Keywords

Health care, Medical Practices, Medical tourism, Service Providers.

Introduction

Health care sector of India is one of the largest contributors of the economy. Regarding the marketing strategies government should encourage cheaper transport and accommodation, special training for service providers and there should be round the clock services for communication and promotion of health services inbound or outbound (Dawn & Pal, 2011; Grewal, Das, Nandan & Kishore, 2009). Health care service providers must ensure state of art in medical technology and procedures. To remain in market place, service providers take initiatives by marketing the best health services (Crooks, Turner, Snyder, Johnston & Kingsbury, 2011; Garg & Bhardwaj, 2012; Kangas, 2010). Health care service providers adopted an approach that most multinational and corporate business enterprises follow in terms of designing marketing strategies, pricing, branding, management and maintaining the quality of services (Bookman & Bookman, 2007; Turner, 2007). This approach, along with increasing global integration of businesses, and the cost & wait-time crises in western health care systems, created opportunities for many health facilities in developing countries (Bezruchka, 2002; Emerging Market Report, 2007).

Medical tourism and health care industry is the largest industry in terms of revenue generation and employment (Emerging Market Report, 2007). The tourism and hospitality industry is largely dependent on the product image and perceived value of the possible customers (Brown, 1969). To create the positive image and perceived value, the tour operators and agents are required to have effective promotional plans. Most companies follow the business cycle in determining their advertising appropriation from the short point of view with regards to sales (Wagner, 1941). Researchers identified that effect of increasing sales efforts have had the undesirable effect of stimulating over extension of capital expenditure during prosperity. Srinivasan et al. (2002) showed that firms with a strategic emphasis on marketing, an entrepreneurial culture, slack resources and strategic flexibility are more proactive having direct and indirect positive effect on the sales of the company with respect to advertising. Kumar (2009) emphasised on the role of internet in the medical tourism. The study showed that most of the medical travelers used internet followed by newspapers for information with regard to the availability and facilities available in the Indian hospitals.

Review of Literature

As travel connotes the feeling of acquiring pleasure and leisure, medical is just opposite to the travel which signifies the pain and disease (Bookman & Bookman, 2007; Deloitte, 2008; Rath, Das, Mishra & Puthan, 2012). A range of nomenclature has been used in this respect like health tourism, medical refugee and medical outsourcing. With longstanding historical background in India, the term medical tourism has been used most frequently which embraces the spas, Ayurveda therapy, and Homeopathic treatments. Broadly speaking, medical tourism is the act of traveling to obtain medical care among three categories as outbound, inbound and intrabound (Deloitte, 2008; United States Agency for International Development [USAID], 2009).

Distinct Products/Services Offered

In the health industry, the product represents goods, services, or ideas offered by a healthcare organization. The product is difficult to be precisely be defined in healthcare, creating a challenge for healthcare marketers (Faidon & Vasiliki, 2012; Hazarika, 2010; Lunt, Smith, Exworthy, Horsfall & Mannion, 2011; Rath et al., 2012). Medical tourism model endowed with surgical procedures; dental treatment, facelifts, hair transplants, liposuction and non-surgical procedures; hair removal, most of which are not covered by health insurance and are either costly or restricted for legal reasons in most developed countries (Kaplan, 2016; Shetty, 2010; Turner, 2007). Many hospitals in India, Thailand, Singapore and Malaysia have provided hotel like amenities to the patients. In order to provide attractive offers, hospitals provide maximum comfort to the patients in form of private elevator, discreet expedited check in process, special in room services, adjustable beds, and medical friendly bathrooms designs & fixtures (Dawn & Pal, 2011; Grewal et al., 2009; Khan, 2010; Kumar, 2009; Suthin, Assenov & Tirasatayapitak, 2007).

Price Effectiveness

For undergoing medical treatment across the border, pricing has a significant role to attract medical tourists (Lee, 2007; Rath et al., 2012).  For magnetizing the attention of medical tourists, competitive pricing is opted by the marketers of different hospitals. India has a competitive advantage with other countries mainly Singapore, Thailand and Malaysia in providing medical treatment and services at comparable cost (Kalshetti & Pillai, 2008; Shetty, 2010; Tourani, Tabibi, Tofighi & Zadeh, 2010). Two types of patients have been identified by the Smaha (2010) travelling across the border for seeking medical care. One who needs surgical treatment but do not have insurance cover and second who required lower cost medical care having insurance coverage. As India is facilitating the lower cost medical treatment and offering world class facilities to international patients, this reduces the cost by 94% as compared to the total cost of medical procedures followed in the USA, the UK and other developed nations (Grail Research, 2009; Karmakar, 2011). Cost is considered as an important criteria in determination of best suitable health care services and facilities which will encourage medical tourists in the selection of best suited hospital to them (Hult & Philipson, 2012; Johnston et al., 2010; Sood & Cox, 2008, Kumar & Sangeeta, 2013). Developing countries are offering these high quality medical treatments due to availability of lower labour cost and accessibility of economical pharmaceuticals by accumulating accommodation and travel expenses also (D’Essence Consulting, 2004; Grewal et al., 2009; Whittaker, 2008).

Channel Decisions to Facilitate Consumers

Marketing of medical tourism is unified with the paramount channel decisions. Being a niche market, health care service providers focus on the distribution channels and positioning the message in the mind of the consumer very efficiently (Kalshetti & Pillai, 2008; Kotler & Keller, 2008).

In facilitating the requirements of foreign patients, medical travel agents established a link between hospitals and patients and also help to recommend best healthcare facilities in the host country (Heung, Kucukusta & Song, 2011; Khan & Alam, 2014; Peters & Sauer, 2011; Turner, 2012).. The foremost desire of a medical tourist is to get most excellent medical treatment which heals all wounds, mentally and physically (Fortis Healthcare Annual Report, 2012; Mohamada, Omarb & Haron, 2012; Voigt, Brown & Howat, 2011). Therefore, insurance companies, foreign tour operators and independent medical referral companies acted as chief channels to help medical tourists in availing best care at affordable prices (Lunt et al., 2010; Martin et al., 2011; Mohamada, Omarb & Haron, 2012

Promotional Effectiveness

Communication technology has changed the scenario of the medical tourism industry. For outbound patients it becomes easy to find out and explore best medical facilities over the world (Khan, 2010; Lam, Cros & Vong, 2011; Tourani et al., 2010). By considering suitability and desires of patients travel agencies keep all type of information about the right medical care and have a proper check on the legitimacy of the service providers. The main aim of communication is to provide each and every information to the patients about the medical facilities, medical procedures and travel arrangements so that they can plan their treatment without any trouble Crooks et al. (2011). At the primary level it was observed that only health care service providers were engaged in promotion of medical facilities both in local and global media but due to earning of high foreign exchange governments of destination countries have also took initiatives in creating awareness towards medical treatments and procedures (Dawn & Pal, 2011; Rerkrujipimol & Assenov, 2009). Corporate hospitals of destination countries are participating in exhibitions, conferences, trade fairs and travel marts (Turner 2012; Viladrich & Baron-Faust, 2014; Georgescua & Necsoib, 2013). Besides, hospitals also work in partnership with the universities and medical schools of various countries to promote facilities and endorse the world level medical facilities to create awareness among the world society (Crooks et al., 2011; Boga & Weiermair, 2011). Further, it is also seen that healthcare providers publish same brochures for developed and developing nations to minimize the promotional cost.

People Effectiveness

Among all the services, health care services are front line jobs as employees span the boundaries between inside and outside the organizations. Healthcare professionals were expected to be efficient and fast in performing skills.  From the patient’s perspective, encounter with the service staff, well trained doctors and nurses are the most important aspect of a health services (Lovelock et al., 2007; Carney, 2011). To attract foreign patients, healthcare service providers should stress on the role of people element in such a high contact services. In low contact services, people are not personally reachable but through phones, mails they are able to reach out to resolve problems of patients (Kotler & Keller, 2008; Zeithaml and Bitner, 2012). Healthcare services required both low contact and high contact reach out to the patients depending upon the level of involvement. To create an effective value exchange between the organization and patients, skilled medical professionals as well as administrative personnel are required. It was acknowledged by all the research reports that having qualified staff and specialized doctors build a competitive advantage to the hospitals (Beladi, Chao, Ee & Hollas, 2015; Boga & Weiermair, 2011; Khan, 2010).

Process Effectiveness

Creating real time services is not an easy task. Description of methods and sequencing them in an order is quite a challenging job for the service organizations. Processes are termed as architecture of services (Lovelock et al., 2007; Zeithalm and Bitner, 2012). Marketer and operational staff in hospitals need to work together for designing the services and fulfilling the customer expectations. In medical tourism customers (patients) are an integral part of every operation and activity performed in hospitals and these services become their experience (Connel, 2006; Martin, Ramamonjiarivelo & Martin, 2011).  Blueprinting of healthcare services is a powerful tool to understand and improve service processes to shape the experience of patients and their companions too. To identify fall points in service delivery and to minimise them is an important insight for service redesign. Blueprinting of service carried out by defining the standards in health services (Zeithalm and Bitner, 2012). As JCI accreditation is one of the most significant standards in attracting a large pool of patients. Sequencing of actions is prescribed by blueprinting as line of interaction and support processes Service personnel and information technology build the process in medical tourism (Berkowitz, 2011).  Finalizing the appointment time with doctors, reducing waiting time, checking availability of beds and rooms, providing single window solution are some major steps that a medical service providers kept in mind while facilitating services (Connel, 2013).

Effectiveness of Physical Evidence

Intangibility of services leads towards uncertainty in the mind of consumers as services cannot be experienced before purchase. To assess the satisfaction of customers’ tangible indications were provided to the customers (Zeithalm and Bitner, 2012). Health care service providers gave emphasis on the development of exterior and interior attributes of the service area (Berkowitz, 2011).   Physical environment is the end point of the service delivery system. In medical tourism, physical evidence plays a major role in enhancing the customer satisfaction. Physical evidence conveyed the planned image of the healthcare services and leaves a long lasting impression on the patients (Tourani et al., 2010). It has been observed by the researchers, private hospitals are more intensely engaged in attracting medical tourists. Most private hospitals have spacious luxury rooms and outstanding amenities. Hospitals offers good ambience including good lighting, color scheme, removing smells and maintaining temperature (Berkowitz, 2011; Chuang, Liu, Lu & Lee, 2014; Johnston, Crooks et al., 2010; Turner, 2012). Having low cost treatment availability, qualified medical practitioners and accreditation from JCI, attract large number of patients but brand image is needed to be built by improving risky sanitation, developing infrastructure, getting world class accreditation and branding cultural dynamics of country for health care services (Anvekar, 2012; Chaudhary & Aggrawal, 2014; Enderwick  & Nagar, 2010; Smith, 2008). 

Methodology

Research Model

The research model includes antecedent of marketing practices including product, price, place, promotion, people, process and physical evidence by using confirmatory factor analysis.

Data collection

This study has taken into account those hospitals in NCR which are responsible for attracting medical tourists for healthcare and sample unit covered 6 super specialty hospitals falling under the list of CGHS, Delhi. Under sample unit, three hospitals belong to public sector and rest three is from private sector. After pretest it is observed that in case of private hospitals key informants are marketing executives operating at middle level and top level. But in public hospitals, respondents are the persons from administrative staff and junior doctors who are engaged indirectly in marketing practices of hospital in some way. So, on the basis of this criteria population for the study has been calculated as 500 which will further used to derive sample size for the study. Sample size of 217 has been taken for the study.

Survey Instrument

As scales of key constructs regarding marketing practices of medical tourism were not available in the literature, so constructs were developed by using marketing mix model in context of medical tourism using a modification procedure (Churchill, 1979). Constructs were pretested with 24 middle level executives of two private hospitals of NCR which are part of this study namely Max and Fortis. To develop the items of measure, practices related to product, price, place, promotion, people, process and physical evidence were considered on five point likert scale ranging from strongly disagree(1) to strongly agree (5). Consistent with the definition of the seven P’s of marketing mix, a questionnaire having 49 items based on the practices of hospitals during recession and upswing phases of cyclical variations pertaining to the seven P’s was developed. For product, promotion, people and physical evidence related practices, a scale developed by Heung, Kucukusta and Song (2010) and Ramanujam (2009) was examined and some items of scale was adapted for the study. For price and promotion related practices scale developed by Yu and Ko (2011) and Ramanujam (2009) at five point Likert scale was adapted. For place related practices scale developed by Ramanujam (2009) for hospitals was adapted.

Results

To measure the internal consistency of scale, Cronabach’s alfa is being applied. Field (2015) affirmed that value of alfa should be higher than 0.80. Higher the value of cronabch’s alfa, higher is the internal consistency. For recession and upswing data reliability has been checked separately. Value of cronabach’s alfa comes out to be 0.956 and 0.959 for recession and upswing respectively.  After applying alfa at first, it has been observed that there is one item among 52 items which if deleted increased the value of reliability. So for improving the reliability of data, item 2 has been deleted which increased value of alfa correspondingly.

A data of 239 was collected from the sampling units and after examining the data 221 were found well for study. Since size of sample was calculated as 217, so after inspecting outliers 4 more questionnaires are removed from the study. Table 1 depicts the profiling of respondents on the basis of public and private hospitals. Public hospitals have 54 and private hospitals have 163 respondents respectively engaged in the study. Table 1 makes it clear that public hospitals have very few numbers of marketing staff as compared to private hospitals.

Extraction of factors affecting medical tourism

Exploratory factor analysis is being applied to determine the factor loadings of the items in scale. Factor loading explicate how much a factor explains a variable (Anderson et al., 2011). Before running factor analysis adequacy of samples and sphericity of data has been checked. KMO and Bartlett test of sphericity has applied which found that factor analysis can be performed. Table 2 shows the value of KMO and Bartlett test for recession and upswing both with cutoff figure 1. Value of KMO is found more than 0.60 in recession (0.969) and upswing (0.948) both which confirms that sample is adequate. Value of Bartlett test (0.000) is also found significant which verified that factor analysis can be performed on both scales.  Principal component factor analysis with varimax rotation is being applied to reduce the data. Further, cross loadings of items are also examined to check whether same items show loading in more than one factor. Cross loading affect the discriminant validity of data, hence it is necessary to highlight such items to increase the validity.

Figure 1: CFA for Upswing Scale

Factor analysis resulted in six factors with 67% variance explained in recession data and 64% in upswing data respectively as shown in table 2 Adaileh & Abu-alganam (2010) and Zenk & Eckhardt (1970) clarified that 50% variance explained is deemed as satisfactory in studies related to social science.  Table 3 shows the results of factor analysis for recession and upswing items. Value of factor loadings and Communalities for each item is depicted in tables and furthermore, value of cronabach’s alfa for each factor is also calculated to check the internal consistency of variables in factors.  Hair et al. ( 2015) classified the significance of factor loadings on the basis of sample size. For a sample of 200, it is suggested that 0.40 factor loadings is sufficient and for 250 sample size 0.35 is considered appropriate score of factor loading. On the basis of this criteria, factor loading >0.40 has taken for this study having sample size 217 Figure 2.

Figure 2: CFA for Upswing Scale
Source: AMOS Output.
*PROD stands for Product
*PRCPHY stands for Process & Physical Evidence.

Renaming of factors has been done by keeping in account the nature of items included in respective factors. According to rotation matrix, factors are ordered as 1) Process and Physical Evidence, 2) Price, 3) People, 4) Promotion, 5) Place, 6) Product. But conceptually these factors lie in different order as 1) Product, 2) Price, 3) Place, 4) Promotion, 5) People, 6) Process, 7) Physical Evidence. On the basis of concepts, these factors are studied according to later order.

As presented in table 4, composite reliability of six constructs in recession data range from 0.874 to 0.952 and in upswing data it range from 0.856 to 0.944. All values are very high and above the threshold limit of 0.7 (Nunnally & Bernstein, 1994). In addition, AVE for each factor exceeded 0.50 which indicate sound convergent validity (Fornell & Larcker, 1981). Besides, AVE of all factors in recession and upswing is higher than the ASV which shows that all factors are distinct from each other and data shows good discriminant validity.

Table 5 depicted that second order CFA provides a good model fit for absolute, comparative and parsimony indices.  For recession model, value of CMIN/DF is 1.258 and RMSEA is 0.035 which makes it a good fit.  GFI (0.803), TLI (0.963), CFI (0.965) and IFI (0.965) has fulfilled cut off criteria. Parsimony fit indices PCFI (0.918) and PNFI (0.809) also demonstrated that model is a good fit. Similarly in case of upswing scale also value of these three indices has confirmed a good model fit as CMIN/DF (1.183), GFI (0.810), RMSEA (0.029), TLI (0.970), CFI (0.971) and IFI (0.972). Parsimony fit indices also shows higher values for PCFI (0.924) and PNFI (0.800) as well.

Discussion and Conclusion

Medical tourism is a historical process evolving rapidly over the years. A regulatory framework needs to establish to make its growth more beneficial for the nation. Health care service providers must ensure state of art in medical technology and procedures. To remain in market place, service providers take initiatives by marketing the best health services (Crooks et al., 2011; Kangas, 2010; The Economic Times, 2016). Regarding the marketing strategies government should encourage cheaper transport and accommodation, special training for service providers and there should be round the clock services for communication and promotion of health services inbound or outbound (Grewal et al., 2009; Lee, 2007).

Managerial Implications

Indian service providers are getting majority of patients from low GDP countries. Being a niche market, hospitals needs to create uniformity in the products and services with a uniform procedure of treatment. Along with hospitals, government of India also requires to endorse medical tourism in premium markets (Europe and USA) to reposition them for a larger share. Because during economic slowdown it is better to focus on high GDP countries. Unique selling proposition (USP) can be offered by different hospitals by analyzing demand of customers. Health service providers need to identify their strengths to determine a target segment. Creating USP in terms of patient safety, zero waiting time and standardized practices can be prove effective.

Limitations and Future Research

In present study data has been collected from NCR. The study can be done in the hospitals of various regions of country which are appealing foreign patients. The study incorporates only six hospitals from public and private ownership. The study can be undertaken between same categories of big private hospitals to evaluate the effectiveness of marketing practices from similar kind of hospitals. Although hospitals are the main pillars of advanced medical tourism but medical tour operators assists foreign patients for getting entry in country and provides other facilities to them.

Hence, a study can be done on medical tour operators by using different dimensions to generalize the implications of study. In present study, marketing practices are analyzed in form of seven P’s.  Same study can be done on each dimension of seven P’s separately. Product, price, place, promotion, people, process and physical evidence can be studied individually for developing better marketing practices.

Conflicts of interest

All contributing authors declare no conflict of interests

Acknowledgements

Researchers received no direct funding for this research

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