Chapter 2 Literature Review 2

Chapter 2
Literature Review
2.1 Concerns Regarding Medical Tourism in Bangladesh
Bangladesh must find a way to capitalize on the potential of the emerging medical tourism sector. Unfortunately, lack of government initiative to encourage this industry is clear. The trend of Bangladeshi patients travelling abroad for medical services has, thus, led to a number of pressing concerns.
2.1.1 Perceived Quality
While other countries of the Southeast Asia region are profiting from medical tourism, Bangladesh not only lags behind but also loses patients to these countries. Patients are willing to go abroad for medical treatment because of the higher perceived quality of the treatment, despite the fact that the same treatment can be achieved more cost effectively within the country. As a result of the increased medical expenditure abroad, financial resources of the country are being regularly diverted out of the economy(HOPE medical tourism)
2.1.2 Marketing and Promotion
More health care facilities are being set up in Bangladesh and established facilities are increasing their capacities. Despite this, the rate of patients depending on foreign health care is increasing. Ironically, while Bangladeshi patients are seeking treatment in Apollo Hospitals in India and Sri Lanka, the Apollo Hospital in Dhaka is being underutilized and the hospital has had to lay off staff. Another reason for such failure could be faulty marketing. Marketing of the high quality of local hospitals is very weak, whereas foreign countries are establishing their reputation in this sector.

2.1.3 Information Dissemination
Another huge problem is that there is a lack of information about the current services provided by the local hospitals. Many patients are simply not aware of the competitively priced service packages available. For instance, procedures like coronary bypass surgeries have been very successful in a number of facilities like the National Heart Foundation and the Ibrahim Cardiac Hospital & Research Center. A range of more complex procedures like liver transplants are also available within the country. However, general ignorance due to lack of information dissemination has led to patients moving elsewhere.

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2.1.4 Trade and Supply of Health services
Health services are traded in various ways. Four dominant modes of exchange include: cross-border delivery, consumption abroad, commercial presence and movement of health personnel. There are mixed implications for such trade. On the bright side, it may trigger upgrading the health care exporter’s infrastructure, technological capacities, and health care standards. Also, for countries which import health services, medical tourism can be an important means of overcoming shortages of resources, particularly for specialized health services. However, trade in health services may also result in a dual market structure or aggravate such tendencies within the health care system. It can result in the creation of higher quality and expensive healthcare facilities which cater to the few wealthy locals as reflected by the recent number of designer hospitals that are being established in Dhaka, as well as lower quality facilities for the large majority
There are, however, numerous constraints to trade in health services. The three broad categories of constraints include: (a) restrictions on entry and terms of practice by foreign health service providers; (b) restrictions on foreign direct investment in the health sector and in related sectors; and (c) domestic infrastructural, regulatory, and capacity constraints. In each case, it is necessary to note whether these barriers are justified, whether they can be overcome, and whether alternative measures can be considered which would both facilitate trade in health services.

Health care service providers and planners in Bangladesh are often more concerned about the cost of health care rather than its quality. The majority of complaints of patients, however, are the behavior, conduct, and attitude of health care workers; yet nothing has been done to incorporate this into the training of doctors and nurses at the national level. Some factors influencing patients’ dissatisfaction in Bangladesh, derived from popular media, include:
Doctors recommending unnecessary medical tests for diagnosis of diseases
Irregular supply of drugs at the hospital premises
Irregular supervision of patients by care providers
Unavailability of specialists
Not providing correct treatment the first time by doctors
Long waiting time
Negative word-of-mouth that dissuades others from taking health care within the country
Not addressing the queries of patients
Lack of assurance of recovery
Low accessibility to the hospitals
Scarcity of doctors and nurses
Presence of extra payments (bribes) in every tier of the service
Low capacity and over priced services of quality hospitals
These issues have to be vigorously addressed before local, as well as foreign patients can be persuaded to consider medical tourism in Bangladesh.
This research will explore the reasons why Bangladeshi patients prefer to be treated abroad and what are the prospects of attracting medical tourist from neighboring countries while retaining our patients. The development of such a sector in our country will help in earning foreign currency and further strengthening the tourism sector. With a decrease in the number of patients travelling abroad, foreign currency losses from the economy can also be prevented.
2.2 Medical Tourism
John Connell (2006) mention medical tourism, where patients travel overseas for operations, has grown rapidly in the past decade, especially for cosmetic surgery. High costs and long waiting lists at home, new technology and skills in destination countries alongside reduced transport costs and Internet marketing have all played a role. Several Asian countries are dominant, but most countries have sought to enter the market. Conventional tourism has been a by-product of this growth, despite its tourist packaging, and overall benefits to the travel industry have been considerable. The rise of medical tourism emphasizes the privatization of health care, the growing dependence on technology, uneven access to health resources and the accelerated globalization of both health care and tourism.

Lee (2006) argues that Asian countries have a competitive advantage in the emerging healthcare industry. There are medical enterprises in countries such as India, Thailand, Singapore and Malaysia that have invested in attracting tourists for this specialist market.

Lee and Spisto (2007) argue that as an international business, medical tourism is not too different from the subcontracting or the off-shoring of services. With higher costs and expertise, in the future, medical tourism is likely to be the new global trend for providing medical services.

Tattara (2010) argues that Medical tourism in poor countries is strictly interlinked with the health privatization process and the ability to provide excellent treatment to some sectors of the population, not caring for the performance of the whole system.

Kanchanachitra et al. (2011) depict that vital human resources for health are available to meet the needs of the populations that they serve, migration management and retention strategies need to be integrated into ongoing efforts to strengthen health systems in Southeast Asia. There is also a need for improved dialogue between the health and trade sectors on how to balance economic opportunities associated with trade in health services with domestic health needs and equity issues.

Vijay (Access in the website 2011) the Indian tourism industry is now promoting medical tourism as a novel hope for the Indian economy. Five-star hospitals are mushrooming around the nation and major investments by big corporate players are expected. The privatization and ‘corporatization’ of health care has created medical tourism where people from rich nations travel to Third World countries to obtain medical care, experience and enjoy the tourism attractions and use other resources. It is a ‘magic lamp’ for those countries to attract overseas patients and earn foreign exchange.

Turner (2011) depicts that despite the rapid expansion of the medical tourism industry, few standards exist to ensure that these business organize high quality competent international health care. Standards should be established to ensure that clients of medical tourism companies make informed choices. Country of care needs to become an integral feature of cross-border care.

The first recorded instance of people travelling for medical treatment dates back thousands of years to when Greek pilgrims traveled from the eastern Mediterranean to a small area in the Saronic Gulf called Epidauria. This territory was the sanctuary of the healing god Asklepios. Spa towns and sanitaria were early forms of medical tourism. In 18th-century Europe patients visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis.

2.3 Medical tourism industry and its mechanisms
The patterns and tendencies in executing medical tourism over recent decades are vague and unidirectional. It might be alternative to regular tourists, which first pick the kind of holiday they want to have, regarding activities, time span, facilities and infrastructure – in short– their preferences. Then, they think of a country and region they can do that in and, at the end, they pick a hotel or resort they want to stay in, trying to utilize their stay and select the most cost-effective option. This could also be the mechanism in medical tourism: patients first decide not on a specific medical facility from the ones all over the world, but, once they recognize their medical needs and other preferences, they choose a country or region and then look for best medical facility within the chosen destination and at that last stage the price might be the differentiator. Therefore, it leaves the price as not-a-first-choice factor.

The sole use of services is only one part of the medical tourism industry. Other components of this complex mechanism shall not be forgotten or underestimated. As an industry, medical tourism consists of a wide scope of stakeholders, acknowledging mainly commercial, for-profit interests. Beneath are presented major participants of the industry.
Insurance Provider

Internet and Website Advertising
Internet diaries

Medical Tourists

Health Care Provider

Policies and Government

Events

Figure 2.1 Medical Tourism Industries and Its Mechanism
(Source: HOPE Publication, September 2015, Belgium)
2.4 Medical Tourism Challenges
The research has revealed that the medical tourism in a particular region has to face a large number of challenges. These challenges or barriers could cause difficulty to the growth of the industry. The major challenges in this field are (Shanmugam, 2013)
Availability of experts
Absence of a strong regulatory framework to control quacks
Absence of training in communication and interpersonal skills
Absence of innovativeness
Absence of international standard service and quality
Inadequacy of supporting staff
Absence of hygienic environment at the tourist destinations, hospitals, hotels, restaurants, etc.

Language acts as a barrier when people have insufficient knowledge of different languages
Other challenges include the inadequacy of supplementary services, which offers hospitality to the international customers at international standard. The lack of transparency and uniformity in prices of different Services and products causes ambiguity in a customer’s mind. As a result, a customer feels betrayed and loses trust on the Place. They share their experiences with other potential medical tourists. In this way a large number of medical tourists are deterred from visiting those places. Instead they seek other places for getting medical care. In addition, Absence of adequate networking in the distribution channels, specific standard, lack of coordination and organized efforts, inadequate infrastructure, water and power supply causes a big harm to the industry(Casken and Eissler, 2013).
2.5 The Main Features/Characteristics of Medical tourism Industry
From the above study, it was found that people target a particular destination for medical tourism because of the following factors
The advantage in costs, i.e. lower cost of a treatment at a particular country than other destinations.

The availability of expertise is better in the preferred country than other countries.

The efficiency and effectiveness of the expert treatment in a particular country.

The availability of technology, medical facilities and the time taken for the treatment in a particular destination.

The method used for treatment in a particular destination.

The convenience for the treatment in a particular destination.

Tourist attractions and the beauty of the place.

Availability of accommodations, transportation, entertainment, shopping and food outlets and ease of communication.

2.6 Drivers of Medical Tourism
K. Pollard introduced a “model of destination attractiveness”. The model covers the complex set of factors that determine patient’s ultimate decision where to pursue treatment abroad. It excludes technology and quality comparisons (as not contributing to being ultimate decision factors) and consists of seven key determinants.

Geographical proximity, travel time, ease and barriers in reaching the destination: Patients are not willing to take long, indirect flights from/to deserted airports, nor are they willingly going through complicated visa procedures.

Cultural proximity including language, religion, cuisine, customs and practices: Medical tourism seems to be influenced by familiarity and cultural similarity, for example former colonial connections (India-UK) and diasporas populations (coming back for treatment to a country people emigrated from).

Risk and reward: Medical tourists need to balance treatment outcomes against potential risks, considering safety, treatment guarantee, track records of particular medical services in destination countries etc.

Price: Not only the treatment costs count, but also travel, accommodation and insurance expenses. KMPG, on the other hand, lists geographical proximity and cultural similarities as prime reasons, later lower costs, better technology and wider treatment options, long waiting periods, tourism and vacation as factors that incentivize patients to follow treatment abroad.

Perceived quality: patients think that foreign healthcare services are of higher quality than in their national systems.

The waiting time: of the treatment in the target country relative to the waiting time in the home country is the second most important driver of selecting a cross-border provider of healthcare.

Trust in the healthcare: system in the target country and in particular the difference in trust in the target country healthcare system and the domestic healthcare system is the third most important driver of opting for a cross-border treatment.

Push and pull factors: The former includes high cost of out-of- pocket payment for procedure in home country, lack of insurance or underinsurance, long wait-times. The latter consist of quality of service, care and facilities, mutual language, vacation aspect, political climate, religious aspect.
McKinsey on the contrary, through conducted research, recognizes quality drivers as the major ones that influence patient’s decision on destination. They cover in order of importance: advanced technology, better quality, quicker access and at the very end – costs of care. The level of importance is presented in Figure 2

Figure 2.2 Medical tourism drivers
(Source: McKinsey Quarterly, Mapping the market for medical travel, 2008)
2.7 Intermediaries
The development of the medical tourism industry created a demand for travel and care-coordinating institutions, which in turn opened a niche for agencies and brokerages to start up businesses. Intermediaries often offer individually tailored packages, which include arrangement of treatment, recuperation, flight, accommodation, leisure etc. The ones located in country of origin are more patient-oriented, whereas the ones located in country of destination are more provider-oriented. Since brokers and agents do not hold any responsibility for patient’s well-being and satisfaction, it may be that they do not investigate the competences, qualifications, quality and scope of provided services of the health care facilities they send patients to. Nonetheless, it is obvious that the position of facilitators in medical tourism mechanism is strongly present, since travel arrangements are challenging for patients, as well as for clinics – reaching clients directly in foreign markets is a very costly promotion and marketing approach. Dr Jagyasi presented, through his research, that the majority of medical tourism professionals find the role of intermediaries significant. On the other hand, it is underlined that intermediaries should elaborate a kind of edge “to avoid the fate of traditional travel agencies”.

Additionally, the nature of patient-intermediary-provider relation induces a dysfunction within this triangle and within the referral fee system. In the situation, when the intermediary receives a commission from the provider per referral, it might be the case that the intermediary sends the medical tourist not necessarily to optimal and best for patient healthcare provider, but more likely to the one that pays the highest commission.

Going randomly through the list of medical tourism agencies, one can notice that some of the agents do not have websites or that the website links lead to nowhere, provide vague or hard to find information about their business and location or do not describe the scope of responsibility they bear as being the intermediary between the patient and healthcare provider. Hence, there seems to be need of regulating medical tourism facilitators, for example by licensing each one of them by the country they function in, therefore it will not allow anyone to be a “medical tourism agent”, as it is the case now.

2.8 Medical Tourism in Bangladesh
D’Essence (2004) suggested that most of the people undertake medical tourism to receive treatments for heart surgery/bypass surgery, overall cardiac care, cosmetic surgery, replacements of joints, Dental treatments, organ transplants or other concerns related to beauty or health. In addition, the author argued that the major players in the neighbor country, India are Apollo Hospitals, Escorts, Hinduja Hospital, Jaslok Hospital and Indraprastha Hospital. These hospitals provide excellent facilities to their customers. Additionally, Suleiman (2013) conducted a study that focused on the number of people treated in various countries. He submitted that more than one hundred thousand medical tourists have visited India in 2012 for cardiac care, joint replacement surgeries, Lasik treatments, etc. Around one hundred thirty thousand visited Jordan for fertility treatments or cardiac care and more than six hundred thousand patients travelled to Thailand for cosmetic surgery, organ transplant, dental treatment, etc. Moreover, eighty thousand people went to Malaysia for cosmetic surgery and beauty treatments. In addition, D’Essence (2004) suggested that people travelled to South Africa to enjoy the nature’s beauty and take help in cosmetic surgery, Lasik and dental treatments. Further, the author emphasized on the challenges that the medical tourism sector could face.

He argued that different countries put huge investments in different medical care practices. For example, The UK and the USA budget aim to promote and improve medical tourism in their respective countries. It is apparent from the fact that they invest a huge amount in million dollars for bone marrow transplant, open heart surgery, liver transplant, replacement of hips, knee surgery and cataract treatments. Developing nations, such as India and Thailand also focus on the above sectors for the growth of inbound medical tourism in their respective countries (D’Essence, 2004).

Moreover, Mamun and Andaleeb (2013) suggested that various services in hospitals need to be upgraded and improved to attract more medical tourists from abroad. The authorsargued that development of dedicated medical staff, hygienic environment, pick -up and drop facilities from airports, high quality diagnostic centres and pharmacies near hospitals, coordination of all appointments to avoid mismanagement and investigation of history of patients to know them better are of equal importance whilst serving international patients. Additionally, hotels, restaurants and accommodation facilities of international standard near hospitals increase the number of medical tourists in a country (Mamun and Andale, 2013). Muraina and Tommy (2012) conducted a study on the medical tourism sector in Bangladesh. The researchers argued that there are various factors for targeting a destination for medical tourism. Apart from the medical requirements, some people travel to see the beauty of nature, while others to see historical places, few people travel for their business purposes and others for cultural or spiritual gains.

However, Bangladesh is far behind in tourism. Although, the country has several tourist destinations, these destinations are yet to be improved to match the international standard.
Moreover, the different tourist attractions in the country have to be made safer for the local people and tourists (Ali, 2012). The transportation and accommodation facilities also need to be improved to attract the international community. Furthermore, Ma mun and Andaleeb (2013) evaluated the tourism sector of Bangladesh with the help of the 5-force model of Porter.
The authors suggested that the private sector and government sector initiative is very important for provision of excellent facilities in the country. There are a number of tourist destinations in the country, such as natural places and historical monuments.

For example, the Sundarbans forest, the sea beach in Cox’s Bazar, St. Martin’s Island, Tea Gardens of Srimongol, Lalbagh Fort, Tajhat Palace, etc. These places need to be improved to high standards to attract more people in the country. The research also stated that safety, security, accommodation and transportation are of great importance to create an international market. Additionally, good quality hospitals and a better health management system will itself retain the local people to receive medical benefits inside the country. Moreover, it will attract people from different countries to visit Bangladesh to receive medical care. This will generate a huge earning for the country.In addition, Afroz and Hasanuzzaman (2012) suggested that Bangladesh needs to be very fast in updating the adequate number of websites apart from the development of the basic medical facilities in the country. Moreover, the authors argued that Bangladeshis living abroad and various embassies of Bangladesh in the world should work together in a harmonious manner to enhance the number of visitors to the country. If this could be achieved, it will be of great help to the nation. Further, the local people tour operators could be of great advantage for the international medical tourists. Additionally, transparent procedures must be developed to enhance trust of the visitors because they will share their experience with others and this would increase the number of visitors in the country. Other entertainment facilities, such as shopping malls, local huts, cinema theatres, museums, parks, places of national importance, sea beaches, national forests, etc. and their approachability are also very significant to attract more people to Bangladesh (Ali, 2012). However, the bureaucratic structures, involvement of different ministries and agencies have made the system complicated. The places outside Dhaka give low rate of return on land investment, tourism infrastructure development, technological development and development of medical facilities. As a result, there is lack of investment in this sector of Bangladesh. In addition, the corruption and the instability in the political environment and legal environment have hampered the image of the country. Consequently, the private sector and foreign investors are discouraged to invest in the development and other plans in Bangladesh (Ali, 2012). As a result, most of the people from Bangladesh are travelling abroad to receive medical treatments and benefits (Muraina and Tommy, 2012). The topmost destinations across the world to get medical care are India, Thailand, Malaysia, Singapore, etc. (Awadzi and Panda, 2006)

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