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Medical Tourism in Thailand 1

By Wanvipha Nuke Hongnaphadol

‘ Consumer choice and motiva tion of medica l : tourism in Tha iland a case s tudy of hea lthca re

consumers vis iting a priva te hea lthca re ’provider in Pa ttaya

The York Management School , Univers ity of York UK

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


Definitions of key terms (1)

• ‘ ’Medical tourism pa tients trave lling overseas for medica l ca re

— — involving specific medica l inte rvention and opera tions combined with re laxa tion on

( , 2006)holidays Conne ll

• ‘ ’Medical touris t / a person leaving his her own country for

( , 2006)medica l trea tment overseas Hancock


(1) (3) (5) mere touris t medica l mere patient

touris t proper

(2) (4) medica ted vaca tioning touris t pa tient

( , 2006: 89)Cohen

A Typology of Medica l Touris ts



• ‘ Health tourism’ a ll kind of trea tments enhancing a s ta te of

well be ing both phys ica lly and psychologica lly, ranging from the spa experience through cosmetic surgery to lifesaving surgery like

( - , heart transplant Caba lle ro Dane ll &Mugomba2007)


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)


Leve l of Procedure Complexity &Risk

Bone marrow transplant cosmetic denta l health Thai he rb & spa &Tha i traditional massage organ transplant surgery procedure checkup alterna tive open heart surgery medicine

s tay a t hote ls or hospita l travel package during recovery

Rela ted Services added by Tourism

Model of Medica l Tourism

(Harryono et al., 2006: 17)

Medica loutsourcing

Tourismmotiva ted



• ‘ ’Cons umer motivation

inte rna l and exte rna l motiva tiona l forces , impe lling people to act to sa tis fy a need or the

( , 2004)reasons for consumer behaviour Le iper– The underlying reasons for consumer behaviour ( Mayo

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

– The bas is of knowledge of consumer decis ion making ( , 1977)process Dann

– The s ignificant founda tion for eva lua ting sa tis faction from’ ( , 1981; -consumers experience Dann Dunn Ross & Iso

, 1991; , 2005)Ahola Yoon &Uysa l


• Cons umer choice– When policy ana lys ts examine hea lthca re sys tems from the

, broades t pe rspective very little about / patient consumer choice ( - , 2008).is mentioned Borkman and Munn Giddings

• Consumer choice applied in the medica l context is a . very inte res ting phenomenon

– Asymmetry of information: why consumer choice is limited in medica l context

• Choice to seek trea tment overseas



Introduction to Medical Tourism (1)

• ( . . — 2003 Europe e g Hungary decla red as the Year of Hea lth Tourism—, , Is rae l

, , , )Belgium Poland Greece Spa in• ( . . , , Latin America e g Cos ta Rica Mexico

)Brazil• ( . . —Middle Eas t e g Duba i Duba i Healthcare City 2010—, , )by Jordan Iran

• South Africa• ( ,Asia Singapore Tha iland, , , India Malays ia

) Philippines• A reversed trend of trave ling overseas to

seek for medica l trea tment


Introduction to Medical Tourism Research (1)

• — The rise of medica l tourism as the major — medica l tourism des tina tion is now in As ia

( , 2006). Conne ll

• Little tourism research has been conducted on consumer motiva tion perspectives

( , 2000; , 2004).Goossens Bansa l &Eise lt



• No empirica l s tudy identifying the motiva tion of trave lle rs to Tha iland ( ., Ritticha inuwat e t a l

2008) ‘ -except the very recent s tudy A factor : clus te r ana lys is of touris t motiva tions a case

. . ’ ( , 2008).of U S senior trave lle rs Sangpikul• Answering the ques tion of why people trave l is

the most cha llenging in touris t behaviour( , 1979).Crompton



Recent bus ines s report• A recent report Asian Medical Tourism Analysis

(2008-2012) shows the revenues genera ted by 3.4 the region of US$ bn from medica l tourism in

2007, 12.7% accounting for nearly of the globa l ‘market and Tha iland has emerged as the la rges t medica l tourism marke t in As ia ’ ( , Velasco

2008: 13).• ‘Tha iland ( is the la rges t medica l tourism hub in

) - Asia in tota l volume and in both high end and- ’ ( , 2008).low end procedures Runcke l



(1): The context of Thailand Tourism in Thailand• ( ) Touris t des tina tion a ttributes of Tha iland

– . . , Five top tourism des tina tions i e BKK Chonburi(Pattaya), , ( )Phuket Chiang Mai and Songkhla Hat Yai( , 1997)Thailand Deve lopment Research Ins titute

• Perception of low risk– A survey conducted by Visa Inte rna tiona l Asia Pacific &

5,000 the Pacific Asia Trave l Associa tion of inte rna tiona l 10 52% trave le rs from marke ts around the world found

cons idering Asia as the ir next trave l des tina tion andThailand - to be the number one pre ferred des tina tion( , 2007).Trave l Agent



(2)The context of Thailand• Geographica l loca tion

– - , A half way s topover point be tween Europe Eas t , Asia &Austra lia and as a ga teway to Indochina

• Competitive advantage– Low labour cos t

• / ( Products supply ins titutiona l and)infras tructure

• ( )English spoken by s ta ff


Medical Tourism in Thailand

• 1970 Thailand became a medica l tourism des tina tion in the s with its expertise in sex change opera tions and cosmetic

surgery ( , 2006).Conne ll• 1997Asian Economic Cris is in

– Currency collapse– Need for economic dive rs ifica tion– Merging medica l expertise and tourism has become a

( , 2007).government policy in many Asian countries Teh• Perceptions of hea lthca re trea tment

– qua lity of tra ined doctors and nurses– ( )JCI Joint Commiss ion Inte rna tiona l Accredita tion

• A priva te hospita l in BKK was the firs t As ian hospita l 2002.accredited by the JCI in

Healthcare (1)

• Diffe rent pa tte rn of previous and new hea lthca re consumers ( , 2002)Hjertqvis t

– , Previous ly the hea lthcare provider was not des igned to serve a rea l .consumer influence

– , ’ In the welfa re s ta te the pa tients specific demands could not be fully responded as .need

– Weste rn hea lthcare consumers today are provided with grea te r access to various means of

information sources in order to compare the’ providers qua lity and .choices


Healthcare (2)

• Freedom of choice and the use of hea lthcare facilitie s in many countries a re predominant in the current

’ hea lthcare consumer s framework when they can benefit from shorte r wa iting times and be tte r qua lity se rvices .

• ‘The s ignificant increase in consumerism’ owing to consumer expecta tions regarding the favourable

outcome of medica l inte rvention encourage more people — to seek medica l ca re pa tients more aggress ive ly seek

.se rvices tha t match the ir expecta tions


Healthcare (3)

• Healthcare is no longer defined by people — rece iving services when they are ill the

.s te reotypica l pa tient• /Cross border hea lthcare pa tient mobility: citizens

of the European Union may go to another EU country for specia lis t trea tments tha t a re not

, available in the ir own country or because the ( , 1999).waiting lis ts a re shorte r Hogg


Healthcare (4)

• Healthcare sys tems in individua l countries are , diffe rent due to the socia l politica l and cultura l

.context• The concept of consumer choice diffe rs be tween

.the UK and US• ‘Theore tica l perspectives on consumerism in

’ health ( , 2005; Brown &Zaves toski Henderson &, 2002) Pete rsen are not universa lly applicable to

.a ll Wes te rn democra tic countries


Healthcare system in Thailand

• - — Amarke t oriented hea lthcare sys tem people have free choice in se lecting a hea lthcare facility

( , 2002)Janja roen &Supakankunti• 3 All Thai citizens have been covered by main public

:hea lth financing schemes


Public health financings chemes

?Who elig ible

Socia l Security Scheme( )SSS

Formal sector employees

Civil Servant Medica l ( )Benefit Scheme CSMBS

Government employee and the ir dependents

Universa l Coverage (30 )Scheme Baht Scheme

The res t of the popula tion

Healthcare system in the UK and the US

Healthcareapproach

Healthins urance

Characteris tic Sys tem Mos t common problem in

healthcares ervice

UK Public driven( )—tax based

independent & public providers

Universa l Health

Insurance

Welfa re s ta te Nationa l Healthcare

Sys tem( )NHS

Long waiting lis t

( )access

Recent NHS, . . re form i e the

introduction of- marke t s tyle

competition into the provis ion of

; hea lthcare government

defines a new role for pa tients

US /Priva te marke t driven

Priva te Health

Insurance

individua lis tic A mixedsys tem

Price(affordability)


Dimensions of the Healthcare Systems of US and UK: (2004); (2004); (2007)Sources Blank and Burau Weitz World Hea lth Organisa tion


Dimens ion US UK

?Citizen rights to hea lthca re Nega tive rights Pos itive rights

?Individual re la tes to socie ty Individualis tic Egalita rian

Nature of sys tem : Mixed and fragmented free market with governmenta l

insurance for specia l vulnerablepopula tions

Centra lised with a national hea lth sys tem

Role of free market Very high Low but ris ing

Payment for ca re : Mixed government through, , - -taxes priva te insurance out of

pocket

government through genera ltaxes

Extent health sys tem publicly (2004)funded

44.7% 86.3%

Universa l coverage No Yes

( , Ownership of facilities hospita ls , )nurs ing homes etc

: - , Mixed priva te for profit, nonprofit government

Predominate ly government

National policy on consumers involvement in healthcare

sys tem

: No variable policie s for different, diseases government

, jurisdictions myriad of health insurance companies

: Yes consumers involvementmanda ted


The Access to NHS (National Health Service)


Long waiting list


The insurance


Theoretical Framework (1)

Concepts on trave l motivation–Maslow’ (1943) s hie ra rchica l needs–Seeking and escaping ( - , 1982) Iso Ahola

as push and pull– Psychologica l and phys iologica l needs

( , 1938; , 1981)Murray Mayo and Jarvis– - Needs based , motiva tion -benefit soughtbased , motiva tion -a ttribute based, and

- psychologica lly based ( motiva tion Pearce , 1983)and Ca ltabiano



– A lite ra ture review on touris t motiva tions indica tes tha t the - pus h pull theory is a useful approach to unders tand trave l motiva tions to

vis it a particula r des tina tion of va rious trave le r ( ., 2000; , 2002).groups You e t a l Klenosky

– The - pus h pull theory has preva iled over other paradigms in inves tiga ting motiva tion underlying touris t and vis ita tion behaviour

( , 1977, 1981; , 1979).Dann Crompton



– (Push Escaping/ ) the des ire to trave l &Pull(Seeking/ ) ( -the choice of des tina tion Iso

, 1982).Ahola– (Push whether to go) (&Pull where to go)

( , 2002).Klenosky– (Push intangible intrins ic des ires of touris ts)

(&Pull / tangible characte ris tics a ttributes of a des tina tion) ( , 2002).Kozak


Medical Tourists Motivation to Destination Countries

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

Intermediaries(representative

offices)

Direct

•Accessible•High quality, low price•Unexpected service•Relaxation/recuperation

Medical Tourist in

Originating Country

Destination Country

( , 1979)adapted from Leiper

Identity: patient, consumer, citizen (1)

• As the role of marke t ra ises the s ignificant is sue ofidentity, , in te rms of hea lthcare marke t the identity of

hea lth se rvice users is cons idered whether they arepa tients ; rece iving services pass ive ly consumers

; shaping and controlling the rece ipt of se rvices orcitizens . utilis ing the ir rights to free hea lthcare

• It is essentia l to explore how hea lth se rvice users have engaged with these identitie s as these words

can be differently conceptualis ed due to diffe rent .hea lthcare sys tems


Identity: patient, consumer, citizen (2)


Identity Des cription Characteris tic s

cons umer • A user of products and service s in both public and priva te sectors

( , 2007)Needham• People who are able to make the ir

own decis ions about the ca re they, rece ive express opinions about the

care and perhaps eva lua te the care( , 2002)Henderson

• Ability to exercise choice , shape and control se rvices they are about to buy

• As a marke t and economic participant• Those who seek hea lthcare in an

active , role and perhaps make the ir owndecis ions• Individua lis tic

• Healthcare-consumer

providerre la tionship• Doctorshopping

citizen • As a politica l actor in the public sector• Collectivis t

pa tient • People with particula r hea lth problems who may be taking medicines or rece iving trea tment

( , 1999)Hogg• 1. 2. pass ive pa tients pa tients who

have low expecta tions of the ir 3. physician pa tients who behave as

consumers , with expecta tions and ability to critica lly eva lua te the qua lity

of trea tment rece ived and ability to ( - , make changes Baron epe l e t a l

2001)

• Ste reotypica l pa tient with pass ive role seeking and following phys ician advice

• -Patient phys ician

re la tionship• Pass ive

: pa tients pa tria rcha l

phys icianapproach

Characteristics of healthcare market (1)

• “ Medical care is uncerta in and unpredictable ; , many consumers do not des ire it do , . not know they need it and cannot know in advance what it would cos t them They

; cannot lea rn from experience they must re ly on the supplie r to te ll them if they , have been well served and cannot re turn the service to the se lle r and have it

.repa ired ”( , 1999: 169)Hogg

• Consumers are uncerta in of the ir health s ta tus and need for hea lthcare in any particula r time

• A product uncerta inty as consumers may not know the expected outcomes of ’ trea tments without the ir phys icians advice

• The consumers cannot tes t the product before us ing it• Recovery from disease is as unpredictable .

( , 2001)Folland e t a l


Characteristics of healthcare market (2)

• “ Medical se rvices are not advertised as other goods and the producer discourages. , comparisons Once the purchase is made consumers cannot change their minds

- .in mid trea tment ”( , 1999: 169)Hogg



Theoretical Framework (recap)

Push &Pull only expla in why people go BUT it does not expla in how deficiency of

’ people s own hea lthcare sys tem is eg How UK people recognise the

? deficiency of hea lthcare


Aims of the study

1. To explore the reasons why major English speaking consumers trave l to Thailand for the ir medica l

trea tment– The motiva tions of potentia l medica l touris ts– Diffe rences in these motiva tions among diffe rent groups both

from the same and diffe rent countries– Inte rre la tionships among these motiva tions

• To inves tiga te the consumer choices in se lecting a particula r trea tment in Thailand over other medica l

tourism des tina tions• To inves tiga te the degree of tourism participa tion of

those medica l touris ts


Research Questions

• What a re the s ignificant motives tha t influence the decis ion of medica l touris ts ? from the UK and the US to trave l toTha iland

1. , ?How are these motives different with respect to age na tiona lity and gender2. ( ) How does Bangkok Pattaya Hospita l BPH perce ive the consumer motiva tion from these

?countries3. To wha t extent does BPH applied perce ived consumer motiva tion to se rvice provis ion for

? ’ medica l touris ts How is a hea lthcare provider s se rvice provis ion re la ted to what motiva tes ?medica l touris ts to vis it the hospita l

2. What are the major keys influencing consumer choices about provide r and? ?des tina tion Why does a medica l touris t choose one des tina tion over another

3. To what extent do medica l touris ts take tourism component as a part in the ir decis ion ?making process

2. ? Is medica l tourism in Tha iland about tourism Is medica l tourism like ly to utilise the tourism?component

3. ?What is about the touris t pa rt of medica l tourism4. ? To wha t extent do medica l touris ts pa rticipa te in tourism


Fact finding• ( ) Samitive j Sriracha Hos pital

• ( ) Bangkok Pattaya Hos pital

• Bangkok Chris tian Hos pital

• Phyathai Hos pital

• Bangkok Hos pital

• ( ) Samitive j Sukhumvit Hos pital

In search of the study site

Bangkok

Chonburi


The study site (1)


The study site (2)

Pattaya


The study site (3)

Bangkok Pa ttaya Hospita l


(1) In s earch of the res earch s ubjectNumber 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


(2) In s earch of the res earch s ubject

• Patients from the US and Europe cons titute 20 about % of the tota l inflow of fore ign

pa tients with a higher proportion seeking for cosmetic surgery, hip and knee replacement

and organ transplant — to Tha iland the same is growing every year by around 40% for the US

and 50% ( , 2007).for Europe patients Teh


: (1)Methodology Data collection

Res earch des ign• Survey approach

– - Semi s tructured inte rviews

– Survey ques tionna ires



1. Stage Exploratory s tudy: - s emi s tructured interview

– - : Pre s tudy piloting the ques tions for inte rview in the UK ( 5 approx British people who have vis ited

)Tha iland for some kind of trea tment– Vis its to hospita l– Inte rview fore ign pa tients in Thailand ( 20 approx

-10 ; 10 )pa tients from the UK from the US



2. Stage Des igning the ques tionnaire :– The fie ld inte rviews are to inform the ques tionna ire

development and to he lp des ign the ques tionna ire items to measure the medica l tourism motiva tions and

.consumer choice


• 3: Stage Main ques tionnaire s tudy– Vis it the hospita l– 150 (75 ; 75 Survey medica l touris ts from the UK from

) ( the US us ing quota sampling na tiona lity and gender)dis tribution



Challenges

• Little academic research has been done on medica l tourism marke t due to its re la tive ly new niche ( - , 2007). market Caballe ro Dane ll &Mugomba

• The nature of seeking medica l care abroad is a re la tive ly priva te matte r therefore finding

respondents of medica l tourism to make up a s ignificant sample s ize .may be cha llenging

• Ethica l concerns– , , Information shee t for pa tients hospita l and hospita l re la ted provis ions

…Inte res ting points

• ‘ ’ ‘ ’?Is medica l tourism about tourism

• ‘ ’ Is cosmetic surgery tourism more re la ted to‘ ’ ?tourism than medica l tourism

• ‘ ’ Would gender reass ignment be more ‘ ’ ‘ cons idered as medica l tourism than cosmetic

’?surgery tourism

• ?Health inequalitie s



.Thank you for your a ttention

Health & Medicine

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