Preface
In 2017, I read an article in a US news magazine about a recent phenomenon known as medical tourism. People were traveling thousands of miles from the US and other developed nations to developing countries such as India for medical treatment. I had never come across this topic and I wondered why anyone in their right mind would want to travel to a developing country for health care. After all, most people believed that the best health care could be found in advanced countries. This was the time of outsourcing and it advanced my interest on medical tourism.
As I started to search for a dissertation topic, I remembered reading this article. Unfortunately, there were very few academic articles on medical tourism at that time. I posited that this topic had a bright and promising future for both development as an industry, and research. This is how I ended up choosing the topic of medical tourism for my dissertation research. I wanted a topic that was new and understudied so that I could make a significant impact on the literature.
Chapter 1 - Introduction
Over five million patients a year travel abroad to seek and consume healthcare that may be too expensive, too delayed, altogether unavailable, or even proscribed in their country of residence (Patients Beyond Borders, 2011; Woodman, 2007). This phenomenon of traveling to foreign countries to obtain medical, dental, surgical, and wellness care is known as “medical tourism,” “health tourism,” or “wellness tourism;” Despite these names, the motivation of this type of traveling is far from recreational (Gatrell, 2011).
Medical tourists generally originate from developed countries, and an overwhelming majority of them seek treatments in developing countries. More specifically, the primary flow of medical tourists is from the United States and Western Europe to mainly South and Southeast Asian countries, including India, Thailand, Malaysia, Singapore, and South Korea, and European countries, including Latvia, Czech Republic, and Hungary (Bookman & Bookman, 2007; Hopkins et al., 2010). Brazil, Mexico, Guatemala, Costa Rica, and other Latin American countries also attract medical tourists, particularly from the United States. Several Middle Eastern countries were initially sources of medical tourists, but now these countries attract patients from affluent developed countries.
Medical tourists from developed countries also seek treatment and medical procedures in other developed countries. For example, Canada provides medical treatment to many Americans (Gatrell, 2011). Europeans traveling within Europe for fertility treatment are also common (Shenfield, 2010), largely because
some European countries restrict certain fertility procedures, forcing their procurement elsewhere. The European Society for Human Reproduction and Embryology reports that between 20,000 and 25,000 cross-border fertility treatments are carried out each year. Over half of all British women who seek treatment abroad go to the Czech Republic, where it is easier to obtain donated eggs. Many Italians escape legal restrictions at home by traveling to Spain for egg donation and to Switzerland for sperm donation. French women go to Belgium for the latter (Gatrell, 2011). Some of the most well-traveled medical tourists are from the U.K. Nearly 50,000 U.K. residents seek treatment abroad every year (Lunt et al., 2012). Significant numbers of medical tourists also come from the U.S., many of whom are among the nearly 47 million Americans who lack health insurance and 108 million who lack dental insurance (Warf, 2010). Though the new “Affordable Healthcare for America Act” is expected to reduce the number of uninsured and underinsured Americans, only time will tell how this might impact the number of Americans seeking health care abroad.
Medical tourism is nothing new – it has existed in different forms for centuries (Hancock 2006; Goodrich 1994) – but its frequency has intensified concomitant with contemporary globalization (Horowitz et al., 2007; Hopkins et al., 2010). According to Hancock (2006), “medical tourism is one of the fastest- growing businesses on earth” (p. vii). Gill and Singh (2011) claim that “More travelers than ever before are now traveling abroad to get high quality medical treatments for less cost, which includes treatments such as general surgery, transplant surgery, cancer treatment, stem cell therapies, dental implant, facial implant, and liposuction, just to name a few” (p. 315). Over 50 countries around the world are promoting packages that combine health care along with recreation (Gahlinger, 2008). Gill and Singh (2011) maintain that medical tourism has reformed the health-care industry and has set a new benchmark for many countries. Both developed and developing countries are considering investing in their infrastructures to stay on top of the aggressive competition as well as to arrest the outflow of patients to foreign countries.
The emergence of medical tourism has opened opportunities for many relevant businesses and industries both in destination and source countries (Gill & Singh, 2011). Some U.S. companies are promoting medical tourism; in fact, some insurance companies offer discounts to patients willing to go abroad for health care (Pafford, 2009). In 2006, Blue Ridge Paper Products, Inc., a company based in North Carolina, incentivized its employees to travel to India for non-emergency surgeries (Burkett, 2007). Similarly, a European owned supermarket chain in the U.S. also promoted medical tourism in India among its employees due to the high cost of treatments in the U.S. (Hopkins et al., 2010). This cycle of savings and incentives benefits the insurance companies, the employers, and the employees.
Another benefit of medical tourism is its economic boost to health and tourism sectors (Connell, 2011). MedRetreat, the first medical tourism agency in the United States, assists North Americans seeking any of 183 medical procedures in any of seven countries: India, Thailand, Malaysia, Brazil, Argentina, Turkey, and South Africa (Gill & Singh, 2011). PlanetHospital, a
California-based organization, connects patients to international health care providers, nearly two-thirds of whom have either a fellowship with medical societies in the United States or the United Kingdom, or are certified for a particular specialty by a medical board (Herrick, 2007). According to York (2008), as medical tourism becomes more prevalent, “continuing education, credentialing, and certification services may be required to help assure patient safety” (p. 99).
Research Objectives and Questions
This study offers insights into the phenomenon of medical tourism, focusing on India as the destination country. One of the major destination countries for medical tourists, India has been experiencing a medical tourism boom since the early 2000s and is at the forefront of this growing phenomenon. Its health care sector is growing briskly and is one of the largest sectors in terms of employment and revenue generation. In the 1990s, the Indian health care sector grew at an annual compounded rate of 16%. It generated $34 billion in 2006 and is projected to generate $40 billion by 2012. It is estimated that a significant portion of this revenue jump will be due to medical tourism growth (Hazarika, 2010). In the early 2000s, approximately 150,000 foreign patients traveled to India every year for different types of treatments (Woodman, 2007), and by 2005 that number had grown to 500,000 (Understanding Medical Tourism, 2008). According to Shetty (2010), by the year 2012, India will generate about $2 billion in revenues from medical tourism, which will account for nearly 46 percent of all medical tourism-related revenues to be earned by all Asian countries in that year (The Daily Star, 2006). By the year 2013, India’s share of medical tourism is expected to be about three percent (Abhyankar, 2013).
India is an ideal place for medical-tourism-related research. Currently, India is second only to Thailand in the number of medical tourists it has attracted since the early 1990s. Also, starting in 2002, India was one of the first countries to promote medical tourism as an export industry by offering special tax incentives to medical tourists’ care providers (Connell, 2011). The country’s diverse medical-care offerings further enhance India as a good case study. These offerings include advanced, hi-tech medical care such as heart surgeries, dental procedures, and hip resurfacing as well as more holistic forms of treatment such as Ayurveda, yoga, and spa therapy. This range provides abundant research opportunities.
Additionally, the author is from India, which enables a familiarity with the research destination. The author speaks several Indian languages and also has a network of people that may assist in procuring interviews for this research. The author’s familiarity with the cultural norms might also help while speaking with people who promote medical tourism. The author is also well-acquainted with Western culture and at ease collecting relevant information from Western patients who have sought medical and other related care in India.
The research design includes primary and secondary data collection. A questionnaire survey administered to Western medical tourists seeking treatment in India provided primary data. Literature on medical tourism, in general, and India, in particular, provided secondary data related especially to past and current trends in medical tourism, an understanding of which may help in predicting future trends in the industry.
This research on medical tourism provides information on what countries medical tourists most often come from and for what types of treatments and reasons. It also indicates what reasons are more or less important in a medical tourist’s decision to pursue medical tourism.
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Specific Research Objectives/Questions
This study has three research questions:
- How do the attitudes and behaviors of patients towards the concept of medical tourism influence their decision to become a medical tourist?
- Why do medical tourists seek treatment in India?
- What are the issues and challenges they face before coming to India as well as while in India and what is the patients’ level of knowledge on the topic.
The research questions were explored through a questionnaire survey. Patients were interviewed both face-to-face and via email (Appendix C). The first half of the questionnaire was a set of Likert Scale questions that sought understanding of and ranked the importance of medical tourists’ attitudes regarding issues such as cost of treatment, cost of overall trip, competence of physicians, opinion on facilities, privacy concerns, concept of vacation, getting treatment in a developing country, health insurance, and other factors. The Theory of Planned Behavior (TpB) framework was used to understand the factors involved in the decision making process of a medical tourist.
The second half of the questionnaire was qualitative, consisting of open ended questions about various destinations and source countries for medical tourists. This half of the questionnaire also asked for participants’ demographic data for the purpose of better understanding the characteristics and profile of those seeking medical care abroad.
In order to compile a representative sample of medical tourists, patients of both advanced, high-tech hospitals and holistic treatment centers were chosen as participants. The facilities are located within the south Indian cities of Bangalore, Hyderabad, and Chennai were chosen as participants. English is widely spoken in all three cities, and each is connected to an international airport. All three cities are considered information technology (IT) hubs in India, and several medical facilities in these cities actively promote medical tourism, including Manipal Hospital, Wockhardt Hospital, and the Heart Institute in Bangalore; Apollo Hospitals and the Institute of Cardiovascular Disease in Chennai; and Care Hospitals and Apollo Hospitals in Hyderabad.
Significance of Study
Academic literature and research on medical tourism, especially that based on firsthand patient and/or administrative interviews, is limited due to the relative newness of the industry (Gatrell, 2011). What is available comes mostly from newspapers, popular magazines, and online articles. This research aims to add new and significant insights to the slowly accruing academic literature on medical tourism.
In addition to contributing to academic literature, the findings of this research may contribute to other fields. Policy makers, for example, might apply the research to improving India’s overall healthcare system. Medical tourism- related industries, such as credit card companies, travel agencies, hotels, food and beverage companies, medical facilities and services, and spas could also benefit from this study. The outcomes of this study could also be useful to prospective medical tourists. As per my knowledge, this is the only study on medical tourism that relies solely on patient interviews.
Policy makers in source countries may also benefit from this study as they examine reasons, beside cost, people bypass treatment in their home countries to seek medical treatment abroad.
Some physicians and medical facilities in the developed world are becoming concerned with the medical tourism trend (Turner, 2007b). As more patients leave their home country for treatment elsewhere, medical professionals and personnel in the home countries, along with the government, may worry about financial losses and also the potential repercussions associated with treatment complications once patients return to their home country. Also concerning to health-care providers and patients alike are the relatively lax laws and regulations in countries such as India that may actually harm foreign patients. The aforementioned concerns are important to this study as these may become significant factors on how people from various sides of the issue perceive medical tourism.
To fully understand the medical tourism phenomenon in India, aspects of the health care system in both India and the source countries need to be examined. Health is affected by, among other things, government policies, budget allocation, people’s behavior, and physical environment. Looking at the history of medical tourism from various perspectives and examining the current policies yields a better understanding of the causes and consequences of medical tourism.
Chapter Outlines
Chapter Two focuses on medical tourism literature. Following a description of medical tourism’s historical development, various definitions of the term will be discussed. The popularity of medical tourism will also be discussed in this chapter, followed by a discussion of major source and destination countries of medical tourism. The last part of Chapter Two provides a general discussion of medical tourism’s advantages and disadvantages.
Chapter Three describes this study’s research methods. It also explains various health behavior theories, including the theory this study used to examine the decision making of medical tourists, the Theory of Planned Behavior (TpB). The study areas and the rationale for their selection will also be outlined, followed by a discussion of this study’s methodological considerations. The chapter concludes with discussion of the respondents’ profiles.
Chapter Four presents the data collection procedures and analyzes both the quantitative and qualitative responses of the study participants. The
geographic concept of place is also examined to understand its role in medical tourism.
Chapter Five discusses the research findings presented in Chapter Four. It also identifies limitations for this research and concludes with recommendations for future for medical tourism research.
Chapter 2 - Literature Review
Medical tourism is a burgeoning industry. According to Hopkins et al. (2010), medical tourism is “a rapidly emerging manifestation of global commercialization of health care” (p. 185). Gupta (2008) writes that “medical tourism is a multi-billion dollar industry promoted by governments and the medical and tourism industries” (p. 4). Although some forms of medical tourism may be centuries old, medical tourism in the twenty-first century is different from any previous characterization. This aim of this chapter is to provide a range of perspectives on historical and contemporary medical tourism as a way of establishing this study’s conceptual framework.
Morphosis of Medical Tourism: Globally and in India
Medical tourism has become a multi-billion dollar industry. According to McKinsey and Company, medical tourism was a $60 billion market in 2006 and they predicted that it could be a $100 billion industry by 2012 (Hansen, 2008). Despite its recent popularity, medical tourism is thousands of years old (Hancock, 2006). Goodrich (1994) points out that different forms of medical tourism have existed for centuries. Written records of Greeks traveling to Tell Brak, Syria, for eye treatment date back 5000 years (Gahlinger, 2008). During ancient times, people from afar frequented mineral springs due to their purported healing nature. People traveled for healing from ailments such as skin conditions, arthritis, and muscular injuries. People in ancient times have always gone to rivers such as the Nile, Ganges, Yangtze, and Jordan to be cleansed physically and spiritually (Goodrich, 1994).
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