Medical Tourism

International Journal of Tourism Sciences, Volume 11, Number 1, pp. 18-51, 2011 Tourism Sciences Society of Korea.
All rights reserved.
Medical Tourism System Model
Tae Gyu Ko
Hallym University
ABSTRACT : The purpose of this research is to develop a medical tourism system model. Applying basic principles of the tourism system model introduced by Leiper, this model presents medical tourism components, their roles and relationships, describing a comprehensive phenomenon in the system. Despite a rapid development of medical tourism industry and businesses in recent years, a number of stakeholders are experiencing unnecessary debates and confusions in this area resulting in duplication of policies, waste of budget and human resources. This seems to be mainly contributed by the lack of a theoretical background like a whole system model which explains simultaneously the components of medical tourism and their roles and relationships. This model introduces and explains main elements of medical tourism such as types of medical tourists, medical tourists generating regions(MTGRs), medical tourist destination regions(MTDRs), types of medical tourists, types of medical service providers, medical agencies, medical tourism products, areas of medical tourism services (medical facilities and services, hotel and food and beverage services, tourism facilities and services, and governmental and socio-cultural factors), and types of relevant human resources. This model also presents the differences of services provided to the various types of medical tourists, and a systematic service procedure incorporating service components and human resources required by the tourists as they move from MTGRs to MTDRS and finally back to MTGRs. Keywords: Medical tourism, Tourism system, Medical tourism system, Medical tourists, Medical tourist generating regions, Medical tourist destination regions, Medical tourism products, Medical tourism services ** Tae Gyu Ko is an associate professor at Department of Convention and Tourism Management, Hallym University, South Korea. E-mail : tgko@hallym.ac.kr
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Introduction
In recent times, medical tourism has emerged in many countries as a new form of trade item or value-added tourist product. These countries have been actively developing this industry through government investment and support. The Korean government has followed this trend and has actively supported it since designating it as one of the governments 22 new development-driving industries in 2009. It has been estimated that the global medical-tourism industry currently generates annual revenues up to US$ 60 billion (negatively 40 billion), with 20% annual growth (Horowitz, Rosensweig, & Jones, 2007). The total number of medical tourists has also increased, from 19 million travelers in 2005 to 25.8 million in 2007, which is an annual growth rate of 16.5% (RNCOS, 2008). However, a new McKinsey study prepared by Ehrbeck, Guevara, and Mango (2008), suggests that the market is not as large as reported, and that most medical travellers seek higher quality and faster service instead of lower costs. McKinsey places the current market at 60,000 to 85,000 inpatients per year, but these numbers could grow substantially if certain barriers, such as noncoverage from payers, were removed. However, despite the high levels of interest in medical tourism in the public and private sectors, in academia and the mainstream media, there is a lack of theoretical research or models that comprehensively explain medical tourism systems and the relationships between systems and their component factors. As a result, there is much room for confusion and problems between industry stakeholders, governments, corporations, academia, research institutes and insurers. Thus a theoretical model that can comprehensively cover the phenomena of medical tourism systems is required, and the medical tourism system model is a vital component of this theoretical foundation. This study aims to develop a medical tourism system model (MTSM) that can explain the roles and function of the components (medical tourists, medical tourist generating regions, medical tourist destination regions, suppliers of medical tourism products, intermediaries, medical tourism services, and human resources) of the medical tourism system. In practice, the model will aid in resolving conflicts among the components of the medical tourism industry and will contribute to the formation of rational policies regarding medical tourism. Through examination of previous domestic and overseas research on medial tourism, this study will limit its scope to developing a medical tourism system model, explaining the relationship and function of the various components of
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the industry, and presenting the mutual relationships existing between them. Leipers tourism system model is analyzed in depth, while main sources include papers regarding medical tourism published in medical journals and tourism journals, and medical tourism magazine Medical Tourism.
Concepts of Medical Tourism

During the past decade or so, increases in customers pursuing quality, cheap medical services, as well as tourists attempting to improve their health while on vacation by working out or visiting health spas have led to the formation of a special niche product known as medical tourism (Connell, 2006). The term is being used generally in the general market and academia, despite not being an accurate reflection of medical services in tourist destinations or the experiences of the tourist (Horowitz, Rosensweig and Jones, 2007). The American Medical Association also uses the term in an official capacity, while the majority of hospitals, insurance companies, corporations, facilitators, doctors, and the media accept and use the term (Edelheit, 2008). However, as Reed (2008) points out, medical tourism is conceptually full of nuances, contradictions and contrasts. Thus, it is difficult to objectively describe the phenomenon, and the lack of dependable data exacerbates this situation. A search using the words medical tourism on Googles search engine reveals 22.6 million results as of October 25, 2010 (http://www.google.com). This may be an indicator of rapid growth in resources related to medical tourism since Horowitzs similar search in 2007, which produced 1.1 million results. In the business field, the Medical Tourism Association created the Medical Tourism Magazine in 2007 in the United States, and as of May 2010 has published its fourteenth issue, providing vital information to the medical tourism industry. In addition, both the domestic and overseas media have shown much interest in the medical tourism industry. Guidebooks for medical tourists have also started to appear (Gahlinger, 2008; Marsek and Sharpe, 2009; Woodman, 2008a-c, 2009a-d, 2010). Furthermore, papers regarding medical tourism have begun to appear in domestic and overseas journals (see Table 1). Although articles regarding health tourism have appeared before 2006, articles discussing medical tourism have not been published before this time. A point of interest here is that the medical field has been more active in research in medical tourism than the tourism field. Birch et al. (2010) propose that a medical tourism approach to the surgical management of obesity ? a chronic disease ? is inappropriate and raises clear
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ethical and moral issues as the authors observed a series of patients who have experienced complications because of medical tourism for bariatric surgery and required urgent surgical management at a tertiary care center within Canada. Sayli et al. (2007) describes Kangal Fish Spring as a health tourism destination and investigates socio-economic and visitor characteristics of the people visiting Kangal Fish Spring. As part of the study, 104 visitors to the destination were surveyed and visitor perceptions about the destination and visitor characteristics were reported. The paper concludes with a discussion about the future of the destination and health tourism in Turkey. Barclay (2009) argues that some doctors in developing countries are treating patients with adult stem cells without waiting for clinical trials to validate the safety of using them for health problems. Balaban and Marano (2010) suggest the issues facing medical tourism as follows: Current epidemiological data on medical tourism are limited. Basic questions such as the prevalence of medical tourism and associated complication rates have not been established. Important directions for future research include: developing consistent definitions, and conducting prospective studies of demographics, motivations, treatment outcomes, and cost benefits to better understand the healthcare implications of medical tourism. Lautier (2008) states that health service exports may represent a quarter of Tunisias private health sector output and generate jobs for 5,000 employees. If one takes into account tourism expenses by the incoming patient (and their relatives), these exports contribute to nearly 1% of the countrys total exports. This study also highlights the regional dimension of external demand for health services and predominance of South-South trade. Concerning the background of transplant tourism (tourism that patients go overseas for kidney transplants) in Japan, Kokubo (2009) identifies three issues as follows: First, globalization caused recipients to go abroad easier and faster. Second, transnational law is difficult to institutionalize. Third, there is economical gap not only international but also domestic. Considering medical tourisms positive and negative impacts on a nations health systems, Leahy (2008) suggests that the universities need to consider aspects of medical tourism that should concern them including continuing education, certification services and ethical issues, thereby helping to assure maximum patient safety. Borman (2004) discusses government reaction to potential ways in which a nations health service could be abused by visitors (medical tourists). Newman (2006) expects that, despite the risks, shopping for a surgical procedure overseas (medical tourism) could eventually become as routine as trying to find the best deal in airfare. Green (2008) argues that medical tourism has the potential to interact with infection medicine and
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public health in several ways: First, medical tourist are being treated in a range of countries with widely differing epidemiological profiles, with a proportion requiring pre-travel vaccination and even anti-malarial prophylaxis. Second, Standard of clinical and laboratory medical practice, facilities and staff education vary around world. Third, Micro-organisms resistant to antimicrobials can transit the world within the bodies and on the body surface of patients who have received treatment in overseas hospitals. Fourth, standards of food hygiene and water hygiene vary enormously around the world. Fifth, the quality of available antimicrobials varies around the world, with counterfeit antimicrobial medications sometimes being a problem. In order to determine whether medical tourism should be encouraged, and if so in what form, Bies and Zacharia (2007) developed an ANP (the Analytic Network Process for Decision-Making) model and find that self-selected medical tourism is preferred over employer- or government-sponsored programs and over the status quo. As mentioned above, there is still much difficulty in gathering empirical findings regarding real world experiences of tourists who engage in medical tourism by their own accord and resources (Lautier, 2008; Lunt and Carrera, 2010), and the actual implications of the medical tourism phenomenon are still unclear (Lautier, 2008). Many countries are offering medical services at relatively low prices, but reliable data regarding the number of medical tourists and other indices is significantly lacking. Discussion regarding issues such as the market, preferred destinations, treatment effects, quality and safety of services, and ethical and legal problems are limited to narrative reviews, which almost cannot be considered as evidence. This lack of reliability, data and policies may be due to a lack of a theoretical foundation regarding medical tourism as a phenomenon. According to Reed (2008), there are two definitions to the term medical tourism that can be found in literature or the internet. One refers to travel for the purpose of receiving health care services, and the other is a more general term used in the corporate and media fields, and is also appearing in both medical and tourism literature. The first definition is related to medical travel, where doctors or nurses travel to developing countries in order to provide health services voluntarily (Edelheit, 2008), while the second definition is the one that matches up with the phenomenon discussed today in academia and the industry. Discussion on the concept of medical tourism up until now has placed it on an equal level with health tourism or subsumed it under as a part of health
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tourism. Smith and Puczko (2009) distinguishes health tourism into medical tourism and wellness tourism, placing these two concepts under a broader term of health tourism. Health tourism refers to tourist destinations attracting tourists by using medical facilities or services outside of traditional tourist attractions (Goodrich and Goodrich, 1987). For example, the use yoga and massages at the Nirmalyam Ayurvedic Retreat and Hotels Company in India may be seen as health tourism rather than medical tourism (Connell, 2006). As it can be seen, health tourism and medical tourism can both overlap and be mutually exclusive. Lunt and Carrera(2010, p.28) offers a more concrete explanation of the relationship between medical and health tourism. Medical tourism, when viewed broadly, is a derivative of health tourism. Certain researchers have seen the two as a combined phenomenon, though with different weight levels of each. Health tourism has been seen as a planned trip away from ones home with the purpose of improving, maintaining and recovering individual well-being. Therefore, health tourism includes medical tourism, which is planned travel away from ones domestic health service system to another nation in order to improve or maintain ones health. There are those who claim that medical tourism stems from global healthcare. Edelheit (2008) argues that medical tourism is a byproduct of global healthcare. As a result of developed countries supporting the medical industries of developing nations, the high medical standards and facilities have been globalized, and as a result patients in developed countries are now able to receive health care of similar quality in other nations. As Connell (2006) claims, there is a tendency for some researchers to place all health-related tourism under the term health tourism, but tourism involving specific medical treatments or procedures are better served by being seen as medical tourism. As examined above, there are differences in perceptions of the concepts of medical tourism by the stakeholders involved. In particular, the tourism industry and the medical industries share different views. While the tourism industry views medical tourism as a combination of medical services and tourism services (Connell, 2006; Garcia-Altes, 2005), the medical industry is less optimistic on the combination of medical and tourism services (AMA, 2008; Bies and Zacharia, 2007; Lunt and Carrera, 2010; Reed, 2008). The reason behind this that each side approaches the concept from their own areas of specialization, which produces observations that are not fully-rounded. The concept of medical tourism differs according to which perspective is taken, and an all-inclusive definition lacks persuasive power. Thus, a systematic and comprehensive observation of the medical tourism phenomenon is required for
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accurate understanding of the concept.

Table 1. Major research on medical tourism Authors Years Topics
Goodrich and Goodrich Borman Hunter-Jones Garcia-Alets Connell Matoo and Rathindran Newman Bies and Zacharia Horowitz, Rosensweig and Jones Hunter Sayli, Akca, Duman and Esengun George and Henthorne Green Lautier Leahy Reed Barclay Kokubo Balaban and Marano Birch, Vu, Karmali, Stoklossa and Sharma Reddy, York and Brannon Lunt and Carrera 1987 2004 2005 2005 2006 2006 2006 2007 2007 2007 2007 2009 2008 2008 2008 2008 2009 2009 2010 2010 2010 2010 Healthcare tourism Health tourism Cancer and tourism The development of health tourism services Medical tourism: Sea, sun, sand and surgery How health insurance inhibits trade in health care Medical tourism Medical tourism: Outsourcing surgery Medical Tourism: Globalization of the healthcare marketplace Medical tourism: A new global niche
Journals
Tourism Management British Medical Journal Annals of Tourism Research Annals of Tourism Research Tourism Management Health Affairs Optometry Mathematical and Computer Modelling Medscape General Medicine International Journal of Tourism Sciences
Psoriasis treatment via doctor fish as part of health tourism: A case Tourism Management study of Kangle Fish Spring The incorporation of telemedicine with Journal of Hospitality medical tourism: A study of Marketing & consequences Management Medical tourism a potential growth factor in infection medicine Journal of Infection and public health Export of health services from Social Science & developing countries: The case of Medicine Tunisia Medical tourism: The impact of travel to Surgeon foreign countries for healthcare The Medical Clinics of Medical tourism North America Stem-cell experts raise concerns about The Lancet medical tourism A consideration of diseased kidney transplants in Japan and transplant Legal Medicine tourism over the world Medical tourism research: International Journal of A systematic review Infectious Diseases The American Medical tourism in bariatric surgery Journal of Surgery' Travel for treatment: students' International Journal of perspective on medical tourism Tourism Research Medical tourism: Assessing the Maturitas evidence on treatment abroad
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System Theory
There must be an understanding of system theory or system approach in order to form a medical tourism system that can comprehensively explain the medical tourism phenomenon. According to Morrison (2009), a system is a collection of groups of various fields that are mutually related in their efforts to achieve a common goal. System theory started in the 1930s, but Bertalanffy was the first to systemize this theory and attempt to link it to other fields of study. Bertalanffy believed that contact with theories of other academic fields was required to further understanding of his field of work, biology. He observed those that were considered ignored or bypassed in the past, and systemized system theory. System theory begins from the assumption that even the most complex phenomenon can be conceptualized into a mutually connected system. The advantage of this system approach is that it can clearly define complex phenomena. Because of this, system theory was adopted in many academic fields, including thourism. Cuervo was the first to utilize system theory in tourism. After this, Leiper (1979, 1995), Gunn (2002), Mill and Morrison (2009), and Morrison(2009) followed with their own specializations. As argued by Goeldner and Ritchie (2008), the most vital part of studying phenomena in the tourism field is the use of system theory. The tourism industry is made up of a combination of various industries, and as a result system theory is emphasized by many researchers (Goeldner and Ritchie, 2008; Gunn, 2002; Leiper, 1979, 1995; Mill and Morrison, 2009; Morrison, 2009). The same applies to medical tourism, where it is useful for understanding the roles, mutual connections and relationships among the various suppliers and customers participating in the medical tourism industry. For example, although Morrison (2009) used system theory to explain hospitality and travel marketing, this same method can be applied to the medical tourism industry. Goeldner and Ritchie(2008: 25) also emphasize the importance of system approach: What is really needed to study tourism is a system approach. A system is a set of interrelated groups coordinated to form a unified whole and organized to accomplish a set of goal. It integrates the other approaches into a comprehensive method dealing with the both micro and macro issues. It can examine the tourist firms competitive environment, its market, its results, its linkages with other institutions, the customer, and the interaction of the firm with the consumer. In addition, a system can take a macro-viewpoint and examine the entire tourism system of a country, state, or area and how it
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operates within and relates to other system, such as legal, political, economic, and social systems. Taking into account that the medical tourism industry is a complex composite industry with a common goal of attracting medical tourists, the system approach may be useful in studying and understanding the various phenomena in the medical tourism industry.
Components of the Medical Tourism System

The components that make up the medical tourism system are the medical tourists, who are the consumers of medical tourism products, the areas between which tourists move in and out, the MTGR and MTDR, and the serviceproviding medical tourism industry, which includes medical tourism products, suppliers, intermediaries and related services.
Medical tourists
Medical tourists, who are the consumers of medical tourism products and related services, can be divided into a variety of types, all of which have distinct qualities. Medical tourists are the core of the medical tourism system, and have considerable influence on it. Studies on the demographics of medical tourists are currently actively pursued. Experts in the tourism field currently define medical tourists as those who travel overseas in order to receive medical treatment or other health-related procedures, and also enjoy a rest or other tourism activities (Connell, 2006; Hunter, 2007; Jagayasi, 2008; Marsek and Sharpe, 2009; Smith and Puczko, 2009; Wood, 2008a-c, 2009a-d, 2010). In the medical field, experts generally define medical tourists as those who travel overseas in order to receive medical treatements, omitting the tourism and leisure aspect of the first definition (Balaban and Marano, 2010; Bies and Zacharia, 2007; Green, 2008; Horowitz et al., 2007; Leahy, 2008; Lunt and Carrera, 2010; Newman, 2006; Reed, 2008). The types of medical tourists can be divided in diverse ways according to the researchers goals (type of treatment/procedure, motivation for travel, length of stay, travel budget etc). According to Cormany (2008), there are six types of medical tourists according to different medical tourism products. Major surgery tourists are those that require major surgery on the heart, spine, joints, and other parts of the body. Minor surgery tourists are those that require dental work or other minor surgeries. Cosmetic/plastic surgery tourists are
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those that desire these kinds of aesthetic procedures, while diagnostic service tourists are those that do not have a specific illness, but wish to receive a general appraisal of their health. Tourists for alternative therapy treatments are those involved in alternative treatments such as Ayurveda or traditional Chinese medicine. Finally, wellbeing tourists travel in order to receive services regarding wellbeing and lifestyle remodeling. If patients are classified according to motivation for receiving treatment in another country, they are grouped into the following categories (Horowitz et al., 2007: 36-37): - Price-oriented: This type of medical tourist avoids the high costs of domestic medical care and looks for low-cost services in other countries. Many are not covered by insurance or have a low coverage rate. Non-insured treatments: These medical tourists seek procedures that are not covered by their domestic insurance policy, such as birth control treatments and gender reassignment surgery. - Displeased with medical policy: Dissatisfied with the public health care systems in countries such as Canada and the United Kingdom, some patients choose to receive treatments overseas to avoid long wait times. Furthermore, there are even tourists who engage in transitional retirement, a derivative of medical tourism, where senior citizens choose to move to another country in order to enjoy better health care (Connell, 2006). Nursing homes are a popular option for wealthier retirees. The Kenyan government has even converted a hotel into a home for retired citizens from the United Kingdom following the decline of its tourism industry. Similar institutions exist in Japan, Thailand and the Philippines.- Controversial issue related: There are medical tourists who wish to receive certain treatments or procedures but cannot because of legal, moral, cultural, and social restrictions. This is especially true in developed nations such as the United States, where stem cell treatments are of great issue, as is abortion (Connell, 2006). Countries such as the United Kingdom forbid abortion, and as a result couples seeking to abort a baby must travel overseas. In vitro fertilization is another of such procedures, and an even more extreme case is traveling to a country where euthanasia is allowed. Switzerland and the Netherlands both have been attractions for so-called death tourists for their policies regarding euthanasia, as has the Northern Territory in Australia for a brief period of time(Connell, 2006). - Protection of privacy: The protection of privacy can also spur medical tourism. Patients that require secrecy regarding certain procedures such as gender reassignment and drug addiction therapy have an option to receive treatement overseas, where they will not be spotted by someone they know. Gender reassignment is a small scale industry but has grown into an important
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medical tourist product. The physical and psychological recovery needed from these procedures would be much easier in an environment free from watchful eyes(Connell, 2006). Even if privacy is not of main concern, there are also some patients who wish to be removed as far as possible from their home country. For example, many famous people have gone to Mauritius in the Indian Ocean for hair grafting clinics (Connell, 2006). - Tourism and leisure: Some patients relish the opportunity to spend their vacation at a resort in a foreign country, and thus elect to receive certain medical procedures overseas. Although the tourism aspect is emphasized by travel agencies to potential tourists, oftentimes it is still the medical procedure that is of priority. While there has been an emphasis on finding a link between recovery from medical procedures and tourist activities, the level to which patients may be able to participate in such activities is as of yet uncertain (Connell, 2006). Medical tourists may also be separated into the degree of accessibility or mobility regarding the destination. Lunt and Carrera (2010) identified five different types of medical tourist based on patient mobility in Europe: temporary visitors abroad, long-term residents, common-borders, outsourced patients, and medical tourists. One of the aspects that the medcial tourism industry must focus on is the safety and protection of medical tourists. These tourists are especially vulnerable as they are unfamiliar with their surroundings and are weakened both physically and mentally, and require higher levels of attention and protection. The American Medical Association released a set of guidelines for maintaining the safe treatment and care of American patients travelling overseas for health care (Caffarini, 2008).
Medical Tourist Generating Region (MTGR)

Medical tourist generating regions refer to the countries or cities that produce medical tourists. Medical tourism agencies and insurers or corporations naturally form relationships to send medical tourists to MTDRs. Because of this, MTGRs become target markets for MTDRs and are subject to marketing and promotion. Before the 2000s, the medical tourism phenomenon was largely comprised of the wealthy classes in developing countries that were seeking high quality health care services in the United States or Europe that not available in their homelands. For example, Switzerland, East Germany, Austria, Hungary, the United States, the United Kingdom, and France were major medical tourism destinations in the late 1980s (Goodrich and Goodrich, 1987).
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However, this trend has now been reversed, and customers from developed countries are seeking health care, and sometimes tourism and leisure services, in developing countries (Horowitz et al., 2007). There are different reasons for these citizens of developed countries traveling overseas for medical care. For example, many from the United Kingdom travel overseas in order to avoid the long wait times associated with the UKs public health care system. However, medical tourists from the United States generally travel overseas due to the high costs of medical care in the US (Reed, 2008). The UK government is especially active in sending their patients to MTDRs. Even in the same country, there can be differences. For example, of the medical tourists leaving the US in 2004, 82% were naturalized citizens, citizens born overseas, or permanent residents. This may indicate an interesting trend where these people are returning to their places of birth or original homelands for medical care. It is not only those from developed countries that are seeking medical tourism services. Surprisingly, many medical tourists hail from developing countries with high purchasing power (Connell, 2006). The wealthy from regions such as Africa, Asia and the Middle East are additional major customers in medical tourism. Even citizens from third-world countries are also seeking quality health care. Medical tourism is an especially attractive option for the wealthy and privileged, with wealthy Nigerian customers spending as much as two billion US dollars per year on health care overseas (Neelankantan, 2003). Wealthy customers from the Middle East are frequent customers of the famous hospitals of Southeast Asia. In 2009, the Woorideul Hospital in Korea treated 1150 overseas customers from 65 countries. This diversity in MTGRs indicates that the medical tourism industry is undergoing rapid globalization. Other factors also contribute to the increasing numbers of medical tourists. As Garcia-Altes (2005) points out, medical tourism is most accessible to the baby boom generation, which has the highest income rates and the highest tendencies to take vacations. They are less sensitive to price, and are more interested in the various factors such as destination, quality, and secrecy that make up marketing strategies. The lifestyle of this generation is increasing the demand for aesthetic clinics, spas, retirement communities, fitness centers and rehabilitation clinics. In addition, those in developed countries today already tend to have experience in tourism, and many are seeking out new and differentiated tourism products. Factors such as long wait times, high medical costs and low insurance coverage contribute to the increasing numbers of medical tourists. Despite this growth, there remain many obstacles to the export of medical
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services by MTGRs. Garcia-Altes(2005) identifies restrictions on foreign hospitals entry into markets, restrictions on direct foreign investment in medical services, regulations on the medical industry, lack of facilities, capacity limitations, manpower and excessive competition as the main obstacles to the growth of the global medical tourism industry.
Medical Tourist Destination Region (MTDR)

Medical tourist destination regions refer to the country or city attracting medical tourists from overseas markets. MTDRs must select target markets from various MTGRs and conduct appropriate marketing promotions. An incorrect choice of target market could bring about a waste of budget, time and manpower. Therefore, marketing strategies must be formed with great effort and precision in analysis of market opportunities, market segmenting, targeting, and positioning with marketing mix. Currently many nations are supporting their medical tourism industries in order to target MTGRs. In terms of region, Asia, the Americas and Europe are the most active in this area. In Asia, the primary MTDRs are India, Israel, Jordan, Malaysia, Singapore, Korea, the Philippines, Thailand, Taiwan, Turkey, and the United Arab Emirates (see Table 2). The competition among these nations has been increasing, especially among Korea, Thailand, India and Singapore. According to the international market research firm RNCOS (2008), the following trends and developments are predicted in the primary Asian medical tourism destinations: - In 2007, 2.9 million medical tourists visited Thailand, India, Singapore, Malaysia and the Phillippines for medical care. - Thailands low medical costs and beautiful scenery has made it the largest MTDR in Asia. However, outbreaks of infectious diseases and political instability in the region could hinder further development. - Singapores medical costs are relatively higher than those of other Asian nations. However, in some cases Singapore offers higher quality medical services and infrastructure than many developed nations. - India is the fastest growing MTDR due to low costs and the founding of several private hospitals. However, ongoing public hygienic problems are a large obstacle. - Malaysia and the Philippines are relatively new MTDRs, but are expected to grow rapidly within the next five years.
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- Many companies and insurers in developed countries are combating rapidly rising medical costs by considering medical services in Asian MTDRs as an alternative. - The Asian medical tourism industry is expected to grow an average of 17.6% per year between 2007 and 2012.
Table 2. Major MTDRs
Asia/Middle East China India Israel Jordan Malaysia Singapore South Korea Philippines Thailand* Taiwan Turkey United Arab Emirates The Americas Argentina Barbados Brazil Canada Colombia Costa Rica Cuba Ecuador Jamaica Mexico United States Europe Belgium Czech Republic Germany Hungary Italy Latvia Lithuania Poland Portugal Romania Russia Spain Africa Other
South Africa Tunisia
Australia New Zealand*
Source: Horowitz et al. (2007: 34) *added by the author
From this, it is predicted that the Asian medical tourism industry will grow to become a 44 billion dollar industry by 2012 (Lancaster, 2004). Globally, the medical tourism industry currently brings in revenues of 60 billion dollars, and is growing at an annual rate of 20%. More conservative estimates have the industry at 40 billion dollars by 2010 (Horowitz et al., 2007). In the Americas, Argentina, Barbados, Brazil, Canada, Colombia, Costa Rica, Cuba, Ecuador, Jamaica, Mexico, and the United States are the well-known destinations. The United States in particular has been a primary MTGR market, but at the same time has utilized its traditionally strong medical care quality to remain one of the most desired MTDRs. However, Bies and Zacharia (2007) have identified several negative impacts of medical tourism on the American health care market, and if insurers and corporations begin to fully embrace sending employees overseas for health care, the United States could lose its strong standing as a MTDR. In Europe, Belgium, the Czech Republic, Germany, Hungary, Italy, Latvia, Lituania, Poland, Portugal, Romania, Russia and Spain are noted MTDRs. For example, Sopron in Hungary is famous for drive-in and out dental services. Eastern European nations such as Hungary are pursuing price-competitiveness in order to attract patients from Western Europe. Germany receives many wealthy patients from the Middle East. In the other regions, South Africa and Tunisia are the notable MTDRs, and Australia and
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New Zealand are the largest medical tourism markets in Oceania. The biggest problem facing the medical tourism industry and its development is the perceptions of potential tourists regarding the quality and safety of health care in the destination country. Therefore, these countries must instill the belief that their health care is of similar quality to the tourists country of origin (Connell, 2006). This is especially for countries such as India, which has had a long reputation of having inadequate health care. Although the situation is rapidly improving, there still exists a perception in the medical service market that lower costs bring about lower quality of care. Thus, most medical tourism advertisements emphasize medical technology levels, dependable service and overseas training and experience for its staff.
Medical Tourism Products

Medical tourism products can be divided into groups based on the patients goals or type of service offered by the suppliers of medical tourism services. Smith and Puczko (2009) identifies the following types of health tourism products. Surgical medical products include cosmetic surgery, dental treatments, and other treatments. Therapeutic medical products include rehabilitation, recovery, seawater therapy, and diet and detoxification. Medical wellness products include therapeutic recreation, lifestyle remodeling, occupational therapy, seawater therapy, and diet and detoxification. Leisure and recreation products include aesthetic treatments, sports and fitness, and body massages. Holistic products include (religious) spiritual healing, yoga and meditation, and new age treatments. Cormany (2008) separated products according to the types of service offered by suppliers of medical services: major surgeries, minor surgeries, cosmetic/plastic surgeries, diagnostic services, alternative therapy treatments, and lifestyle/wellbeing services. In all, medical tourism products can be categorized into the following six groups (see Table 3): major surgeries, minor surgeries, cosmetic/plastic surgeries, wellbeing/lifestyle services, alternative therapy treatments, and diagnostic services.
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Table 3. Major medical tourism products

Orthopedic surgeries: hip replacement, hip resurfacing, knee replacement Spinal procedures: spinal fusion, spinal disc replacement Limited cardiac procedures: angioplasty, cardiac diagnostic procedures Gynecological surgeries: partial hysterectomy, total hysterectomy, radical Hysterectomy, bilateral salpingo oophorectomy General surgeries: vascular, stomach and bowel, kidney and urinary, gallbladder removal, Hernia repair, cataract surgery, LASIK surgery, hemorrhoid removal, Endo laser vein surgery Other medical procedures: bariatric surgery, fertility treatment, Oncology, transplants, stem cell treatments, sex resignment, addiction treatments Dental procedures: dental work, cosmetic dentistry, crowns, bonding, veneers, whitening, bridges, bone grafts, root canals, tooth extractions Eye, ear, nose, and throat treatments Facial cosmetic surgery: rhytidectomy, eyelid surgery(blepharoplasty), nose reshaping, brow or forehead lift, ear surgery: otoplasty Body contouring: liposuction(lipoplasty, tummy tuck(abdominoplasty), breast augmentation(augmentation mammoplasty), breast lift(mastopexy), thigh lift, buttock lift, lower body lift(belt lipectomy) Chinese medicine, acupuncture, herbal treatments, Ayurvedic treatments, Pancha Karma, tai-chi Spa therapy, yoga therapy, meditation therapy, holistic therapy, thermal therapy(mineral springs, balneo therapy), thermo therapy, thalasso therapy, Algae therapy, aroma therapy, cryo therapy, electro therapy, magneto therapy,-healing mud(fango therapy), occupational therapy(stress management), massage(pampering), diet(nutritional) programs, detox programs, New Age, spiritual tourism
Major Surgeries
Minor Surgeries
Cosmetic/Plastic Surgeries Diagnostic Services Alternative Therapy Treatments
Wellbeing/Lifestyle Remodeling Services
Source: Gahlinger(2008: I-IV), Marsek and Sharpe(2009: 39-76), Smith and Puczko.(2009: 7)
Types of Medical Service Providers

There are a variety of models dealing with how the medical tourism industry provides patients with medical services in MTDRs. Cormany (2008) lists the following medcial service models. The hospital service model is the most standard model that involves the patient receiving diagnosis and treatment at a hospital, then recovering and resting at the hospital, a hotel or a resort. Examples include Thailands Bumrungrad International Hospital, Singapores Raffles Hospital Group, Indias Apollo Hospital Group, and Koreas Severance Hospital. The medi-resort service model involves treatment and recovery occurring in a resort that is equipped with medical facilities. Malaysias Palace of the Golden Horses and Thailands Chiva-som Spa Resort are the more
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famous facilities. Such a model cannot exist in Korea at the moment because of medical regulations. The fly-in & airport service model involves treatment at a hospital inside the airport at which the patient lands, such as Munich International Airport in Germany. Patients do not have to travel long distances after exiting the plane and can receive treatment quickly, but such facilities are limited in capacity. The cruise ship model involves treatment and rest inside a cruise ship, and Renaissance Cruises is an example of such a model. Oftentimes a patient can receive all the necessary treatments and recovery procedures during the same cruise, but can also board the cruise after receiving treatment at a nearby hospital. Johns Hopkins Hospital offers such linked services with cruises. The drive-in & out model involves driving to a neighboring country to receive simple treatments or to buy certain pharmaceuticals and then returning. Los Algodones and Tijuana is located on the US-Mexico border, and are a prime example of such a model. Sopron in Hungary is another. The airlinehospital joint model involves receiving diagnoses during the flight on an appropriately equipped airplane, and the results of the diagnoses are directly sent to hospitals in the MTDR before the patient arrives, speeding up the treatment process. Emirates Airlines offers such services, but only on certain routes.
Medical Tourist Intermediaries

Intermediaries serve as a link between the specialists of various fields involved in medical tourism. The government forms policies on medical tourism, improves systems, and supports budgets to intervene in the medical tourism industry, and can even send its own citizens to overseas hospitals, such as is done by the British Healthcare Service. This is done to minimize wait times and costs that would be required for expanding infrastructure. Since 2005, BHS has subsidized medical costs for citizens traveling overseas (within three hours by air) to receive treatments (Horowitz et al., 2007). Insurers and labor unions can also play the role of intermediary. Insurance companies and corporations with their own insurance policies are examining outsourcing medical services as a way to reduce costs, and are offering incentives to those who travel overseas for treatments (Caffarini, 2008; Reed, 2008). Reduced insurance rates, cashbacks, travel cost subsidies for even traveling companions are also be offered. Tourism-related associations and groups are also important intermediaries. The Korean International Medical Service Association is an example of such a body. Media related to to medical tourism is also important
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in that publications such as the American Medical Tourism Associations Medical Tourism provide a broad range of information for potential consumers, contributing to the growth of the global medical tourism market. For this development to occur, intermediaries must play an important role in connecting suppliers and consumers. Whether they receive commissions or provide free services, intermediaries introduce and connect a wide range of services to the medical tourist. In particular, agencies play a large role for both consumers and suppliers by planning medical tourism products and engaging in marketing promotions. Medical tourism agencies are those that provide specialist services for overseas consumers who wish to receive medical treatment (Woodman, 2008a). They may also be called medical (health) travel(tourism) agents, medical travel planners, medical travel facilitators, medical travel brokers, and medical travel expediters. Medical tourism agencies have many different roles, with some being part of a largery corporation, while others are mom-and-pop operations. Some specialize in a certain type of procedure or product and are located in a country that is known for such products, while others deal with multiple types of services in many different countries. Currently, most medical tourism agencies are poorly funded and are small in scale and employees. Although the medical tourism agency industry is mature in countries such as the United States, the situation is less prosperous in other countries, where there are only a few companies able to operate properly.
Medical Tourism Services

Types of medical tourism services The components of medical tourism services can be largely divided into four groups (see Table 4). These may change according to the researcher, but Cormany (2008) identifies four factors that the consumers of medical tourism take into account when selecting MTDRs. These factors must be taken into consideration by the suppliers of services in MTDRs when forming marketing strategies or products. Medical facilities and related services, accommodations and F&B (food and beverage) services, tourist facilities and services, and government policies and sociocultural elements are such factors. As seen in Table 4, each of the four major groups has many subcategories. Only MTDRs that can prepare according to these service factors and accordingly supply services to medical tourists will be able to succeed in attracting customers and growing.
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Because the primary purpose of medical tourism is receiving medical services, how a MTDR is able to reinforce trust and safety of its medical care in medical tourists minds becomes one of the most important aspects. In particular, medical tourists are always apprehensive of the standard of medical technology of MTDRs, and thus additional levels of care and detail are required in this area when compared to the other three categories. Along with the fame of its medical staff, the level of medical facilities is of most importance to medical tourists. The bed capacity, the presence of JCI (Joint Commission International) certification and other international standards, registration of doctors and nurses, level of expertise in certain areas, doctor-patient ratio, and ambulance services are some of the factors that customers take into account. With the growth of the global medical tourism industry hospitals all around the world are increasing international marketing activities. Medical tourists, when subjected to this, are curious about how these international hospitals compare to those in their home country. One way for overseas hospitals to prove their high standards is receiving certification from the International Society for Quality in Healthcare (ISQua). Along with the JCI, the following bodies participate in ISQua (Watson, 2008). Australian Council on Healthcare Standards, - Quality Improvement Council, Australia, - Quality Health New Zealand, - Canadian Council on Health Services Accreditation, - Irish Health Services Accreditation Board(now HIQA), - Council for Health Services Accreditation of Southern Africa, - Joint Commission on Hospital Accreditation, - CHKS-HAQU Health Care Accreditation Unit, UK, - Japan Council on Quality in Health Care, - Egyptian Health Care Accreditation Organization. In order to receive international accreditation, much time and resources is required. Because of this, some hospitals do not see the need to puruse international accreditation if they do not aim to attract medical tourists from developed countries. However, accreditation not only increases the attractiveness of the hospital, but also lowers the chances of possible conflicts or legal issues with patients. In the case of JCI, 140 hospitals from 26 countries had received the accreditation as of 2007 (Timmons, 2007). The transfer of medical records to doctors in the home country is also important, as the patient requires such records after returning. Currently, the most efficient method is digitizing the patients medical card or diagnosis report and sending it by electronic methods. However, only one of four doctors in the United States use the Electronic Medical Records (EMR) system, which is one of the lowest usage rates worldwide. Usage of the Comprehensive EMR System, which
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sends diagnosis and treatment information to pharmacists and other related personnel in the medical industry, is even lower at less than 10% (Power, 2009). This may be due to the fact that converting paper records to electronic ones is a time intensive process. Nevertheless, if medical tourism is to continue to grow, a method of rapidly sending and sharing patient records among doctors internationally is required, such as the EMR system. Taking this one step further, the implementation of a ubiquitous health system (u-Health System) would be of great benefit to the global medical tourism industry (Yoon, 2009). The accommodation and food, and the related services, is also of great importance for an MTDR when catering to the needs of sensitive and vulnerable medical tourists. Because medical tourists also are restricted in mobility and diet during treatment and recovery, additional attention must be paid to these customers, and the following factors can be taken into account by medical tourists when choosing an MTDR: placement of medical staff at the spa facility, possibility of a health diagnosis, treatment programs inside the spa, traditional treatment methods (yoga, acupuncture and so on), rest, diet, wellbeing education (tai chi, yoga and so on), and exercise facilities. Facilities that can meet the dietary requirements recommended by doctors to patients are also required. Tourism and leisure facilities and services are also very important for medical tourists. Apart from the medical tourists that receive services related to their surgeries, the other types of medical tourists have a high possibility of pursuing recreational activities after their medical care. A survey of patients at Thailands Bumrungrad Hospital revealed that 85% of patients or their companions experienced at least one kind of tourism service during their stay (Medical Tourism Association, 2010). Utilizing local travel agencies or travelling to famous tourist spots, shopping and other culture activities by oneself is also possible. Therefore, tourist and leisure facilities and services must also be developed continually to attract medical tourists. Finally, political and social circumstances as well as government policies regarding visas, and the attitude of the local population to foreigners is also an important factor in MTDR choice. In particular, visa policies have a great effect on MTDR selection.
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Table 3. Factors of each destination component which may strengthen or weaken an areas appeal toward the medical tourists
1. Costs-medical 2. Labor available-medical 3. Training available medical (medical schools, nursing programs) 4. Financial inducements for labor-medical 5. English commonly spoken among medical staff 6. Facilities: a. Capacity b. Accreditation c. Licensure of staff d. Specializations e. Staff : patient ratio f. Ambulance service 7. Equipment available for rental(oxygen, wheelchair, etc.) 8. Private nurses available for hire 9. Medications: a. Availability b. Safety of medication quality c. Parallels to US medication 10. Indigenous disease threats 11. Privately operated facilities 12. Operation of 'aftercare' facilities 13. Ease of medical records transfer back to the home country 1. Costs-lodging 2. Costs-food and beverage 3. Number of 3/4/5 diamond rooms available(Are int'l ratings available?) 4. Hospitality labor availability 5. Hospitality training available 6. Financial inducements for labor-hospitality 7. English commonly spoken among hospitality staff 8. Availability of potable water in facilities 9. Reliability of electricity in facilities 10. Licensure & regulation for a. Food & beverage operations b. Hotel accommodations c. Spa facilities 11. Dietary accommodations available (gluten free, low sodium, doctor prescribed) 12. Internet availability 13. Hotel accommodations: a. Disability & special services accommodations b. Private baths c. Elevators d. Room service availability (24 hours?) e. Proximity to hospitals f. Heat/air g. Value for services provided ratio 14. Presence of spa services: a. Medical personnel associated with spa b. Spa treatments c. Traditional treatments (acupuncture, herbal, Ayuveda, etc.) d. Instruction in relaxation, diet, wellness (tai chi, yoga, nutrition, etc.) e. Diagnostic services f. Exercise/workout facilities 1. Costs-general labor 2. Commonality of spoken & written English 3. Availability of educated translators 4. Airport: a. Direct service from major cities b. Airlines servicing area c. Accommodations for disabilities d. Airfare rates e. Frequency of flights 5. Local transportation: a. Avail. of taxis, limos b. Avail. of buses, other public transport in hospital/hotel areas c. Safety of available transport options d. Accommodation for disabled available 6. Reliability of infrastructure: a. Electric service b. Public services c. Waste management 7. Safety from crime 8. Local political stability 9. Distribution of service for: a. Cell phones b. Internet 10. Ease of limited mobility maneuverability (wheelchair, pedestrian friendly?) 11. Weather appeal for vacation and for recovery 12. Destination appeal: a. City offerings b. Relaxation c. Education d. Culture e. Sightseeing f. Traditional medicine as supplement/alternative 13. Receptivity by locals to Americans 14. Current awareness/image of locale by Americans 1. Political stability of country 2. Stability of labor force -union strike potential 3. Currency fluctuations 4. Access to money/credit 5. Safety of country 6. Respect of individual rights: a. Culture of tolerance b. Gender equality c. Protection of disabled d. Freedom from unreasonable arrest 7. Legal system a. Established laws b. Evenness of enforcement c. Ownership rights d. Legal recourse e. Protection of patients f. Malpractice recognized g. Accounting and financial disclosure h. Tax system I. Recognition of patents, intellectual property rights 8. Ease of access: a. Need for visa (by residents of target markets) b. Visa access c. Visa processing time 9. Type of market (economic model): a. Capitalism b. Privatization c. Regulation/deregulation of areas impacting healthcare and tourism 10. Cultural strain: a. Likeness of source and host country culture b. Host country's citizen attitudes toward source country
Medical Facilities & Services Circle
Hotel & Food/Beverage Circle
Tourism Support Facilities & Services Circle
Governmental & National Factors Circle
Source: Cormany (2008:36)
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Service differences according to medical tourist type The requirements of medical tourists can differ according to their type. Cormany (2008) formed a diagram where the type of medical tourist and type of service were combined to indicate what levels of service were required by medical tourists (see Figure1). The diagram displays the four categories of medical tourism service offered to the six types of medical tourists. Each section of the pie represents a type of medical tourist or medical tourism product. From the 12 oclock position, the sections are tourists for cosmetic surgery, tourists for major surgery, tourists for diagnostic services, tourists for alternative therapy treatments, and tourists for wellness/lifestyle remodeling. Each pie is further divided into four sections, with each section representing the types of medical service required for each type of medical tourist. The sections, from the center, are medical facilities and related services, accommodation and F & B services, tourist facilities and related services, and government policies and sociocultural factors.
Source: Cormany(2008: 35) *medical facilities and services, **hotel and F&B services, ***tourism facilities and services, ****government services and socio-cultural factors
Figure 1. Six categories of medical tourists and the relative impact the four components may have on each
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For example, patients seeking major surgeries such as heart surgery, cancer treatment, and joint replacement surgery, will place more emphasis on the level of the medical staff, equipment and facilities, and recovery options? Reflected by the innermost section of the pie, the section related to medical facilities and related services, being the largest. The tourism and leisure section is the smallest, as the possibility of freely moving around post surgery is small for these patients. On the other hand, medical tourists requiring well-being services will require a high level of accommodation and food, and tourist facilities and services, and will place less importance of medical facilities. This is reflected in the diagram. Overall, patients that require surgery? Major, minor and cosmetic ? Will place more importance on medical facilities and services over the other three service factors. Meanwhile, those requiring alternative therapies, diagnoses and well-being products will value accommodation and F & B, and tourist facilities and services much more than the other factors. Therefore, when planning medical tourism products, the types of medical tourists must be taken into account when evaluating courses of action. As the industry develops, overlapping functions and roles are starting to appear among the four service factors mentioned above. According to Cormany (2008) many hospitals are learning and emulating hotel management methods, and some hospitals even have hotels inside. Thailands Bumrungrad Hospital is one of a few hospitals that offer hotel-like lobby services and concierge services, as well as fast check-in and out services, and a variety of catering and interpretation services. These efforts minimize the amount of time that patients spend in separate hotels, while also bringing about opportunities for hotels to emphasize their individual merits by becoming consultants or managers at such hospitals. Some hospitals are becoming less medical facility and more resort? The Barbados Fertility Center has rearranged all of its rooms to face the ocean. Another example is Bodyline Resorts in Thailand, which attempts to attract patients recovering after surgery by designing their facilities to patients needs (Cormany, 2008). Human Resources in Medical Tourism Services For MTDRs to provide satisfactory services to medical tourists, specialists are required. Taking into account Table 4, there are four major categories of specialists: medical services specialists, accommodation and F & B services specialists, tourism service specialists, and government related service specialists. More specifically, medical service specialists include international
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doctors and nurses. Accommodation and food services require the expertise of floor services, room services, food services, leisure and sports specialists, therapists, and lifestyle remodelers. Tourism service specialists include coordinators, marketers, guides, operators, interpreters, and translators. Government service specialists include customs officers.
Medical Tourism System

There exist many tourism system models in the tourism field. This study takes Leipers 1995 tourism system as a foundation for a medical tourism system to explain phenomena. Compared to Gunn (2002)s supply-demand approach, and Mill and Morrison (2009)s marketing-focused approach, Leipers model more appropriately explains tourism phenomena such as tourist origins and destinations, stopovers, and tourist services provided by the industry.
Source: Leiper(1995: 25)
Figure 2. Tourism System
Leiper explains tourism phenomena in terms of five components of tourism: tourists, traveler generating regions, transit route regions, tourist destination regions, and tourism industries. Medical tourism phenomena can then be explained using four components of medical tourism system: medical tourists,
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medical tourist generating regions (MTGR), medical tourist destination regions (MTDR), and medical tourism industries. Each component is a basic component of the medical tourism system, and each are mutually connected and interdependent in their mechanisms. Medical tourists require the four areas of the services which are needed for successful medical tourism. Even if the components of the services influence each other, in general a medical tourism agency plays a major role in arranging the schedule of medical tourists for the four service components. Medical service may be the most important factor which the medical tourists consider when they choose a destination for medical tourism. Accommodation, food and beverage, tourism experience, and government regulations and socio-cultural factors are also crucial factors affecting the choice of a medical tourism destination.
Figure 3. Medical Tourism System
The medical tourism system can be presented as Figure3, using the components mentioned before, and is a diagram designed to explain the roles and relationships between the components of the system by placing the four components on the same plane, and expressing the services and their suppliers according to the routes of the medical tourists. The method that Leiper (1995, pp. 22~24) used to explain the tourism system model, through the travels of a character, Herr Schmidt, is benchmarked and utilized to explain the medical tourism system model. Let us take the case of an American patient named
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James Dean who currently resides in the United States. Along with a caregiver, he has decided to visit Raffles Hospital in Singapore in order to receive a hip replacement surgery. Firstly, in the MTS, Mr. Dean is a component of the system as a medical tourist. The medical tourist is the most basic component of this system. If there are no medical tourists, the other components lose their reason for existence. Of the medical tourists in the MTGR, there are six categories of patients, from Group 1 to Group 6. Mr. Dean is in Group 1, major surgery patients, as he is going for a hip replacement procedure. There are two ways for him to travel to Korea. He can visit by his own means, or he can use a (medical) tourist agency. In the United States, insurers or employers (or labor unions) send their employees or customers for overseas treatments through travel agencies. Mr. Dean could have health insurance, but could also not be fully insured, or could also not be insured at all. If he is not insured, he must make direct contact with the travel agency. If he does not wish to use the travel agency, he must take care of all the aspects of the travel by himself. Secondly, there are two different geographical areas in the MTS: the medical tourist generating region (MTGR), and the medical tourist destination region (MTDR). It is assumed that as the majority of travelers are also patients, there are no intermediary destinations. Here, the MTGR is the United States, and the MTDR is Singapore. In the MTGR, medical tourists, insurers, corporations, labor unions, and travel agencies play an important role in stimulating the medical tourism industry. Mr. Dean will primarily use air transportation when moving between MTGR and MTDR (and back). Depending on the destination, other patients may be able to use sea (cruises, ferries) and land transportation (trains, cars). As these kinds of transportation methods are part of the tourism industry, Mr. Dean is already receiving tourism services. In other words, once the tourist begins his journey, he is automatically subject to the forces of the tourism system. Here, Mr. Dean is also subject to marketing activities by medical tourism agencies (travel agencies or hospitals) in Singapore or in the United States. He can conduct research through local marketers in the MTDR, through online methods, or through agencies or insurers who have experience dealing with Singapore. Consulting with patients who have received treatments at a particular hospital is also a feasible option. Thirdly, there are largely four types of medical tourism services that can be provided by the MTDR to Mr. Dean: medical facilities and related services, accommodation and F & B services, tourist facilities and services, and government and social factors (for more details on each type, see Table4).
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When Mr. Dean is picked up at the airport by a coordinator sent by a travel agency or a hospital, he will go to his hotel. Then he will visit the hospital and speak with a doctor regarding his desired medical procedure. In this case, Raffles Hospital fits under the category of hospital in terms of medical service providers. Once he is recovered and fit, he can discuss with his doctor regarding participation in tourist activities. Because the purpose of his trip is primarily to receive a medical treatment, participation in tourism must be undertaken after serious consideration. On the other hand, patients falling under Group 4 to 6 (Mr. Dean is a Group 1) have less restrictions regarding tourism activities. Once Mr. Dean has received his treatment and recovered (as well as participating in tourism activities if possible), he returns to the airport to return to the MTGR, the United States. This entire process is planned and executed by the coordinator. In the case that any complications or side effects arise either in the MTDR or MTGR, he may receive the assistance of a local lawyer. Mr. Dean receives the relevant services in the MTDR through specialists and experts. There are international doctors and nurses at the hospital, hotel staff, therapists and lifestyle remodelers at the recovery center, guides and other tourism service manpower at tourist spots or shopping centers, and airport staff at the airport. The service provided to Mr. Dean by these people bears much significance on his decision to visit the MTDR again or otherwise recommend the destination to potential medical tourists (KTO, 2008; 2009a, b). Thus, in order for an MTDR to maintain growth and development, the people related to the medical tourism industry must work to provide service that is both high in quality and quantity, and maximize customer satisfaction. Finally, the ability of a country or city to attract medical tourists in the medical tourism system is influenced not only by these direct factors but also other external circumstances. The political, economic, social and cultural situation can all play a role, as can environmental changes, exchange rates, visa policies, labor markets, openness towards foreigners, and outbreaks of diseases. Fundamentally, the tourism industry is sensitive to political and social factors. For example, the difficulty of gaining entry into the United States for those from the Middle East after the September 11 attacks forced many of these people to change the MTDR to Singapore, Thailand and other Southeast Asian nations (Connell, 2006). Thailands mass election protests in 2009 led to many tourists avoiding the country. Furthermore, the various financial setbacks and crises such as the Asian financial crisis in 1997 and the global economic depression in 2008 has made many tourists less likely to travel. The fact that medical tourists take into account the local attitudes towards foreigners or
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sociocultural similarity when selecting MTDRs indicates that social and cultural factors do play a role in decision making. Environmental factors also play a role, with the 2004 tsunami in Indonesia having a heavy impact on tourism in the region, and the 2010 volcanic eruptions in Iceland forcing cancellation of most air traffic in Europe for a period of time and causing significant economic damage to the European tourism industry. The movement of tourists, as a part of services provided by the tourism industry, is thusly affected by environmental factors. In terms of exchange rate, if the currency of the MTDR falls, or if the currency of the MTGR rises, the number of medical tourists increases (Export rise effect, Bull, 1992). Japanese and Chinese medical tourists visiting Korea recently are benefitting from this exchange rate situation. Furthermore, if the visa application process in the MTDR is difficult or time-consuming, tourists tend to select other destinations. Korea is well known among visitors from developing countries for impolite and rude attitudes from the customs office, as has been reported in the media (KBS, 2009). Issues with labor movements and strikes that can affect airports and public transportation systems are also detrimental to medical tourists, as are outbreaks of diseases such as SARS and H1N1 influenza. The Asian tourism industry was greatly affected by the SARS outbreak in 2003, and the global tourism market shrunk as a result of the H1N1 influenza outbreak (UNWTO, 2006; 2010). Summing up the above, the medical tourism system includes at least the following four components: a medical tourist, a medical tourist generating region (MTGR), a medical tourist destination region (MTDR), and the medical tourism industry that provides the related services. In addition to these components, external factors mentioned above can greatly affect the trends and flexibility of this system.
Relationships Between Components of the Medical Tourism System

At each phase of the medical tourists travels from the MTGR to MTDR and back to the MTGR, the services demanded and supplied are different. Much preparation is required before leaving the MTGR in this first place, which requires many different services. Before departure, the selection of a medical travel agency, destination, treatment options, companions, hospitals and doctors is required, as is the cleanup of medical records, whether the patient will engage in tourism activities, and airline and accommodation
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arrangements. Specialists aiding in this process include local doctors and travel agents. At this stage, MTDRs must form efficient marketing strategies towards their target markets. Even more specialists and services are required as the patient arrives at the MTDR. Unlike regular tourists, medical tourists are in states of physical and mental weakness. Services required at this phase include airport pickups, hotel check-in, transportation to hospitals and checking in, diagnosis and treatment by doctors, recovery and rest, checkout procedures, tourism activities (when possible), and departure. Specialists here include coordinators, translators, hotel resources, local doctors and nurses, other medical staff, therapists, nutritionists, spa and resort staff, and tour guides. Once treatment is finished, the patient returns to the MTGR. Even after returning, the medical tourist requires careful attention and service. Consulting with a local doctor regarding the treatment received overseas is required, as is further rest and recovery. In particular, any side effects or complications resulting from the treatments may even require a return to the destination to receive additional treatment, which requires more support from the tourist agency. In the case of legal issues, local and overseas legal services may be required.
Suggestions for the Use of the Medical Tourism System Model, Limitations of the Study, and Suggestions for Further Studies
This study has taken Leipers tourism system model and applied it to the medical tourism field, resulting in the development of the medical tourism system model. This model takes the medical tourist as consumer and MTGR and MTDR as supplier as the basic framework, categorizes the six types of medical tourists and four types of services and associated specialists within this framework, and identifies the different degrees of services required by each type of medical tourist. In addition, these have been identified with a focus on the agency as an intermediary between consumer and supplier, and the relationship between the services and specialists required at each phase of a medical tourists trip is systematically presented. The medical tourism system model can be used in the following ways. Firstly, the MTSM describes the geographical nature of the industry, and any country or city interested in medical tourism can play the role of MTGR and MTDR. Therefore, this model can be used to comprehensively and systematically explain the medical tourism phenomenon occurring between two
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countries or cities. Secondly, the MTSM can be used as a theoretical framework for discussion or analysis of medical tourism. As mentioned earlier, there is a lack of theoretical models that can comprehensively and systematically explain the medical tourism phenomenon, and as a result there is much room for unwarranted misunderstandings and conflicts between various parties. This model can resolve these problems and can be used to understand other industries connected to the medical tourism industry. Thirdly, the MTSM can be used to understand the medical tourism phenomenon from another perspective. Studies up until now have primarily focused on the MTDR, but taking the perspective of the MTGR is also important in identifying issues and examples in attracting medical tourists on the part of MTDRs. In particular, this model may be of help in identifying target market MTGRs and forming related marketing strategies. Lastly, the MTSM is not only for the theoretical use of the tourism field, but can also be of relevance to other academic fields for interdisciplinary research and study. For example, this can apply to system theory, economics, business management, psychology, geography, medicine, medical business, ecology, and environmental science. Clayton and Redcliff (1996) have claimed that models are servants, not masters. This indicates that one specific model cannot perfectly explain a complex and dynamic social phenomenon. The MTSM is no exception, in that it cannot offer complete solutions to the issues facing the medical tourism industry, despite it being designed to aid comprehensive understanding of these issues. It instead may be used as a complementary tool to the fundamental management systems of the medical tourism industry. There are many issues that cannot be explained by one or two models in the medical tourism phenomenon. The experiences and knowledge attained by the people working in this industry may be even more effective in explaining or resolving such issues. The limitations of this model are as follows: First, this model does not present human resources (e.g. international medical doctors and nurses, medical tourism coordinators, medical tourism marketers, tourism and hospitality service workers, and therapists and so on) who play major roles in the medical system. Second, the MTGR in this model illustrates the case of health service system in the U.S.A. and does not explain other countries health service system. Third, this model does not represent the views of medical academics and businesses while representing the views of tourism academics and businesses. A number of medical academics and businesses do not favor the involvement of tourism services in medical services, refusing to use the term of medical tourism. Fourth, this model does not include the details of major four
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services (medical services, accommodation and food and beverage services, tourism services, and governmental and socio-cultural systems) in MTDR. There is much potential for future studies using this model. Studies on the relationship between the suppliers and consumers of the medical tourism industry, or those on the formation of marketing strategies according to target market or consumer group. Studies on the business situations between MTGR agencies and MTDR agencies, between agencies and insurers and employers would also have significance. Furthermore, strategies of affiliation between the four service subtypes in MTDRs could provide fruitful subjects for future study.
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Received December 05, 2010 Revised March 20, 2011 Accepted April 17, 2010

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International Journal of Tourism Sciences, Volume 11, Number 1, pp. 18-51, 2011 Tourism Sciences Society of Korea.

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Medical Tourism System Model

Medical Tourism System Model

Concepts of Medical Tourism

Medical Tourism System Model

Medical Tourism System Model

accurate understanding of the concept.

Medical Tourism System Model

Components of the Medical Tourism System

Medical Tourism System Model

Medical Tourist Generating Region (MTGR)

Medical Tourism System Model

Medical Tourist Destination Region (MTDR)

South Africa Tunisia

Australia New Zealand*

Source: Horowitz et al. (2007: 34) *added by the author

Medical Tourism System Model

Medical Tourism Products

Table 3. Major medical tourism products

Cosmetic/Plastic Surgeries Diagnostic Services Alternative Therapy Treatments

Wellbeing/Lifestyle Remodeling Services

Types of Medical Service Providers

Medical Tourism System Model

Medical Tourist Intermediaries

Medical Tourism Services

Medical Tourism System Model

Medical Tourism System Model

Medical Facilities & Services Circle

Hotel & Food/Beverage Circle

Tourism Support Facilities & Services Circle

Governmental & National Factors Circle

Source: Cormany (2008:36)

Medical Tourism System Model

Medical Tourism System

Source: Leiper(1995: 25)

Figure 2. Tourism System

Medical Tourism System Model

Figure 3. Medical Tourism System

Medical Tourism System Model

Relationships Between Components of the Medical Tourism System

Medical Tourism System Model

Medical Tourism System Model

Medical Tourism System Model

Medical Tourism System Model

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