Dissertation on medical tourism. Most of the publications on medical tourism are focused on the phenomenon of the trend and its risks and benefits for patients; however, researcher is hoping to study the subject of inequalities that local communities of

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Chapter 1


1.1    The Emergence of Medical Tourism

Medical tourism is described as an emerging trend in tourism industry. Health care systems worldwide are facing privatisation and globalisation and therefore medical industry is becoming more of a business opportunity nowadays. There are several factors influencing the growth of medical tourism – most of them are connected to cheaper costs and long waiting lists for treatments. However, popularity of low cost airlines and better accessibility to information (mainly via Internet) had a significant influence on the popularity of this trend. Medical tourism has a long history. First recorded signs of travelling for medical purposes go back to the 19th century, when French and German Spas were growing in popularity.

General definition of medical tourism indicates that the trend is focused on travel for medical purposes, however the discussion is raised over what kind of treatments should be included in the medical tourism definition. Moreover, there is a debate on whether medical tourism definition should be focused on content of medical services offered or on motivation for treatment abroad. It is crucial to remember close relationship and differences of medical tourism and wellness tourism. While medical tourism is focused on medical treatments, which are often seen as essential health care, wellness tourism is non-invasive and undertaken in order to prevent illness or any medical difficulties rather than treat them; both medical and wellness tourism could be classified as healthcare tourism (Henderson, 2004, pp.111-122).

However, one could argue whether this classification is correct since medical tourism is growing fast and develops different trends within. Cosmetic surgery or fertility treatment could not be classified to either medical or wellness tourism as they are invasive but unnecessary (in objective point of view) treatments. Therefore, the theory presented by Henderson (2004, pp.111-122) is not considerate of all aspects of health tourism.

Smith and Puczko (2009, p.7) demonstrated much more developed classification of health tourism:

Figure 1.1 Classification of health tourism

As presented in the figure 1.1 health tourism is levelled and represents several products that are sometimes not recognised as health tourism (e.g. beauty treatments). It can be easily stated that tourists often do not realise that they are participating in health tourism (that concerns wellness rather than medical tourism where tourists are more aware of the nature of their journey) (Smith and Puczko, 2009, p.8).

There are specific medical tourism destinations established. Those are mostly emerging countries of Eastern Europe and Asia; however it is not always the case. Some of the medical tourism destinations are Costa Rica, Czech Republic, India, Jordan, Malaysia, Saudi Arabia, Switzerland, Thailand, Turkey, and United States of America. As it can be noticed, medical tourism is not focused only on emerging countries but also well-developed destinations; that is due to quality and availability of services in certain countries. Tourism Research and Marketing (2006, p.20) presents an inbound international medical tourism trips by world region:

Table 1.2 Inbound international medical tourism trips by world region

Based on those statistics, it is estimated that medical regions attract around 19 million tourists annually. This data, however, could not be very relevant at this stage, as medical tourism is at the level of constant growth and the numbers are expected to be much higher nowadays. Moreover, India and other Asian countries are actively promoting themselves as medical tourism destinations, therefore balance of inbound international medical tourism trips is likely to be different at the present (Tourism Research and Marketing, 2006, p.20).

Kumar (2009, p.186) reports that tourism is an important source of income for most of the countries worldwide (only in 1999, international tourist arrivals were estimated at 700 million which resulted in $500 billion income within industry and 250 jobs worldwide). Such popularity of tourism resulted in development of different trends in order to meet tourism demand and medical tourism is one of those trends.

India alone is said to attract 150,000 medical tourists in 2004. Its medical tourism market is estimated to be worth US$333 million (in 2004) and the number of medical tourists is said to be growing at the rate of 30% annually. Interesting fact about India’s medical care system is that in 2004 it had very limited health care with four doctors for every 10.000 people (e.g. it is 27 doctors per 10,000 people in United States). This information can raise a discussion on risks and ethical considerations attached to medical tourism. Main ethical concern to be discussed is the issue of patients from wealthy countries travelling to emerging destinations in order to receive healthcare that local community cannot afford. Moreover the aspect of other risks will be discussed, e.g. lack of follow up care (Tourism Research and Marketing, 2006, p.61).

1.2 Medical tourist motivation

One of the most recognised reasons for tourists to travel to foreign countries in order to receive medical treatment is cheaper cost of health care (it is estimated that some treatments in medical tourism destinations are up to 80% cheaper than in the United States). Another factor influencing popularity of the medical tourism is perception of quality of health care. It is considered as sensible to check different health institutions before making decision on important surgery/treatment. On the other hand, it could be argued that making judgments on health institution that patient have not seen or been to before have a high factor of risk included. Other factors influencing international travel for medical purposes are long waiting lists, holiday factor and desire for privacy of a treatment. However, no significant study had been made on the subject yet and those are only general assumptions of medical tourist motivators. At the present, the Guadalajara Convention & Visitors Bureau is undertaking research on the push and pull factors of visitors motivation. It is the first in-depth study on understanding medical tourist motivation. Cormany (2010) reports that ‘Guadalajara is investigating additional motivations such as availability of treatment, cultural roots of the travellers, specialization of treatments, and other factors that may not have been considered yet. In these explorations, traveller demographics are important, and something recognized by nearly all medical destinations, but psychographic dimensions are also being explored by Guadalajara CVB’.

1.3 Aim and objectives

Aim and objectives of this study are to present how the researcher will achieve the research objectives and explain how they will be met.

The aim of the project is:

to investigate into medical tourism trends, tourists motivation and examine the subject of inequalities and ethical considerations within medical tourism.

Objectives of the research are:

  1. To critically analyse literature of medical tourism trends and consumer motivation and define its position in tourism industry.
  2. To undertake research of identifying consumer motivation process in medical tourism.
  3. To study and critically appraise any inequalities and ethical concerns among local communities of emerging countries caused by medical tourism.
  4. To carry out and discuss the results of the primary research and to critically appraise it with information gained from the secondary data.

1.4 Overview of the research project

This research is being conducted in order to learn about medical tourism trend. It is fast growing part of tourism industry and is already considered to be a significant trend in some countries. The researcher aims to seek not only into tourist motivation, trends and destinations of medical tourism but is willing to critically appraise this market’s risks and benefits. Moreover, one of the main interests of the researcher is to study ethical considerations of medical tourism. Most of the publications on medical tourism are focused on the phenomenon of the trend and its risks and benefits for patients; however, researcher is hoping to study the subject of inequalities that local communities of medical tourism destinations could be experiencing. Research will be based on secondary data and supported by primary data (Internet semi-opened survey) in order to provide the reader with the most accurate, up to date information and present an objective point of view on the medical tourism phenomena.

Chapter 2

Literature review

2.1 Literature review outline

Health conscious and ageing population of Western countries accepted medical tourism as a great alternative to failing health care systems in their countries. There are several factors influencing growing popularity of medical tourism including: low air travel costs, holiday factor, long waiting lists in developed countries, expensive healthcare and many others (Tourism Research and Marketing, 2006, p.7). The subject of medical tourism is, however, perceived as a very controversial; not only due to possible risks for the tourist but also major lack of regulations and possible negative effects on local communities. In order to fully understand the medical tourism trend, a multiple research on the areas of sociology, consumer behaviour, sustainability, policies and psychology needs to be undertaken. Information will be gathered from several sources including academic textbooks, journal articles, newspapers and on line resources, which will provide readers with a broad range of opinions and views on this subject area.

2.2 Tourism at the present

Tourism is ‘a major force in the economy of the world, an activity of global importance and significance’ (Cooper et al, 2008, p.3). This statement can easily be proven with the numbers – the travel and tourism industry of world domestic product was 10.3% with turnover of US$6.477.2 billion; it supported 234 million jobs, which is 8.7% of the total world employment (data from 2006) (World Travel and Tourism Council in Cooper et al, 2008, p.3). It is therefore clear that travel and tourism industry is highly developed and due to the demanding nature of the society, new trends are constantly being created. Sometimes it is due to acts of terror or nature (e.g. World Trade Centre Attacks – commonly described as 9/11) which puts a pressure on travel and tourism industry and often results in changes in policies, regulations and health and safety standards, other than that, it is tourists that influence travel and tourism industry.

Cooper et al (2008, pp. 663-664) describes globalisation as a powerful force shaping national and regional economies. It influences all aspects of population’s life. Key drivers for globalisation in tourism are:

  • ‘decreasing costs of international travel allowing access to most markets in the world;
  • Increasing income and wealth in the generating countries;
  • Newly emerging destinations and the increased demand for international travel;
  • Adoption of free trade agreements, removing barriers to international transactions;
  • Computer and communications technology encouraging ‘e-business’ and
  • Worldwide acting suppliers utilising global distribution systems.’

Cooper et al (2008, p.664)

Indeed, globalisation has a massive impact on travel and tourism industry and its trends, including emerging trend of medical tourism.  

Of course, there are several other factors influencing the growth of medical tourism, those are briefly speaking price, quality, availability and timeliness (Tourism Research and Marketing, 2006, pp.13-14).

It is stated that due to the medical tourism gaining attention from a relatively short time, there are some general data on the subject, however, available figures can often be associated with service providers therefore their credibility, in some cases, may be doubtful. Available data indicates that health-orientated holidays account for about 15% of the total European international holiday market, which brings the number of 37 million trips a year. It is also reported that the total expenditure in European Union for medical reasons accounts for €12 billion a year which is almost a third of the total health travel market in Europe (Tourism Research and Marketing, 2006, p.17).

Due to its big potential and high expenditure, medical tourism is being treated like any other trend within tourism industry. It is being actively advertised and special packages are created in order to attract customers. Not only it is suppliers but also governments that target this area of tourism, e.g. ‘the Singapore government has been actively involved in medical tourism development’ and is ‘aimed at making Singapore’s world-class healthcare services easily accessible to international patients’ (Tourism Research and Marketing, 2006, p.23).

Moreover, medical tourism boosts economy of the other industries, e.g. insurance sector. In a bid to reduce the financial difficulties of employee healthcare, several corporations are now looking into medical tourism. It is also stated that some of the medical facilities in the United States are accepting referrals from medical tourism agencies (Medical Tourism: Globalization of the Healthcare Marketplace, 2007).

2.3 Medical Tourism Trends

Health tourism (medical and wellness tourism), in general, is about increasing one’s health and wellbeing. One of the examples are spas from 18th and 19th centuries in some of the European countries. Over the years, visiting spa had become a popular tourist activity and got to be associated with health tourism. There are several factors that influenced the growth of medical tourism, those are mainly high costs of treatment in well developed countries, long waiting lists, affordability of air travel and favourable economic exchange rates (Medical tourism: Sea, sun, sand and…surgery, 2005). Growth of popularity of Internet has also had an impact on connecting patients with hospital networks. Other than that, the popularity of cosmetic surgeries and other treatments not covered by health insurance, like LASIK eye surgery or cosmetic dental surgery had created demand for cheap treatments abroad.

Asia is well established in medical tourism world with Eastern European countries rapidly entering the market. Nevertheless, countries of Asia are still most recognised on the market, e.g. Thailand got recognized as a medical tourism destination in 1970s due to its specialization in sex change operations and cosmetic surgeries, whilst India is considered as a contemporary global centre of medical tourism. It is said to offer an upgraded technology, well qualified staff and low cost of treatments (Medical tourism: Sea, sun, sand and…surgery, 2005).

In order to promote and develop medical tourism, international events are being held. As stated before, India is one of the most developed medical tourism centres. India Medical Tourism Expo is just one of many successful events in this area of tourism (Tourism Research and Marketing, 2006, p.93).

Medical tourism is a very well developed industry and its segments need to be clearly explained in order to understand the scale of the trend. Medical tourism segments are: illness (medical check-ups, health screening, dental treatment, joint replacements, heart surgery, cancer treatment, neurosurgery and transplants), wellness (acupuncture, aromatherapy, beauty care, facials, exercise and diet, herbal healing, homeopathy, massage, spa treatment, yoga), enhancement (cosmetic surgery, breast surgery, facelifts, liposuction, cosmetic dental work) and reproduction (fertility treatment, birth tourism) (Tourism Research and Marketing, 2006, p.11).

Apart from long waiting lists and high prices of medical treatments in western countries, there are other factors that push tourists towards this trend. The pressure of media creates a self-obsessed and self-conscious society, making those more susceptible an easy target for plastic surgeries companies. Moreover, those who decide to have a plastic surgery often want to keep it private, therefore travelling to other country seems like a perfect option for some of patients. The big advantage of medical tourism is often an exotic location. As this sector is a private-dominated practice, there are hospitals built in the most beautiful locations, which often influences final decision of medical tourist, who is tempted by joining their often painful surgery with a holiday experience (Smith and Puczko, 2009, p.102).

There are several different medical tourism destinations, some of them are already well established and some others are emerging into medical tourism market. Most American tourists would seek treatment in Latin American countries (e.g. Mexico, Brazil or Argentina) which are very popular with plastic surgeries seekers. On the other hand, there are India and Thailand which are marketing themselves with high-tech facilities and well qualified staff and specialise in complicated, more serious surgeries, such as cardiac surgeries or hip or knee replacements. Other popular destinations are Singapore, Belgium, South Africa and Central and Eastern Europe (which is popular with mostly dental services). Herrick (2007) gives readers an insight into the cost of medical procedures in selected countries (in U.S. dollars).

Table 2.1: The cost of medical procedures in selected countries

The difference in costs between United States (U.S.) and medical tourism countries (India, Thailand and Singapore) are astonishing. Looking at heart-valve replacement in U.S. which costs $274.395 at a retail price compared to $9.500 in India saves a patient the total of $265.895 (a medium household income in 2008 in U.S. was $52.029) (U.S. Census Bureau, 2010). Looking at the differences in prices between the countries, it come as a little surprise that medical tourism is growing bigger even though the lack of regulations occurs.

2.4 Tourists motivation

Cooper et al (2008, p.45) highlights the importance of motivation in order to understand tourist behaviour. Maslow’s hierarchy of needs is one of the most popular theories of motivation. It is mostly applied to tourist motivation in general rather than in specific trend of medical tourism. Maslow’s hierarchy of needs consists of five levels. Those are (presented from the lowest to the highest):

  • Psychological – hunger, thirst, rest, activity
  • Safety – security, freedom from fear and anxiety
  • Belonging and love – affection, giving and receiving love
  • Esteem – self-esteem and esteem for others
  • Self-actualisation – personal self-fulfilment’
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Cooper et al (2008, p.45)

Even though, the hierarchy is highly popular and widely used, it is not clear why and how the five basic needs were selected, other than that, in the era of several different trends in tourism industry, when some of them are as extreme as dark or medical tourism, the Maslow’s hierarchy will not be relevant.

There are also different types of tourists. Using Cohen’s classification, those are:

  • ‘The organised mass tourist – low on adventurousness he/she is anxious to maintain his/her ‘environmental bubble’ on the trip. Typically purchasing a ...

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