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CHAPTER 1
INTRODUCTION

1.1 INTRODUCTION
Tourism has emerged as a key sector of the world economy and has become a
major workforce in global trade. It has been making a revolutionary and significant
impact on the world economic scenario. Tourism has been identified as the major
export industry in the world (Gosh Viswanath, 1998). The multifaceted nature of this
industry makes it a catalyst to economic development and helps balanced regional
development. It is a low capital, labour intensive industry with economic multiplier
and offers and opportunity to earn foreign exchange at low social cost.
Tourism industry acts as a powerful agent of both economic and social
change. It stimulates employment and investment, modifies economic structure and
makes positive contributions towards balance of payments. The money spent by the
foreign tourists in a country is turned over several times. In the process, the total
income earned from tourism is a number of times more than the actual spending. The
multiplier effect of tourism receipts is completely recognized as spreading to
secondary and tertiary spheres of the economic activities of a nation. It encompasses
economic, social cultural, educational and political significance. Marketing and
promotion are of vital importance in tourism because of the competitive nature of the
industry both within and between the generating countries. Tourism creates direct,
indirect and induced employment. It produces a vast spectrum of employment form
highly qualified and trained managers of five-star hotels to room boys, sales girls, and
artisans. With its faster growth, new horizons of employment open up for the
unemployed and underemployed youth of the developing countries.
1.1.1 Economic Growth and Tourism
Tourism has been a major social phenomenon of the societies all along. It is
motivated by the natural urge of every human being for new experience, adventure,
education and entertainment. The motivations for tourism also include social,
religious and business interests. The increase of education has fostered a desire to
know more about different parts of the globe. The basic human thirst for new


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experience and knowledge has become stronger, as communication barriers are
getting overcome by technological advances. Progress in air transport and
development of tourist facilities have encouraged people to venture out to the foreign
lands.
Tourisms importance, as an instrument for economic development and
employment generation, particularly in remote and backward areas, has been well
recognized the world over. It is the largest service industry globally in terms of gross
revenue as well as foreign exchange earnings. Tourism can play an important and
effective role in achieving the growth with equity objectives which India has set for
itself. Tourism is one economic sector in India that has the potential to grow at a high
rate and can make sure consequential development of the infrastructure of the
destinations. It has the capacity to capitalize on the countrys success in the services
sector and provide sustainable models of growth.
It has the potential to stimulate other economic sectors through its backward
and forward linkages and cross-sectoral synergies with sectors like agriculture,
horticulture, poultry, handicrafts, transport, construction, etc. Expenditure on tourism
induces a chain of transactions requiring supply of goods and services from these
related sectors. The consumption demand, emanating from tourist expenditure, also
induces more employment and generates a multiplier effect on the economy. As a
result, additional income and employment opportunities are generated through such
linkages. Thus, the growth of the tourism sector can lead to large scale employment
generation and poverty alleviation.
The growth in the tourism sector emerged as a very important contribution to
the national economy and contributed quite a lot for employment generation in
various tourism related activities. The not direct employment multiplier in the case of
tourism is fairly high and is estimated as 2.36 which implies that direct employment
of one person in the tourism sector creates employment to 1.36 persons in other
sectors of the economy due to linkages with tourism .These linkages are in the sectors
like agriculture horticulture, poultry, handicrafts, construction, sports etc. Further
these directly/indirectly employed following the development of tourism may also
need more goods & services as a result of such employment than what they would


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have demanded otherwise. Additional demand will thus generate more employment
and further multiplier effect will come into force through successive chain of
transactions. In fact investment in tourism has the potential to create more jobs
compared to many other sectors and all the more at a lower level of investment. The
labour/capital ratio is very favorable in tourism sector compared to many other
industries with 47.5 jobs for a million rupee investment as has been seen in the survey
conducted by the Ministry of Tourism (MoT), government of India (Kanjilal, 2006).
The economic benefits that flow into the economy through growth of tourism
in shape of increased national and State revenues, business receipts, employment,
wages and salary income, buoyancy in Central, State and local tax receipts can
contribute towards overall socio-economic improvement and accelerated growth in
the economy. Tourism is overwhelmingly an industry of Private sector service
providers, although the public sector has a significant role to play in infrastructure
areas either directly or through publicprivate partnerships (PPPs) approach. It is a
multi-sectoral activity characterized by multiple services provided by a range of
suppliers. It is quite similar to manufacturing industry, where the supply chain is as
important as the end product. The related sectors include airlines, surface transport,
hotels, basic infrastructure and facilitation systems, etc. Thus, the growth of tourism
cannot be attained unless the issues related to all the sectors are addressed
simultaneously.
Another important feature of the tourism industry, which is of particular
significance to India, is its contribution to national integration and preservation of
natural as well as cultural environments and enrichment of the social and cultural
lives of people. Over 382 million domestic tourists visiting different parts of the
country every year return with a better understanding of the people living in different
regions of the country. They have a better appreciation of the cultural diversity of
India. Tourism also encourages preservation of monuments and heritage properties
and helps the survival of arts forms, crafts and culture.
It is also important to note that tourism has become an instrument for
sustainable human development including:


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Poverty alleviation
Environmental regeneration
Job creation
Advancement of women and other disadvantaged groups.
1.1.2 Size of Global Tourism
According to the World Tourism Organisation (WTO), the year 2008 saw
more than 922 million international tourist arrivals, and the tourism receipts were of
the order of US $ 944 billion. The World Travel and Tourism Council (WTTC) for
2009 the contribution of the Travel & Tourism economy to total employment is
expected to rise from 219,810,000 jobs in 2009, 8.4% of total employment or in 1 in
every 11.8 jobs by 2019. Gross Domestic Product (GDP) is expected to rise from
9.4% (US$5, 474 billion) in 2009 to 9.5% (US$10, 478 billion) by 2019. However
Real GDP growth for the Travel & Tourism economy is to be -3.5% in 2009, down
from 1.0% in 2008, but to average 4.0% per annum over the coming 10 years with
export earnings from international visitors and tourism goods are to generate 10.9% of
total exports (US$1, 980 billion) in 2009, growing (in nominal terms) to US$4, 132
billion (9.8% of the total) in 2019. (World Travel & Tourism Council, 2009)
1.2 TOURISM IN INDIA
India as a tourist destination exercises immense attraction from various angles.
Tourism has emerged as a major industry of the Indian economy, contributing
substantially to foreign exchange earnings and serving as a potential generator of
employment opportunities. India is the largest democratic republic in the world with
immense possibilities of growth in the tourism sector, with its vast cultural and
religions heritage and varied natural attractions, but the country has only a meager
share in world tourism. It is a land of contrasts, that is, from tropics to snows. It
presents a diversity of rare natural and cultural endowments, which is the traditional
symbol of India, i.e. unity in diversity. India has Gods plenty of natural beauty
ranging form the towering Himalayas in the north to the sun-kissed beaches of the
east and the breathtaking beauty of the west. Each area of the country offers a
different experience with its own specific festivals and culinary culture. Indias rich
cultural heritage and glorious tradition are linked with the development of tourism in


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India. The great German scholar, Max Muller, observed: if we were to look over the
whole world to find out the country most richly endowed with all the wealth, power
and beauty that nature can bestow in some parts a very paradise on earth.

The best performing states of India include Uttaranchal, Rajasthan, Andhra
Pradesh, West Bengal, Karnataka, Uttar Pradesh, Orissa and Haryana. Even though
Indias share in international tourism is less than 0.4 percent, the tourism sector alone
accounts for 5.8 percent of the total employment generated in India. Tourism
contributes 5.6 percent of the national income with in India (Anbalagan, M., Selvam,
V., Amudha, R. 2005). According to World Travel and Tourism Council, India will be
a tourism hotspot from 2009-2018, having the highest 10-year growth potential. The
Travel & Tourism Competitiveness Report 2007 ranked tourism in India 6
th
in terms
of price competitiveness and 39
th
in terms of safety and security. Despite short-and
medium-term setbacks, such as shortage of hotel rooms, tourism revenues are
expected to surge by 42% from 2007 to 2017. Indias 5,000 years of history, its
length, breadth and the variety of geographic features make its tourism basket large
and varied. It presents heritage and cultural tourism along with medical, business and
sports tourism.
1.2.1 Size of India Tourism
There has been a remarkable growth over the years in foreign tourist arrival to
India due to the various efforts made, including promoting India through the
Incredible India campaign in overseas markets. This global campaign had attracted
the attention of tourism industry observers as well as tourists. Foreign tourist arrivals
(FTAs) in India increased from 2.65 million in 2000 to 5.58 million in 2010. The
foreign exchange earnings (FEE) from the tourism sector in 2010 were $ 14193
million, an increase of $10729 million over 2007 (Ministry of Tourism India, 2010).
The contribution of the Travel & Tourism economy to employment is
expected to rise from 31,105,000 jobs in 2009, 6.4% of total employment or 1 in
every 15.6 jobs to 40,037,000 jobs, 7.2% of total employment or 1 in every 13.8 jobs
by 2019. Real GDP growth for Travel & Tourism economy is expected to be 0.2% in
2009 and to average 7.7% per annum over the coming 10 years (World Travel &
Tourism Council, 2009).


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Table 1.1
Foreign Tourist Arrivals/FATs in India and Foreign Exchange Earnings/FEE in
US million Tourism in India, 2000-2010

Year
FTAs in
India (in
million)
Percentage (%)
change over the
previous year
FEE from Tourism
in India (in US
million)
Percentage(%) change
over the previous year
2000 2.65 6.7 3460 15.0
2001 2.54 -4.2 3198 -7.6
2002 2.38 -6.0 3103 -3.0
2003 2.73 14.3 4463 4.38
2004 3.46 26.8 6170 38.2
2005 3.92 13.3 7493 21.4
2006 4.45 13.5 8634 15.2
2007 5.08 14.3 10729 24.3
2008 5.28 4.0 11832 10.3
2009 5.17 -2.2 11394 -3.7
2010 5.58 8.1 14193 24.6
Source: (i) Bureau of immigration, Govt. of India,
(ii) Reserve Bank of India,
(iii) Ministry of Tourism Govt. of India,

Though the growth in tourism in India has been impressive, Indias share in
global tourist arrivals and earnings is quite insignificant. Indias rank in world tourist
arrivals in 2008 was 41. It is universally acknowledged that the tourism resources in
the country have the potential to generate significantly higher levels of demand from
the domestic and international markets, and, if exploited intelligently in a sustainable
manner, can prove to be the proverbial engine of growth for the economy.
1.2.2 Scope of Tourism in India
India has many tourist attractions that have healing abilities and are capable
of providing rewarding experiences of life. India has the Himalayan ranges in the
north, a long coastline surrounded by seas in the south. In addition, India is rich in
varied landscapes, enchanting historical sites and royal cities, clean beaches, serene
mountain retreats, rich cultures and festivities to enjoy and rejuvenate.
In any part of the year, India can offer a wide selection of destinations
and experiences. In summer, there are lovely retreats amidst the heady beauty in the


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Himalayas or the lush-heights of the western Ghats with cool trekking trails, tall
peaks, or stretches of white water for the adventure seekers. In the cool Indian
winter, cities come alive with cultural feasts of music and dance. The sun-clad
beaches are ideal locations for rejuvenation in the winter. The wild-life sanctuaries
with their abundance of flora and fauna provide delights to the mind and
rejuvenation to the body. Various tourism themes are being promoted in India,
which are described below:
Adventure Tourism: The country offers a wide range of adventure sports
for tourists. Trekking and skiing in the Himalayas; white water rafting on the rivers
such as Ganges and Beas; camel and jeep safaris in the deserts of Rajasthan,
paragliding in Himachal Pradesh, water-sports in Goa; Scuba diving in Andaman
and Lakshadweep islands are some of the options available to adventure seeking
tourists. Lakshadweep islands also offer excellent wind surfing and snorkelling in
the crystal clear waters of the lagoons.
Eco-Tourism: The Himalayan Range spread across five Indian states
providing widest monotonic geographical variety. Wide sweeping valleys and
deep gorges give way to thick deciduous forests and alpine meadows, undulating
tea gardens and slopes, bar narrow terraces, gently contoured hills, snow draped
peaks surrounded by a fluff of clouds, thundering rivers and deeply fissured
glaciers provide excellent locations for eco-tourism. In the southern part of India, the
south and eastern Ghats, especially the Nilgiri Ranges, have its own unique appeal
to eco-tourism.
Architectural Treasures: India has rich architecture traditions, which have
the beginning as old as 3
rd
millennium BC. Indian architectural tradition is the living
vital art of the various dynasties, which ruled over it. The Buddhist stupas (dates
back to 230-500 AD); Jains sculpture at ancient Palitana, Ajanta, Ellora, and Mount
Abu; the Hindu temples with profuse carvings and Gopurams of the South India;
arches and domes, filigrees in architecture promoted by Mughals; presidency
towns built by modern rulers like British, French, Portuguese, are some of
the vital arts assimilating the influence of various dynasties that ruled over the
country.


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Sun and Sand Coastal Tourism: Indias coastal states such as Gujarat,
Masharashtra, Goa, Karnataka, Kerala, Tamil Nadu, Andhra Pradesh, West
Bengal and Orissa have a choice of beaches. Many breathtaking beaches
promise perfect escape to tranquility. While some of them are for quite beaches (like
Chorwad, Ahmedpur and Mandvi in Gujarat; Gopalpur in Orissa), the beaches in Goa
are popular for wind-surfing and yatching.
The Backwaters: Kerala is said to have sprung from the ocean. All along
the coast, these exotic backwaters, canals, lagoons and inlets create an intricate
maze that stretches for 1900 km. across the land. The serene villages in the
backwaters of Kerala are living portrait of Keralas rural life.
Forts and Palaces: Indias once famous princely kingdoms, which carried
feudal traditions, have built forts and palaces, some of which have been converted
into hotels now. Jaipur, Jodhpur, Jaisalmer, Bikaner in the state of Rajasthan;
Mysore in Karnataka; Mughals forts in Northern India are some of the examples of
several fascinating forts and palaces.
Hill Delights: A journey through the hill resorts of India promises a deep and
refreshing communion with nature in its varying beauty. Lush river valleys
surrounded by snow-caped peaks, fruit-laiden orchards, gurgling streams and dense
forests evoke enchantment and delights of hilly regions. The misty dawn on
mountains creating magnificent landscapes extend to the entire north-eastern states,
whose natural beauty has earned the title seven sisters.' Other hill states,
Himachal Pradesh and Jammu & Kashmir provides a breathtaking variety of the
Himalayan splendour. The Nilgiris in the South have the picturesque Anantagiri,
Udhagamandalam, Madikeri and Munnar. Mount Abu in Rajasthan, Panchgani in
Madhya Pradesh and Mahabaleshwar in Maharashtra are other hill regions with
tourist attractions.
The Deserts: The state of Rajasthan has the mystique of the desert with
sand dunes closer to the splendid cities of Jodhpur, Bikaner and Jaisalmer. The
royal edifices take the tourists to the magnificence of the bygone era. Turbaned
men with proud moustaches, and village girls in colourful attires and heavy jewellery
swaying in the desert sands to match with the enchanting rhythm and melodies, are


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other attractions of the deserts of India.
The Jungle: India is a land of wildlife providing delight for the natural
lovers. Total area of Indias protected wildness is approximately 140,000 sq. km.
and constitutes 4 percent of the centurys total land area. The country has
preserved vast tracts of forests and habitats in its nearly 100 national parks over 400
wildlife sanctuaries. Indias climatic and geographic diversity makes it the home of
over 350 mammals and 1200 bird species, many of which are unique to the sub-
continent. The wildlife parks and sanctuaries, filled with varieties of tigers and
elephants, the peacocks and the rhinoceros, are fascinating diversity of terrain, flora
and fauna. In northern India, Corbett National Park and Dudhwa National Park in
Uttar Pradesh, Kanha National Park and Bandhavgarh National Park in Madhya
Pradesh and Rajasthans Ranthambore National Park and Sariska Tiger Reserve,
are all the home of the magnificent predator-the tiger. These also have varieties of
deers, and a range of lesser cats, mammals and birds.
Island attractions: The Andaman and Nicobar, and Lakshadweep islands
are enriched with white and sandy beaches, crystal-clear water and picturesque coral
reefs. Sun-bathing in these islands along with snorkelling and scuba-diving are
tourist attractions.
Pilgrimage: India holds attractions, for pilgrim tourists of diverse religions,
where religion is considered more than the act of worship, but a way of life. For the
Hindus age-old cities of worship like Prayag (that provide holy confluence of
Ganga, Yamuna and Saraswati rivers); Puri (Jagannath temple); Konark (Sun
temple); Kanchipuram, Madurai, Tiruchirappalli and Kanniyakumari (Southern
Gopurams), provide peace and reverence. In addition, there are also religious
places that are carved with craftsmanship, at Belur and Halebid. In these temples,
the interior and exterior walls are decorated with intricately-carved deities stylized
motifs from nature and friezes depicting the life in the reign of the Hoysalas. There
are also worship places for the Muslims (Delhi - Jumma Masjid), Christians
(Churches in Goa and Kerala), Buddhists (Bodhgaya, Saranath, Kushinagar),
Sikhs (Golden Temple) and Jains (Sravanabelagola), that have tourist attractions.
North-East Region: Life moves at a serene pace in the north- eastern region


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of India with the seven sister states are generously blessed with the natural beauty.
The region is enriched with magnificent landscapes naturally created by
verdant valleys, emerald tea gardens, lush forests and tumultuous rivers. A misty-
dawn of the mountains, bronze sun-set across the expanse of the Brahmaputra,
and the clang of prayer bells at monasteries, provide healing to mental and
physical well-being of the visiting tourists.
In nut shell, India has many tourist attractions that have healing abilities
and are capable of providing rewarding experiences of life. India has the
Himalayan ranges in the north, and a long coastline surrounded by three seas
in the south. In addition, India is rich varied different landscapes, enchanting
historical sites and royal cities, clean beaches, serene mountain retreats, cultures
and festivities to enjoy and rejuvenate.
The above said tourism may be an added asset for attracting to promoting
health tourism in India.
1.3 CONCEPT OF HEALTH TOURISM
The wealth of a country is judged among other things by the health of its
citizens. Worldwide, countries are seeking to provide viable healthcare solutions to
its population. Improvement in healthcare in a society means more than the
availability of doctors or hospitals or medicines. Improvement in healthcare occurs
through promotion of health consciousness through a range of activities that would
suit to various sections of the society children, youth and elders. In this
perspective, Indian traditional healthcare systems such as Ayurveda and Yoga, as
also the concept of spiritual healings are popular amongst both domestic and
international tourists.
It is generally considered that a person who travels from one region (or a
country) to another for the purpose of undertaking treatment is a healthcare
tourist. However, this definition excludes people who travel to another region (or a
country) to explore, enjoy and rejuvenate, either the body or the mind or both
without undergoing medical treatment. Flow of tourism is far higher in absolute
number as well as volume of business generated if the latter aspect is taken into
account. Tourism to, and associated activities to places like sea-side, mountains,


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river-beds, forests, plains, valleys, temples or historic monuments provide
rejuvenation to the body and mind and thereby bestow the overall well-being upon
the person involved with such activities.
In any part of the year, India can offer a wide selection of destinations
and experiences. In summer, there are lonely retreats in the Himalayas or the lush-
heights of the Western Ghats with cool trekking trails, tall peaks, or stretches of
white water for the adventure seekers. In the cool Indian winter, cities come alive
with cultural feasts of music and dance. The sun-claud beaches are ideal locations
for rejuvenation in the winter. The wild-life sanctuaries with their abundance of
flora and fauna provide delights to the mind and rejuvenation to the body.
Healthcare tourism, however, could be defined in a broader perspective.
Patients traveling abroad with the objective of overall wellness, without any urgent or
elective medical procedures, may also be covered under the healthcare tourism.
Healthcare tourism thus could become a common form of vacationing, and covers a
broad spectrum of healthcare services, mixing with leisure/relaxation, with the
overall objective of wellness and healthcare. The objective of the healthcare
tourism is to offer an opportunity to be away from the daily routine and come
into a different surrounding for relaxation. During the stay, the tourist receives an
orientation that will help improve life in terms of health and general well being. It is
like rejuvenation and cleansing process at all levels - physical, mental and emotional.
1.3.1 Features of Health Tourism
There are some distinguishing features of healthcare tourism which are
outlined below:
One of the important features of healthcare tourism is that it is not an
impulsive activity. However, packages are woven with attractive features to draw
the tourists. Another important feature of healthcare tourism is the willingness to
spend. While, the cost of packages is attractive to wealthier segments, this may not
be working in favour to attract patients from poorer countries. In such a scenario, the
non-availability of such facilities in the home country and the quality of services
provided in the host country play an important role.


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Healthcare tourism is also non-seasonal. This attribute can either be used
to buffer seasonal business for resorts and location- specific properties, or as the main
business itself. Some countries such as Thailand are promoting healthcare tourism
as main business for the properties developed for this purpose. In India, some of
the hospitals/healthcare centers in Kerala that provide Ayurvedic treatment adopt
this model of business. The non- requirement for custom-builds is a strong
characteristic in favour of the hotels. The patient and the family in this model stay in
hotels during pre-operative and to some extent during the post-operative periods.
Another important feature of healthcare tourism is that the average duration of
stay is longer as compared to the conventional corporate/holiday travel. Depending
upon the procedures and nature of treatment, the average stay of a healthcare tourist
ranges between two weeks to two months. For example, procedures as complex as
open-heart surgery, including post-operative care, involve a stay for at least two
weeks.
It has been reported that the persons who travel outside the country seeking
low cost healthcare are predominantly uninsured or underinsured population in
developed countries. In addition, the new trend is that the corporates in developed
countries are increasingly sending their employees to low cost healthcare destinations
to reduce the expenditure on healthcare for their employees.
Successful treatment associated with satisfactory services are considered as
important factors for getting repeat business, as healthcare tourism is not a one time
business. In conventional tourism, the satisfactory services alone are enough to get
repeat business.
The objective of this study is to explore antecedents to promoting health
tourism in India. Therefore, India can take strategies position to cater demand supply
goal in the international market by adopting right marketing strategies.

1.3.2 Definition and classification of health tourism
Medical Tourism and Healthcare Tourism are interchangeably, however
According to World Tourism Organization (WTO), Tourism associated with
travel to health spas or resort destinations where the primary purpose is to improve the
travelers physical well being through a process comprising physical exercises and


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therapy, dietary control, and medical services relevant to health maintenance is
defined as Medical Tourism.
Health Tourism has three branches of different tourism
Medical Tourism
Wellness Tourism
Curative Tourism
Health tourism structure is shown in Figure 1.1 and 1.2
1.3.2.1 Medical Tourism
Figures 1.1 explain that Medical Tourism is the major branch of health
tourism. In this tourism surgical and non-surgical are consider major activities.
The focus of present study is on medical tourism. Therefore, concerti
definition of medical tourism is explained Para No. 1.5, Page No. 25.
1.3.2.2 Wellness Tourism
Wellness tourism in many ways, this is one of the most ancient forms of
tourism, if one considers the scrupulous attention paid to well-being by Romans and
Greeks, the quests for spiritual enlightenment of Mediaeval pilgrims, or the medical
seaside and spa tourism of the 18
th
and 19
th
century European lite. Arguably,
however, there has been an unprecedented intensification in the pursuit of wellness in
the history of tourism in recent years. The proliferation of wellness centres, holistic
retreats, spas, spiritual pilgrimages, complementary and alternative therapies is
unprecedented (House of Lords Report 2000).
Myers, Sweeney and Witmer (2005) define wellness as being a way of life
oriented toward optimal health and well-being in which the body, mind, and spirit are
integrated by the individual to live more fully within the human and natural
community.
Adams (2003) refers to four main principles of wellness:
a) Wellness is multi-dimensional;


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b) Wellness research and practice should be oriented towards identifying causes
of wellness rather than causes of illness;
c) Wellness is about balance; and
d) Wellness is relative, subjective or perceptual.
The destination in wellness tourism is often an alternative space in which one can
engage in self analysis without the stresses and distractions of home. The addition of a
supportive, like-minded community can sometimes help to further encourage the
individual on a journey of self-discovery. However, for other wellness tourists, the
age old preoccupation with rest, relaxation and escapism reigns supreme. But
arguably all wellness tourists are self-aware, active seekers of enhanced well-being,
health and happiness.
1.3.2.3 Curative Tourism
Travel for treatment and recreation became one of the major purposes of
tourism. Curative tourism is not exclusive to those who have body disorders, but also
include others who want to relax, retrieve vitality and for mental, physical and
spiritual fitness.
The term curative tourism has not exactly been raised as an independent
concept; instead most of the research was mainly about health tourism. As a result,
many scholars have defined health tourism, which implies curative and/or medical
tourism in different ways. Abeles and Kipnis (1998:695) defined health as: A
condition of social, psychological and physical well-being and many different
avenues can be pursued so that this state is achieved. This definition emphasises a
balanced condition in the whole body, whether it is physical, psychological or
spiritual, and is matching the definition that is given by the World Health
Organisation (WTO), where health does not mean the absence of disease, instead it is
a balance in the whole body, physically, psychologically and spiritually
Suad Imran (in Jallad 1995: 12-13): Curative tourism is a temporary
movement, by which the tourist (patient) travels for the purpose of treatment, whether
it is medical or therapeutic in healing certain disease or for relaxation and physical up
keeping. This movement should be voluntary or by a doctor recommendation


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Fig 1.1
Health Tourism Structure (1)

Figure 1.2 shows classification of health tourism given by Jallad (2000:11-12)
distinguished between, medical tourism, curative tourism and wellness tourism as
follows:
A. Travel for the purpose of treatment of certain body ailment or for doing a
surgery under medical supervision in hospitals or medical centres, and then
the patient (tourist) may need to stay some period of time in spas for recovery
purposes. This type is called Medical Tourism.
B. Travel for the purpose of treatment of certain disease or for convalescence
under medical supervision, by using natural curative resources such as thermo-
mineral springs, salt lakes, mud and radioactive sand and climatic therapy.
This is called Curative Tourism.
C. Travel for the purpose relaxation, recreation, enjoyment, to escape a way
from daily tensions and for revitalisation in any health resort or spa without
medical supervision, and the tourist has no body ailments. This type of
tourism is called Wellness Tourism.
Health Care Tourism






Wellness Tourism Medical Tourism




Non-Cosmetic Surgery Cosmetic Surgery
Or
Elective surgery


Source: Caballero Danell & Mugomba, 2006


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Fig 1.2
Health Tourism Structure (2)






















Source: Jallad, 2000

1.4 CROSS BROADER TRADE IN HEALTH TOURISM
Many countries probably did not think of health care as something that is
traded internationally. However, it is being increasingly offered cross-border in two
ways (fig. 1.3). Vast majority of cross border health care services are availed by the
patients from developed countries, by undertaking travel to the host countries, which
are increasingly developing countries. In such cases, the services are very
specialized and are either available at low cost or a decision to purchase the

Health Tourism



Wellness Tourism Curative Tourism Medical Tourism

Alternative Medical
& Treatment
Complementary Medicine


Medical Treatment

Surgery (Cosmetic and Non Cosmetic Surgery)




Dental


Reproductive Tourism


Fertility

Birth


Sex Change




Source: Jabbari, 2007


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service was taken after waiting for long period in home countries. This category of
trade in healthcare services also includes unplanned emergencies that may
occur when a foreigner falls sick or injured while traveling to other countries. In
such cases, neither the service nor the service provider crosses a border; instead, the
patient goes to where the service is available. Consequently, this is not typically
considered as trade in the way it is generally understood, although some suggest that
it should still be considered as trade in health care services.
Fig 1.3
Two Forms of Trade in Healthcare













Source: Export-Import Bank of India, Research

Another form of trade in healthcare services would be when the healthcare
services cross the border, the service provider as well as the patient stay wherever
they are. This type of cross border trade in healthcare services happens with the
advancement in communication technologies. The use of advanced diagnostic
testing technologies, satellite communication, tele-health consultation, and
the Internet may make it possible, and perhaps even desirable, for a patient from
one country to get the advice and expertise of highly regarded specialists in other
countries. In fact, there are examples of physicians being able to assist in
surgeries through satellite transmissions linking a doctor in one country with a
surgery being performed in another country. Such form of trade in healthcare

Patients travel Services
Across boarder are provided
To avail health- across
Care services boarder
Mode-1
Mode-2
Healthcare
Tourism


18
services are minuscule at present; however, with the advent of technology, trade in
health care services under this mode is likely to become increasingly common.
1.4.1 Background of the Health Tourism
Though the concept of healthcare tourism is thousands of years old, it has
got its prominence rather recently. In ancient Greece, pilgrims and patients came
from all over the Mediterranean to the sanctuary of the healing god, Asklepios, at
Epidaurus. In Roman Britain, patients took the waters at a shrine at Bath, a
practice that continued for 2,000 years.
Since 18th century, wealthy Europeans traveled to Spas in the Nile. In the
21st century, relatively low-cost air travel has facilitated the growth of the industry,
as traveling across continents has become affordable to even middle class
population. Currently, healthcare tourists are traveling in large numbers to countries
/ regions, where the quality of healthcare is at comparable standards and yet the cost is
significantly lower. Such healthcare destinations also offer numerous options for
touring, sight-seeing, shopping, exploring and even lounging of healthy diets. The
evolution of healthcare tourism in the world is depicted in Fig.1.4.
Fig. 1.4
Progress of Healthcare Tourism


Source: Export-Import Bank of India, Research



19
1.4.2 Tradable Healthcare Solution
There are two major types of healthcare solutions in the world (a)
traditional or indigenous system, and ( b) allopathic or modern healthcare
system. While the latter can be defined as cosmopolitan, as they are
not limited to a region or territory, acceptance of the former as a valuable
healthcare solution is increasing all over the world. The renewed interest in
using traditional healthcare solutions is mainly due to the advantages of minimal
side effects and recognition of time-tested health solutions.
Fig. 1.5
Tradable Health care Solution




















1.4.2.1 Traditional Therapies
In many countries, the citizens have varied health seeking behaviours with
the prevalence of multiplicity of medical or healing systems. Many of these systems
have evolved over a period of time, due to competitive environment and have gone
through changes in healing solutions. In a competitive environment, some of these
healing systems either may get absorbed by a dominant healing system or probably
die out. A healthcare system may thus be defined as a pattern of social institutions
and cultural traditions that evolves from deliberate behaviour to enhance health. It

Healthcare
Solution

Traditional
Therapies

Faith/Spir
itual
Healing

Modern Health care
System/Medical
Tourism


20
should be, against this background, noted that every healing system is a service that
is being availed by a particular group of people. With the globalisation, the spread
of such systems is also faster with more number of people going for diverse
therapies that are originally unique to a country. When the end users move to
another region or territory, they may be called healthcare tourists. In the context of
India, notable traditional healthcare systems that are attracting international
travelers include Ayurveda and Yoga.

In India, in addition to existence of modern medicine, indigenous or
traditional medical practitioners continue to practice throughout the country.
Popular indigenous healthcare traditions include Ayurveda, Siddha, Unani,
Homeopathy, Naturopathy, and Yoga.
1.4.2.1.1 Ayurveda
The Ayurveda (meaning science of life) system deals with causes, symptoms,
diagnoses, and treatment based on all aspects of well-being (mental, physical, and
spiritual). These professionals, traditionally, have been inheriting the skills from
their ancestors. However, with the advent of education, a variety of institutions offer
training in indigenous medical practice.
1.4.2.1.2 Siddha
The Siddha system defines disease as the condition in which the normal
equilibrium of the five elements in human beings is lost resulting in different
forms of discomfort. The diagnostic methods in Siddha medical system are based
more on the clinical acumen of the physician after observation of the patient,
pulse and diagnosis and clinical history.
1.4.2.1.3 Yoga
Yoga is a science as well an art of healthy living physically, mentally,
morally and spiritually. Yoga is believed to be founded by saints and sages of India
several thousand years ago. Yoga has its origin in the Vedas, and its philosophy is
an art and science of living in tune with the universe. Yogis gave rational
interpretation of their experiences about Yoga and brought a practically sound and
scientifically prepared method within every ones reach.


21
1.4.2.1.4 Naturopathy
Naturopathy has several references in the Vedas and other ancient texts,
which indicate that these methods were widely practised in ancient India.
Naturopathy believes that all the diseases arise due to accumulation of morbid
matter in the body and if scope is given for its removal, it provides cure or
relief. It also believes that the human body possesses inherent self-constructing and
self-healing powers. Naturopathy differs slightly with other systems of medicine, as
it does not believe in the specific cause of disease and its specific treatment but
takes into account the totality of factors responsible for diseases such as ones un-
natural habits in living, thinking, working, sleeping, or relaxation, and the
environmental factors that disturbs the normal functioning of the body.
1.4.2.1.5 Unani
Unani system of medicine believes that the body is made up of four basic
elements viz., earth, air, water and fire, which have different temperaments i.e. cold,
hot, wet and dry. After mixing and interaction of four elements a new
compound having new temperament comes into existence i.e. hot-wet, hot-dry,
cold-wet and cold-dry. The body has simple and compound organs, which got their
nourishment through four humours, viz. blood, phlegm, yellow bile, black bile.
Unani system of medicine believes in promotion of health, prevention of diseases
and cure.
All these traditional healthcare systems are attracting national and
international patients, and generate tourism flows. In addition to such healthcare
systems, there are also faith/spiritual healers, who are largely present in rural parts of
India. Some spiritual leaders use one or more of the traditional therapies, viz,
Ayurveda, Yoga or Naturopathy as one of the healing modes to cure their clients.
Such spiritual leaders are attracting large gathering, especially international
travelers from various countries.
Both the Government of India and state governments have realized the
potential of attracting tourism leveraging traditional wellness systems of India.
Some state governments have been projecting their states as center for traditional
wellness systems (e.g. Kerala as Ayurveda hub and UP as Yoga hub). Some state


22
governments have announced tourism policy leveraging the potential of
traditional healthcare systems. The attempts by the state Governments to attract
tourists are not restricted to traditional medical systems, but also through leveraging
spiritual tourism/faith healing. For example, Andhra Pradesh has drawn up an action
plan to promote spiritual tourism, especially to attract German tourists,
combining visits to famous temples along with Yoga, meditation and Vedanta.
Similarly, Uttar Pradesh is promoting the state as Yoga hub, leveraging the
presence of religious circuits and being a land of Sadhus.
In addition to indigenous therapies/healthcare systems, there are also healing
solutions that are prevalent in different societies. One such healing solution popular
across the world is faith healing or spiritual healing.
1.4.2.2 Faith/Spiritual Healing
Faith healing refers to healing that is believed to have occurred supernaturally,
as a result of prayers or other forms, rather than through the use of medicines or
the involvement of physicians. Such healing services are often referred to as
miracles. Since such healing solutions are available only in some parts of the world, it
is important for people from other regions to travel for availing such healing
services.
The concept of spiritual tourism is not well defined. In a general context,
spiritual tourism can be interchanged with religious tourism. However, religious
tourism (pilgrimage) is one of the various forms spiritual tourism. It may be
mentioned that pilgrimage used to be one of the oldest forms of tourism flows all
over the world. Pilgrim centers such as Mecca, Jerusalem, temples in India are
attracting large flow of tourists since many years. Religious events such as Kumbha
Mela have also been traditionally attracting large number of tourists. Spiritual
tourism adds to this form of tourism by travelers who are looking for a meaning
while on vacation. Thus, spiritual tourism, in a broader context, also includes
availing of healthcare systems that are providing psychological peace, mental
strength, and inner-purity. Many concepts and solutions could be brought under this
umbrella, such as journeys to sacred places, Yoga / meditation camps, or even trips
focusing on astrology and mythology. However, in the context of popularity and


23


origin of India, we may mainly highlight Yoga as one such solution.
At present, spiritual tourism is one of the fastest growing segments in
the travel industry worldwide. The growing individualism in our society has
led to the growth of spiritual tourism. Fig. 1.6 explains the commonly used methods
of spiritual healing.
There are mainly non-economic dimensions in spiritual tourism. In general,
the faith healers do a free service with the objective of providing health for all;
however, a nominal fee is charged for undergoing a structured healing course. In
many cases, the healers keep a box to receive offerings, which shows that the fees
collected are not under compulsion.
Large number of tourists is traveling to destinations that offer spiritual
healthcare/faith healing. National governments are also promoting spiritual tourism
considering its potential. Government of Malaysia, through the Tourism Malaysia
promotes spiritual tourism with the existing tourism circuits of Hindu temples,
Chinese shrines, mosques, churches and gurdwaras.
Fig 1.6
Methods of Spiritual Healing













Source: Export-Import Bank of India, Research



24
Malaysia Tourism promotes religious festivals, such as Lantern festival of Chinese,
St. Annes Feast celebrated by Christians and Thaipusam festival celebrated by
Hindus to attract large number of tourists from all over the world. Faith healing in
Nepal, a neighbouring country to India, dates back to the pre-historic times with the
Shamans using tantric spirits to heal the people. Philippines promotes spiritual
tourism and projects the country as international Mecca of spiritual tourism.

1.4.2.3 Modern Health Care System/Medical Tourism
Medical Tourism, a term unknown until a few years ago, sounds paradoxical.
Indeed, it is hard to imagine stronger polarity between two areas of social life, than
that between tourism and hospitalization. Tourism, a voluntary leisureactivity often
perceived as a luminal reversal of everyday life (Graburn, 1977) and a time for
hedonistic pleasure, free from obligations and external constraints, stands in sharp
contrast to medical treatment and hospitalization. Two domains seem to be
fundamentally incompatible. While tourism is associated with freedom and pleasure,
hospital evokes images of constraints and sufferings. One does not visit a hospital
unless one needs to. As a travel writer noted: the dentist chair and the antiseptic
smells of a hospital waiting room are synonymous with pain and a sense of
helplessness. They just dont blend with travel and vacations (Ross, 2001). However,
during the last decade, the medical travel movement has accelerated sharply.
The present phase of modern medical travel is characterized by an industry
approach whereby uninsured and underinsured consumers from industrialized
countries seek first-class quality at developing country prices, a trend commonly
referred to as medical outsourcing. At the same time, the medical travel industry is
increasingly grounded in tourism. Well developed healthcare systems and advances in
technology have supported medical travel among Western countries for many years.
However, medical travel in Asia is relatively new, mostly emerging in the aftermath
of the Asian financial crisis in 1997. With the middle-class clientele in many countries
affected by the economic downturn, private hospitals were faced with a significant
drop in local business.


25
1.5 MEDICAL TOURISM
1.5.1 Definition
The term medical tourism has emerged from the practice of citizens of
developed countries traveling to developing countries around the world, to receive
a variety of medical services, mainly due to continually rising costs of the
same services and complicated procedures to avail such medical services in
their home countries. Thus, medical tourism can be defined as provision of cost
effective private medical care in collaboration with the tourism industry for
patients needing surgical and other forms of specialized treatment. Thus, patients
going to another country for either urgent or elective medical procedures could be
defined as medical tourists. This process is being facilitated by the corporate sector
involved in medical care as well as the tourism industry - both private and public.
Medical tourism or medical travel is the act of traveling to other countries to
obtain medical, dental, and surgical care. Almost two decades ago, Goodrich &
Goodrich (1987:217) defined health-care tourism as "the attempt on the part of a
tourist facility (for example a hotel) or destination to attract tourists by deliberately
promoting its health-care services and facilities, in addition to its regular tourist
amenities".
In 1999 a report, on regional healthcare, released by the European Union (EU)
tipped medical tourism to be a lucrative industry for Europe with the dominant market
operators cited as being Switzerland and Germany and the targeted consumers;
wealthy individuals from the Middle East and Eastern Europe. While the
fundamentals of the definition remain valid, a combination of leisure and health-care,
the facilities referred to 20 years ago generally included spas, resorts, hot springs,
were added to this definitions. This definition seems somewhat exclusive in that it
was for the select few i.e. those who could afford to engage in such leisure pursuits.
Such as Connell (2006:2) define medical tourism as a popular mass culture "where
people travel often-long distances to overseas destinations (India, Thailand, Malaysia)
to obtain medical, dental and surgical care while simultaneously being holidaymakers,
in a more conventional sense ....


26
Include some definition in meaning way, Medical Tourism: a global analysis
(2005), where medical tourism is described as any form of travel from one's normal
place of residence to a destination at which medical or surgical treatments is provided
or performed. The travel undertaken must involve more than one night away from the
country of residence. The focus of the second definition is on the nature of the
treatment provided and the destination without making reference to the simultaneous
pursuit of leisure.

Another definition of Medical tourism is occurs when international patients
travel across boundaries for their healthcare and medical needs (Monica, 2007).
Medical tourism can be broadly defined as provision of 'cost effective' private medical
care in collaboration with the tourism industry for patients needing surgical and other
forms of specialized treatment (India Medical Care, 2007).
The combination of medical and tourism seems to be a promising relatively
new Type of niche tourism. Medical tourism is where "tourists" primarily seek
medical treatment abroad and afterwards the more conventional form or tourism
experience related to leisure and relaxation in tourist places (Caballero et all, 2006). In
the past decades several Asia countries are dominate this industry but most countries
have sought to enter the market (Connell, 2006).
Nowadays medical tourism defined in many researches, as the act of traveling
to other countries to obtain medical, dental, and surgical care or where people travel
to other countries to obtain medical care maybe include complementary (alternative)
and traditional medicine like (spa water or climate ,black mud, stone ,sand, ... ). It also
includes medical services (inclusive of elective procedure and complex specialized
surgeries) like knee/hip replacement, heart surgery, dental procedures and different
cosmetic surgeries .Also Leisure aspect of traveling may be included on such medical
travel trips. On the other hand medical tourism is where the healthcare services are
sought and delivered outside of the home country of the customer, wherein the
provider and the customer use non-formal channels of communication-connection-
contract, with no or minimal regulatory or legal oversight to assure quality and with
limited formal recourse to reimbursement or redress.


27
Many countries have adopted a proactive approach for medical tourists and are
facilitating it as a revenue generating business. The Indian government has begun to
recognize the potential of tourism to Indian economy and has begun to invest in
tourism infrastructure (Diekmann, 2011).
1.5.2 Factor Supporting Medical Tourism in Developing Countries
In South Asia, South-East and East Asia. Asia represents the most potential
medical tourism market in the world. According to a recent article on
Hotelmarketing.com, Asias medical tourism industry is expected to be worth at least
$4 billion by the year 2012. Currently, an estimated 1.32 million medical tourists
come to Asia from all over the world, including the U.S. and Europe (actually, quite a
bit of the current travel comes from within the Asian region itself) (Vequist, Valdez
and Morrison, 2009). India, with its low cost advantage and emergence of several
private players, represents the fastest growing Market. It is also crucial that the more
advanced developing countries open their market more significantly and provide
increased opportunities for this industry (IHT, 2007). The main Factors contributing
to this phenomenon include long waiting lists for surgery, costly health care in
industrialized countries, no or minimal insurance coverage in many developed
countries, anonymity and surprising by medicine surgery in other countries, powerful
communication between the various nations and states in the world, having natural
resources in many developing and Asian countries for offering complementary and
traditional medicine has led to the recent natural progression within health and
medical from developed counties to developing countries (Jabbari, 2007). Many
Asian countries involved after 1990 in the Asian economic crises and they need to
find economic diversification and solution for wake of this crisis (IHT, 2007). In the
recent decades Medical tourism is a fast growing industry in the Asian region and
many countries are actively promoting it and the others such as India have sough to
enter the market (Connell, 2006). According to Indian Cultural Heritage News (2007),
Indian medical facilities are unique in the regions that can providing a massive
potential for medical and health tourism and India can become a hub of medical
tourism in the region in future. The first and most important growth factor for medical
tourism in developing countries is the enormous costs of treatments and therapies in


28
the developed countries. Also Waiting times for procedures in industrialized nations
,Facilities in international travels, access to various air lines, establishing powerful
cultural and political communications between nations and states are the helpful
factors in developing medical tourism (Jabbarii, 2007).
Ecommerce, which is the cause of enhanced knowledge of people in IT
domain and created internet lines, is the first powerful communication factor between
the various nations and states in the world (Levett, 2005). Moreover, the traditional
methods and natural resources for therapy and treatment in developing Asian
countries, has led to attract many patient by different religions in the world and
caused to growth of this market for these countries (Huff-Rousselle et al, 1995).
Successful countries in this sector of tourism have recognized and examined existing
the potentials and planning appropriately of needs for other countries, especially
neighboring ones, and invested accordingly. Many Asian countries are rapidly-
growing practice of traveling to another country to obtain health care. Also India with
high potentiality for attract medical tourism have sought to enter this market.
The special geographical location of India, the history of medical sciences, the
availability of medical and Para medical teams/faculties, low-cost and high-quality
healthcare services, may led to high importance of medical tourism in economic and
medicine fields in India. It seems that medical tourism is the most growing sectors of
tourism in the resources, and many countries interested in developing tourism industry
have noticed this sector of tourism industry and are planning for this. This
international trade in medical services has huge economic potential for developing
countries and serious implications for health care across the globe (Karla et al., 2007).
1.5.3 Reasons for Medical Travel
There are several reasons for the increase in medical travel. First, the
demographics of the developed nations are causing a significant increase in demand
for health care. In Japan, the United States of America, the United Kingdom and
many other European nations, the proportion of the population older than 60 years, in
relation to the total population, is increasing rapidly. Similar trends are being seen in
many countries across the world. At the same time, life expectancy in most countries
has also increased steadily over the years; the combined result is significant strain on


29
national health-care systems. The inability of many health-care systems to deal with
the increase in demand does, in many cases, lead to compromised levels of service
and decreased access through long waiting lists and high costs. This drives many
individuals to seek alternatives to domestic health care. Such alternatives can be
found in the economically stratified global health-care marketplace (Turner, 2007),
which offers everything from cutting-edge surgical procedures such as organ
transplants to cosmetic procedures and wellness packages at a wide range of prices.
As is the case in many economic sectors, outsourcing to more affordable health
service provision abroad is increasing. Private health-care facilities in countries such
as India, Malaysia, Philippines, Singapore and Thailand are utilizing the prevailing
cost differentials, relative to countries such as Canada, the United Kingdom and the
United States of America, to attract international customers who have the financial
means to access medical care abroad. The cost of medical treatment of different
countries is shown in table 1.2
Table 1.2
Cost of Medical Procedure in Different Country
Medical
Procedure
USA Mexico Costa
Rica
India Thailand Korea
Angioplasty 57,000 17,100 14,000 10,000 9,000 21,600
Heart Bypass 144,000 21,100 26,000 10,000 26,000 26,000
Heart Valve
Replacement
170,000 31,000 31,000 3,000 24,000 38,000
Knee Replacement 50,000 11,50 12,000 9,000 14,000 19,800
Hip Resurfacing 30,000 31,400 13,000 10,000 18,000 22,900
Hip Replacement 43,000 13,800 13,000 10,000 16,000 18,450
Special Fusion 100,000 8,000 16,000 14,000 13,000 19,350
Face Lift 15,000 8,000 6,500 9,000 8,600 5,000
Breast Implants 10,000 9,000 4,000 6,500 5,700 13,600
Rhino Plasty 8,000 5,000 6,000 5,500 5,400 6,000
Lap Band/Bariatric 30,000 9,200 9,000 9,500 14,000 11,500
Above cost in US $*
Source: www. Inidahelathtourism.com
International accreditation and name recognition linked to quality care
provision are laying to rest many of the concerns individuals may have, regarding
professional competence, patient safety and quality in low-cost health care abroad.
Combined with inexpensive air travel, low-cost telecommunications, digitized patient


30
records, widespread access to information through the internet, and an increasingly
sophisticated medical travel industry to manage all these processes on the patients
behalf, travelling abroad for medical treatment is an appealing alternative for
uninsured or underinsured individuals. The alternatives available through medical
travel are not only within the reach of individuals in developed countries but also to
the people from developing and least developed countries who have the financial
means to find sophisticated and affordable medical care in neighbouring countries
(UNESCAP, 2009). Improving patient safety, medication, infection prevention and
control, quality performance, and improvement and the environment of care is a
primary concern for hospitals and medical facilities involved in medical tourism
voluntarily seek JCI accreditation. In India Quality Council of India (QCI), an
organization of Government of India has set up National Accreditation Board for
Hospitals and Healthcare Providers (NABH). In a NABH accredited hospital, there is
strong focus on patient rights and benefits, patient safety, control and prevention of
infections in hospitals and practicing good patient care protocols like special care for
vulnerable groups, critically ill patients and better and controlled clinical outcome.
1.5.4 Meaning and Categories of Medical Tourists
The Medical Tourism industry is still across. Service providers are strategizing
to position their products for different targeted segments. Each such segment is being
labelled as medical tourist. In the earlier days of the medical tourism, the wealthy
people from developing and under-developed world travelled to developed countries
to avail quality medical facilities that were not available in their own countries. Rich
Indians travelled to US and UK for medical treatment. Recent years have witnessed a
reversal in this trend. People from developed countries are travelling to developing
countries offering comparable quality medical care. Reasons often cited are affordable
costs and medical services available without wait or with a short wait. There is a
growing demand for alternative therapies and therapies like Yoga and Tai chi that
border wellness and might extend into the realms of spirituality. Further there are
opportunities to combine medical treatment with leisure and vacationing. Erik Cohen
(2010) suggests a typology of medical tourists based on the extent to which medical
treatments play an important role in tourists motivations for and conduct on the trips,


31
relative to vacationing. First is a Mere Tourists. This is an individual who does not
make any use of medical services while vacationing in the host country. Second type
is a Medicated Tourist who receives medical treatment for health problems
incidentally occurring while in host country. Medical Tourist Proper, the third type, is
an individual whose visit to the host country includes both tourism and medical
treatment (for matters unrelated to the trip). Tourists travelling to the host country
with the intention of receiving treatment while vacationing, as well as, those deciding
on such treatment once in the country will fall within this category. A Vacationing
Patient is an individual who visits the host country mainly to receive medical
treatment, but makes incidental use of vacationing opportunities, especially during the
convalescence period that follows the medical procedure. This is the fourth type.
Finally, a Mere Patient visits the host country solely to receive the medical treatment,
and does not make use of any vacationing opportunities (Fig.1.7)
Fig.1.7

Classification of Tourist

Mere Tourists Medicated Tourist Medical Tourist Proper


Vacationing Patient Mere Patient

Source: Erik Cohen, 2010

A McKinsey (Ehrbeck, Guevara, & Mango, 2008) article suggests that though
the market for medical travel has captured worlds attention and imagination, it isnt
as large as reported. It further mentions that most medical travellers seek high quality
and faster service instead of lower cost. On the basis of quality of medical treatment,
authors segment buyers into 5 discrete types. The largest segment is 40 percent of all
medical travellers. They seek worlds most advanced technologies. They are in search
for high quality medical care available anywhere in the world, giving little attention to
the proximity of potential destination or the cost of care. Example includes people
travelling to developed countries for treatment. Second segment comprises of 32


32
percent market, include patients who seek better care then they could find in their
home countries. They travel from under-developed and developing countries to
developed countries. In selecting the destination, these patients generally trade-off
perceived quality against burdens such as costs, distance and unfamiliar culture. The
third segment, about 15 percent of the market, comprises of the medical patients who
want quicker access to medically necessary procedure delayed by long wait times at
home for orthopaedic and cardiac complications. 9 percent of the travellers represent
the fourth segments that seek lower costs for medically necessary procedures. They
seek to save significant part of the cost of treatment. The choice of destination for
treatment is in accordance with the costs of treatment offered by the services
providers. The last category representing a meagre 4 percent of market comprises of
the patients seeking lower costs for discretionary procedures such as breast
augmentation and reduction, liposuction etc. This segment seeks smaller but
specialised service providers rather than larger multi-specialty hospital. (Fig.1.8)
Fig. 1.8 Medical Tourist Segment

40%
32%
15%
9%
4%
Most advanced technology
Better quality care for
medically necessary
procedures
Quicker access for medically
necessary procedures
Lower cost care for medically
necessary procedures
Lower cost care for
discretionary procedures

Source: Ehrbeck, Guevara and Mango, 2008.


33
Another report (UNESCAP, 2009) categorizes medical travellers on similar
lines into four categories. The first group includes patients from developed countries
who do not have, or have inadequate, health insurance coverage. Many of these
individuals come from Australia, Europe and Japan, a large number coming from the
United States of America. The second group includes individuals, also primarily from
developed countries such as Canada and the United Kingdom , who face long waiting
lists for non-elective surgery and other critical procedures. In the United Kingdom,
many individuals choose to pay for medical treatment abroad to avoid long waiting
lists even though the national health-care system, in spite of being overstretched,
ensures free treatment to all its citizens. The third group includes individuals looking
for affordable cosmetic procedures. Many of these individuals come from Australia,
Europe and Japan, with a significant number again coming from the United States of
America. For example, most health insurance in the United States of America covers
critical care, not cosmetic care and beauty treatments. The increased demand for
surgical procedures such as facelifts, hair transplants, dental treatment and
liposuction, as well as non-surgical procedures such as Botox and hair removal, and
the relatively high cost of these procedures is driving many individuals to find more
affordable alternatives abroad. The last segment of medical travellers includes
individuals seeking quality assured- often specialized- care that is unavailable or in
short supply in their own countries. A significant number comes from the Middle
East. This last group also includes an increasing number of medical travellers from
developing and least developed countries seeking better health-care infrastructure at
affordable prices in their own neighbourhood.
Fig. 1.9

Categorization of Tourist

Insurance Coverage Long waiting Period Unaffordable cosmetic Non-availability
in home county procedures or short supply
quality treatment
in home country

Under insured Not Insured
Source: UNESCAP, 2009


34

A Deloitte (Yap, Chen, & Nones, 2008) report segments medical tourists on
the basis of complexity of medical procedure/ treatment and the extent of follow-up
care needed after leaving the country where the treatment was received (See Figure
1.10).
Figure 1.10
Classification of Medical Tourists by Requirement for Follow-up Care vs.
Complexity of Treatment


Less invasive surgery
for example laparoscopic
procedures
More invasive/ complex
for example bypass,
transplant,
cancer treatment
Elective cosmetic
for example lasix, cosmetic,
etc.
More invasive surgery
for example hip or knee
replacement
Increasing complexity

Source: Yap, Chen, & Nones, 2008
Another research (Chen, Kuo, Chung, Chang, Su, & Yang, 2010) classifies
medical tourists segments on similar lines. First segment seeks low-risk procedures
with high price differential and long stay after retirement; second is the segment that
requires high-risk procedures with less attention to price difference. Third and last is
the group of medical tourists who seek banned procedures that are not allowed legally
in home countries of foreign patients, such as stem cell therapy. It is therefore often
difficult to define the market and determine the size. One, there is a large number of
expatriates who have been living in India for a long time. They might hold insurance
policies from the host country or might be covered by some other type of security.
Many of them are earning in India and therefore pay in Rupees like any other
domestic medical tourists. Many service providers tend to use a differential pricing
policy for international medical tourists. Many expatriates have friends and visitors
who register themselves as domestic patients. Similarly, there are many non-resident
Indians (NRIs) and persons of Indian origin (PIOs) who seek medical treatment as
domestic patients while on holiday back home. Further, nationals of neighbouring
I
n
c
r
e
a
s
i
n
g

n
e
e
d

f
o
r

f
o
l
l
o
w

u
p

c
a
r
e



35
countries with or without relatives in India also present themselves as resident
patients. Similarly there is a segment of tourists who give ayurveda, yoga and similar
therapies a try for sake of excitement rather than expressively requiring a medical
treatment(fig. 1.11). Further there are huge medical establishments who cater only to
affluent segments of Indians from other states. Examples are select hospitals in
Mumbai who cater to Gujratis, Marwaris and Parsis. They are reluctant to cater to
international tourists where they would have to undergo the hassle of accreditations,
documentation, etc. This is large domestic medical tourists segment that is not
accounted for in the definition of the market.
Fig. 1.11
Classification based on Perceived risk in Medical Treatment



Low risk procedure High risk procedures with Banned procedure
with high price differential less attention price difference in home country


Source: Chen, Kuo, Chung, Chang, Su, & Yang, 2010
1.6 MARKET DESCRIPTION OF MEDICAL TOURISM
1.6.1 Medical Tourism Market with other factor
The market description is based on an analysis made of the medical tourism
reality, what services operators offer how countries market their destinations and
package them with medical treatments, the social issues that have arisen and the
effects of the absence of a legal framework to keep up with the development of the
medical tourism niche market. The flow of health tourist also explains how
infrastructure in medical tourism destinations are changing in order to host tourists,
they are by giving special attention to the safety and technological requirements,
among other things, in an effort to compete against medical institutions in various
regions for the medical tourist's disposable income. The figure no. 1.12 provide a
better understanding of the current status of medical tourism and anticipated
developments, given by Caballero Danell & Mugomba, (2006) have developed a map
in order to document all Information collected for describe market descriptions.


36
Fig. 1.12
Market Description of Medical Tourism








Source: Caballero Danell & Mugomba, 2006

1.61.1 Product
Researchers within field of medical tourism predict and approximately 40
million global medical tourists in 2010 (Jeffery, 2006). While the medical tourism
package may generally be divided into two main elements: the medical procedure and
the holiday/leisure element there are ancillary elements that make the package
possible. An Indian corporate hospital websites indicates that the main consistent
elements are of a package are; medical treatment, personally tailored leisure packages
to aid healing, translators, luxury accommodation during the course of the treatment,
car rentals, visa and foreign exchange expertise, coordinators and emergency medical
assistance. The medical component of the medical tourism package may include any
one or more of the following services, which would be complemented by a leisure
component as well, either after or before the medical procedure.


Consumer
Benefit
Branding
Legal
Framwork
Infrastructure
Target Market
Social Issues
Operators
Communication
Channel
Product


37
Table 1.3
Types of Services provided in Medical Tourism
Serious Illnesses Cosmetic Surgery
Plastic surgery
Skin Treatment
Health control check
Orthopaedic
Heart
Magnetic Resonance
Dialysis
Rheumatism
Psoriasis
Pain Management
Rehab
Neurology
Health Coaching
Health control
Balance week (stress treatment)
Private-coach week (work-out treatment)
Back in form (overweight)
Re-start program (serious lazy asses)
Stress treatment
Massage and Spa
Balanced diet theory & practice
Skin Diseases
Teeth Surgery / Treatment Sight Treatment
Bleaching with laser
Teeth-coloured filling
Ceramic Inlays
Porcelain veneers
Crowns and Bridges
Implants
Gums Treatment
Dental Care (for adults and children)
Dental Surgery
Lasik surgery
Eye Diseases


1.6.1.2 Social I ssues
Medical tourism yields many benefits for the economies of countries that
choose to partake in the tourism industry. Apart from being good for the country's
image, expenditures by in bound medical tourists contribute to national reserves of
foreign currency thus increasing the host countries national income which ideally is
re-invested into economy through the provision of public services. The rewards to the
tourist industry, and especially the hotel sector, are considerable because of the often
necessary stay required of the patient for recuperative purposes (Connell, 2006:8). As
a niche market within tourism the market description reveals while there are plenty of
economic gains.


38
There are some sentiments that what medical tourism comes down to is
subsidized MDCs (more developed countries) health care at LDC (less developed
countries) rates. Generally the key countries identified thus far in this research that
promote medical tourism are relatively less-developed such as India, Malaysia,
Thailand, South Africa, Mauritius, Mexico and Antigua. According to the World
Health Organisation (WHO) the ideal export strategy for health services in any
country must be based on the principle that the primary obligation of governments is
to provide universal coverage of health care to their local communities. Therefore the
development of an export strategy is secondary. The literature reviewed thus far does
not give any indication of whether medical tourism destinations offer adequate
national health care services for the locals. However there seems to be a uni-
directional medical tourism flow which the articles and sources researched thus far do
not dispute i.e. that people are moving from developed to less developed countries
seeking affordable medical treatment.
The impracticality of surgery follow-up due to the geographic distance once
the medical tourist leaves the host destination is another important issue as the risk of
surgery gone wrong and the inability to remedy it contributes to the other associated
risks of consuming medical tourism. Of growing concern is that if medical services
can be marketed like consumer goods such as cars, TVs and home appliances then
the ease of consuming a medical tourism package may result in individuals opting for
unnecessary surgery. This ease of obtaining medical treatment is of concern to some
health care experts as "The surgery may be too soon. This is one of the 'side-effects' of
having surgery too available, (Nachammai, 2006:1).
In India, where medical tourism generates significant income for the country,
private corporations run the large specialist hospitals catering to tourists medical
needs. The government subsidizes these corporations on the premise, ideally, that a
proportion of the revenue will revert back to finance the public sector but this hasnt
happened yet (Gupta, 2007). This revenue is meant to give the public sector the means
to improve the public service healthcare quality and ensure that the service will be
delivered at zero costs. Gupta (2007) explains that the more medical tourism develops
the higher the demand for professionals to work in the private medical care sector.


39
These professionals are lured from the public sector thus generating a shortage of
skilled specialists in the public hospitals. Nevertheless, the impacts of medical
tourism are not only negative. A positive outcome is the probable return of Indian
medical professionals, residing abroad, to India as medical tourism opens up new
employment possibilities in their country of origin (Ramesh, 2006).

1.6.1.3 Legal framework
Experiencing double-digit growth medical tourism is forecasted to grow to 40
million trips or account for 4% of the global tourism volume by 2010. However the
legal aspects of medical tourism are undefined at present. Given the anticipated
growth of the medical tourism niche market by the corporate sector this suggests a
need for the development of a framework of global standards or at least guiding
legislative framework. The following discussion highlights issues surrounding the
absence of a global legal framework.
All medical procedures performed abroad or at home carry an element of risk.
Even routine surgery may sometimes lead to medical complications. A patient may be
dissatisfied with the results of their surgery or medical treatment, and wish to seek
legal recourse. Currently there is no international governing regulation for medical
tourism. The regulation of goods and services has long since been the function of the
World Trade Organisation (WTO). Under the umbrella of GATS (General Agreement
on Trade of Services) there are four modes of supply of which consumption abroad
is the most relevant mode to the subject of our research as it refers to the crossing of
geographic borders to obtain health services i.e. medical tourism (Smith, 2006).
In the United States (US) the lack of adequate health insurance, which affects
more than 43 million people, is one of the reasons motivating Americans to seek
surgery interventions abroad. Individuals without health insurance have great
difficulty accessing the health care system and frequently do not participate in
preventive care programs. When health problems arise they seek more affordable
medical treatment options abroad (SeattlePI.com). Adams (2005) in an article
appropriately titled Medical Tourism, affirms that part of the price that is paid for
surgery in the United States not only goes to tedious paperwork but also to pay all the
types of malpractice insurance doctors have to get in order to perform surgeries. The


40
cost of malpractice insurance in the US is USD 100,000 while the comparable
malpractice insurance in India is USD 4000. This is due to the affinity that Americans
seemingly have for taking legal action. In other countries the general practice is to use
disclaimers that the patient signs where he/she agrees not to sue the hospital or
doctors under certain conditions. While the disclaimer protects the medical tour
operators they leave the patients relatively vulnerable to unscrupulous medical
professionals. However it must be noted that it is in the best interest of the medical
tourism destinations to provide impeccable services as anything less would be
detrimental to their branding efforts.
As medical tourism increases worldwide, it is likely that an international
regulatory authority will come into being. Currently the consequences of this lack of
international agreements related to insurance coverage and payments for treatments
serve as a constraint in the medical tourism development. If an international legal
framework were to come into place then issues of jurisdiction between a patient's
home country and the country where the medical treatment was availed can be
resolved.
1.6.1.4 Consumer benefits
Untimely and rising medical care costs are the qualms that most would be
medical tourists have with the health services in their own countries and are thus
driving them to seek medical care abroad. A review of medical tourist packages and
medical tourist testimonials reveals that there are many incentives for engaging in
medical tourism. Perhaps the biggest incentive is there are no waiting queues for
treatment as the medical tourism operators and intermediaries are not only working to
deliver cost-effective procedures with leisure as an added feature but to provide the
procedures in a timely manner. Research indicates that surgery is 30% to 70% cheaper
than in the home country of the medical tourist. An indication of prices quoted on the
Global Health Tours website as at the time of our research ranged from US$69,000
(India) for bone marrow transplant as opposed to US$250,000 (USA), US$6,000
(India) for orthopaedic surgery as opposed to US$20,000(USA) or root canal
procedures performed by top dentists in both destinations; US$1,000 in the USA as
opposed to US$100 in India (Travelite India, 2006).


41
The temporary residences that patients and accompanying persons are placed
in during the stay of their visit is of 4 to 5 star luxury quality, with hospitals
resembling more luxury hotels than a general ward for post-op patients. After the
procedure there is the opportunity to engage in the more conventional forms of
tourism; as the destinations researched, are established and well-recognised leisure
travel destinations. Having surgery abroad also offers a degree of anonymity for those
wishing privacy from family and friends in their home countries. It also awards some
the opportunity to have medical procedures that may be legislated against in their
home countries.
1.6.1.5 Target Market
Previous studies on health-care tourism identify two types of marketing
segments; 1) health afflictions that prompt individuals to seek health-care tourism and
2) income levels (Goodrich & Goodrich, 1987). As a subset of health tourism this
may be applied to medical tourism as well. Perhaps most importantly the main
purpose of market segmentation is to distinguish between consumers seeking wellness
tourism (spa or the seemingly popular Ayurveda treatment from India) and those
seeking medical surgery (invasive surgery).
Within the framework of this study candidates for medical tourism are people
who have been waiting for surgery for a substantial period of time in their country of
residence, who either have deteriorating health afflictions that require immediate
attention or those who are simply tired of waiting. Today in many Western countries
the public health system is under attack for inadequate and untimely provision of
services as needed. The NHS (National Health Service) in Britain is currently
embroiled in conflict with health-related unions over mass retrenchment to remedy
budget deficits (BBC News, 2006). In the US there is currently a health care crisis in
California where the privatisation of the health care has resulted in sky rocketing costs
and 7 million people without health insurance and a reported 46 million people
nationwide without adequate health cover (The Mercury News, 2006). These are few
examples of systemic failures at national level that are in fact creating opportunities
for medical tourism destinations in other countries.


42
Demographics have also had an influence on the medical tourism target
market. The increasing pressure on national healthcare systems may also be attributed
to a change in the demographics of regional Western Europe and the USA. According
to findings by an independent industry analysis specialist firm, Datamonitor, aging
populations in the US and Western countries in general are putting a strain on heath
care systems; where in the US it is reported that an estimated 76 million baby
boomers will turn 65 years old in the next 10 years. One of the implications of this has
seen growth in outsourcing and off-shoring activities (Datamonitor, 2005).
In addition the target market also includes uninsured and under-insured
consumers seeking more affordable health treatment outside of their home country.
Almost all of the medical tour operators websites analysed revealed that within the
testimonial section where past patients documented their experience of the medical
tourism package, the two most prominent factors motivating them to seek medical
services abroad were long waiting lists and the significant price differences (Globe
Health Tours, 2006).
In any industry, technology, manufacturing or service-based, sometimes
market forces will dictate market feasibility. Global issues today are examples of such
market forces that affect both conventional tourism patterns and the medical tourism
sector. As a consequence medical tourism is not immune either. Within conventional
tourism there is significant research and evidence that shows the impact on the
industry of wars, natural disasters, epidemics and other significant natural and man
made catastrophes. Post-2001, the Gulf region provides an example of a destination
whose target marketing strategy in terms of out-sourcing patients had to be re-
developed. In general, citizens of countries within the Gulf region are increasingly
more likely to encounter visa problems for travelling to the US for healthcare than
before. However this has proved to be a win-win situation for countries such as India,
Singapore and Thailand, tipped to be the emerging giants within the medical tourism
industry (The Hindu Business Line, 2004). Healthcare tourism planners in India,
according to a medical expert in India, should address two gaps; health insurance that
comes with contingency cover for foreign patients and a well-defined role for tour


43
operators, the former as discussed earlier under the social issues theme (The Hindu
Business Line, 2004).
Wellness tourism is more tailored for people seeking a form of relaxation or
stress relief at a spa or yoga retreats or suitably equipped wellness centres. This leads
us to what we consider an ideal illustration of the primary difference between medical
tourism and wellness tourism that reiterates the definition of medical tourism as
presented in the in this study. While a medical tourist product has two components,
the medical procedure and the leisure element, wellness packages are single units for
example a spa resort, a wellness clinic or a yoga retreat. The market review reveals
that the target marketing strategies destinations adopt to market the two entities as a
single package have to be complemented by an appropriately effective branding
campaign to over come some of the social issues by highlighting the benefits of
medical tourism. While prominent social issues have already been highlighted a
discussion of the various identified branding strategies within medical tourism is
necessary.
1.6.1.6 Branding
In this section the description of the observed branding strategies will be
supplemented by reviewed branding academic literature. The purpose of this is an
attempt to rationalize the varying strategies adopted by medical tourism destinations
or medical operators within destinations. Tourism research has shown that the tourism
product image, be it a destination, event or trip has become a key marketing concept
that has a bearing on the decision-making process for the consumer. In the case of
tourism-related travel, according to Hem and Iversen (2004) there is sufficient
evidence from past studies, which shows that perceptions of destinations and the
resulting purchases or travel decisions are positively correlated.
The concept of branding is defined as a name, term, sign, symbol, design,
logo, slogan or a combination of these, and used to identify the goods or services of
one seller or group of sellers and to differentiate them from those of competitors
(Doyle, 1998 as cited in Singh, 2004:94; Hem & Iversen, 2004:84). As an extension
of this destination branding, is the selection of a consistent element mix to identify
and distinguish the destination through positive image building (Hem & Iversen,


44
2004). While we agree with the provided definition of branding we find it somewhat
lacking for the purposes of this study. We propose another element; pre awareness of
the destination be it through 1) history; for example the historical connection between
India and Britain and the attendant ethnic migration of Indians to Britain, and the
reserve migration of Indian doctors armed with British medical qualifications and
contacts setting-up medical facilities in India, 2) familiarity with the destination
through previous visits or media representation, 3) or the close migratory patterns
between Mexico and North America or Asia as an established destination of Western
Europe holiday-makers.
As is common in many sun, sea and sand destinations the destination image
has emerged as a crucial marketing concept in the tourism industry (Echtner &
Ritchie, 1991, p. 4; Kim & Richardson, 2003 as cited Hem & Iversen, 2004).
Evidence of this differentiation can be found in the use of slogans. Within product
branding, slogans are short phrases that communicate descriptive or persuasive
information about a brand and they summarize the intent of a marketing campaign
thus contributing to brand equity. This argument for product branding through slogans
may also be ascribed to destination branding within medical tourism (Keller,
2003:204). A review of certain medical tourism destinations slogan use suggests that
their function as a branding tool is twofold. Firstly, it is to re-iterate an existing brand
of the destination as a travel destination. Secondly, to engender an awareness of what
the destinations additional medical tourism product offering while simultaneously
differentiating the destination from competitors (Hem & Iversen, 2004).
According to Hem & Iversen (2004) the purchase of a destination mix
(geographic site, activities, duration etc) has an inherent uncertainty. The intangibility
of tourism service products disallows the consumer from conducting a trial run before
committing to the purchase. Within medical tourism this uncertainty may be further
exacerbated by the nature of the tourism product, a medical procedure. The
geographic discrepancy between the potential consumer and the host destination may
also lead to even higher uncertainty levels. Therefore, the decision involves greater
risk and extensive information search and depends on tourists mental construct of
what a potential destination has to offer relative to their needs. Thus brands have to be


45
strong enough overcome this uncertainty by increasing customers trust of the
invisible, enable them to better visualize and understand the intangible benefits of the
services (Singh, 2004).
Whatever the case may be the branding campaigns appear to be working as
Globe Health Tours (an American tour operator) claims that there is a wave of North
American and European patients heading to well-established medical tourist
destinations mainly India, Thailand and Singapore for top-class orthopaedic surgery,
plastic surgery, infertility treatment and cardiology that come much cheaper than in
their home country. Some medical tourism campaigns feed of existing knowledge of
the destination perhaps due to advances in other industries while for others history
may serve as a better platform. Whatever marketing platforms exist, as a typology of
tourism, branding is an important element of perception creation. With this
knowledge, tourism marketers today target the senses of would-be-tourists, creating
tantalizing images, which perhaps lead to the consumer subconsciously correlating a
positive perception of the destination product and ones own needs (Hem & Iversen,
2004).
1.6.1.7 I nfrastructure
This not only refers to the actual construction of facilities, hotel/resort quality
hospitals, but also externalities within the medical tourism framework such as the
local community, medical advances in technology and intellectual capital. Research of
the niche market shows that there have been various strategies implemented within
the different medical tourism destinations in an effort to aid market development.
According to an Asian Wall Street journal article, Malaysia's government permitted
the promotion of hospitals and medical tourism packages overseas (Kilrich, 2004).
There are many other government initiatives that have been undertaken to facilitate
the development of medical tourism in various developing countries.
As mentioned earlier the evidence thus far reveals that tourism medical tourist
flows are predominately uni-directional, from more developed to less developed
nations. The medical tourism enterprises from destinations reviewed have, to some
extent, government involvement in the development of infrastructure for this tourism
typology. Be it through more efficient systems for processing incoming visas for


46
those seeking the product or providing marketing platforms to better enable the
medical tour operators to reach target markets. As a consequence perhaps its the
scale of resources required to enter this niche market that prompts government
involvement. India is a prime example, where the Ministry of Health and Family
Welfare and the Ministry of Tourism have actively developed policies and
infrastructure tools to encourage the growth of the industry. The Incredible India
homepage (official) has links to health tourism sites. Other initiatives taken up by
governments include the health sector of Barbados where, a media article from 2005,
purported that the highly specialised Invitro Fertilisation programme currently being
developed will serve as a platform for medical tourism towards the Caribbean
destination in a effort to diversify the incoming tourist typologies.
In countries such as Oregon, the Netherlands, Sweden, New Zealand, Norway,
Denmark, Israel, Switzerland and the United Kingdom, politicians and governments
in their role as policy makers or health funders, health insurers, and health
professionals are asking which health services should be publicly funded, for whom
(Edgar, 2000:190). There is a general trend towards privatisation of healthcare, which
in turn leads to a reduction in subsidized healthcare. It is widely accepted that in any
economy the privatisation of health ideally leads to more efficient delivery of health
services however this is usually accompanied by an increase in average health costs as
mentioned under the target market theme the NHS (National Health Service) in the
UK. Nevertheless governments sometimes deem it is necessary to provide a
framework for the development of private health care in an attempt to ease the
demands on the public health systems and the national budget.
Another infrastructure issue is the absence of certified medical tourism
statistics. The absence of defined characteristics to collect statistics means that the
actual market size of medical tourism is unknown except for claims by governments
and medical groups about the annual medical tourists that visit their destination. India
has an annual Medical Tourism Expo and it has been predicted that medical tourism
will earn India as much as US$2 billion by 2012 (Connell, 2006:4). This serves as an
economic indication of the size of the medical tourism market. The implication of this
on our research is that while the are many articles that coin this niche the new tourism


47
with positive rapid growth perhaps it has always been around only now its become
publicised. The many different labels that can be loosely applied to this type of
tourism well-being tourist, health tourist, surgery tourist, medical tourist and
cosmetic tourist among others also make it challenging to quantify and qualify the
niche market.
As a subset of tourism, observations reveal that for the medical tourism market
to grow an efficient logistics system is necessary to facilitate this predominantly
unidirectional flow. Targeted consumers must have easy access to the medical tourism
destination. Despite the strategies: branding, product, pricing among others, that a
medical destination may develop, our research reveals that all actions are futile if the
consumption of the service is anything but easy. For example if acquiring a visa for
the medical tourism destination requires going through many channels then would-be
medical tourists are better off on the waiting lists for surgery within their home
countries. Or if travel connections between the consumers home market and the
medical tourism destination are such that the opportunity cost of foregoing medical
tourism is more favourable then the consumer is most likely not to engage in medical
tourism.
1.6.1.8 Distribution Channels
Within the tourism and hospitality industry, as modes of distribution, service
intermediaries have a number of standard functions which include: 1) making services
locally available when a geographic distance exists between the consumer and the
producer, 2) gathering the appropriate service components to make packages and
retailing them, 3) building relationships between the consumer and the producer and
4) to some extent co-producing the service (Bitner & Zeithaml, 2003). Interestingly,
according to Bitner & Zeithaml (2003) traditional service providers with a limited
distribution area such as doctors and dry cleaners, opt not to use distribution channels
as they directly distribute their services consumers. Therefore, with the rise of medical
tourism are doctors still defined as traditional service providers?
Danell, 2006 has developed model below to categorise specific channel
distribution such as the Internet and conducting a comparison between different


48
operators that use this channel as a primary marketing medium and possibly
benchmarking.
Fig. 1.13
The Medical Tourism Distribution Channel Model
















Source: Mugomba & Caballero Danell, 2006

This model(fig.1.13 ) has to categories three identified channel distribution
modes that link the consumer to the destination; operators, representatives within
targeted consumer markets that are also referred to as intermediaries and word of
mouth. Only the first two channels have been explored as the sources used during our
study were secondary sources. Therefore no accounts by medical tourists were
included. A comparative discussion was made of the different operators' choice of
distribution media and also a look at the operations of intermediaries.
1.6.2 Competition
Thailand, Singapore, Malaysia, India and Philippines are the major
destinations in the Asian medical tourism market. Thailand is more popular among
Western European medical tourists for cosmetic surgery. Singapore and India
specialize in complex procedures with India having a cost advantage and Singapore a
Medical Tourism
Operators
Representatives in the
consumers country
Word of mouth
Consumer
(Patient)
Destination
Distribution Channel Model



















49
technology advantage. Global economic downturn has resulted in decline in visitors
numbers in Singapore and the same holds true for medical tourists also. The health
care industry in Thailand has seen rapid growth in recent years, ahead of the countrys
GDP. In Thailand, medical costs are lower than in Singapore and also, it is a much
more popular tourist destination. The cost of healthcare in Thailand is about five times
lesser than it is in the US. The government of Singapore has formed a collaboration of
industry and government representatives to create a medical hub in Singapore. The
Malaysian government is aggressively promoting medical tourism. It has extended the
visa period for health tourists from one month to six months. Major hospitals in
Malaysia are targeting new markets such as Vietnam and Cambodia.
Taiwan provides high- quality healthcare at very competitive prices but is a
slow starter. A liver transplant costs half as much in Taiwan as in Singapore. China is
a key target market for Taiwanese hospitals. The government has announced a $318
million project to help further developed countries medical services.
The Korean government is promoting the nations growing medical tourism
industry and has set a target of 100,000 foreign patients by 2012. However, Korea is
considered to be a latecomer in medical tourism industry.
India is one of the lowest cost and highest quality of all medical tourism
destinations. It offers low- cost cardiovascular and orthopaedic procedures, at about
one- tenth the cost of similar surgeries in the US (Koncept Analytics, 2009).
1.6.3 Market Drivers
Over the years, the medical tourism industry has become quite large. In 2008
Deloitte estimated that the world medical tourism market in 2008 was around US$ 60
billion and that it is expected to grow to US$ 100 billion by 2010. It is also estimated
that around 6 million people a year worldwide will travel for medical care by 2010
(Herrick, 2008). Whereas at the beginning of the rise of the medical tourism industry
there were only a handful of hospitals and only about 4 or 5 countries promoting
themselves as medical tourism destinations, today there are hundreds of hospitals and
clinics and over thirty different countries promoting it (Edelheit, 2009).


50
On the demand side, factors contributing to the growth of medical tourism are
closely intertwined. Authors agree that rising health care costs in industrialized
countries coupled with the availability of high-quality medical services at
significantly lower prices in developing countries has become the primary incentive
for patients seeking treatments abroad. According to Deloitte (2008a), medical
services in India, Thailand and Singapore can be as low as 10% of those in the United
States. Other research indicates that surgery is 30% to 70% cheaper than in the home
country of the medical tourist (Caballero-Danell and Mugomba, 2007) and even 80%
in some cases (Herrick, 2007). For example, an open heart surgery may cost about
US$ 150 000 in the U.S. while in Indias best hospitals the costs range between US$ 3
000 and US$ 10 000 (Connell, 2006). An MRI in Brazil, Costa Rica, India, Mexico,
Singapore or Thailand costs between US$ 200 to US$ 300, compared to over US$ 1
000 in the U.S (Herrick, 2008). According to prices quoted on the Global Health
Tours website, a bone marrow transplant and a root canal procedure in the U.S. cost
about US$ 250 000 and US$ 1 000 respectively, as opposed to US$ 69 000 and US$
100 in India (in Caballero-Danell and Mugomba, 2007). Mattoo and Rathindran
(2006) add that there is significant evidence that the upper-end of the quality
distribution of both professionals and hospitals in several advanced developing
countries lies well above the minimum acceptable standard in industrial countries.
Because of this, many medical tourism destinations are proud to offer first-class
services at third-world prices.
Rising incomes in industrialized countries have also fuelled the demand side
of medical tourism. Although medical procedures and treatments are considerably less
expensive in developing countries, a medical tourist needs to have enough disposable
income so as to be able to pay for the medical and traveling costs out-of-pocket, given
that most of these procedures are not covered by health insurance companies. Higher
incomes have also translated in the possibility of buying more wellness and
preventive medicine (Bookman and Bookman, 2007). According to Connell (2006)
medical tourism has been particularly attractive to elites, even -perhaps especially- in
developing countries. Nevertheless, other authors disagree claiming that what is
different about the current trend in medical tourism is that traveling to other countries


51
in search of medical care is no longer exclusive to elites paying premium prices
abroad, but is rather accessible to the mass population which now has the possibility
of medical care and leisure abroad at a cost-effective price (Caballero-Danell and
Mugomba, 2007). Horowitz, Rosensweig and Jones (2007) identify two types of
medical tourists in the United States: one group of patients is middle-class adults with
no health insurance or inadequate coverage; the other group is people searching for
treatments that are not covered by their health insurance such as cosmetic surgery,
fertility treatments and gender reassignment procedures. What is common in both
groups, however, is that they have enough resources to purchase healthcare in low-
cost medical tourism destinations but insufficient to afford the same services in their
home country.
The development and expansion of medical tourism has not only been
demand-led but has also resulted from the countries ability of supplying high quality
medical services at significantly lower prices. Strong economic growth in developing
countries has provided the resources and opportunities to improve capacity and
infrastructure constraints that had hindered the development of this industry in the
past (Deloitte, 2008a). Horowitz, Rosensweig and Jones (2007) claim that it is due to
these advances that potential medical tourists today are able to compare prices and
arrange healthcare travel plans anywhere in the world. Similarly, Bookman and
Bookman (2007) point out that new telecommunications technologies such as
telediagnosis and teleanalysis have reduced geographical barriers and have facilitated
the cross-border trade in medical services. The Internet, as the most effective
communication channel for the medical tourism industry, has made possible, for
example, video-conferencing between patients and doctors as well as real time
guided tours of medical facilities (Caballero-Danell and Mugomba, 2007).

1.6.4 Customer Satisfaction
Customer satisfaction is a critical issue in the success of any business system,
traditional or innovative (Ho & Wu, 1999). Customer satisfaction, a business term, is
a measure of how products and services supplied by a company meet or surpass
customer expectation. Customer satisfaction is the ultimate result of meeting a
consumers expectation from the performance of products. Most satisfied customers


52
normally have the intention to re-purchase the products if product performance meets
his or her expectation (Alam & Yasin, 2010).
Customer satisfaction is an abstract concept and the actual manifestation of the
state of satisfaction will vary from person to person and product/service to
product/service. The state of satisfaction depends on a number of psychological and
physical variables which correlate with satisfaction behaviours such as return and
recommend rate. The level of satisfaction can also vary depending on other factors
such as other products against which the customer can compare the organization's
products.
Customer satisfaction is defined as result of cognitive and effective evaluation,
where some comparison standard is compared to the actually perceived performance.
If the perceived performance is less than expected, customers will be dissatisfied. On
the other hand if the perceived performance exceeds expectations customer will be
satisfied (Kang, 2006).
Work done by Parasuraman, Zeithaml and Berry (1991) delivered
SERVQUAL- an instrument which provides the basis for the measurement of
customer satisfaction with a service by using the gap between the customer's
expectation of performance and their perceived experience of performance. This
provides the researcher with a satisfaction "gap" which is semi-quantitative in nature.
Cronin and Taylor extended the disconfirmation theory by combining the "gap"
described by Parasuraman, Zeithaml and Berry as two different measures (perception
and expectation) into a single measurement of performance relative to expectation.
1.7 MEDICAL TOURISM VALUE CHAIN
Acharyulu and Reddy (2004) (Fig. 1.14) conceptualised value chain for an
international patient as following:
Medical travel operators can be broadly classified into two groups. First, there
are medical service providers such as hospitals and clinics. Hospitals that actively
attract international patients are not involved only in the medical procedure itself, but
are, in many cases, also responsible for all patient logistics from arrival to departure.
Often the hospitals involvement starts before arrival with the processing of the visa
requirements and ends only after departure with patient follow up.


53
Figure 1.14
Value Chain for International Medical Tourist

















Adapted from Achayulu and Reddy (2004)

Source: Adapted from Achayulu and Reddy (2004)

The second group consists of medical travel facilitators who function like
agents and associated service providers. These are often smaller companies with just a
few people on their payroll and most of them have spread their risk by dealing with
hospitals and clinics in a number of different countries. Those medical travel agents
which are dealing exclusively with hospitals of only one country or region are
exposed to the same risks as the hospitals with which they work.
These facilitators offer global health-care options that will enable international
patients, primarily from source countries to access international health care at fraction
of the cost of domestic care or shorter wait time. By selling a type of medical value
travel, they focus particularly on the self-insured patient. Some companies charge
International
patient in need
of health care

Airport pick-up
transport,
receiving patient

Planned hospital
accommodation
hotel hospital

Planned hospital
accommodation
hotel hospital


Information
centre in the
country internet

Hospital
scheduling/patient care
management/pre &post
operative care


Dropping at
airport


Air ticket booking
for air travel

Tourism plan
recreation/
sightseeing visits

Flow on Information

Movement of patients


54
clients a flat rate commission or a percentage of the total cost of care. Others do not
directly charge customers, but are paid by the hospitals to which their clients travel
for treatment.
The companies typically provide experienced nurse care managers to assist
patients with pre and post procedure medical issues. They also help provide resources
for follow-up care upon the patient's return. Medical travel packages can include all
costs associated with medical care, air and ground transportation, hotel
accommodation, provision of a cell phone in the destination country for ease of
communication, practical assistance from a local company representative at the
health-care facility, travel arrangements for a companion, stays in nearby resorts
during the post-operative recovery period and vacation to tourist destinations.
For the purpose of this study a simple medical tourism value chain is
considered. It broadly comprises of three components/ stages (Keckley & Underwood,
2008) (See Figure 1.15).
Figure 1.15

Medical Tourism Value Chain








1.7.1 Pre Procedure Stage
In this first stage the tourist is typically engaged in navigating the process and
arriving at a decision to buy the procedure. A customer enters the procedure with
search of relevant information from various sources. However, given the complexity
many customers prefer to use services of an intermediary referred to as medical
facilitator. Prime responsibility of the medical facilitator is to seamlessly coordinate
the outbound medical tourism programme.
Medical facilitators are intermediaries that guide the use of medical tourism
for patients who find using their services more convenient and expedient than
organising various service providers on their own. They offer single window solutions

Pre procedure
stage

Procedure
stage

Post-procedure
stage


55
to the customers. They have experience in the medical tourism process and are able to
address any concerns or questions that patients might have. Facilitators also provide
assistance with logistics and travel arrangements. Patients may even be able to get
lower rates from medical facilitator than directly from clinical programmes abroad
(Keckley & Underwood, 2008). A medical tour operator is an important facilitator.
Literature has referred to four types of medical facilitators- Medical Travel
Planners, Travel Agencies, Hotel Groups and Provider Groups. Long before the actual
medical procedure/ treatment, a customer must decide about a number of key issues,
including the choice of facilitator, hospital, doctors, destination country, costs,
conveniences, risks, etc. not necessarily in that order. Pre procedure stage typically
ends with patient reaching the destination.
1.7.2 Procedure Stage
This is the key component of the medical tourism value chain. Procedure stage
begins with patient reaching the destination and hospitals/ service providers offering
pickup facilities followed by pre-counseling for treatment, necessary medical
examinations required before the medical procedure.
Medical procedure includes preparing for the procedure, organising a doctor
and Para medical team, operating theatre, procedure, prosthesis, medical supplies, etc.
1.7.3 Post Procedure Stage
Post procedure stage has two important components the post operative care
and follow-up care. The post operative care includes doctors visits and monitoring
for complications, recuperation in hospital and physical therapy, medical supplies,
meals, post operative recuperation in destination country but outside the hospitals, etc.
An important concern of medical tourist is the follow up care facilities long after they
have left the country of treatment.
Normally there is a tie-up between the medical service providers and doctors
in the customers country who are responsible for follow up on behalf of service
provider. After the post operative care when the tourist is fit to move around, he/ she
may demand post treatment leisure as a part of the package.


56
1.8 SELECT COUNTRY EXPERIENCES
The joint initiatives of tourism and healthcare industries are reasons for
success in some countries. Government has taken initiatives to support the tourism
and healthcare industries in other countries by way of policy packages, aimed at
creation of infrastructure attracting healthcare tourists. Some countries are leveraging
its capabilities of offering traditional wellness systems, which becomes their unique
proposition and sharpen their competitiveness. In this section, such country
experiences are summed up for select countries.

1.8.1 Thailand
Tourism industry has been regarded in Thailand as one of the prime activity
that contributes to the national economic development. Thailand has been
highlighting elements such as Spas and alternative therapies in their promotional
strategies for several decades. However, since late 1990s, Thailand has been
emphasising the state-of-the-art hospitals and skilled medical professionals in their
promotional strategies. Healthcare tourism is positioned as an extension of its well-
known Spa and wellness treatment offerings. Many hospitals in Thailand have
installed technologically advanced equipments such as Gamma Knife Brain Surgery
equipments. Thailand has also been emphasising on associated services such as health
check-ups, optical services, dental services, rejuvenation and skin care, face lifting,
rhinoplasty, breast augmentation or reduction, fixing of ear and digital hearing aids.
In addition to having state-of-the-art hospitals and technologies, Thailand has
developed high professionalism in healthcare tourism in such a manner that many of
the hospitals are furnished like a hotel, and customers are treated as hotel guests rather
than patients. Hospitals provide ambulances or other such transports at airport for
transfer of patients as also the accompanying persons. With world-class medical
facilities and specialists, and warm hospitality of service staff, patients are attracted to
come to Thailand for vacationing and treatment.
The experiences of hospitality and tourism industry, particularly the travel
agents, have been successfully leveraged by the healthcare industry in Thailand.
Further, the innovative promotional strategies of the national carrier, Thai Airways


57
International, have also helped in development of healthcare tourism industry in
Thailand.

Communication technology has also been leveraged by the healthcare tourism
industry in such a way that the patients can identify and select the hospital / doctor
suitable for the treatment, identify the favourable destination for holiday /
recuperation, seek online appointments for various healthcare services, and customise
the required packages with the travel / tourism operator. The hospitals are also
equipped with equipments for receiving patient history through satellite.
Major hospitals in Thailand have set-up recuperating facilities at tourist
centres such as Phuket or Chiang Mai. The city of Chiang Mai, in particular, is
branded as a healthcare destination with its blend of Spas and high-quality, low-cost
medical, dental and therapeutic services. The city has about 10 private hospitals with
over 2000 beds and 700 doctors, currently operating at 50% capacity on an annual
basis.
It may be mentioned that aggressive and collective marketing by all
stakeholders, including the Royal Government of Thailand, has positioned the country
in the global map of healthcare tourism. In the Marketing Plan (2005) of the Tourism
Authority of Thailand (TAT), healthcare tourism has been identified as a major
Special Interest tourism product to be promoted in all of its geographical markets.

TAT has been collaborating with the Ministries of Public Health and
Commerce (MOPH) to implement a national strategy to develop Thailands potential
in the field of health and wellness. TAT has identified staff training and skill
development as a major requirement for development of healthcare tourism sector.
MOPH is collaborating with the Thai Spa Association to formulate procedures for
accreditation and certification, to ensure international quality standards.
Hospitals are encouraging the staff to develop their language skills targeting
the international patients. Many hospitals have staff with knowledge of Japanese,
Arabic and English to cater to the requirements of international patients.


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1.8.2 Singapore
Singapore has been considered as one of the successful countries in attracting
international tourists. The travel and tourism industry contributes significantly to
national economy. The healthcare market in Singapore is a mixed basket comprising
competent public and private sector service providers. Together, they provide quality
healthcare services, both for Singaporean and foreign patients. The trend in market
share of private and public sector healthcare services in Singapore (in terms of
workload and revenue based on inpatient discharges and day surgery) during 1993-
2002, indicates that the private sector market share has shrunk from 20% in 1993 to
16% in 2002 in terms of workload, and 43% in 1993 to 36% in 2002 in terms of
revenue. However, private sector has been contributing significantly to international
patients in Singapore. During the period 1993-2002, the share of private hospitals in
catering to foreign patients, both for day surgery as well as inpatient services,
remained around 80%.
Singapore on its records has several achievements in healthcare: these include
worlds first successful peripheral blood stem cell transplant and cord blood transplant
from an unrelated donor; Asias first unicompartmental arthroplasty; Southeast Asias
first heart transplant using an Electronic Heart Assist (Left Ventricular Assist Device),
and first adult living donor liver transplant; successful separation of craniopagus
conjoined (joined at the head) twins from Nepal; and successful completion of tooth-
in-eye surgical procedure. Singapore has also significantly achieved quality and
technological ability in healthcare sector. It may be mentioned that the Centre for
Transfusion Medicine in Singapore is internationally reputed for its high standards of
blood safety practices and management of blood transfusion services.
Singapore projects itself as a destination for international tourists with its
highly developed transport and communication infrastructure, good living conditions,
orderly and tourist friendly environment, duty free shopping and variety of
recreational attractions. The Singapore Tourism Board (STB) is the national tourism
organisation responsible for planning, developing, marketing and administering the
tourism industry in the country. STB has three major departments to promote
Singapore as a healthcare hub, viz., Economic Medical Hub Department, Clinical


59
Medical Hub Department, and Allied Health, Wellness and Complimentary Medicine
Department. STB is strategically promoting Spa tourism with the objective of
removing the negative connotation of massage parlours. The Government of
Singapore has classified Spas as a discrete licensing category.
Various government initiatives include providing a greater focus on clinical
research, medical staff recruitment, intensified marketing and closer cooperation
between the public and private sectors. Such initiatives later led to the formation of
Singapore Medicine, a multi-agency government initiative, aimed at making
Singapore as one of leading destinations for healthcare services in Asia. Singapore
Medicine serves as a gateway connecting international patients with the service
healthcare providers of Singapore.
The Government has enacted two major Acts, viz., the Medical (Therapy,
Education and Research) Act, 1972 (MTERA) and Human Organ Transplant Act,
1987 (HOTA), which facilitates easier transplantation surgeries in Singapore. All
citizens and permanent residents (excluding Muslims) are included in HOTA, for
organ donations, unless they register their objection. Foreigners visit Singapore to
undergo transplantation surgeries, as there are procedural delays in home countries.
Many healthcare establishments have set up international patient service
centres to exclusively serve the needs of international patients. These centres act as
one-stop service centres; patients can obtain information about the services offered by
various healthcare establishments and cost of treatments from such centres. Dedicated
staff at these centres assist in fixing appointments, take care of referrals and
admissions, organise visa, travel assistance, medical transportation and interpretation
services. The centres also provide information on accommodation for the
accompanying persons as also information on other tourist attractions.
1.8.3 Malaysia
Malaysia is another country in Asia strategically attracting international
tourists. Travel and tourism is one of the prime activities in Malaysia significantly
contributing to the national economic development. Malaysia aims to diversify the
economy and reduce the countrys dependence on the manufacturing sector through
its wider policy to boost its service industries. Tourism has been identified as one of


60
the key segments under the services sector. Within the tourism sector, healthcare
tourism was initially introduced in 1998 as one of the sustainable growth areas
following the Asian financial crisis. The Malaysian Government has set up a Medical
Tourism Committee with representation from the tourism ministry, Malaysian
Industrial Development Authority, Malaysian Airline System, industry associations,
including the Malaysian Association of Hotels, Malaysian Association of Tour and
Travel Agencies, Primary Care Doctors Organisation of Malaysia, and the Malaysian
Medical Association. The code of ethics formulated by the Association of Private
Hospitals of Malaysia.
The Government also has announced Fast Track Immigration Clearance for
foreign patients provided that the relevant hospital informs either Malaysia Airport
Berhad at Kuala Lumpur International Airport or the immigration authorities, at any
point of entry to Malaysia, preferably three days in advance. The patient and
accompanying persons may also get extension of their stay on medical grounds from
the Malaysian Immigration Department under such fast track. Major thrust markets
for marketing healthcare services for Malaysia include Arab countries. The ethnic
community and cultural ties between the Gulf region and Malaysia make the region as
a natural target market for Malaysia. Tourists from Gulf region are reportedly availing
wellness and cosmetic related services while travelling to Malaysia.
Tourism Malaysia, the promotional arm of Ministry of Tourism, Government
of Malaysia participates in international travel marts and helps promote Malaysia as a
healthcare destination. Tourism Malaysia has over 30 branch offices and about 10
representative offices all over the world.
The Government is also encouraging multinational healthcare firms to invest
in Malaysia in order to encourage private sector participation in this sector.
Immigration conditions for entry of foreign medical specialists and supported clinical
research in health institutions are also relaxed to promote the emergence of clinical
centres of excellence. Tax incentives have been introduced to encourage hospitals to
upgrade their facilities to cater to the foreign patients.



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1.8.4 Philippines
Philippines is another country taking significant steps to cash-in on the
booming tourism industry, including healthcare tourism. Travel and tourism in
Philippines is significantly contributing to the national economic development.
Promotion of healthcare tourism received importance with the launch of Philippines
Medical Tourism Programme (PMTP), a private-public initiative, with the
involvement of industries such as wellness, Spa, health, tourism and retail business,
through Executive Order No. 372 by the President of Philippines in October 2004.
The Order created a public private partnership, which brings together relevant
government agencies and private sector representatives under a Task Force, which
formulates a development strategy for sub-sectors such as Medical and Surgical Care,
Traditional and Alternative Healthcare, and Health and Wellness Care (Spas).
Philippines has been projecting dentistry services, cosmetic surgery, eye-bag
removal, face-lift, nose lift, tummy tuck, enhancement of organs, non-surgical
specialties such as dermatology, family practice or internal medicine. Philippines has
also been projecting its advantages such as availability of welltrained competent
medical professionals, fluency in English, healthcare cost differential, technological
advances and a vibrant tourism sector with compassionate and caring professionals, in
its promotional programmes. The broad policy framework for development of
healthcare tourism under the National Tourism Strategy of Philippines include:
Broadening the marketability of the Philippines by promoting Spa and medical
tourism;
Contributing to regional development in terms of employment generation and
increase in local government revenue;
Increasing investments relative to health holiday activities;
Promoting and developing the countrys thermal springs and other resources
for health tourism program.
The Government has included medical tourism in the Investments Priorities
Plan (2006), which outlines incentives for prospective investors in this Sector. The
IPP has also introduced the concept of International Medical Zone which will be a
notified area developed into a center for professional healthcare. The Department of


62
Health plans to classify certain medical zones under medical tourism zones, which in
turn would be accredited by the Department of Tourism.
Incentives provided by the Government for development of Spa tourism and
medical tourism include reduced import tariff on select Spa / medical equipments and
tax holiday for hospitals.
1.8.5 China
Although statistics / information related to healthcare tourism in China is not
readily available, it is worthwhile to recognize the countrys potential to offer
healthcare solutions to the world through outward flow of healthcare services.
Already the Traditional Chinese Medicine (TCM) is prevalent in many parts of the
world. Thus, the potential of TCM as a source for generating tourism may not be
restricted to tourism inflows into China alone, but also as outflow of services to other
countries. China has adopted diverse strategies to popularize TCM in several parts of
the world. These include integration of TCM into national healthcare system, setting
up of quality systems from production of raw materials to final products, setting up of
support institutions and adopting a science-based approach to promote in international
markets.
1.8.6 South Africa
Tourism is one of the important industries in the South African economy.
Traditionally, medical tourism in South Africa was largely for cosmetic and
reconstructive surgery, dental as well as orthopaedic surgery. However, the scope of
the medical tourism sector in South Africa has expanded to cover all medical and
surgical specialties as well as tertiary healthcare services, from simple procedures to
complex medical and surgical procedures. Number of tourism agencies have
enhanced their canvas to include medical tourism and formulated strategies to attract
international tourists. Packages have been woven to attract international tourists
which include providing professional services and hand-holding of international
tourists when necessary, providing information and advisory services to help identify
appropriate healthcare institutions and sightseeing places for recuperation.


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1.8.7 Jordan
According to industry estimates, the healthcare tourism in Jordan is estimated
to be generating approximately JOD 500 million per annum30. In terms of numbers
about 100,000 non-Jordanian Arab patients visited Jordan for healthcare purpose,
mainly for treatment such as coronary, kidney, brain and eye surgeries. Yemenis
constituted an estimated 30% of patients, followed by Libyans (25%), and Sudanese
(20%). Patients from countries such as Algeria, Tunisia, Iraq and Palestinians also
come for medical treatment in Jordan. It is estimated that Jordan has generated US $
600 million per annum as hospital fees from visiting healthcare patients alone.
Ministry of Health, Government of Jordan has set a plan to achieve US $ 1 billion
revenue per annum from healthcare tourism.
The Ministry of Health, Government of Jordan has formed a Committee
following the recommendations of Economic Consultative Council to establish links
with Arab countries to attract patients needing treatment. Around 60 private hospitals
in Jordan have formed an association, Private Hospital Association of Jordan.
Ministry of Health, Government of Jordan has set up Health Tourism Board, which
has set up promotional desks at various terminals of the Queen Alia International
Airport, to provide information and advisory services to the visiting Arab patients.
Tourism operators in Jordan have been projecting the Dead Sea coast as one of
the prime destinations for rejuvenation. Large volume of investment has happened in
this area to attract healthcare tourists. The main attraction of Dead Sea is its soothing,
abnormally salty water. The salt content of the water is 31.5% making the water so
buoyant that it is impossible for the visitor to sink. The water also contains 21
minerals including high levels of
magnesium, sodium, potassium, and bromine and 12 of these minerals are found in no
other body of water in the world.
Studies have shown that the combination of Dead Sea water and the rich black
mud found along the shoreline to have significant health benefits such as increasing
blood circulation, easing discomfort from arthritis, healing allergies, and revitalizing
skin. Visitors to the Dead Sea also take advantage of another nearby tourist spot,


64
Hammamat Main (Main Hot Springs), located 264 meters below sea level, to enjoy
bath in mineral rich water.
1.8.8 Cuba
Health tourism in Cuba is well known among international communities in
view of the healthcare technologies treatment procedures developed by the
professionals in the country. Cuban healthcare institutions are offering treatments to
various health problems such as hypertension, pigmentary retinosis (or night
blindness), Parkinsons disease, psoriasis, deformities of the spinal column, bone
tumours, paralysis, and rheumatic diseases.
Cuba has a large network of hospitals equipped with latest technologies and
highly skilled professionals, some of them have specialised in giving unique
treatments. Besides, mineral springs and Spa centres are also being projected as
destinations for wellness in Cuba. It is reported that Cuba has over 30 mineral springs
with medicinal properties.
1.8.9 Inferences from Country Experiences
From the above analysis, it may be inferred that many of the competitor
countries in this arena are strengthening their capabilities in modern healthcare
systems. India, while strengthening its capabilities in modern healthcare systems, is
also leveraging its inherent strengths in traditional healthcare systems, such as
Ayurveda, Siddha, Yoga, Naturopathy, and faith-healing / Spiritualism. In addition,
India has diverse tourism destinations like the backwaters, architectural treasures,
forts and palaces, hills, springs, deserts and jungles, with wider themes, such as
adventure tourism, coastal tourism, eco-tourism, spiritual tourism, to cater to the
requirements of tourists to achieve a state of overall wellbeing. India also holds an
edge over competitor countries, as the country is enriched with techniques of
concentration, mind-control, natural resources, intellectual capital, cultural diversity
and tolerance. Thus, India is in an advantageous position vis--vis many of its
competitor countries.


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1.9 SUMMARY
This chapter expressed that tourism industry acts as a powerful agent of both
economic and social change. It stimulates employment and investment, modifies
economic structure and makes positive contributions towards balance of payments. It
has emerged as a major industry of the Indian economy, contributing substantially to
foreign exchange earnings and serving as a potential generator of employment
opportunities, because India as a tourist destination exercises immense attraction from
various angles, with its vast cultural and religious heritage and varied natural
attractions. Healthcare tourism thus could become a common form of vacationing,
and covers a broad spectrum of healthcare services, mixing with
leisure/relaxation, with the overall objective of wellness and healthcare. India has
great potential for health tourism. Health tourism has three branches. Medical tourism
is the major branch of the health tourism. For the purpose of medical travel is such as
cost effectiveness, not available in own country and waiting time.
Medical Tourism is the service industry so value chain is the very important
role in medical tourism specially for the point of view international level.