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Article history:
Received 26 February 2010
Accepted 18 August 2010
The aim of this study is to determine the factors inuencing the development of medical tourism in Hong
Kong. A qualitative research method was adopted to collect data from representatives of private and public
hospitals, government bodies, and medical institutions. The results reveal that policies and regulations,
government support, costs, capacity problems, and the healthcare needs of the local community are
the main barriers to the development of such tourism. Several strategies for lifting these barriers are
suggested, such as new promotional activity policies, government action to encourage investment in the
medical tourism market, and cooperative efforts by the hospitality sector and medical institutions to
develop medical tourism products.
! 2010 Elsevier Ltd. All rights reserved.
Keywords:
Medical tourism
Barriers
Tourism development
Hong Kong
1. Introduction
The globalization of healthcare has given rise to a new form of
tourism that is commonly known as health tourism. Within the
health tourism arena, medical tourism is among the fastest growing
sectors, and many countries are now making legal and practical plans
to serve it. Reduced transportation costs, higher incomes, knowledge
and technology transfer, and competitive prices all favor travel to
distant countries for medical reasons. One of the fastest growing
tourism markets in the world, medical tourism now generates
US$60 billion in business annually worldwide (Jones & Keith, 2006;
MacReady, 2007), and the number of countries offering state-ofthe-art medical facilities and services to foreign tourists is on the
increase. This international trade in medical services also has huge
economic potential for the global economy (Bookman & Bookman,
2007), and medical tourism is emerging as a particularly lucrative
sector for developing countries. According to Ramirez de Arellano
(2007), investment in this sector is a means of increasing income,
improving services, generating foreign exchange earnings, creating
a more favorable balance of trade, and boosting tourism generally.
Many countries have seized the business opportunities that
medical tourism offers. In 2005, for example, India, Malaysia,
Singapore, and Thailand attracted more than two and a half million
medical tourists (Tata, 2007). Colombia, Singapore, India, Thailand,
Brunei, Cuba, Hong Kong, Hungary, Israel, Jordan, Lithuania,
Malaysia, the Philippines, and the United Arab Emirates have
emerged as major healthcare destinations, and Argentina, Bolivia,
* Corresponding author. Tel.: 852 27666330; fax: 852 23629362.
E-mail addresses: hmvheung@polyu.edu.hk (V.C.S. Heung), hmdeniz@polyu.
edu.hk (D. Kucukusta), hmsong@polyu.edu.hk (H. Song).
0261-5177/$ e see front matter ! 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.tourman.2010.08.012
Brazil, Costa Rica, Mexico, and Turkey are also in the process of
making themselves attractive such destinations, particularly in the
area of cosmetic surgery (Singh, 2008). At present, Asia constitutes
the most important medical tourism region (Connell, 2006).
Hong Kong aims to be a center for medical excellence in the
region, and is well-known to deliver high-quality healthcare
services. Hong Kongs hospitals operate to the highest standards and
feature medical practitioners who are the best in their elds of
specialization. It is predicted that the annual income generated from
medical tourism in Asia could reach US$4.4 billion by 2012 (Singh,
2008), and Hong Kong is well-placed to capture a major share of
that gure. As noted, India, Singapore, Thailand, and Malaysia are
already actively promoting medical tourism. However, although
Hong Kong is listed as a medical tourism destination, and is known
as a center for traditional Chinese medicine and a hub for cancer
care in Asia (Singh, 2008; Teh & Chu, 2006), only limited attempts
have been made to promote medical tourism. Given its reputation
for healthcare excellence, its peaceful environment, and its high
economic and social welfare status, it is surprising that Hong Kong
has no structure or activities in place to promote this emerging
tourism sector. With many countries positioning themselves to take
advantage of this hugely lucrative industry, Hong Kongs response
appears inadequate.
The main purpose of this study is to investigate, analyze, and
explain the factors inuencing the development of medical tourism
in Hong Kong based on data gathered from private and public
hospitals, government bodies, institutions, and doctors. Its ndings
will contribute to the literature by revealing the barriers to the
development of the medical tourism industry. They will also prove
of practical value to both Hong Kong and other countries that are
trying to develop this industry. The remainder of the article is
996
2007; Tan, 2007). Awadzi and Panda (2006) point out that one
negative effect may be the diversion of funds from other areas of
the economy to medical tourism. Most locals cannot afford e and
thus may not welcome e the high-cost services on offer to medical
tourists, although patients from developed countries or regions
may consider them reasonable.
2. Literature review
2.2. Previous studies
2.1. Medical tourism development
Advances in technology and the spread of information have
changed the nature of exchange, and also the nature specialization
and communication among countries. Medical tourism is partly
the result of the globalization of both healthcare and tourism, which
already constitute major arenas of transnational economic activity
(Bookman & Bookman, 2007). Gupta (2004) denes medical tourism
as the provision of cost-effective medical care for patients in collaboration with the tourism industry. The process is usually facilitated
by the private medical care sector, but involves both the private
and public sectors of the tourism industry. Medical tourists can take
advantage of having medical surgery or treatment while enjoying
a stay in one of the worlds popular tourist destinations. Connell
(2006) characterizes medical tourism as a popular cultural phenomenon whereby people travel long distances to obtain medical, dental,
and surgical services while vacationing. The medical procedures they
obtain include not only elective surgeries such as cosmetic and dental
operations, but also more complex surgeries that require specialist
knowledge and technology (Singh, 2008). Medical check-ups and
health screening are preventive medical services that are also
considered to fall within the scope of medical tourism.
This tourism sector is making a signicant contribution to
many of the worlds economies. The medical tourism industry now
generates about US$60 billion worldwide annually, with Malaysia,
Thailand, Singapore, and India alone projected to generate more
than US$4.4 billion by 2012 (Singh, 2008). Indias medical tourism
business is projected to be worth US$2 billion a year by 2012
(Bookman & Bookman, 2007; Singh, 2008), and Singapore hopes to
attract one million foreign patients annually and push the industrys
gross domestic product (GDP) contribution to more than US$1.6
billion. Malaysia expects its medical tourism income to be around
US$590 million in ve years time, and in Thailand and South Korea
the industry is set to generate more than US$4 billion by 2012
(Medical Tourism, Asias Growth Industry, 2007) According to
Awadzi and Panda (2006), many Third World countries see medical
tourism as a gold mine and are promoting it aggressively, thus also
boosting competition in the industry. These authors also highlight
the importance of ensuring the protection of medical tourists by
developing proper guidelines and certication procedures.
The expansion of medical tourism in developing countries often
results in changes in the nature of the healthcare services offered
and in hospitals physical amenities. According to Cohen (2008),
leading hospitals in Thailand have acquired an international
reputation and a growing number of foreign patients. It has done so
by giving its hospitals the appearance of high-class hotels, separating indoor public spaces from treatment facilities, creating
a cozy atmosphere, prompting staff to be more responsive to client
requests, establishing constructive relationships between doctors
and patients, and employing state-of-the-art medical equipment
and techniques (Cohen, 2008).
Hume and DeMicco (2007) state that joint partnerships with
medical facilities provide an excellent way for hotels to differentiate their services. However, the growth of medical tourism can
have negative effects on the general healthcare system of a destination. Uncontrolled such growth may place the physical and sociopsychological well-being of the local population at risk (Burkett,
997
Fig. 1. A supply and demand model of medical tourism (Heung et al., 2010).
998
2.4.4. Malaysia
Modern healthcare facilities, qualied medical experts, and low
prices are the chief characteristics of the Malaysian medical tourism
market. In addition, like Thailand, Malaysia has the advantages of such
physical attractions as beautiful beaches and resorts. Also like
Thailand, the country became involved in medical tourism in 1998 in
the wake of the Asian nancial crisis (Connell, 2006). Its government
leads the effort to market such tourism overseas through various
promotional activities. According to recent market analysis, Malaysias
patients come from Indonesia, Singapore, Japan, and West Asia. The
Malaysian government also encourages the healthcare industry
through tax incentives (Leng, 2007), and the low prices of the countrys medical treatments are a major advantage. Thirty-four private
hospitals in Malaysia are engaged in heath tourism, and although
none of them is JCI accredited, many have received International
Organization for Standardization (ISO) certication (Yap, 2007).
A qualitative research method was adopted in this study. Qualitative research essentially refers to any kind of research that
produces ndings not arrived at by statistical procedures or quantication (Strauss & Corbin, 1990). Qualitative methods are generally
employed when the researcher needs to identify variables that will
later be tested quantitatively or when he or she has determined that
quantitative measures cannot adequately describe or interpret
a situation. This study is exploratory in nature because medical
tourism is a new area that has not yet been fully explored; hence, the
grounded theory approach was employed (Strauss & Corbin, 1998).
Hong Kong has been a leading nancial center since the 19th
century. Its healthcare system consists of both a public and private
3. Methodology
999
1000
Table 2
Prole of the interviewees (hospitals, professionals, and institutions).
Industry sector
Name of organization
Respondents
position
Public hospitals
Grantham Hospital
Caritas Medical Care
Prince of Wales Hospital
Yan Chai Hospital
Top executivea
Top executive
Medical doctor
Senior managerb
1
2
3
4
Top executive
Senior manager
Senior manager
Top executive
6
7
8
Top executive
Top executive
Senior manager
Senior manager
9
10
11
12
Private hospitals
Medical and
Hong Kong Medical Association
tourism bodies Federation of Medical Societies
Hong Kong Hospital Authority
Hong Kong Tourism Board
Number
a
Top executives (general managers, hospital chief executives, presidents, and
vice-presidents).
b
Senior managers (general managers, executive directors, senior project
managers, and senior event and product managers).
Table 3
Results of content analysis and group comparisons.
Themes
Sub-categories
Public
Private
Medical and
tourism bodies
Rank
Economy
++++
++++
++++
Infrastructure/superstructure
Capacity problems
Land scarcity
Supportive facilities/establishments for medical tourists and their companions
Physical environment is not suitable
Separate hospitals are needed for medical tourists
++
+
+
+++
+
++
++
++
++
4
7
6
8
7
++
++++
+
+
++
6
2
7
9
7
+
+++
++
Promotion
+
++
+
++
++
++
Expertise/manpower
+
+
+
+
+
++
Government attitude
Investment potential
+ Number of responses.
a
Theme constitutes overlapping factors.
+
+
+
+++
++
+
++
7
5
7
++
++
+
+
+
++
+++
++
8
8
8
7
3
7
7
+
+
+
+
7
7
8
8
8
+
1001
Facilities and
Attractions
Infrastructure/
Superstructure
Capacity
Land
Supportive Facilities
Physical Environment
Separate Hospitals
Policies and
Restrictions
Advertising
Restrictions
Need for New
Policies
Rules and
Formalities
Language and
Communication
Promotion
Internet
Icon/Brand
Promoting Doctors
Promoting Institutions
Promoting Specialized
Treatments
MEDICAL
TOURISM
DEVELOPMENT
Government Attitude
Public-Private
Partnership (PPP)
Support
Local Healthcare
Needs
Facilitating Visits to
Hong Kong
Investment Potential
Cooperative Action
Private Sector Interest
Expertise/Manpower
Specialization
Limited Number of
Specialists
Deficient Nursing
Special Nursing
Training
Economy
Costs
1002
4.3.2. Infrastructure/superstructure
The sub-categories of capacity problems, land scarcity,
supportive facilities, physical environment, and separate hospitals
are grouped under the theme of infrastructure/superstructure. A
major problem for Hong Kongs development as a medical tourism
destination is the insufcient capacity of its public healthcare
system, which already has to deal with the healthcare needs of its 7
million residents. Locals can purchase public healthcare for a small
fee, but there are long waiting lists, especially in public hospitals.
For example, the average waiting time to see a specialist is more
than seven months, although the HA is trying to reduce this. Some
patients are able to take advantage of the much more expensive
care in the private market and wait relatively less time. A common
belief among the respondents was that many hospitals, whether
public or private, suffer from an inadequate number of beds.
I dont think Hong Kong can afford this kind of manpower that
needed to serve medical tourists. So, it is not that we have no
interest or are not competitive enough.the reality at the moment
is that our beds are already full, and we just do not have the spare
capacity (Respondent 8).
Another concern, particularly among the hospital executives,
was the scarcity of land and the relatively high land costs. Land
scarcity and a high population density render the expansion of
existing hospitals impossible.
They [medical tourists] need extra beds, and everything is so costly
there is no way that they would be able to recuperate before having
to leave Hong Kong.thats the major difference [with other
destinations]. In Hong Kong, there is no room and the government
is not prepared .On Lantau Island, for example, they could do it
[build new hospitals] because places are cheap. You could not put
[new] hospitals in Central or in Causeway Bay (Respondent 10).
The respondents also highlighted the insufcient support
facilities in Hong Kong, particularly for companions or family
members accompanying medical tourists. Hospitals would need to
provide special facilities and services (perhaps with the attributes
of a ve-star hotel) for both patients and their companions. In
addition, to attract medical tourists, Hong Kong must offer much
more than shopping attractions to complement medical services.
And the family coming along with the patient.the patient may be
admitted to a private hospital, and the room may be good enough
for him or her to stay for an initial check-up or surgery, but what
about the family? (Respondent 4)
I think what we are missing is.say, you go to Thailand. Thailand is
well known for its spas, and people want to go to the spa afterwards. You know, have cosmetic surgery and then go and spend
time under a banyan tree, or whatever. You enjoy some luxury as
well as undergoing surgery (Respondent 6).
The respondents from the public sector stated that separate
hospitals would need to be built for medical tourism in Hong Kong:
We would like to see separate facilities rather than the same
hospitals, with some being for medical tourism and the rest for the
local population. We would prefer a separate infrastructure, maybe
a separate hospital totally devoted to medical tourism (Respondent 12).
1003
Up to now, the private sector has been quite happy focusing its
business on local people because they charge a lot, and local people
can pay. So what is the payoff in focusing on foreigners?
(Respondent 2).
In some countries that promote medical tourism, hospitals
engage in cooperative activities with hotels. For example, Thailands
Phuket-based Bangkok Hospital Phuket has been collaborating with
nine hotels since 2006. The interviewees in this study suggested that
similar cooperative activities, such as partnerships between hotels
and hospital investors, should also be encouraged in Hong Kong:
I think Bumrungrad Hospital in Thailand works with hotels to offer
packages. As far as I know, this has not happened in Hong Kong
(Respondent 6).
4.3.8. Language and communication
To provide medical services of an international standard,
medical tourism destinations need to hire medical staff who can
speak foreign languages. Although Hong Kongs ofcial languages
are Cantonese and English, language difculties may represent
a barrier for some international patients.
Hong Kong doctors do not speak Putonghua well. Their English is
OK, and they can even communicate effectively with people from
other Asian countries. But Putonghua? I doubt it (Respondent 3).
4.3.9. Facilities and attractions
Despite its good hotels, restaurants, and thousands of shops,
another major constraint to medical tourism in Hong Kong is the
lack of natural attractions and facilities. Unless medical tourists are
obliged to undergo a specialized treatment or complex surgery in
Hong Kong because it is not available elsewhere, and such treatment or surgery is their sole reason for undertaking a trip to Hong
Kong, the general tendency is to prefer to obtain treatment in
a relaxing environment. Hong Kong thus needs to provide facilities
and services that provide relaxation and recreation, not only for
patients, but also for their companions.
5. Implications, recommendations, and conclusion
5.1. Study implications and recommendations
This study has important implications for the key players in the
medical tourism industry, both in Hong Kong and elsewhere. The
following suggestions are recommended to lift the barriers that
hinder the development of medical tourism in Hong Kong.
# Costs. Costs in Hong Kong are high. Instead of focusing on cheap
medical tourism products, Hong Kong could target higherincome medical tourists by focusing on specialized treatments
or complex surgery that require a high level of expertise.
A primary target market could be high-income groups from
mainland China.
# Capacity. Designated hospitals are needed to overcome the
current lack of capacity. New medical establishments such as
medical centers and hospitals could be completely devoted to
and promote specic areas of expertise/medical tourism products, such as Chinese medicine, cancer treatment, or cosmetic
surgery. Due to land scarcity, these specialized or branch
hospitals would need to be located in the outer regions of Hong
Kong, where there is more available land. The Hong Kong
government recently identied four suitable sites in Wong Chuk
Hang, Tseung Kwan O, Tai Po, and Lantau, and invited
1004
5.2. Conclusion
The analysis and discussion contained herein suggest that Hong
Kong has been an Asian medical destination for more than 30 years.
1005