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  1. 1. By Wanvipha Nuke Hongnaphadol Medical Tourism in Thailand ‘ Consumer choice and motivation of medical tourism in Thailand: a case study of healthcare consumers visiting a private healthcare provider in Pattaya’ The York Management School University of York, UK
  2. 2. Definitions of key terms (1) <ul><li>‘ Medical tourism’ </li></ul><ul><li>patients travelling overseas for medical care —involving specific medical intervention—and operations combined with relaxation on holidays (Connell, 2006) </li></ul><ul><li>‘ Medical tourist’ </li></ul><ul><li>a person leaving his/her own country for medical treatment overseas (Hancock, 2006) </li></ul>Medical Tourism in Thailand
  3. 3. <ul><li>(1) (3) (5) </li></ul><ul><li>mere tourist medical mere patient </li></ul><ul><li>tourist proper </li></ul><ul><li> (2) (4) </li></ul><ul><li> medicated vacationing </li></ul><ul><li> tourist patient </li></ul>Medical Tourism in Thailand (Cohen, 2006: 89) A Typology of Medical Tourists
  4. 4. Definitions of key terms (2) <ul><li>‘ Health tourism ’ </li></ul><ul><li>all kind of treatments enhancing a state of well being both physically and psychologically , ranging from the spa experience through cosmetic surgery to lifesaving surgery like heart transplant (Caballero-Danell & Mugomba, 2007) </li></ul>Medical Tourism in Thailand
  5. 5. Medical Tourism in Thailand Health Tourism Wellness Tourism Medical Tourism Non-Elective Medical Care/Illness & Elective Medical Care Preventive Medical Care Enhancement/ Beauty Surgery Spa Tourism e.g. Aromatherapy Acupuncture Massage Yoga etc. e.g. Heart Surgery Bypass Operation Neurosurgery Cancer Treatment Transplants Hip replacement etc. e.g. Medical Check-ups Health Screening etc. e.g. Cosmetic Surgery Sex Change Operation Liposuction etc. (Adapted from TRAM, ATLAS, 2006)
  6. 6. <ul><li>Level of Procedure Complexity & Risk </li></ul><ul><li>Bone marrow transplant cosmetic dental health Thai herb & spa & Thai traditional massage </li></ul><ul><li>organ transplant surgery procedure checkup alternative </li></ul><ul><li>open heart surgery medicine </li></ul><ul><li>stay at hotels or hospital travel package </li></ul><ul><li>during recovery </li></ul><ul><li>Related Services added by Tourism </li></ul><ul><li>Model of Medical Tourism </li></ul><ul><li> (Harryono et al., 2006: 17) </li></ul>Medical Tourism in Thailand Medical outsourcing Tourism motivated
  7. 7. Definitions of key terms (3) <ul><li>‘ Consumer motivation’ </li></ul><ul><li>internal and external motivational forces impelling people to act to satisfy a need, or the reasons for consumer behaviour (Leiper, 2004) </li></ul><ul><ul><li>The underlying reasons for consumer behaviour (Mayo & Jarvis, 1981; Pearce, 1982, 1991; Pearce & Caltabiano, 1983) </li></ul></ul><ul><ul><li>The basis of knowledge of consumer decision making process (Dann, 1977) </li></ul></ul><ul><ul><li>The significant foundation for evaluating satisfaction from consumers’ experience (Dann, 1981; Dunn Ross & Iso-Ahola, 1991; Yoon & Uysal, 2005) </li></ul></ul>Medical Tourism in Thailand
  8. 8. Definitions of key terms (4) <ul><li>Consumer choice </li></ul><ul><ul><li>When policy analysts examine healthcare systems from the broadest perspective, very little about patient/consumer choice is mentioned (Borkman and Munn-Giddings, 2008). </li></ul></ul><ul><li>Consumer choice applied in the medical context is a very interesting phenomenon. </li></ul><ul><ul><li>Asymmetry of information : why consumer choice is limited in medical context </li></ul></ul><ul><li>Choice to seek treatment overseas </li></ul>Medical Tourism in Thailand
  9. 9. Introduction to Medical Tourism (1) <ul><li>Europe ( e.g. Hungary—declared 2003 as the Year of Health Tourism —, Israel, Belgium, Poland, Greece, Spain) </li></ul><ul><li>Latin America (e.g. Costa Rica, Mexico, Brazil) </li></ul><ul><li>Middle East (e.g. Dubai— Dubai Healthcare City by 2010—, Jordan, Iran) </li></ul><ul><li>South Africa </li></ul><ul><li>Asia (Singapore, Thailand , India, Malaysia, Philippines) </li></ul><ul><li>A reversed trend of traveling overseas to seek for medical treatment </li></ul>Medical Tourism in Thailand
  10. 10. Introduction to Medical Tourism Research (1) <ul><li>The rise of medical tourism—as the major medical tourism destination—is now in Asia (Connell, 2006). </li></ul><ul><li>Little tourism research has been conducted on consumer motivation perspectives (Goossens, 2000; Bansal & Eiselt, 2004). </li></ul>Medical Tourism in Thailand
  11. 11. Introduction to Medical Tourism Research (2) <ul><li>No empirical study identifying the motivation of travellers to Thailand (Rittichainuwat et al., 2008) except the very recent study ‘A factor-cluster analysis of tourist motivations: a case of U.S. senior travellers’ (Sangpikul, 2008). </li></ul><ul><li>Answering the question of why people travel is the most challenging in tourist behaviour (Crompton, 1979). </li></ul>Medical Tourism in Thailand
  12. 12. Introduction to Medical Tourism Research (3) <ul><li>Recent business report </li></ul><ul><li>A recent report Asian Medical Tourism Analysis (2008-2012) shows the revenues generated by the region of US$ 3.4 bn from medical tourism in 2007, accounting for nearly 12.7% of the global market and ‘ Thailand has emerged as the largest medical tourism market in Asia ’ (Velasco, 2008: 13). </li></ul><ul><li>‘ Thailand is the largest medical tourism hub (in Asia) in total volume and in both high-end and low-end procedures’ (Runckel, 2008). </li></ul>Medical Tourism in Thailand
  13. 13. Introduction to Medical Tourism Research (4) <ul><li>The context of Thailand (1): Tourism in Thailand </li></ul><ul><li>Tourist destination (attributes) of Thailand </li></ul><ul><ul><li>Five top tourism destinations i.e. BKK, Chonburi ( Pattaya ), Phuket, Chiang Mai and Songkhla (Hat Yai)(Thailand Development Research Institute, 1997) </li></ul></ul><ul><li>Perception of low risk </li></ul><ul><ul><li>A survey conducted by Visa International Asia Pacific & the Pacific Asia Travel Association of 5,000 international travelers from 10 markets around the world found 52% considering Asia as their next travel destination and Thailand to be the number-one preferred destination (Travel Agent, 2007). </li></ul></ul>Medical Tourism in Thailand
  14. 14. Introduction to Medical Tourism Research (5) <ul><li>The context of Thailand (2) </li></ul><ul><li>Geographical location </li></ul><ul><ul><li>A half-way stopover point between Europe, East Asia & Australia, and as a gateway to Indochina </li></ul></ul><ul><li>Competitive advantage </li></ul><ul><ul><li>Low labour cost </li></ul></ul><ul><li>Products/supply (institutional and infrastructure) </li></ul><ul><li>English spoken (by staff) </li></ul>Medical Tourism in Thailand
  15. 15. Medical Tourism in Thailand <ul><li>Thailand became a medical tourism destination in the 1970s with its expertise in sex change operations and cosmetic surgery (Connell, 2006). </li></ul><ul><li>Asian Economic Crisis in 1997 </li></ul><ul><ul><li>Currency collapse </li></ul></ul><ul><ul><li>Need for economic diversification </li></ul></ul><ul><ul><li>Merging medical expertise and tourism has become a government policy in many Asian countries (Teh, 2007). </li></ul></ul><ul><li>Perceptions of healthcare treatment </li></ul><ul><ul><li>quality of trained doctors and nurses </li></ul></ul><ul><ul><li>JCI (Joint Commission International Accreditation) </li></ul></ul><ul><ul><ul><li>A private hospital in BKK was the first Asian hospital accredited by the JCI in 2002. </li></ul></ul></ul>Medical Tourism in Thailand
  16. 16. Healthcare (1) <ul><li>Different pattern of previous and new healthcare consumers (Hjertqvist, 2002) </li></ul><ul><ul><li>Previously, the healthcare provider was not designed to serve a real consumer influence. </li></ul></ul><ul><ul><li>In the welfare state, the patients’ specific demands could not be fully responded as need. </li></ul></ul><ul><ul><li>Western healthcare consumers today are provided with greater access to various means of information sources in order to compare the providers’ quality and choices. </li></ul></ul>Medical Tourism in Thailand
  17. 17. Healthcare (2) <ul><li>Freedom of choice and the use of healthcare facilities in many countries are predominant in the current healthcare consumer’s framework when they can benefit from shorter waiting times and better quality services . </li></ul><ul><li>The significant increase in ‘ consumerism ’ owing to consumer expectations regarding the favourable outcome of medical intervention encourage more people to seek medical care—patients more aggressively seek services that match their expectations. </li></ul>Medical Tourism in Thailand
  18. 18. Healthcare (3) <ul><li>Healthcare is no longer defined by people receiving services when they are ill—the stereotypical patient. </li></ul><ul><li>Cross border healthcare/ patient mobility : citizens of the European Union may go to another EU country for specialist treatments that are not available in their own country, or because the waiting lists are shorter (Hogg, 1999). </li></ul>Medical Tourism in Thailand
  19. 19. Healthcare (4) <ul><li>Healthcare systems in individual countries are different due to the social, political and cultural context. </li></ul><ul><li>The concept of consumer choice differs between the UK and US. </li></ul><ul><li>Theoretical perspectives on ‘ consumerism in health’ (Brown & Zavestoski, 2005; Henderson & Petersen, 2002) are not universally applicable to all Western democratic countries. </li></ul>Medical Tourism in Thailand
  20. 20. Healthcare system in Thailand <ul><li>A market-oriented healthcare system—people have free choice in selecting a healthcare facility (Janjaroen & Supakankunti, 2002) </li></ul><ul><li>All Thai citizens have been covered by 3 main public health financing schemes: </li></ul>Medical Tourism in Thailand Public health financing schemes Who eligible? <ul><ul><li>Social Security Scheme (SSS) </li></ul></ul>Formal sector employees <ul><ul><li>Civil Servant Medical Benefit Scheme (CSMBS) </li></ul></ul>Government employee and their dependents Universal Coverage Scheme (30 Baht Scheme) The rest of the population
  21. 21. Healthcare system in the UK and the US Medical Tourism in Thailand Healthcare approach Health insurance Characteristic System Most common problem in healthcare service UK Public driven (tax based)—independent & public providers Universal Health Insurance Welfare state National Healthcare System (NHS) Long waiting list (access) Recent NHS reform, i.e. the introduction of market-style competition into the provision of healthcare; government defines a new role for patients US Private/ market driven Private Health Insurance individualistic A mixed system Price (affordability)
  22. 22. <ul><li>Dimensions of the Healthcare Systems of US and UK </li></ul><ul><li>Sources: Blank and Burau (2004); Weitz (2004); World Health Organisation (2007) </li></ul>Medical Tourism in Thailand Dimension US UK Citizen rights to healthcare? Negative rights Positive rights Individual relates to society? Individualistic Egalitarian Nature of system Mixed and fragmented: free market with governmental insurance for special vulnerable populations Centralised with a national health system Role of free market Very high Low but rising Payment for care Mixed: government through taxes, private insurance, out-of-pocket government through general taxes Extent health system publicly funded (2004) 44.7% 86.3% Universal coverage No Yes Ownership of facilities (hospitals, nursing homes, etc) Mixed: private for-profit, nonprofit, government Predominately government National policy on consumers involvement in healthcare system No: variable policies for different diseases, government jurisdictions, myriad of health insurance companies Yes: consumers involvement mandated
  23. 23. Medical Tourism in Thailand The Access to NHS (National Health Service)
  24. 24. Medical Tourism in Thailand Long waiting list
  25. 25. Medical Tourism in Thailand The insurance
  26. 26. Theoretical Framework (1) <ul><ul><li>Concepts on travel motivation </li></ul></ul><ul><ul><li>Maslow ’s (1943) hierarchical needs </li></ul></ul><ul><ul><li>Seeking and escaping (Iso-Ahola, 1982) as push and pull </li></ul></ul><ul><ul><li>Psychological and physiological needs (Murray, 1938; Mayo and Jarvis, 1981) </li></ul></ul><ul><ul><li>Needs-based motivation, benefit sought-based motivation, attribute-based , and psychologically-based motivation (Pearce and Caltabiano, 1983) </li></ul></ul>Medical Tourism in Thailand
  27. 27. Theoretical Framework (2) <ul><ul><li>A literature review on tourist motivations indicates that the push-pull theory is a useful approach to understand travel motivations to visit a particular destination of various traveler groups (You et al., 2000; Klenosky, 2002). </li></ul></ul><ul><ul><li>The push-pull theory has prevailed over other paradigms in investigating motivation underlying tourist and visitation behaviour (Dann, 1977, 1981; Crompton, 1979). </li></ul></ul>Medical Tourism in Thailand
  28. 28. Theoretical Framework (3) <ul><ul><li>Push ( Escaping /the desire to travel) & Pull ( Seeking /the choice of destination) (Iso-Ahola, 1982). </li></ul></ul><ul><ul><li>Push ( whether to go ) & Pull ( where to go ) (Klenosky, 2002). </li></ul></ul><ul><ul><li>Push ( intangible intrinsic desires of tourists ) & Pull ( tangible characteristics/attributes of a destination ) (Kozak, 2002). </li></ul></ul>Medical Tourism in Thailand
  29. 29. Medical Tourists Motivation to Destination Countries Medical Tourism in Thailand <ul><li>Push factor </li></ul><ul><li>Physical/psychological factors </li></ul><ul><li>Overburdened healthcare system in home country </li></ul><ul><li>Unaffordable </li></ul><ul><li>Inaccessible </li></ul>Intermediaries (representative offices) Pull factor Direct <ul><li>Accessible </li></ul><ul><li>High quality, low price </li></ul><ul><li>Unexpected service </li></ul><ul><li>Relaxation/recuperation </li></ul>Medical Tourist in Originating Country Destination Country (adapted from Leiper, 1979)
  30. 30. Identity: patient, consumer, citizen (1) <ul><li>As the role of market raises the significant issue of identity , in terms of healthcare market, the identity of health service users is considered whether they are patients receiving services passively; consumers shaping and controlling the receipt of services; or citizens utilising their rights to free healthcare. </li></ul><ul><li>It is essential to explore how health service users have engaged with these identities as these words can be differently conceptualised due to different healthcare systems. </li></ul>Medical Tourism in Thailand
  31. 31. Identity: patient, consumer, citizen (2) Medical Tourism in Thailand Identity Description Characteristic s consumer <ul><li>A user of products and services in both public and private sectors (Needham, 2007) </li></ul><ul><li>People who are able to make their own decisions about the care they receive, express opinions about the care and perhaps evaluate the care (Henderson, 2002) </li></ul><ul><li>Ability to exercise choice , shape and control services they are about to buy </li></ul><ul><li>As a market and economic participant </li></ul><ul><li>Those who seek healthcare in an active role, and perhaps make their own decisions </li></ul><ul><li>Individualistic </li></ul><ul><li>Healthcare consumer-provider relationship </li></ul><ul><li>Doctor shopping </li></ul>citizen <ul><li>As a political actor in the public sector </li></ul><ul><li>Collectivist </li></ul>patient <ul><li>People with particular health problems who may be taking medicines or receiving treatment (Hogg, 1999) </li></ul><ul><li>1. passive patients 2. patients who have low expectations of their physician 3. patients who behave as consumers , with expectations and ability to critically evaluate the quality of treatment received and ability to make changes (Baron-epel et al, 2001) </li></ul><ul><li>Stereotypical patient with passive role seeking and following physician advice </li></ul><ul><li>Patient-physician relationship </li></ul><ul><li>Passive patients: patriarchal physician approach </li></ul>
  32. 32. Characteristics of healthcare market (1) <ul><li>“ Medical care is uncertain and unpredictable ; many consumers do not desire it, do not know they need it, and cannot know in advance what it would cost them. They cannot learn from experience; they must rely on the supplier to tell them if they have been well served, and cannot return the service to the seller and have it repaired.” </li></ul><ul><li>(Hogg, 1999: 169) </li></ul><ul><li>Consumers are uncertain of their health status and need for healthcare in any particular time </li></ul><ul><li>A product uncertainty as consumers may not know the expected outcomes of treatments without their physicians’ advice </li></ul><ul><li>The consumers cannot test the product before using it </li></ul><ul><li>Recovery from disease is as unpredictable . </li></ul><ul><li>(Folland et al, 2001) </li></ul>Medical Tourism in Thailand
  33. 33. Characteristics of healthcare market (2) <ul><li>“ Medical services are not advertised as other goods and the producer discourages comparisons. Once the purchase is made, consumers cannot change their minds in mid-treatment.” </li></ul><ul><li>(Hogg, 1999: 169) </li></ul>Medical Tourism in Thailand
  34. 34. Theoretical Framework (recap) <ul><li>Push & Pull only explain why people go BUT it does not explain how deficiency of people’s own healthcare system is </li></ul><ul><li>eg How UK people recognise the deficiency of healthcare? </li></ul>Medical Tourism in Thailand
  35. 35. Aims of the study <ul><li>To explore the reasons why major English speaking consumers travel to Thailand for their medical treatment </li></ul><ul><ul><li>The motivations of potential medical tourists </li></ul></ul><ul><ul><li>Differences in these motivations among different groups both from the same and different countries </li></ul></ul><ul><ul><li>Interrelationships among these motivations </li></ul></ul><ul><li>To investigate the consumer choices in selecting a particular treatment in Thailand over other medical tourism destinations </li></ul><ul><li>To investigate the degree of tourism participation of those medical tourists </li></ul>Medical Tourism in Thailand
  36. 36. Research Questions <ul><li>What are the significant motives that influence the decision of medical tourists from the UK and the US to travel toThailand? </li></ul><ul><ul><li>How are these motives different with respect to age, nationality and gender? </li></ul></ul><ul><ul><li>How does Bangkok Pattaya Hospital (BPH) perceive the consumer motivation from these countries? </li></ul></ul><ul><ul><li>To what extent does BPH applied perceived consumer motivation to service provision for medical tourists? How is a healthcare provider’s service provision related to what motivates medical tourists to visit the hospital? </li></ul></ul><ul><li>2. What are the major keys influencing consumer choices about provider and destination? Why does a medical tourist choose one destination over another? </li></ul><ul><li>3. To what extent do medical tourists take tourism component as a part in their decision making process? </li></ul><ul><ul><li>Is medical tourism in Thailand about tourism? Is medical tourism likely to utilise the tourism component? </li></ul></ul><ul><ul><li>What is about the tourist part of medical tourism? </li></ul></ul><ul><ul><li>To what extent do medical tourists participate in tourism? </li></ul></ul>Medical Tourism in Thailand
  37. 37. <ul><li>Fact finding </li></ul><ul><li>Samitivej (Sriracha) Hospital </li></ul><ul><li> </li></ul><ul><li>Bangkok (Pattaya) Hospital </li></ul><ul><li>Bangkok Christian Hospital </li></ul><ul><li>Phyathai Hospital </li></ul><ul><li>Bangkok Hospital </li></ul><ul><li>Samitivej (Sukhumvit) Hospital </li></ul>Medical Tourism in Thailand In search of the study site Bangkok Chonburi
  38. 38. The study site (1) Medical Tourism in Thailand
  39. 39. The study site (2) <ul><li>Pattaya </li></ul>Medical Tourism in Thailand
  40. 40. The study site (3) <ul><li>Bangkok Pattaya Hospital </li></ul>Medical Tourism in Thailand
  41. 41. In search of the research subject (1) Number of foreign patients being serviced at Thai private hospitals JAN-DEC 2007 Medical Tourism in Thailand Source : Department of Export Promotion 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
  42. 42. In search of the research subject (2) <ul><li>Patients from the US and Europe constitute about 20 % of the total inflow of foreign patients with a higher proportion seeking for cosmetic surgery , hip and knee replacement and organ transplant to Thailand—the same is growing every year by around 40% for the US and 50% for Europe patients (Teh, 2007). </li></ul>Medical Tourism in Thailand
  43. 43. Methodology: Data collection (1) <ul><li>Research design </li></ul><ul><li>Survey approach </li></ul><ul><ul><li>Semi-structured interviews </li></ul></ul><ul><ul><li>Survey questionnaires </li></ul></ul>Medical Tourism in Thailand
  44. 44. Methodology: Data collection (2) <ul><li>Stage 1. Exploratory study : </li></ul><ul><li>semi-structured interview </li></ul><ul><ul><li>Pre-study: piloting the questions for interview in the UK (approx 5 British people who have visited Thailand for some kind of treatment) </li></ul></ul><ul><ul><li>Visits to hospital </li></ul></ul><ul><ul><li>Interview foreign patients in Thailand (approx 20 patients-10 from the UK; 10 from the US) </li></ul></ul>Medical Tourism in Thailand
  45. 45. Methodology: Data collection (3) <ul><ul><li>Stage 2. Designing the questionnaire : </li></ul></ul><ul><ul><li>The field interviews are to inform the questionnaire development and to help design the questionnaire items to measure the medical tourism motivations and consumer choice. </li></ul></ul>Medical Tourism in Thailand
  46. 46. Methodology: Data collection (3) <ul><li>Stage 3: Main questionnaire study </li></ul><ul><ul><li>Visit the hospital </li></ul></ul><ul><ul><li>Survey 150 medical tourists (75 from the UK; 75 from the US) using quota sampling (nationality and gender distribution) </li></ul></ul>Medical Tourism in Thailand
  47. 47. Challenges <ul><li>Little academic research has been done on medical tourism market due to its relatively new niche market (Caballero-Danell & Mugomba, 2007). </li></ul><ul><li>The nature of seeking medical care abroad is a relatively private matter therefore finding respondents of medical tourism to make up a significant sample size may be challenging. </li></ul><ul><li>Ethical concerns </li></ul><ul><ul><li>Information sheet for patients, hospital, and hospital related provisions </li></ul></ul>Medical Tourism in Thailand
  48. 48. Interesting points… <ul><li>Is ‘medical tourism’ about ‘tourism’? </li></ul><ul><li>Is ‘cosmetic surgery tourism’ more related to ‘tourism’ than medical tourism? </li></ul><ul><li>Would ‘gender reassignment’ be more considered as ‘medical tourism’ than ‘cosmetic surgery tourism’? </li></ul><ul><li>Health inequalities? </li></ul>Medical Tourism in Thailand
  49. 49. Thank you for your attention. Medical Tourism in Thailand