History and background of medical tourism

CHAPTER 1

INTRODUCTION

The practice of travelling abroad to obtain medical and health care services is called as medical tourism. The benefits of medical tourism are getting widely popular among people because people are getting aware about the benefits of medical tourism like the lower cost of the medical procedures and can enjoy their holiday in a exotic location during the recovery period. This outsourcing for health care is grown as a new trend and many American and European tourists prefer medical tourism for cosmetic and medical procedures. The countries which are lack of advanced medical procedures leads the people living there to fly abroad to get appropriate medical services.

The practice of travelling abroad is a trend which developed from the ancient period and there is a long history of people travelling to other countries for health purposes. In Italy and throughout the Roman provinces, the Ancient Romans constructed resorts with thermal health spas, and the Ancient Greeks would travel ‘to [on the Saronic Gulf] to visit the sanctuary of the healing god, Asklepios, who revealed remedies to them in their dreams’ (Bookman and Bookman 2007: 4-5).

From the 15th to 17th centuries, the poor sanitary conditions in Europe prompted an interest by the rich in medicinal spas, mineral springs and the seaside for health purposes. These wealthy individuals would also travel to renowned medical schools for medical assistance (Swarbrooke and Horner 2007: 16, 33). This continued into the 18th and 19th centuries where spa towns, particularly in the south of France, became popular for health cures, the sun, and escaping the cold climatic conditions in the north of Europe (Holden 2006: 21-23). The rapid urbanisation and social change experienced during Industrialisation aggravated the unsanitary and poor living environments in Britain and some sections of Europe, with anti-urban values and a growing concern for health developing as a result (Holden 2006: 30). The formation of the railways allowed increasing and diverse flows of people to more distant seaside and coastal resorts, which provided a distinctive and escapist environment from urbanisation, and the opportunity to practice what was viewed as a healthy pastime of sun-seeking (Holden 2006: 30; Swarbrooke and Horner 2007: 16,33)

Spa tourism and sun-seeking persisted into the 20th century. Medicinal springs, spas, Beaches and resorts, particularly in warm and dry climates, continued to be considered therapeutic through long exposures to the sun, fresh air and water (Swarbrooke and Horner 2007: 33).Thus it is easy to understand that the health tourism has developed from the ancient age with myths and beliefs and as cure from natural resources to the current stage of various medical and surgical procedures and cosmetic therapies and for alternative therapies like yoga, naturopathy and ayurvedic medicine. Michael Moody (2007) indicates that the medical tourism trend began when residents of one country would go to another country to have cosmetic or dental procedures completed while on vacation or to recover from such procedures in a vacation like destination.

Today, countries like India, the East Indies, South America and South East Asia offer treatment facilities at par with international standards at just a fraction of cost. The factors such as high cost of healthcare in developed countries, long waiting list in government medical facilities and the reduction of air fare are the majority of reasons which contributed for the growth of the medical tourism. The hospitals in India, the East Indies, South American countries and South East Asia offer a high quality medical care which is par with international standards in very cheap money compared to developed nations.

India is one of world’s favorite tourist destinations and has many hospitals of international standard and English speaking staffs and therefore there are less chances of language barrier for the western patients. India has alternative therapies like Yoga naturopathy siddha and ayurvedic medical practices. One of the recent survey conducted in India on the healthcare indicates that the medical tourism in India will grow to US $ 125 to 250 million in the year 2012.(CII McKinsey study).The low cost and high standard treatment and care are the reasons which accelerates the medical tourism in India. The following example will illustrate about the economical as well as tourist benefits of medical tourism in India. Howard Staab, a self-employed carpenter from North Carolina, flew to India for his medically necessary heart surgery, scheduled a side trip to the TajMahal, and returned home to work in North Carolina. He spent a total of less than $10,000, instead of the $200,000 required from the local hospital ( Milstein and Smith 2006).This indicates that India has patients for procedures like heart surgery which requires state of art facilities and highly skilled medical team. Other than that it also shows the money difference when compared with developed nations. Kerala like any other states in India also has lot of potential to be a market leader in medical tourism.

Kerala often described as “God’s own country”is one of the favorite tourist destinations in India. The geography of Kerala is embellished with lush green coconut groves, scenic beaches, tranquil backwaters and enriched culture. There is a pride of place in the field of medicine for this Indian state and medical tourism is the new facet of Kerala.

Medical tourism is very popular in some states of India and this study focuses on a city of Kerala state. Kerala is considered one of the most favorite tourist destinations in India because of its beaches, hills, lagoons, backwaters and enriched culture. This state has tremendous potential to boom its medical tourism and the tourism industry is promoting itself with several ayurvedic and health packages.

This study focuses on the trends of medical tourism in the city of Trivandrum which is located on the southernmost state of India called Kerala. This city is the current capital of the state of Kerala and it is known for its scenic beauties and beaches.This city also has several international standard hospitals and traditional ayurvedic resorts and clinics.

Objective of the Research Study

The principle aim of this study was to investigate and critically analyse the recent trends in the medical tourism in the Trivandrum, the southernmost city of India. This study also analyses the behavior of the medical tourist and their expectations in the services provided by the hospital or the clinic and the tourist operators or agencies. This study also focuses to address the a gap that exists in similar study conducted before. The aim was to address the gap between available literature and demand for further research on the subject by adopting a clearly defined and structured research design, utilizing both quantitative and qualitative research methods.

1. Find the factors that drive Medical Tourism in Trivandrum
2. Analyse the issues which determine success of medical tourism in Trivandrum
3. Identify the problems faced by Medical Tourism in Trivandrum
4. Make suitable suggestions for improvement of Medical Tourism in Trivandrum

Rationales

The first and foremost reason for choosing the topic of the study is to lay out before the readers the state of the Indian medical tourism sector at a moment in time when it is in great flux. Moreover the author was working in one such hospital which was market leader in medical tourism in the city of Trivandrum. The medical tourism sector is believed to be a great boon of economical growth in Kerala and therefore by doing a study at this particular time may give readers awareness about the situation challenges and scopes. Other than that medical tourism it is an area of interest of the author as he wants to analyse the trends and issues involved in the medical tourism industry in Trivandrum city. The purpose of this research note is to outline some of the challenges and opportunities ahead, as health tourism finds its prominence in the practical and conceptual domains of tourism. Further there are predictions for Trivandrum city to flourish with medical tourism in next five to ten years and it is right time to analyse the challenges and scopes ahead.

Structure of the study

This study explores the trends of medical tourism in Trivandrum city and the issues around it. The need for further research on the topic has been established with carrying out a secondary research followed by primary research and by comparing evaluating the primary and secondary research. According to McDaniels carrying out exploratory research will gave the researcher clarification to understand the magnitude of topic area and thereby permitted a clearer and stronger perception of the environment and the situation which arise within it. (McDaniels, 2001).

CHAPTER 2

LITERATURE REVIEW

The medical tourism has an advantage of providing cost effective medical care collaborating with the health care industry and with the travelling industry to the patients who need medical treatment in a location different to their home town. Thus medical tourism occurs with the combination of healthcare services and tourism and travel domain. The facts that led the growth of the medical tourism are the availability cheap and high quality medical care in one geographical location and existence of long queue of patients for medical procedure and high prices of medical care in one geographical region. The outcome of these factors is the growth of medical tourism resulting in people moving to another geographical location for health care.

DEFINITION

The term medical tourism is a term coined in recent period but the practise seems to exist from ancient period and the trends in medical tourism have changed with the time.

The health tourist travel to their favourite destination for different medical and surgical procedures, cosmetic surgeries, alternative medicine, and spas and health resorts. The considerations and risk for different procedures vary accordingly. The medical tourism has gained social, economical and political interest but it has gained scant attention in tourism literature generally.

Bookman and Bookman (2007) define medical tourism as travel with the aim of improving one’s health, and also an economic activity that entails trade in services and represents the splicing of at least two sectors: medicine and tourism. The health tourism is seen as means of leisure oriented and stress relief as many people opt for sun and spas. Although there is no single definition for health tourism, it could be broadly defined as people traveling from their place of residence for health reasons (Ross 2001). Several demographic, economic, and lifestyle factors are driving such tourism (Handszuh and Waters 1997; Ross, 2001). Bennett et al. (2004: 123) acknowledge a liberal definition of health tourism would be ‘any pleasure-orientated tourism which involves an element of stress relief’, meaning it is an enjoyable and relaxing activity

Pollock and Williams (2000: 165), Laws (1996 in Henderson 2004: 112) and tries to see the health tourism with the view that it is a separation between the ordinary and the extraordinary; the everyday world of work and home versus the combination of health and tourism in ‘leisure, recreational and educational activities’. Then Schofield has a view that health tourism is a means to achieve improvement in physical, mental and social well being. (Schofield 2004: 137). The above all definitions try to define health tourism as a means to escape from every day routine and improve stress free healthful life.

Henderson (2004: 113) insists that health tourism as ‘travel where the primary purpose is treatment in pursuit of better health’ that may involve ‘hedonistic indulgences of spas and alternative therapies’, while medical tourism ‘incorporates health screening, hospitalization, and surgical operations. Ross (2001) after analysing various factors and literature tries to define health tourism as any kind of tourism that involves a person or his family member for the purpose of wellbeing and he considers that health tourism mainly focuses on two main domains as pampering and wellness. Pampering are services like massage, herbal wraps and exfoliating scrubs whereas wellness involves with improving physical and mental state and sometime it may involve with the treatment.

MEDICAL TOURISM AND ITS TRENDS

The concept of medical tourism have undergone many changes in recent times and there is a change in the trends like people from developed countries moving to developing countries for medical procedures for the difference in the cost. The global medical standards and regulations have been implemented in different countries and this in turn raises the number of people seeking cost advantage and best treatment in their preferred destination. The market of medical tourism depends on awareness and application of significant issues such as social diversities, consumer benefits, branding of products, legal frame work infrastructure, target markets, the actual product and communication channels (Dannell & Mugumba).Therefore it is understood that the people from developed countries choose their destination after analysing various features and therefore there exist high competition between the countries to promote medical tourism.

The one more key component in this medical tourism is the medical concierge services. These are medical travel companies that provide service to the traveller and they act as a link between tourist and the destination (Lagiewski, 2007).They have a vital role in the tourist experience from planning, stay, and post stages of the trip. The medical travel guide meets the tourist at the airport and he is the local agent who works as interpreter, guide and assists the tourist to stay in communication with his loved ones in his home. (Smith and Forgione, 2007).

According to Connell (2006) the ability to the countries to ensure the medical tourist that healthcare is of safe quality is a vital factor and this will be the main barrier for a destination to promote itself as most favourite destination In order to combat this concern, international accrediting agencies are in the process of certifying the quality and safety of global healthcare delivery. The tourist decides to engage in medical tourism on the basis of five a factor identified by Lagieweskii.Her study identifies the first and foremost as the alternative healthcare facility to their country’s facility which should be of high standard and at affordable cost. This factor is the main factor and when the tourist is satisfied with first factor the next will be cost of treatment and travel of great importance. The tourist may seek other country because of the e big waiting list in their home country. There may be some reasons like remote destination for tourist for certain cosmetic procedures. The nature of the country is also an important factor because tourist seeks a country free from risk factors associated with safety, security and actability. ( Lagiewski,2007).

The country trying to make itself as most preferred destination for medical tourism it should emphasize on the fact that its overall appeal and the experiences offered to the other competing destinations. (Dwyer and Kim 2003).Dwyer and Kim insists that the destination should have the competitive advantage to become successful in the medical tourism industry. According to Dwyer and Kim the existence of two type of resource group may lead to achieve competitive advantage. They are the endowed resources and created resources. Endowed resources are natural heritage and cultural attributes to a specific destination and created resources are services associated with the tourist such as accommodation, food and beverage establishments, and manmade attraction. There can be created resources such as special events entertainment and shopping which adds extra value to he destination. There can be supporting factors such as general infrastructure; quality of service; accessibility of the destination; hospitality of the host population; and market ties.

Growth has been facilitated by the rise of the Internet, and the emergence of new companies, that are not health specialists, but brokers between international patients and hospital networks. It has also grown because of rapidly improving health care systems in some key countries, where new technologies have been adopted. Above all it has followed the deliberate marketing of health care (in association with tourism) as medical care has gradually moved away from the public sector to the private sector, ensuring that a growing majority of people, especially in the richest countries, and particularly in the United States, must pay-often considerably-for health care

Finally, the factors like growth in medical tourism is done by the changing life style where people are ready to undergo cosmetic surgery, involving such elective procedures as rhinoplasty, liposuction, breast enhancement or reduction, LASIK eye surgery and so on, or more simply the removal of tattoos, have created new demands. Various forms of dental surgery, especially cosmetic dental surgery, are not covered by insurance in countries like the UK and Australia; hence dental tourism has become particularly common. In Asia these trends are ‘the unlikely child of new global realities: the fallout of terrorism, the Asian economic downturn, internet access to price information, and the globalisation of health services’ (Levett, 2005)

India and medical tourism

India is a country of rich culture and heritage and one of the most favorite destinations for tourism. It is one of the existing oldest civilizations in the world for a period of more than 4000 years and it has fusion of traditions, customs and diversity. (myindia).The survey conducted by lonely planet about the world’s favourite tourist destination among 134 countries ranks India as one among the world’s top 5 tourist destination.(lonelyplanet)

There are similar surveys and rankings for India as National Geographic describes India as “Land of mystery and majesty”. The company i – explore also ranks India as one of the tp 5 destinations in world. The Forbes traveller states India as one the fast growing travel markets. (ICRImedical tourism)

A number of destinations within India developed as havens for rest and recuperation such as hill stations at Darjeeling and the lakes in Kashmir where during the colonial era members of British era would retreat for cool breeze and a change of scenery. Late during the 19th century people began travelling India in search of alternative life style often focusing on yoga or meditation and following the footsteps of celebrities. India is building on these traditions as a wellness destination by a developing expertise in medical tourism (Garcia Altes 2005: conell 2006a).

The main marketing segments for medical tourism in India are patients from USA and European and middle east nations, while growing niche is formed by Indian expatriates ,particularly those live in USA and the UK.(Conell 2006), who combine medical treatment with visits to family and friends.

Medical tourism as a niche has emerged from the rapid growth of what has become an industry, where people travel often long distances to overseas countries to obtain medical, dental and surgical care while simultaneously being holidaymakers, in a more conventional sense. It has grown dramatically in recent years primarily because of the high costs of treatment in rich world countries, long waiting lists (for what is not always seen institutionally as priority surgery), the relative affordability of international air travel and favorable economic exchange rates, and the ageing of the often affluent post-war baby-boom generation. Growth has been facilitated by the rise of the Internet, and the emergence of new companies, that are not health specialists, but brokers between international patients and hospital networks. It has also grown because of rapidly improving health care systems in some key countries, where new technologies have been adopted. Above all it has followed the deliberate marketing of health care (in association with tourism) as medical care has gradually moved away from the public sector to the private sector, ensuring that a growing majority of people, especially in the richest countries, and particularly in the United States, must pay-often considerably-for health care

“Medical tourism” is an important part of the Indian tourism industry and holds immense growth potential. The medical tourism sector had experienced a phenomenal growth in the flow of medical tourists – from10,000 patients in 2000 to stupendous 180,000 by 2005. (Source: RNCOS report on ‘Indian Tourism Industry Forecast (2007-2011)

The Indian government takes meticulous steps in promoting medical tourism and it tries to increase the growth of foreign medical tourist by providing medical visas called M visas. These M visas are valid for one year and it is issued for the accompanies and Indian ministry of tourism has stocked its 13 overseas offices with information regarding these visas.( Meleigy)

In 2002,2.2 million foreigners visited India :those numbers increased by 20 percent the following year(Mathew 2004).The tourist literature produced by the Indian government portrays India as a country rooted in tradition and also sufficiently modern to offer western style amenities (Bandyoupdhay and Morais 2005) A study by McKinsey and Confederation of Indian Industry says that at its current pace of growth, healthcare tourism alone can rake over 8,000 crore additional revenue by 2012.(cii mckinsey study)

There are several states in India and the private hospitals in India target for the medical tourist other than the home patients. The southern state of Kerala which is very rich in culture and heritage and ancient medical practice like Ayurvediac ,Siddha and Yoga leads in attracting the foreign tourist for medical health and leisure tourism.

Kerala

Kerala is a bizarre anomaly among developing nations, a place that offers real hope for the future of the Third World. Consider: This small state in India, though not much larger than Maryland, has a population as big as California’s and a per capita annual income of less than $300. But its infant mortality rate is low, its literacy rate among the highest on Earth, and its birthrate below America’s and falling faster. Kerala’s citizens live nearly as long as Americans or Europeans. Though mostly a land of paddy-covered plains, statistically Kerala stands out as the Mount Everest of social development; there’s truly no place like it. The National Geographic Traveler, which once made Kerala the cynosure of all eyes in the world travel circuit by describing it as one of the 50 paradises in the world. (National Geographic)

Kerala is one of the most visited tourists destination of India. It is globally famous for its enchanting tourists’ attractions that are off beat than any other tourists’ places in the world. Every year hundred and thousands of tourists from all over the world come to Kerala to enjoy holidays in splendor. The state is endowed with palm fringed beaches, verdant hill stations, captivating beaches, emerald paddy fields, historical churches and more of all picturesque backwaters. This makes the marketing medical tourism easier in Kerala.

Accreditation of health centers

The quality of the medical care is the first and foremost factor considered by the medical tourist. According to the medical tourism association the accreditation is the means of way to attain safety and overall positive results to the patients who travel from one country to another for treatment purposes. The medical tourist can look into the accreditation to ensure the safety of the treatment in the hospital. The accreditation program is very essential to help patients, employers and insurance companies who can look into the accreditation status and thereby can find the hospitals with highest quality of care during their entire patient experience. The medical tourism industry grows day by day and therefore there is a necessity to ensure that hospitals, clinic and rehabilitation centers entering medical tourism posses proper infrastructure to meet the medical tourist. There is a need to certify that the center has proper communication facilities, transparency in quality and pricing, informed consent, proper medical care and further follow up facilities. The accreditation is focused on the fact that international patients have special needs and requirements than domestic patients. The accreditation is usually given by bodies which may by government or non government with the panel of expert members to examine and find whether the organization meets the requirements.(medical tourism association)

The accreditation to the allopathic medical practice in Trivandrum is provided by the international accreditation bodies such as Joint Commission International (JCI), ISO 9001 – 2000 etc. Other than the international bodies Trivandrum city has hospitals certified by NABH, a board set up by government of India. (See appendix).These are the major accreditations of medical service in India. The ayurvedic practice is the unique specialty and most popular medical practice in India and they have accreditation done by Body set up by Government of Kerala as “Green leaf” and “Olive leaf” and green leaf is the highest degree of accreditation and its followed by olive leaf and these accreditation ensures the quality of ayurvedic treatment in Kerala. (expresshealthcare)

Ayurvedic tourism in Kerala

Kerala is usually marketed as a health destination for its ayurveda packages. Medical tourism is marketed along with ayurveda and other health packages. Kerala ayurveda tourism has becoming a huge selling point for Kerala tourism industry. State promotes Kerala ayurveda tourism as a part of medical tourism to the world. Today popularity of Kerala ayurvedic treatment has gained such a momentum that tourist from across the world come to Kerala to rejuvenate and for therapeutic treatment.

Ayurvedic medical practice is the most ancient medical system originated in India before 10,000 years ago and in India the ayurvedic practice is more popular in kerala where it is practiced in traditional way. As per ayurveda specialists, the rainy season (June – August) is the best time for ayurvedic treatments as the atmosphere remains dust free and cool, which helps open the pores of the body to the maximum.(Messerli and Oyama 2004)

Ayurveda believes in the treatment of not just the affected part, but the individual as a whole. Kerala ayurvedic treatments and rejuvenation therapies are natural way to refresh and eliminate all toxic imbalances from the body and to regain resistance and good health. Most of the ayurvedictherapies help to strengthening the immune system, preventing and curing diseases without any side effects.

There are number of resorts and hospitals throughout state which are integral parts of Kerala ayurveda tourism and offering customized ayurveda holiday packages which help you to rejuvenate the body and soul and to start a fresh life. Kerala ayurveda provides number of treatments ranging from de-stressing, anti-ageing, weight loss, joint pains and general rejuvenation.

Elements of medical tourism in Trivandrm

Review of similar studies.