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Medical Tourism in Thailand 1

By Wanvipha Nuke Hongnaphadol

‘Consumer choice and motivation of medical tourism in Thailand: a case study

of healthcare consumers visiting a private healthcare provider in Pattaya’

The York Management SchoolUniversity of York, UK

http://www.york.ac.uk/


Definitions of key terms (1)

• ‘Medical tourism’patients travelling overseas for

medical care—involving specific medical intervention—and operations combined with relaxation on holidays (Connell, 2006)

• ‘Medical tourist’a person leaving his/her own country

for medical treatment overseas (Hancock, 2006)


(1) (3) (5) mere tourist medical mere patient

tourist proper

(2) (4) medicated vacationing tourist patient

(Cohen, 2006: 89)

A Typology of Medical Tourists



• ‘Health tourism’all kind of treatments enhancing a

state of well being both physically and psychologically, ranging from the spa experience through cosmetic surgery to lifesaving surgery like heart transplant (Caballero-Danell & Mugomba, 2007)


Health Tourism

Wellness Tourism

Medical Tourism

Non-Elective Medical

Care/Illness & Elective

Medical Care

Preventive Medical

Care

Enhancement

/Beauty Surgery

Spa Tourism

e.g.AromatherapyAcupuncture

MassageYogaetc.

e.g. Heart SurgeryBypass Operation

NeurosurgeryCancer Treatment

TransplantsHip replacement etc.

e.g. Medical Check-ups

Health Screening

etc.

e.g. Cosmetic Surgery

Sex Change Operation

Liposuction etc.

(Adapted from TRAM, ATLAS, 2006)


Level of Procedure Complexity & Risk

Bone marrow transplant cosmetic dental health Thai herb & spa & Thai traditional massage organ transplant surgery procedure checkup alternative open heart surgery medicine

stay at hotels or hospital travel package during recovery

Related Services added by Tourism

Model of Medical Tourism

(Harryono et al., 2006: 17)

Medicaloutsourcing

Tourism motivated



• ‘Consumer motivation’

internal and external motivational forces impelling people to act to satisfy a need, or the reasons for consumer behaviour (Leiper, 2004)– The underlying reasons for consumer behaviour

(Mayo & Jarvis, 1981; Pearce, 1982, 1991; Pearce & Caltabiano, 1983)

– The basis of knowledge of consumer decision making process (Dann, 1977)

– The significant foundation for evaluating satisfaction from consumers’ experience (Dann, 1981; Dunn Ross & Iso-Ahola, 1991; Yoon & Uysal, 2005)


• Consumer choice– When policy analysts examine healthcare systems from

the broadest perspective, very little about patient/consumer choice is mentioned (Borkman and Munn-Giddings, 2008).

• Consumer choice applied in the medical context is a very interesting phenomenon. – Asymmetry of information: why consumer

choice is limited in medical context• Choice to seek treatment overseas



Introduction to Medical Tourism (1)

• Europe ( e.g. Hungary—declared 2003 as the Year of Health Tourism—, Israel, Belgium, Poland, Greece, Spain)

• Latin America (e.g. Costa Rica, Mexico, Brazil)

• Middle East (e.g. Dubai—Dubai Healthcare City by 2010—, Jordan, Iran)

• South Africa• Asia (Singapore,Thailand, India,

Malaysia, Philippines) • A reversed trend of traveling overseas

to seek for medical treatment


Introduction to Medical Tourism Research (1)

• The rise of medical tourism—as the major medical tourism destination—is now in Asia (Connell, 2006).

• Little tourism research has been conducted on consumer motivation perspectives (Goossens, 2000; Bansal & Eiselt, 2004).



• No empirical study identifying the motivation of travellers to Thailand (Rittichainuwat et al., 2008) except the very recent study ‘A factor-cluster analysis of tourist motivations: a case of U.S. senior travellers’ (Sangpikul, 2008).

• Answering the question of why people travel is the most challenging in tourist behaviour (Crompton, 1979).



Recent business report• A recent report Asian Medical Tourism

Analysis (2008-2012) shows the revenues generated by the region of US$ 3.4 bn from medical tourism in 2007, accounting for nearly 12.7% of the global market and ‘Thailand has emerged as the largest medical tourism market in Asia’ (Velasco, 2008: 13).

• ‘Thailand is the largest medical tourism hub (in Asia) in total volume and in both high-end and low-end procedures’ (Runckel, 2008).



The context of Thailand (1): Tourism in Thailand

• Tourist destination (attributes) of Thailand– Five top tourism destinations i.e. BKK, Chonburi

(Pattaya), Phuket, Chiang Mai and Songkhla (Hat Yai)(Thailand Development Research Institute, 1997)

• Perception of low risk– A survey conducted by Visa International Asia

Pacific & the Pacific Asia Travel Association of 5,000 international travelers from 10 markets around the world found 52% considering Asia as their next travel destination and Thailand to be the number-one preferred destination (Travel Agent, 2007).



The context of Thailand (2)• Geographical location

– A half-way stopover point between Europe, East Asia & Australia, and as a gateway to Indochina

• Competitive advantage– Low labour cost

• Products/supply (institutional and infrastructure)

• English spoken (by staff)


Medical Tourism in Thailand

• Thailand became a medical tourism destination in the 1970s with its expertise in sex change operations and cosmetic surgery (Connell, 2006).

• Asian Economic Crisis in 1997– Currency collapse– Need for economic diversification– Merging medical expertise and tourism has

become a government policy in many Asian countries (Teh, 2007).

• Perceptions of healthcare treatment– quality of trained doctors and nurses– JCI (Joint Commission International Accreditation)

• A private hospital in BKK was the first Asian hospital accredited by the JCI in 2002.

Healthcare (1)

• Different pattern of previous and new healthcare consumers (Hjertqvist, 2002)– Previously, the healthcare provider was not

designed to serve a real consumer influence.

– In the welfare state, the patients’ specific demands could not be fully responded as need.

– Western healthcare consumers today are provided with greater access to various means of information sources in order to compare the providers’ quality and choices.


Healthcare (2)

• Freedom of choice and the use of healthcare facilities in many countries are predominant in the current healthcare consumer’s framework when they can benefit from shorter waiting times and better quality services.

• The significant increase in ‘consumerism’ owing to consumer expectations regarding the favourable outcome of medical intervention encourage more people to seek medical care—patients more aggressively seek services that match their expectations.


Healthcare (3)

• Healthcare is no longer defined by people receiving services when they are ill—the stereotypical patient.

• Cross border healthcare/patient mobility: citizens of the European Union may go to another EU country for specialist treatments that are not available in their own country, or because the waiting lists are shorter (Hogg, 1999).


Healthcare (4)

• Healthcare systems in individual countries are different due to the social, political and cultural context.

• The concept of consumer choice differs between the UK and US.

• Theoretical perspectives on ‘consumerism in health’ (Brown & Zavestoski, 2005; Henderson & Petersen, 2002) are not universally applicable to all Western democratic countries.


Healthcare system in Thailand

• A market-oriented healthcare system—people have free choice in selecting a healthcare facility (Janjaroen & Supakankunti, 2002)

• All Thai citizens have been covered by 3 main public health financing schemes:


Public health financing schemes

Who eligible?

Social Security Scheme (SSS)

Formal sector employees

Civil Servant Medical Benefit Scheme (CSMBS)

Government employee and their dependents

Universal Coverage Scheme (30 Baht Scheme)

The rest of the population

Healthcare system in the UK and the US

Healthcare approach

Health insurance

Characteristic

System Most common problem in healthcare service

UK Public driven (tax based)—independent & public providers

Universal Health Insurance

Welfare state National Healthcare System (NHS)

Long waiting list (access)

Recent NHS reform, i.e. the introduction of market-style competition into the provision of healthcare; government defines a new role for patients

US Private/market driven

Private Health Insurance

individualistic A mixed system

Price (affordability)


Dimensions of the Healthcare Systems of US and UKSources: Blank and Burau (2004); Weitz (2004); World Health Organisation (2007)


Dimension US UK

Citizen rights to healthcare? Negative rights Positive rights

Individual relates to society? Individualistic Egalitarian

Nature of system Mixed and fragmented: free market with governmental insurance for special vulnerable populations

Centralised with a national health system

Role of free market Very high Low but rising

Payment for care Mixed: government through taxes, private insurance, out-of-pocket

government through general taxes

Extent health system publicly funded (2004)

44.7% 86.3%

Universal coverage No Yes

Ownership of facilities (hospitals, nursing homes, etc)

Mixed: private for-profit, nonprofit, government

Predominately government

National policy on consumers involvement in healthcare system

No: variable policies for different diseases, government jurisdictions, myriad of health insurance companies

Yes: consumers involvement mandated


The Access to NHS (National Health Service)


Long waiting list


The insurance


Theoretical Framework (1)

Concepts on travel motivation– Maslow’s (1943) hierarchical needs– Seeking and escaping (Iso-Ahola,

1982) as push and pull – Psychological and physiological needs

(Murray, 1938; Mayo and Jarvis, 1981)– Needs-based motivation, benefit

sought-based motivation, attribute-based, and psychologically-based motivation (Pearce and Caltabiano, 1983)



– A literature review on tourist motivations indicates that the push-pull theory is a useful approach to understand travel motivations to visit a particular destination of various traveler groups (You et al., 2000; Klenosky, 2002).

– The push-pull theory has prevailed over other paradigms in investigating motivation underlying tourist and visitation behaviour (Dann, 1977, 1981; Crompton, 1979).



– Push (Escaping/the desire to travel) & Pull (Seeking/the choice of destination) (Iso-Ahola, 1982).

– Push (whether to go) & Pull (where to go) (Klenosky, 2002).

– Push (intangible intrinsic desires of tourists) & Pull (tangible characteristics/attributes of a destination) (Kozak, 2002).


Medical Tourists Motivation to Destination Countries

Push factor•Physical/psychological factors•Overburdened healthcare system in home country•Unaffordable•Inaccessible

Intermediaries

(representative offices)Direc

t

AccessibleHigh quality, low priceUnexpected serviceRelaxation/recuperation

Medical Tourist in

Originating Country

Destination Country

(adapted from Leiper, 1979)

Identity: patient, consumer, citizen (1)

• As the role of market raises the significant issue of identity, in terms of healthcare market, the identity of health service users is considered whether they are patients receiving services passively; consumers shaping and controlling the receipt of services; or citizens utilising their rights to free healthcare.

• It is essential to explore how health service users have engaged with these identities as these words can be differently conceptualised due to different healthcare systems.


Identity: patient, consumer, citizen (2)


Identity Description Characteristic s

consumer • A user of products and services in both public and private sectors (Needham, 2007)• People who are able to make their own decisions about the care they receive, express opinions about the care and perhaps evaluate the care (Henderson, 2002)

• Ability to exercise choice, shape and control services they are about to buy• As a market and economic participant• Those who seek healthcare in an active role, and perhaps make their own decisions• Individualistic

• Healthcare consumer-provider relationship• Doctor shopping

citizen • As a political actor in the public sector• Collectivist

patient • People with particular health problems who may be taking medicines or receiving treatment (Hogg, 1999)• 1. passive patients 2. patients who have low expectations of their physician 3. patients who behave as consumers, with expectations and ability to critically evaluate the quality of treatment received and ability to make changes (Baron-epel et al, 2001)

• Stereotypical patient with passive role seeking and following physician advice

• Patient-physician relationship• Passive patients: patriarchal physician approach

Characteristics of healthcare market (1)

• “Medical care is uncertain and unpredictable; many consumers do not desire it, do not know they need it, and cannot know in advance what it would cost them. They cannot learn from experience; they must rely on the supplier to tell them if they have been well served, and cannot return the service to the seller and have it repaired.”

(Hogg, 1999: 169)

• Consumers are uncertain of their health status and need for healthcare in any particular time

• A product uncertainty as consumers may not know the expected outcomes of treatments without their physicians’ advice

• The consumers cannot test the product before using it• Recovery from disease is as unpredictable.

(Folland et al, 2001)


Characteristics of healthcare market (2)

• “Medical services are not advertised as other goods and the producer discourages comparisons. Once the purchase is made, consumers cannot change their minds in mid-treatment.”

(Hogg, 1999: 169)



Theoretical Framework (recap)

Push & Pull only explain why people go BUT it does not explain how deficiency of people’s own healthcare system iseg How UK people recognise the deficiency of healthcare?


Aims of the study

1. To explore the reasons why major English speaking consumers travel to Thailand for their medical treatment

1. The motivations of potential medical tourists2. Differences in these motivations among different

groups both from the same and different countries3. Interrelationships among these motivations

2. To investigate the consumer choices in selecting a particular treatment in Thailand over other medical tourism destinations

3. To investigate the degree of tourism participation of those medical tourists


Research Questions

1. What are the significant motives that influence the decision of medical tourists from the UK and the US to travel toThailand?

1. How are these motives different with respect to age, nationality and gender?2. How does Bangkok Pattaya Hospital (BPH) perceive the consumer motivation

from these countries?3. To what extent does BPH applied perceived consumer motivation to service

provision for medical tourists? How is a healthcare provider’s service provision related to what motivates medical tourists to visit the hospital?

2. What are the major keys influencing consumer choices about provider and destination? Why does a medical tourist choose one destination over another?

3. To what extent do medical tourists take tourism component as a part in their decision making process?

1. Is medical tourism in Thailand about tourism? Is medical tourism likely to utilise the tourism component?

2. What is about the tourist part of medical tourism?3. To what extent do medical tourists participate in tourism?


Fact finding• Samitivej (Sriracha) Hospital

• Bangkok (Pattaya) Hospital

• Bangkok Christian Hospital

• Phyathai Hospital

• Bangkok Hospital

• Samitivej (Sukhumvit) Hospital

In search of the study site

Bangkok

Chonburi


The study site (1)


The study site (2)

Pattaya


The study site (3)

Bangkok Pattaya Hospital


In search of the research subject (1) Number of foreign patients being serviced at Thai private hospitals JAN-DEC 2007

Oceania

Australia 36,472

Newzealand 8,175

Others N/A

Total 44,647

Middle East

UAE 81,713

Oman 32,898

Kuwait 5,746

Bharain 3,013

Qatar 16,722

Yemen 2,440

Others 9,828

Total 70,647

South Asia

Bangladesh 28,979

India 34,661

Pakistan 3,648

Srilanka 1,485

Maldieves 5,038

Others 7,191

Total 81,002

Country Number of foreign patients

North America

US 127,552

Canada 23,244

Total 150,796

Europe

UK 109,179

Germany 43,879

France 35,453

Sweden 22,288

Others 46,769

Total 257,568

East Europe

Russia 9,585

Others 2,161

Total 11,746

East Asia

Japan 116,475

China 46,980

South Korea 27,181

Taiwan 5,127

Others 4,400

Total 200,163

ASEAN

Cambodia

24,163

Burma

36,257

Vietnam

4,483

Indonesia

7,164

Philippines

12,527

Others

16,179

Total

100,773

Source: Department of Export Promotion


In search of the research subject (2)

• Patients from the US and Europe constitute about 20 % of the total inflow of foreign patients with a higher proportion seeking for cosmetic surgery, hip and knee replacement and organ transplant to Thailand—the same is growing every year by around 40% for the US and 50% for Europe patients (Teh, 2007).


Methodology: Data collection (1)

Research design• Survey approach

– Semi-structured interviews

– Survey questionnaires



Stage 1. Exploratory study: semi-structured interview

– Pre-study: piloting the questions for interview in the UK (approx 5 British people who have visited Thailand for some kind of treatment)

– Visits to hospital – Interview foreign patients in Thailand

(approx 20 patients-10 from the UK; 10 from the US)



Stage 2. Designing the questionnaire:– The field interviews are to inform the

questionnaire development and to help design the questionnaire items to measure the medical tourism motivations and consumer choice.


• Stage 3: Main questionnaire study– Visit the hospital– Survey 150 medical tourists (75 from the UK;

75 from the US) using quota sampling (nationality and gender distribution)



Challenges

• Little academic research has been done on medical tourism market due to its relatively new niche market (Caballero-Danell & Mugomba, 2007).

• The nature of seeking medical care abroad is a relatively private matter therefore finding respondents of medical tourism to make up a significant sample size may be challenging.

• Ethical concerns– Information sheet for patients, hospital,

and hospital related provisions

Interesting points…

• Is ‘medical tourism’ about ‘tourism’?

• Is ‘cosmetic surgery tourism’ more related to ‘tourism’ than medical tourism?

• Would ‘gender reassignment’ be more considered as ‘medical tourism’ than ‘cosmetic surgery tourism’?

• Health inequalities?



Thank you for your attention.

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