medical care (Deloitte Development LLC, 2015).Since travelling abroad for health care can be significantly less costly than health care obtained in the United States, more and more people are considering to “offshore’ their medical needs (Andrea, 2015). Patients Beyond Borders, a medical research group that surveys foreign hospitals, had identified 20 foreign medical sites which it believes provide value and quality for foreign patients travelling other countries for health care (Deloitte Development LLC , 2015)
Table 5: Hospitals for Medical Travellers (Deloitte Development LLC , 2015)
(Deloitte Development LLC, 2015)Country
Medical Institution with International Standards (Deloitte Development LLC, 2015)
Mexico (Deloitte Development LLC , 2015)
Christus Muguerza Alta Especialidad Hospital, Monterrey (Deloitte Development LLC, 2015).
Costa Rica (Deloitte Development LLC, 2015)
Clinica Biblica Hospital, San Jose (Deloitte Development LLC, 2015).
Brazil (Deloitte Development LLC , 2015)
‘ Hospital do Coracao, Sao Paulo (Deloitte Development LLC, 2015).
‘ Hospital Israelita Albert Einstein, Sao Paulo (Deloitte Development LLC, 2015).
‘ Hospital Samaritano, Sao Paulo (Deloitte Development LLC, 2015).
India (Deloitte Development LLC , 2015)
‘ Asian Heart Institute, Bombay (Deloitte Development LLC, 2015).
‘ Apollo Hospitals, Hyderabad (Deloitte Development LLC, 2015).
‘ Indraprastha Apollo Hospital, Delhi (Deloitte Development LLC, 2015).
‘ Shroff Eye Hospital,Bombay (Deloitte Development LLC, 2015).
‘ Wockhardt Hospital, Bombay (Deloitte Development LLC, 2015).
Thailand (Deloitte Development LLC, 2015)
‘ Bangkok Hospital Medical Center, Health clinic in Bangkok (Deloitte Development LLC, 2015).
‘ Bumrungrad International Hospital, Bangkok (Deloitte Development LLC, 2015).
‘ Samitivej Sukhumvit Hospital, Bangkok (Deloitte Development LLC, 2015).
Singapore (Deloitte Development LLC, 2015)
‘ Alexandra Hospital, Singapore (Deloitte Development LLC, 2015).
‘ Changi General Hospital, Singapore (Deloitte Development LLC, 2015).
‘ Johns Hopkins Singapore International Medical Centre, Singapore (Deloitte Development LLC, 2015).
‘ KK Women’s and Children’s Hospital (Deloitte Development LLC, 2015).
‘ Mount Elizabeth Hospital (Deloitte Development LLC, 2015).
Source adopted (Deloitte Development LLC, 2015)World Report. Available
at: http://www.deloitte.com/healthcarenews.com,accessed on march 30,2015.
Rising healthcare costs in the United States will continue to drive American patients to seek treatment on a global basis (Smith, 2014).Deloitte Centre for Health Solutions projected that U.S. outbound medical tourism could reach upwards of 1.6 million patients by the end 2015, with sustainable annual growth of 35 percent (Saxena, 2014). Concurrently, U.S. inbound medical tourism will see relatively slow growth of report up to 561,000 travelers by 2017 (Deloitte Development LLC, 2015). Increased access to low-cost global transportation such as major air carriers offering special off-peak pricing will enhance access to medical tourism opportunities for U.S. outbound patients (Deloitte Development LLC, 2015).
In recent years, Mexico has been the popular medical destination for the Americans (Cortez, 2013).The proximity to the United States and the relatively low travel costs, have been attracting Americans and Canadians. Stomach surgery, eye exams and routine checkups are among the major services that Americans are seeking in Mexico (Hansen, 2013).However, orthopaedic procedures are the popular treatment for U.S. health consumers (Glinos, 2013). Mexican dentists often charge one-fifth to one-fourth of US prices (Roig-Franzia, 2012).According to the World Health Organization 2014, Mexican hospitals are similar in quality and care to those in the United States (The World Health Organization, 2014). Based from an article in (Health-Tourism of Mexico , 2014), the prices of medical procedures in Mexico can be between 50 percent to 75 percent lower than that of the US average costs (Balaji, 2014). With state-of-the-art facilities comparable to American hospitals, Mexico has become one of the prominent destinations for US medical tourists (Glinos, 2013).
Medical Tourism is a growing segment in India (Alleman, 2010). It is estimated that over 180,000 patients visited India’s medical centres during just the first eight months of the 2014 fiscal year (Mckinsey, 2014).The country has already established a reputation in cardiac care, cosmetic surgery, joint replacement, and dentistry, and is actively working to expand into other areas that may attract well-heeled foreigners and the 12 million Indian expatriates who can combine regular visits to India with non-emergency medical procedures (Wolfe, 2012)
According to an editorial in Indian Healthcare. in 2015 (Healthbase.com, 2015). India’s medical tourism sector is expected to grow at an annual rate of 30 percent to become a Rs 9,500-crore industry by 2015 as foreign arrivals will increase to avail treatment at lower costs (IndianHealthcare.in , 2015). India is giving Thailand a stiff competition in healthcare services for overseas patients with cost of surgery lower by over 30% and the cheapest in entire Southeast Asia (Ministry of Indian Tourism, 2015). A heart-valve replacement costs about 0.3 million dollar in the US, in India it can be done in 10,200 dollar, which also includes to and fr airfare and a vacation package (Deloitte Development LLC , 2015). Indian traditional treatments like Ayurvedic Therapies and much more, practically covers every aspect of medicine combining modern treatments with traditional experience (Indian Institute of Tourism and Travel Management (IITTM), 2014). India delivers premier medical facilities with hospitals and specialized multi-specialty health care centres providing their expertise in fields such as cosmetic surgery, dental care services, heart surgeries and coronary bypass grafting (Cati, 2014).
Singapore received 410,000 foreign patients in 2014 with nearly half of them coming from the Middle East (Ministry of Planning and International Cooperation,Jordan National Competitiveness Team, 2015). Patients come from neighbouring countries, such as Indonesia and Malaysia where as in patient arrivals from South Asia, Indochina and the Middle East are growing (Nakra, 2014). Singapore is attracting patients at the high end of the market for advanced treatments like cardiovascular and neurological surgeries along with the advanced stem cell therapy procedures (Pocock, 2014).The country is well known for having advanced JCI accredited hospitals and health centres like Alexandra Hospital, Singapore , Johns Hopkins Singapore International Medical Centre, Singapore (Andrea, 2015). Hence, a wide range of medical procedure is available in Singapore which includes cardiology, ophthalmology, and oncology East (Ministry of Planning and International Cooperation,Jordan National Competitiveness Team, 2015). Due to the relatively affordable medical treatment cost, patients from United States and the United Kingdom are also starting to choose Singapore as their medical travel destination. By 2016, the Singaporean government aims to attract one million international patients annually (Ministry of Planning and International Cooperation,Jordan National Competitiveness Team, 2015).
Malaysia is one of the primary destinations of medical travellers in the ASEAN region (Shaywitz, 2012). Based from an article on Business Wire (Bloomberg Businessweek, 2014), Malaysia received around 75% of medical tourists from the ASEAN region, followed by Japan and Europe at 3% each, India at 2% and others at 17% in 2014 (Birschel, 2014). Most international patients come from neighbouring countries with less developed medical infrastructure such as Indonesia and other developed countries from the West (Sullivan, 2013). Due to the past political instability in Thailand as well as Singapore’s high exchange rate, most of the international medical tourists come from neighbouring countries in Asia (Kubendran, 2012). The Malaysian government is primarily focused on the continuous promotion of medical tourism in the country (Bloomberg Businessweek, 2014). It has extended the visa period for health tourists from one month to six months due to increase in demand of medical services (Hansen, 2013). Major hospitals in Malaysia are targeting new markets such as Vietnam and Cambodia (Anonymous a, 2014).According from theoutpatient sourcing article on Business Wire (Bloomberg Businessweek, 2014), it is expected that the revenues from medical tourism will grow at a Compound Annual Growth Rate (CAGR) of around 37% during the forecasted period of 2012 – 2016.
2.2.4.The Global The Global Health Care Marketplace
There are several factors that lead to the continuous increase of global medical tourism which includes expensive health care cost, long waiting time for some surgical treatments, increase quality of care from foreign countries, and affordability of travelling abroad (Cohen, 2013). According to research conducted by (Connell, 2011)states that, as the health care expenses have expanded massively, patients in the developed world are searching overseas for medical treatment purposes. The medical tourism marketplace consists of a growing number of countries competing for patients by offering a wide variety of medical, surgical, and dental services (Horowitz, 2014).
Consumers are faced with escalating healthcare costs in the United States and are forced to comparison shop in order to seek alternative sources for treatment (Smith, 2014).Several affluent medical travellers visit the developing countries such as the United States, Australia primarily because of high medical technology and well renowned physicians (Cooperman.S, 2011). Middle class patients choose to travel to third world countries for medical treatment because of the benefit of having huge savings. According to (Horowitz, 2014), the following listed country destinations are the most frequently identified countries in by the survey analysis conducted by World Health Organisation 2014 on the Medical Tourist Destinations.
Table 6: Medical Tourism Destinations (The World Health Organization, 2014)
Asia/Middle East The Americas Europe Africa Other
‘ South Korea
‘ United Arab Emirates ‘ Argentina
States ‘ Belgium
‘ Czech Republic
‘ Spain ‘ South Africa
‘ Tunisia ‘ Australia
Source: Horowitz, M.D., Rosensweig, & Jones (2014). Medical Tourism: Globalization
of the Healthcare Marketplace.
Medical tourists are presently travelling to faraway countries for reconstructive surgery, dental procedures, weight loss surgery, artificial insemination, ophthalmologic care, orthopaedic replacement surgery, cardio vascular surgery, organ and cellular transplantation, sexual reassignment procedures, and even executive health evaluations (Horowitz, 2014).European countries like UK, Germany waiting times for fertility treatments may be very long, and at an important period in couples’ lives, hence many ‘fertility tourists’ have gone overseas (Graham, 2014). According to (Horowitz, 2014),the table below depicts the most frequently identified procedures in according to the world health organisation and Deloitte development report 2015,world wide.
Table 7: Procedures for Which Patients Pursue Medical Tourism (The World Health Organization, 2014), (Deloitte Development LLC , 2015),
Procedure ‘ Breast augmentation/mastopexy/breast reduction (Deloitte Development LLC , 2015)
‘ Facelift/blepharoplasty (Deloitte Development LLC, 2015)
‘ Liposuction/body contouring (Deloitte Development LLC , 2015)
Dentistry (Deloitte Development LLC, 2015)
‘ Cosmetic dentistry (Deloitte Development LLC , 2015)
‘ Dental reconstruction/ Prosthodontics (Deloitte Development LLC, 2015)
Cardiology and Cardiac Surgery (Deloitte Development LLC, 2015)
‘ Coronary artery bypass (Deloitte Development LLC, 2015)
‘ Cardiac valve replacement/reconstruction (Deloitte Development LLC, 2015)
‘ Percutaneous coronary angioplasty/stunting (Deloitte Development LLC, 2015)
‘ Stem cell therapy for heart failure (Deloitte Development LLC, 2015)
Orthopaedic Surgery and
Spine Surgery (Deloitte Development LLC, 2015)
‘ Hip replacement/resurfacing (Deloitte Development LLC, 2015)
‘ Total Knee replacement (Deloitte Development LLC , 2015)
‘ Arthroscopy/joint reconstruction (Deloitte Development LLC, 2015)
‘ Laminectomy/spinal decompression (Deloitte Development LLC , 2015)
‘ Disk space reconstruction/disk replacement (Deloitte Development LLC , 2015)
Bariatric Surgery (Deloitte Development LLC , 2015)
‘ Gastric bypass (Deloitte Development LLC, 2015)
‘ Laparoscopic adjustable gastric banding (Lap-Band; Inamed/ Allergan, Inc.; Irvine, California) (Deloitte Development LLC , 2015)
‘ Body contouring subsequent to massive weight loss (Deloitte Development LLC , 2015)
Reproductive System (Deloitte Development LLC, 2015)
‘ In vitro fertilization (Deloitte Development LLC , 2015)
‘ Hysterectomy (Deloitte Development LLC, 2015)
‘ Prostatectomy/transurethral resection (Deloitte Development LLC, 2015)
‘ Gender reassignment procedures (Deloitte Development LLC, 2015)
Organ and Tissue Transplantation (Deloitte Development LLC, 2015)
‘ Solid organ transplantation (Deloitte Development LLC, 2015)
‘ Renal (Deloitte Development LLC, 2015)
‘ Hepatic (Deloitte Development LLC , 2015)
‘ Bone marrow transplantation (Deloitte Development LLC, 2015)
‘ Stem cell therapy (Deloitte Development LLC , 2015)
‘ Cardiac arrest
‘ Neurologic diseases (Deloitte Development LLC , 2015)
Other Services (Deloitte Development LLC , 2015)
‘ LASIK eye surgery (Deloitte Development LLC, 2015)
‘ General medical evaluation/check up Wide range of diagnostic studies (Deloitte Development LLC , 2015)
Source adopted from (The World Health Organization, 2014) written by Horowitz, M.D., Rosensweig, & Jones (2014).
A face-lift in Costa Rica costs about a third of that in the United States and rather less in South Africa (Connell, 2011). Common surgeries such as knee replacements range in cost from $65,000 – $550,000 in the U.S., yet can be performed in Costa Rica for about $12,000 (Koster, 2014).Furthermore, a bypass operation in India is about a sixth of the cost in Malaysia (Cati, 2014).Given by the huge medical treatment cost differentiation to various medical country destinations worldwide, the desire to pursue such health care avenues is possibly high. With the rapid development of modern age technology in several emerging destinations, low-cost medical services are therefore one of the primary motivations for several international patients to seek out health care to foreign countries (Hansen, 2013). It should not be surprising that hospitals in Asia Pacific are appealing to the American public as low-cost medical providers that offer quality care at unparalleled fees (Marlowe, 2011).
Furthermore, European patients favour India, Thailand and Malaysia (Connell, 2011).Singapore, Malaysia, India, Thailand and the Philippines are some of the major destinations in the Asian medical tourism market industry (Keckley, 2010). India can offer liposuction and breast enhancement surgery for a fifth of the rate this would cost in Germany; hence it has focused on this particular European market (Connell, 2011).And so, India is more popular among Western European medical travellers for cosmetic surgery (Connell, 2011). On the other hand, Singapore has sought to compete on quality rather than price and stresses its superior technology (Connell, 2011).Singapore and India specialize in complex procedures with India having a cost advantage and Singapore a technology advantage (Anonymous a, 2014).
2.2.5.Top Reasons for which Medical Tourism is Popular
The medical tourism trend has been made famous for the Americans, Canadians, British and other patients in developing economies who travel abroad in search for low-cost high quality medical treatments (Al-Sabbahy, 2012). The following are the top reasons why medical travellers choose to take advantage of this growing industry.
Cheaper health care cost is one of the key motivators that patients travel abroad for medical treatment purposes. As health care expenses escalates, patients in the developed world are looking abroad for medical services (Connell, 2011). Health care services include a number of countries promising ‘first-class services at third-world prices’ (Wolfe, 2012).For instance, a cardiac surgery in a US hospital can easily cost more than $150,000 where as in Hospitals of India and Thailand can offer comparable quality care for $50,000 (Deloitte Development LLC, 2015). This cost difference can easily cover the travel expenses of the patient and immediate family and still allow for enormous savings (Baker, 2015).According to (Deloitte Development LLC, 2015)(Consumers in Search of Value), the following is the cost of medical procedures in the North America(USA) compared to the medical treatment cost in different rising destinations in Asia, for example India, Thailand, Singapore and Malaysia.
Table 8 : Comparing Costs of Medical Procedures with USA to the Asian countries India, Thailand and Singapore (Deloitte Development LLC, 2015)
Major medical procedures w/average total medical/hospital cost in a western-level hospital
$U.S. Costs from ‘Patient Beyond Border’ by Josef Woodman, 2015. Details below
Procedure Countries Cost as a % to U.S.
U.S. India Thailand Singapore Malaysia India Thailand Singapore Malaysia
Heart By pass 1,35,000 11,000 12,000 19,500 10,000 9% 9% 15% 8%
Heart Valve Replacement 170,000 10,000 11,000 13,500 10,000 7% 7% 9% 7%
Angioplasty 65000 12000 14000 14000 12000 20% 24% 24% 21%
Hip Replacement 44,000 9,000 11,000 11,000 10,000 22% 29% 29% 24%
Hysterectomy 21,000 3500 5,500 6,500 3500 16% 25/% 31% 16%
Knee Replacement 50000 9500 11000 14000 9000 20% 26% 34% 20%
Spinal Fusion 68000 6000 8000 10000 6500 10% 11% 16% 12%
Source compiled from “Patient Beyond Border’ by Josef Woodman,2015. The table used from this book available from ABILITY Magazine at http://www.abilitymagazine.com,Note: Costs are for surgery, including hospital stay only. Costs assumptions taken for India (21%); Malaysia (26%); Thailand (33%); Singapore(38%).
Source adopted from (Deloitte Development LLC , 2015), Medical Tourism: Consumers in Search of Value. accessed on 30 March,2015.
Thailand, a major competitor of India offers the lowest priced option of sufficient quality for Westerners (Andrea, 2015). The major purpose is expenses saving, with treatment in other countries running about one-tenth of typical U.S. expenses because lower costs for wages, administration and insurance services(Birschel, 2014).
‘ Access to use the innovative medical technology
The primary reasons why a citizen of one country might travel to another country are always the same: cost and access (Connell, 2011). Inaccessibility, either on the grounds that the technology is not feasible, is restricted or illicit, or the waiting time is too long in the home country, can lead to medical tourism (Patsner, 2013). Stem cell-based therapies are the most common treatments that are not accessible to Americans, regularly in the view restrictive government regulations or acts (Runckel, 2012). Therefore, medical tourists also travel to offshore medical destinations where they have procedures that are not extensively available in their own country of origin.
‘ No Wait-lists
With healthcare costs rising in the United States and increased willingness to seek private care in countries with government-run systems in order to avoid waits, motivation for medical tourism is increasing (Patsner, 2013).Another primary reason in choosing to offshore health care to foreign countries is to circumvent delays associated with long waiting lists (Ajzen, 2009). In state-run healthcare programs like those in Canada or the UK countries, waiting lists can stretch out to more than a year for crucial surgery and past three for redundant surgery (Runckel, 2012).Hence, patients seek medical treatments abroad for a faster response to their medical needs.
‘ Travel Opportunity
Medical tourism has grown in a number of countries such as India, Singapore, and Thailand, many of which have deliberately linked medical care to tourism, and thus boost the attractions of nearby beaches (Connell, 2011).A number of popular sun-sea-sand tourism destinations have, in the last decades, attempted to diversify into health tourism in order to achieve a more balanced, sustainable approach to tourism development (Ariwa, 2010). The opportunity to travel to exotic destinations is an additional benefit for several medical travellers. For instance, South Africa offers safari medical tourist packages, where a family visits for treatment followed by a wildlife safari (Runckel, 2012).In India, Hyderabad medical travellers that undergone non-major surgeries can enjoy a relaxing recovery in a beach resort.
2.2.6.Considerations, Risks and Opportunities of Medical Tourism
Medical tourism is not without challenges and pitfalls due to increase in competition among the developing nations (Andrea, 2015). Common concerns are the quality of care, cultural and language issues, postsurgical follow-up and extended coverage for travel and accommodations (Birschel, 2014). With the increasing medical tourism trend, many health care tourists who are willing to have medical procedures abroad are faced with critical concerns regarding quality and safety. The biggest hurdle that medical tourism has had to face and continues to face, is the challenge of convincing distant potential visitors that medical care in relatively poor countries is comparable with that available at home (Ariwa, 2010).
Therefore, a public perception of ‘you get what you pay for’ might signify cheap medical care to be as inferior quality (Connell, 2011). In order to address and meet the required quality standards, a non-profit organization, Joint Commission International (JCI) certifies hospitals around the world in providing health care services (World Health Organization, 2013). JCI may provide a useful point of reference for patients selecting offshore medical facilities (Horowitz, 2013).Hospitals worldwide that are authorised by the Joint Commission International (JCI) and/or the International Organization of Standardization consistently improve patient safety by providing proficient care of the most astounding quality and value. Health tourism presents concerns and dangers along with opportunities.
Its universal development has been encouraged by the ubiquity of the World Wide Web. The Internet (computers and telecommunication) makes it feasible for patients to communicate internationally on healthcare service issues, and they are more taught about wellness, illness prevention, and therapeutic medicines (Gremillion, 2011).Nowadays, international patients search the web and read patient blogs in order to reassure health care quality and safety before travelling abroad. In some destinations, including Hungary and Mauritius, medical tourism possibilities are advertised in in-flight magazines and standard government tourist publications on the assumption that tourists might avail themselves of small-scale procedures such as dentistry during otherwise standard tourist visits (Connell, 2011).
American patients are the recipients of aggressive marketing campaigns by many foreign hospitals touting their low-cost services, coupled with the opportunity for an exotic vacation (Smith, 2014).Although the primary motivation for medical travellers is inexpensive medical treatment, taking a holiday vacation after a medical procedure is an added benefit to many individuals (Cortez, 2013). Global marketing techniques are on the rise, causing many of worldwide hospitals to partner with travel agencies to further promote the benefits of a complete turnkey package of medical tourism services (Smith, 2014).
2.3. Medical Tourism in India with special focus on Hyderabad
In accordance with World Health Organization’s (WHO), Indian health care system is rated 112th in the world. India became known as a destination for medical tourism as early as the 1970s because it specialized in Cardiac and liver transplants operations, and later moved into cosmetic and Neuro surgeries (Connell, 2011).In Malaysia, Thailand and India alone, an estimated 5 million medical travellers visited in 2013 to till February 2015, earning these countries over $7.8 billion in treatment costs (IndianHealthcare.in , 2015). Patients that come to India for medical needs mainly come from Japan, USA, South Asia, European countries like UK, Germany, Middle East and ASEAN countries due to the affordable costs and quality standards and geographically easy to access from any part of the world (Andrea, 2015). In compliance with Pocock and Phua, the following table 9, illustrates a comparative analysis of health services between Malaysia and Thailand and India.
Table 9: Export of Health Services (Pocock, 2014)
Country Estimated earnings
No. foreign patients
Origin of patients (in order of volume)
India(2014) (Pocock, 2014)
Rupees 40 billion (US$ 6.4 billion)
South Asia, UK,
ASEAN countries Cardiac and Neurosurgery,
Liver transplants, cosmetic
Malaysia (2014) (Pocock, 2014)
MYR (US$88 millions) 342 489 Indonesia,
Singapore, Japan, Europe Cardiac and cosmetic
Thailand(2014) (Pocock, 2014)
Baht 36 billion
(US$ 1.1 billion) 571 000 Indonesia,
Malaysia, Middle East Cosmetic and sex
Source adopted from Pocock, N. and Phua, K. (2014). Medical tourism and policy implications for health systems: a conceptual framework from a comparative study of Thailand, India and Malaysia.
Bindi Varghese (2014) focused on medical tourism growth in Hyderabad, which has become a major destination in India compared with other states and has increased the Asian medical tourism market. Thailand has become more popular for cosmetic surgery among the Western European medical tourists, while India, Hyderabad had been specialised in the complex procedures having cost advantage and Singapore known for its technology advantage (Varghese, 2014).
Carlson G., and Greeley .H(2014), place emphasis on the issues of macro environments that effects the relationships that are existing between the international patients and hospital staff.Cost variation, Communication barriers,Complexity of the procedures and extent of follow up care after care needed after leaving the country where the treatment was received (Carlson .G., 2014).
Horowitz, Michael, D., (2013) and Rosensweig, Jeffrey, A (2013) intensifies on the medical tourists travel to India for surgical purposes which enhances the changing scenario for medical tourism that involved a traditional form of international health care at which patients travel from less developed nations with low GDP to developing countries for advanced medical treatment (Horowitz, 2013). There are potentially two categories: working class adults who require elective surgery with no health insurance and likely to have procedures that are not covered under health insurance such as gender reassignment operations, or fertility treatment (Horowitz, 2013).The key issue to be considered here is that a faraway country provides privacy and confidentiality for patients undergoing plastic surgery or sex-change procedures (Horowitz, 2013).
Although the medical tourism industry is growing rapidly and has captured international attention because of its seemingly high profit potential ,little academic research has been carried out on medical tourism (Heung, 2010).With the increasing number of foreign medical tourists as well as the importance of delivering high quality service from both a consumer point of view and a competitive perspective (Jyothis, 2009; Lee, 2009; Mueller, 2010), it is prudent to investigate the overseas medical tourist’s expectations and perceptions of medical tourism service quality standards. Thus, the main purpose of this research is to analyse International medical tourists’ expectations and perceptions of the service quality of foreign health care facilities (e.g., hospitals, clinics, and doctor’s offices), using the modified SERVQUAL scale developed by (Mangold, W. G., & Babakus, E, 1992).
Mangold and Babakus (1991), define service quality as ”the outcome of a process in which consumers’ expectations for the service are compared with their perceptions of the service actually delivered” (Babakus, 2014; Mangold, 1991) (p. 60). Expectations are shaped as a consequence of consumers’ past experiences, verbal correspondence, news stories, advertising endeavours by a particular administration firm and competitors, and individual needs (Lovelock, 2002; Mangold, 1991; A. Parasuraman, 2005; A. Parasuraman, 1991). Once formed, expectations provide a standard of comparison or frame of reference against which consumers anticipate and judge a service firm’s performance ( (A. Parasuraman, 1991; Lovelock, 2002). Perceptions of the service actually delivered are seen as a function of the technical quality (what is delivered), the functional quality (how it is delivered) and the service firm’s image in the mind of the consumer (Mangold, 1991).
In a health care environment, consumers tend to rely on the functional aspects of the service delivery process (e.g., doctors’ and nurses’ demeanour towards patients and length of time waiting for a procedure) when assessing the service quality since, in general, they do not have the expertise to evaluate specialised quality (e.g., precision of a medical diagnosis and subsequent treatment and procedures; (Mangold, 1991; Wong, 2009).Service quality is a vital antecedent of customer satisfaction (Cronin, 2002; Jabnoun, 2003).
In turn, customer satisfaction leads to developing and maintaining loyal customers who may become advocates for a firm and promote the organization further by making positive referrals through credible word-of mouth communication (Zeithaml, Bitner,& Gremler,2009). Zeithaml et al. (2009) have suggested that consumers do not perceive service quality as a one-dimensional concept. Instead, their assessment of service quality includes their expectations and perceptions of multiple factors. More specifically, Parasuraman, Zeithaml, and Berry(1988) have defined the service quality concept in terms of five major dimensions
‘ Tangibles: Appearance of physical facilities, equipment, personnel, and
‘ Reliability: Ability to perform the promised service dependably and
‘ Responsiveness: Willingness to help customers and to provide prompt
‘ Assurance: Knowledge and courtesy of employees and their ability to
convey trust and confidence
‘ Empathy: Providing caring, individualized attention to customers.
These dimensions represent how consumers organize information about service quality in their minds. Among these dimensions, reliability has been consistently shown to be the most important determinant of service quality, followed by assurance and responsiveness, with tangibles and empathy having the weakest influence on perceptions of service quality(Parasuraman, Berry, & Zeithaml, 1991; Parasuraman et al., 1988; Zeithamlet al., 2009).
Research on service quality and its related dimensions by Parasuraman et al.(1985, 1988) led to the development of the SERVQUAL scale’the most widely used, valid, and generally accepted service quality measurement tool(Atilgan, Akinci, & Aksoy, 2003; Brown & Bond, 1995; Ladhari, 2009).SERVQUAL is a multi-item instrument, containing 22 pairs of items, for quantifying the service expectation-perception gap using the five generic dimensions described previously (Parasuraman, 1998; Parasuraman et al.,1988). Half of the items are intended to measure consumers’ expected level of service for a particular industry (expectations), while the other 22 matching items are intended to measure consumer perceptions of the present level of service provided by a particular service firm (perceptions; Babakus& Mangold, 1992). Service quality is measured on the basis of the difference scores, i.e., the gap scores, between the perceived level of service provided (perceptions) and the level of service that should be provided (expectations) across the five dimensions of service quality.The SERVQUAL scale and derivations from it have been used extensively in both the non-health and health service industries (O’Connor, Trinh,& Shewchuk, 2000; Pakdil & Harwood, 2005). Although some concerns have been stated about the expectations concept (Boulding, Kalra, Staelin, &Zeithaml, 1993; Teas, 1993) and the theoretical aspects of the scale (Cronin & Taylor, 1992; Taylor & Cronin, 1994; van Dyke, Kappelman, & Prybutokt,
1997), SERVQUAL has been widely applied and is highly valued (Atilganet al., 2003; Buttle, 1996; Ladhari, 2009).
2.4.2.SERVQUAL in Medical Tourism Research
In the only known study in the medical tourism literature that specifically addressed the topic of service quality, Jyothis and Janardhanan (2009) used a modified 32-item version of the SERVQUAL scale to measure the service quality of health tourism providers in Kerala, India. Their instrument contained items that measured tourism aspects of medical tourists’ experiences(e.g., local tours, shopping arrangements, cultural programs, and entertainment),
in addition to their expectations and perceptions of medical care service quality. They found that foreign health tourists’ perceptions of the service quality they received fell short of their expectations across all five dimensions of service quality, with the largest gap being in the area of reliability, followed by responsiveness, tangibles, assurance, and empathy
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