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Tourism Management 32 (2011) 995e1005

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Tourism Management
journal homepage: www.elsevier.com/locate/tourman

Medical tourism development in Hong Kong: An assessment of the barriers


Vincent C.S. Heung*, Deniz Kucukusta, Haiyan Song
School of Hotel and Tourism Management, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong

a r t i c l e i n f o

a b s t r a c t

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

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structured as follows. First, medical tourism is dened, and its


position in Asia analyzed. Second, the qualitative research methodology employed in the study is discussed, and the data collected
are analyzed. Finally, the barriers to medical tourism development
in Hong Kong are identied and presented in a framework.

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,

Several studies have analyzed the factors and dimensions that


inuence a countrys medical tourism industry. Smith and Forgione
(2007), for example, developed a two-stage model of the factors that
inuence a patients decision to seek healthcare services abroad.
In the rst stage, they identied the factors determining a patients
choice of destination. In the second stage, they then evaluated
those determining the choice of a healthcare facility. They argue
that country-specic characteristics, such as economic conditions,
political climate, and regulatory policies, inuence the country
choice, whereas such factors as costs, hospital accreditation, quality
of care, and physician training affect the healthcare facility choice.
Caballero-Danell and Mugomba (2007) developed a map that
documents medical tourism information collected from the electronic media, newspapers, periodicals, magazines, and academic
material. According to their map, the components of the medical
tourism market include consumer benets, branding, the legal
framework, infrastructure, products, target markets, communication
channels, operators, intermediaries, and social issues. Ye, Yuen, Qiu,
and Zhang (2008) examined Hong Kong medical tourists motivation
by adopting a case study approach that employs push and pull
motivation theory. The results of their study reveal that these tourists are mainly concerned with medical matters, rather than destination attributes. The motivational factors that Ye et al. (2008)
consider include destination attributes, healthcare quality, promotions, companionship, costs, and reputation. Although the lucrative
nature of medical tourism has garnered it signicant attention,
particularly in developing countries, only a few academic studies
have focused on this topic. The aforementioned studies concentrate
on specic areas of the medical tourism industry, such as its
economic, medical, and marketing aspects, from either the supply or
demand perspective (Bookman & Bookman, 2007; Connell, 2006;
Smith & Forgione, 2007). However, no previous research focuses
on the factors that inuence the development of such tourism.
2.3. Conceptual framework
(a)Heung, Kucukusta, and Song (2010) recently developed
a conceptual model of medical tourism to provide a comprehensive picture of the industry in terms of supply and demand.
Fig. 1 depicts this integrated model.
The conceptual model has two parts: supply and demand. The
latter represents the factors that affect tourists destination choice
and medical treatment options. These are the factors that drive the
medical tourists decision. The former basically addresses how well
a destination is prepared to meet the demands of these tourists.
The present study focuses on the supply side of the model, which
considers such factors as the current situation of the medical
tourism industry in terms of infrastructure and superstructure
facilities, promotional activities, quality assurance, and communication facilities, all of which are considered signicant in attracting
medical tourists. Hence, these supply-side factors were chosen as
the key issues to be addressed in our interviews and in the development of the studys interview questions.
Although only a few studies have focused on medical tourism,
they have identied most of the key barriers to its development.

V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005

997

Fig. 1. A supply and demand model of medical tourism (Heung et al., 2010).

For instance, according to Smith and Forgione (2007), such factors as


costs, healthcare quality, accreditation, and physician expertise are
important in medical facility selection, whereas a countrys regulatory and economic conditions also affect the country choice. These
factors are thus considered to be the main barriers to the development of Hong Kongs medical tourism sector in this study. In addition,
Ye et al. (2008) also found pull factors, such as service quality, medical
expertise, hospital hardware, and the advertisement of these
facilities, to affect medical tourists motivations. The results of these
studies were considered when formulating the key issues for our indepth interviews. The factors proposed as barriers to medical tourism
development are discussed in detail in the following sections.
2.4. Medical tourism in Asia
Medical tourism is relatively new in Asia. The Asian nancial crisis
of 1997 resulted in signicant losses for the regions businesses,
including private hospitals. These hospitals thus began trying to nd
solutions to their problems and, accordingly, began to offer new and
attractive health packages. Thailand was the rst country to enter the
medical tourism industry, and it quickly became a hub for cosmetic
surgery. India, Malaysia, and Singapore followed suit, and the four
counties together attracted more than 1.4 million medical tourists
in 2003 (Tata, 2007). Malaysia now attracts 100 000 foreign medical
tourists a year, and Singapore and India are experiencing fast growth
in this area as a result of effective marketing strategies. However,
Thailand remains the leader in the Asia-Pacic region, attracting
400 000 medical tourists in 2003 (Teh & Chu, 2006). In 2005,
approximately 250 000 foreign patients sought medical care in

Singapore, 500 000 traveled to India for medical purposes, and


Thailand treated about 1 million foreign patients (Hutchinson, 2005).
2.4.1. India
India is positioning itself as a primary medical destination,
offering everything from alternative treatments to the most complex
medical procedures (Connell, 2006; Singh, 2008). Many hospitals
have attained Joint Commission International (JCI) accreditation,
a U.S. scheme that assures the quality of healthcare in hospitals. India
has become renowned for low cost, though advanced, medical
procedures such as heart surgery, joint replacements, and hip
resurfacing, in addition to other relatively simpler treatments.
Medical tourists also visit India for such alternative treatments as
Ayurvedic medicine and yoga.
The countrys medical tourism market is now worth US$333
million and is growing by 30% per annum (Chacko, 2006; Nautiya &
Dogra, 2005). The main appeal of its medical industry is its low costs.
In addition, India has a skilled human resource pool comprising
very well-educated and well-known doctors and trained nurses.
Communication is not a problem, as English is widely spoken
(Connell, 2006). As medical tourism products combine healthcare
and tourism components, strategic co-ordination between the
two sectors is essential. In India, there is co-ordination among the
national government, state governments, and numerous federal
bodies to promote medical tourism.
2.4.2. Singapore
Singapore is another leading Asian medical hub, boasting
excellence in quality, safety, and trustworthiness, as well as

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V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005

international accreditation. Like India, Singapores hospitals are


accredited by the JCI. Singapore attracts medical tourists from
developed countries such as United States and from neighboring
countries such as Indonesia and Malaysia (Singh, 2008). The Singaporean government strongly supports the sector and has
identied it as a new growth area. The city state offers complex
neurosurgical procedures and highly advanced medical treatments
such as liver and heart transplants. To attract additional medical
tourists, Singapore has also signed government-level agreements
with several countries in the Middle East, such as the United Arab
Emirates, to offer medical services. These government-led initiatives have also attracted investors (Tata, 2007).
2.4.3. Thailand
Medical tourism is an integral part of Thailands tourism and
healthcare industries. As a medical tourism destination, it offers JCIaccredited hospitals and U.S.-certied physicians. The country also
offers a broad range of medical treatments e from heart surgery to
organ transplants e in modern facilities at much lower prices than
those in Western countries (Singh, 2008). The Japanese constitute the
largest proportion of medical tourists to Thailand, although patients
from the United States, United Kingdom, and Middle East also come in
signicant numbers. Thailands competitive advantage in this sector is
pricing (Cohen, 2008). Healthcare costs are 50% cheaper than in
Singapore, three times cheaper than in Hong Kong, and ve to 10
times cheaper than in Europe and the United States (Kittikanya, 2004).
The Thai government in 2004 published a policy to develop and
promote the country as the leading healthcare provider in Asia by
2010 (Tata, 2007). The governments strategy is to increase
marketing and public relations activities directed at foreigners,
improve management, and develop healthcare products and
services. The main medical tourism spots being promoted in
Thailand are Bangkok, Chiang Mai, Koh Samui, and Phuket.
The Thai Ministry of Public Health also cooperates with the Thai
Ministry of Tourism to promote medical travel to Thailand. Moreover, Thailand and Malaysia are in the process of exploring the joint
promotion of medical travel to gain a competitive advantage over
other countries. Bangkoks Bumrungrad Hospital is the leader in
this eld, and is considered to be among the frontrunners in
medical travel worldwide (Medical Tourism at Bumrungrad
Hospital, 2006). The countrys hospitals offer a variety of facilities,
including interpretation in more than 10 languages, and their
quality is assured through JCI accreditation (Singh, 2008).

sector, with public healthcare services provided by the Department


of Health and the Hospital Authority. The former provides primary
care (preventive and outpatient services), and the latter manages
the public hospitals. The private healthcare sector provides the
majority of primary care services. Hong Kong is not only one of the
worlds fastest growing cities, but is also one of Asias most popular
tourist destinations, not least for its numerous shopping centers.
According to the latest available gures, 29.5 million tourists visited
Hong Kong in 2008 (Hong Kong Tourism Commission, 2009).
Hong Kong has modern medical facilities, and several of its
private hospitals have been accredited by the U.K.-based Trent
Accreditation Association. A few Trent hospitals can now boast
accreditation from two international bodies, having been accredited
both by the JCI and under the Trent Accreditation Scheme (TAS).
Most private hospitals are moving toward obtaining both types of
accreditation. The Hong Kong Hospital Authority (HA) also recently
announced that another international accreditation agency, the
Australian Council on Healthcare Standards (ACHS), would assess
several private and public hospitals in early 2010 (Lee, 2009). To
achieve standardization, however, the Hong Kong government aims
to have all hospitals accredited to the same standards in the long run.
Although promotional activities and government support for
medical tourism are limited in Hong Kong, many patients, particularly
baby boomers, come from mainland China for healthcare services
(Hong Kong Advantages for Medical Tourism, 2007). A few travel
companies have even begun to attract Chinese mainlanders to Hong
Kong specically for medical treatment. In terms of the services on
offer, some institutions focus on check-ups and other basic healthcare
services, but Hong Kong is also becoming dominant in the advancement of cancer treatment (oncology) using a combination of cuttingedge technology and traditional Eastern therapies (Davis, 2008).
Inskeep (1988) asserts that tourism requires systematic planning
if it is to be developed properly, responsive to market demands, and
integrated into an areas total development pattern. Good tourism
planning leads to tourism development. In other words, if the
medical tourism sector is to be developed in a particular region, then
that region must properly plan for it. In many countries, such as
India, Thailand, Singapore, and Malaysia, the government has supported medical tourism by establishing special departments,
engaging in partnerships with other countries, or launching
promotional activities. Compared with these countries, Hong Kong is
not currently a key player in the medical tourism market. Although
there have been some constructive attempts to boost the sector in
Hong Kong, the medical tourism concept has generally been
neglected by both the government and the private sector. This study
aims to determine the reasons for this situation and identify the
barriers to medical tourism development that exist in Hong Kong.

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).

2.5. Medical tourism development in Hong Kong

3.1. Identication of key issues

Hong Kong has been a leading nancial center since the 19th
century. Its healthcare system consists of both a public and private

The key issues were identied through an extensive review of


the literature, including previous studies of medical tourism

3. Methodology

V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005

(Bookman & Bookman, 2007; Connell, 2006; Smith & Forgione,


2007; Ye et al., 2008) and the theoretical framework developed
by Heung et al. (2010). These key issues primarily involve the
factors that inuence the development of medical tourism in
a country or region.
3.2. Data collection
Qualitative data were collected through in-depth interviews
with hospital representatives, the chief executives and directors of
medical organizations, and representatives of relevant authorities
in the healthcare sector. As no denitive list of the institutions or
hospitals that engage in medical tourism in Hong Kong could be
found, the interviewees were identied through the ofcial
websites of the Hospital Authority (HA) and the Hong Kong Private
Hospital Association (HKPHA). There are 56 private and public
hospitals in Hong Kong. A letter was sent to the administrators of all
of the private and public hospitals listed on these sites and to ve
different professional bodies (The Hong Kong Medical Association,
The Medical Council of Hong Kong, The Federation of Medical
Societies of Hong Kong, the HA, and the Hong Kong Tourism Board)
explaining the purpose of the study and requesting an interview.
This initial letter received eight responses. To increase the
response rate, a follow-up letter was sent to those institutions
that had not responded to the rst letter, and an additional two
responses were received. A third and nal letter was sent to the
remaining institutions, a further two administrators responded.
The nal in-depth interview sample thus comprised 12 administrators from medical organizations representing different sectors
of the medical tourism industry in Hong Kong, including private
hospitals, public hospitals, medical associations, and tourism
bodies. A semi-structured questionnaire was prepared to guide
the interviews, whose aim was to determine the barriers to the
development of medical tourism in Hong Kong. The interview
questions were open-ended and mainly focused on the issues
surrounding such development, including infrastructure, superstructure, promotional activities, and medical service quality.
The interview questions are listed in Table 1. Two interviewers
conducted each interview. One asked the questions, and the other
took notes and audio-recorded the responses. Each in-depth
interview lasted about 60e90 min.
Table 1
Interview questions.
1. Do you see Hong Kong as a medical tourism center in Asia? Why or why not?
2. What are the factors affecting Hong Kong in developing its medical
tourism industry?
3. Do you think that the infrastructure and superstructure in Hong Kong
are adequate to cater for the growth of medical tourists?
4. How can the government support medical tourism in terms of promoting
it within and outside Hong Kong?
5. What are the human resource issues related to medical tourism
development in Hong Kong?
6. Do you think that Hong Kong has the expertise and manpower to deal
with medical tourists from different countries?
7. Do you think that medical tourism staff should be specically trained?
What do you think is the situation in Hong Kong?
8. How does the economic situation in Hong Kong affect medical tourism
development?
9. How can the private and public sectors be encouraged to support
medical tourism efforts or investment?
10. What are some activities and effective ways of promoting medical
tourism in Hong Kong?
11. How can medical service providers communicate with medical
patients or tourists more effectively?
12. Does Hong Kong have the facilities and attractions to cater for the
needs of medical tourists?
13. Can you think of any other factors that could be a barrier to development?

999

To validate the interview content and clarify any ambiguities,


summaries of the interview transcripts were sent to the interviewees
for verication. In addition, follow-up questions were posted to them
whenever clarication was needed. All of the interviewees replied via
e-mail to conrm that the content was consistent with their original
responses except for a few minor changes in wording.
3.3. Data analysis
Data analysis was undertaken in three stages. In the rst stage,
the raw data were transcribed from the interview audiotapes and
prepared for content analysis. These transcripts were reviewed to
check for data redundancy. The review ended if there was redundancy in the information gathered, that is, if no new information
was obtained (Dunn,1986; Patton, 1990). In addition, the notes taken
during the interviews were reviewed, with key words, phrases, and
concepts identied. Finally, content analysis, which is widely used in
social science and management research (Berg, 2004; Neuendorf,
2002), was then carried out on the transcribed and veried interview data to classify them into themes and categories.
The second stage of data analysis was the initial coding stage.
Open coding was employed to identify variations within the categories and to combine closely related categories in which overlap
was found. Two researchers were involved in the coding, and they
carefully interpreted and cross-validated the categories. Following
the open-coding process, the organized materials were read several
times by the researchers, with the content of each interview further
analyzed. Each researcher then compared and rened the ndings
and developed sub-categories.
In the third and nal stage, the researchers employed further
coding to rene the results of the rst two stages. The transcripts
were carefully read again to identify the broad context of the factors
hindering the development of medical tourism in Hong Kong.
The themes and sub-categories that emerged were subjected to
comparison among the public and private sectors and other
medical tourism bodies. Axial coding permitted the rened subcategories to be put together to identify the main categories or
themes (Dey, 1998; Strauss & Corbin, 1990) and the relationships
among themes to be identied. During this process, the themes and
main categories identied were validated by comparing the information provided by the different respondents and then further
comparing the information obtained in the interviews with data
gleaned through observation and analysis of secondary documents
(Mehmetoglu & Altinay, 2006). Finally, a framework was developed
after revisiting the coded and categorized statements and identifying the inter-relationships among them.
4. Findings and discussion
4.1. Interviewees and themes
As previously noted, data were collected through interviews
with hospital executives/representatives and representatives of
healthcare and tourism authorities. The proles of the interviewees
are presented in Table 2, from which it can be seen that the
respondents were grouped into three categories: public sector,
private sector, and medical and tourism bodies. Five of the interviewees were hospital chief executives, and three were medical
specialists. The medical and tourism bodies were represented by
one medical doctor, one president, and two senior managers.
The content analysis results revealed specic themes, which
were grouped and quantied with their associated patterns
(sub-categories). Details of the themes and sub-categories that
emerged are listed in Table 3. The theme policies and regulations
was considered to overlap with some of the factors belonging to the

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V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005

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

Hong Kong Sanatorium


and Hospital
Matilda International Hospital
St. Pauls Hospital
Baptist Hospital

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).

government attitude, investment potential, and promotion


themes, the interrelationship among which is depicted by a dashed
line. The results of the aforementioned comparison of the
responses given by the representatives of the public and private
sectors and the other medical and tourism bodies are also presented in Table 3. The opinions expressed by each group of
respondents are shown, along with the number of responses.
All of the respondent groups cited high costs as a major obstacle
to the development of medical tourism, ranking it rst, followed
by the healthcare needs of the local community. Inadequate

promotion of specialized treatments and capacity problems were


ranked third and fourth. Government support, regulations on
advertising, and the need for the development of new policies were
other strong factors. These factors are grouped by theme and
discussed separately in the following sections.
4.2. Framework and comparison with literature
A framework based on the amalgamation of the categories and
themes was designed to depict the relationships among them. Fig. 2
shows this framework of the barriers to the development of
medical tourism in Hong Kong. It can be seen that costs, expertise/
manpower, government attitude, investment potential, infrastructural and super-structural factors, promotion, communication,
facilities and attractions, and policies and regulations were identied as the main barriers to such development. The solid arrows in
Fig. 2 represent the direct inuences on the development of
medical tourism, and the dashed arrows the inter-relationships
among the factors. For example, restrictions on advertising, the
need for new policies, and strict medical rules and formalities
are grouped under the theme of policies and regulations, and can
be understood from the gure to be interrelated.
According to Smith and Forgiones (2007) two-stage model of
the factors inuencing a patients decision to seek healthcare
services abroad, once a destination has been selected, the patient
must choose from among the medical/tourism facilities on offer in
that destination. Some of the barriers identied in this study, such
as costs, laws and regulations, accreditation, and training, are
similar to those they identied, whereas others, such as facilities
and attractions, communications, infrastructure, and superstructure, are new. In Caballero-Danell and Mugombas (2007) map of

Table 3
Results of content analysis and group comparisons.
Themes

Sub-categories

Public

Private

Medical and
tourism bodies

Rank

Economy

Costs are high for medical tourist patients in Hong Kong

++++

++++

++++

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

More governmental support is needed


Needs of local community (local healthcare problems)
New investments should be encouraged
Visiting Hong Kong should be facilitated by the government for Chinese patients
Privateepublic partnership (PPP)

++
++++
+

+
++

6
2
7
9
7

Policies and regulationsa

Restrictions on advertising hinder medical tourism development (promotion)


Lack of new policies (i.e., land) and development plans (investment potential)
Medical formalities (strict rules and regulations) (government attitude)

+
+++
++

Promotion

Need for an icon or brand name to promote medical tourism


Promotion for medical professionals
Promotion for institutions
Inadequate promotion on the Internet
Hong Kong should promote specialized treatments

+
++
+
++

Need for cooperative action between hotels and hospitals


Private sector is not interested

++
++

Expertise/manpower

Medical tourism requires expertise and specialization


Limited number of specialists
Manpower deciency (nursing)
Special training is a necessity for medical tourism

+
+

+
+
+

Language and communication

Foreign languages can be a problem

++

Facilities and tourist attractions

Lack of tourist attractions as a medical tourism destination

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

V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005

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

Fig. 2. Framework of barriers to medical tourism development in Hong Kong.

the market structure of medical tourism, consumer benets,


branding, legal framework, infrastructure, products, target markets,
communication channels, operators, intermediaries, and social
issues are identied as the components of the medical tourism
market. The only common factors between their study and ours,
however, are the promotion of medical tourism, the legal framework, and infrastructure. The case study carried out by Ye et al.
(2008) on the motivations of Hong Kong medical tourists and the
barriers to medical tourism identied some factors similar to
those revealed here, for example, destination attributes, healthcare
quality, promotion, companionship, costs, and reputation.
However, the two studies serve different purposes in the medical
tourism context.
4.3. Barriers to development of medical tourism
The barriers identied in this study are similar to some of those
highlighted in the literature as hindering tourism development in
general. For instance, Keyser (2002) pointed out that limited access
to nancial markets, limited condence on the part of international
and domestic investors, complicated taxation requirements and
procedures, limited budgetary allocation, a lack of integration,
and limited tourism promotion all constrain the development of
tourism in a particular region.
4.3.1. Economy (costs)
Although destination attributes and the quality of healthcare
inuence medical travel decisions, the primary motivator is

generally economic (Marlowe & Sullivan, 2007). The treatment


costs for medical tourists are often a quarter to a tenth of the price
they would pay at home (Adams, 2006). Individuals also travel
to distant countries to receive medical treatments that are not
covered by their insurance policies or because insurance coverage
is too expensive in their home country. The low healthcare costs in
the countries currently promoting medical tourism represent their
major advantage. These costs are relatively high in Hong Kong, and
are thus the main barrier to the development of such tourism there.
The following comment made by Respondent 7 illustrates this.
In Hong Kong, we are in the high range.in terms of salaries and
the cost of medical care, although we do not charge our citizens for
healthcare. We are subsidizing them through our healthy nancial
property market, good economy, and good GDP, but relatively low
tax rate. So, the healthcare system is deemed to be heavily
subsidized by public nance. But if you look at the salary structure,
we are listed as the second most expensive city in the world, with
Tokyo as number one.
Hong Kongs high healthcare costs may be due to its system of
nancing healthcare, which is mainly funded by the government, in
contrast to countries that have adopted national insurance systems,
such as Taiwan, Singapore, and South Korea. A highly subsidized
public healthcare system covers everyone, protecting all individuals from the signicant nancial risks that may arise from major or
prolonged illnesses (Yau & Lung, 2004). It also means that the
hospital structure remains the same for decades. In Hong Kong, an
increase in the aging population ratio, rising patient expectations,

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V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005

and high-tech medicine and expensive drugs have pushed up


healthcare costs (Yuen, 1999), particularly for private healthcare
seekers and non-locals. To control these increasing costs and to
lessen some of the governments burden for medical care, Hong
Kong is moving toward private-sector solutions, such as insurance
programs.

4.3.3. Government attitude


Almost all of the respondents mentioned that government
support is needed for the development of medical tourism:

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.

According to the interviewees, the Hong Kong government needs


to ease the problem of land scarcity by making more land available.
Also, in addition to hospitals insufcient capacity, the main focus of
the HA is the needs of the local community. In a sense, the healthcare
needs of the local community hinder the development of medical
tourism, as Hong Kongs hospitals and healthcare professionals are
busy addressing those needs. The interviewees thus pointed out that
the government must encourage investment in such tourism,
for example through privateepublic partnership (PPP) initiatives.
Considering the burden of the public sector healthcare in Hong Kong,
PPP may represent a good strategy for the government.

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).

The point is that the government keeps saying develop medical


tourism, but neither the government nor the tourism industry has
helped us to do it (Respondent 5).

The overall concept that we support is PPP, and we have it on


a number of levels for the building of hospitals. Potentially, we have
four pieces of land, and land is a very expensive commodity in Hong
Kong. We also have staff arrangements. We are exploring these
models right now to see which PPP model would suit Hong Kong
best as we move forward (Respondent 12).
4.3.4. Policies and regulations
Registered medical practitioners are not allowed to advertise in
Hong Kong to attract more patients, in accordance with the regulations of the Medical Council of Hong Kong (Medical Council of
Hong Kong Guidelines, 2008). This situation has resulted in inadequate promotional activities on the part of hospitals and practitioners. The Internet is the main tool by which prospective medical
tourists seek information about the qualications of foreign
medical professionals. Many private hospitals in countries that
promote medical tourism thus provide detailed information about
their services, together with promotional packages, on the Internet.
The Hong Kong Medical Council has very strict rules on so-called
advertisements. You cannot advertise anything other than your
basic qualications, and advertising on the Internet is still not
allowed. You can only give details of your basic qualications and
the services you provide on the Internet, but not in a newspaper or
a magazine (Respondent 3).
In addition to ethical considerations, medical doctors are also
bound by the laws and ofcial regulations constituting the legal
framework that regulates medical practice. Unlike many of the
countries that promote medical tourism, Hong Kong law restricts
certain treatments and surgeries, which limits the medical products that can be made available.
Overseas patients seek different things. For example, people who live
in the United Kingdom, and because of the law are not allowed to
undergo an organ transplant, go to India to do it. The reason why
India is their rst choice is probably because of the weaker legal
environment. There is no obstacle to doing something that is against
the law in the United States or the United Kingdom. But in Hong
Kong we follow common law and UK law, so it would affect those
people in the same way. I think that medical tourism cant be applied
in Hong Kong because we dont have the exibility (Respondent 4).
4.3.5. Promotion
In countries such as Greece, South Africa, Jordan, India, Malaysia,
the Philippines, and Singapore, the government actively promotes
medical tourism. The governments of these countries sometimes

V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005

even include such tourism in their national tourism marketing


campaigns. A hospital or medical center with an iconic brand needs
to be established and promoted in Hong Kong. Such a development
would support the generation of medical tourism products,
because promotional activities are usually shaped by the products
themselves.
We need to build a brand with an image. Hong Kong itself has
a good medical reputation, but we need to have an iconic type of
organization that patients can easily recognize (Respondent 1).
Clearly, Hong Kongs legal and regulatory restrictions on medical
service-related promotional activities, such as the promotion of
specialists and other doctors, medical institutions, and specialized
treatments via the Internet or other media channels, hinder its
development as a medical tourism destination.
4.3.6. Expertise/manpower
The sub-categories of clinical expertise and specialized treatments, limited number of specialists, shortage of nurses, and the
need for special training are grouped into the theme of expertise
and manpower. Undoubtedly, gaining access to superior medical
expertise is one motive for medical tourists seeking specialized
treatments, and some of the respondents noted that Hong Kong
needs more specialists.
The number of doctors, especially specialists, is few. There is limited
capacity, unlike in Thailand, where there are thousands of doctors
who can concentrate on medical tourism. So, if we want to have
medical tourism, then we need more specialists in specic areas
and also highly trained nursing staff and other health professionals
related to those specialties (Respondent 2).
A shortage of medical manpower, both in terms of specialists
and high-quality nurses, thus constitutes another barrier to the
development of medical tourism in Hong Kong. The provision of
top-quality healthcare services requires both high-quality nursing
staff and good post-operative care (McCallum & Jacoby, 2007).
The qualications for nurses involved in medical tourism need to be
claried, and programs that will result in better nursing care
developed (Ben-Natan, Ben-Sefer, & Ehrenfeld, 2009). The need for
trained nurses is as signicant as that for specialists. The Hong Kong
government recently announced that 60 additional senior-year
places would be provided for nursing degree programs in the
2010e11 academic year. The HA has also re-opened some of its
nursing schools and provided additional training places in 2009e10
(Hong Kong Government, 2009).
4.3.7. Investment potential
Medical tourisms investment potential can be divided into the
two sub-categories of private-sector interest and cooperative
action. The bulk of medical tourism is served by the private sector
in such countries as Australia, Thailand, the United States, and the
United Kingdom, especially in terms of analyzing available opportunities, leading development, and formulating strategies. For this
reason, the governments in these countries can concentrate their
efforts on public hospitals and doctors (Teh & Chu, 2006). Medical
tourism activity remains largely in the private sector, with largescale specialist hospitals that generally operate for prot. As such
tourism develops in a destination, the demand for private hospitals
increases, and more qualied doctors are needed, many of them
being drawn from the public sector (Gupta, 2004). The situation in
Hong Kong is different, however, as the private sector is not actively
investing in medical tourism for several reasons, including the lack
of available land, the governments attitude, and, possibly, general
satisfaction with existing business and economic conditions.

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

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V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005

expressions of interest from the market to develop private


hospitals (Hong Kong Government, 2009).
Government support. Governments can support medical
tourism in many ways, although they must also ensure that
measures are in place to prevent the healthcare needs of the
local community from being compromised. Capacity problems
can be solved by encouraging local and foreign investment in
the healthcare sector, which can be facilitated by the appropriate easing of regulations. The government should also
support PPP to eliminate the nancial, technical, and operational risks of new medical tourism investments and projects.
Travel facilitation. The government should make it easier for
medical tourists to visit Hong Kong. Although Hong Kong has
no visa limitations for individuals from many developed
countries, new policies are needed to facilitate the entry of
mainland Chinese patients seeking medical services.
Policies and plans. To encourage investors and boost investment
in medical tourism, new policies and development plans are
needed. For instance, the land policy should be reviewed
to encourage new hospital development. Area and height
restrictions could be made more exible, and land could be
granted a discounted premium for hospital development.
Investment. Policies aimed at decreasing the expense of setting up
medical tourism facilities, such as tax deductions and nancial
support for equipment, the provision of land for medical tourism,
and the support of overseas investment in medical tourism,
should also be developed to promote medical travel (Tata, 2007).
Promotional activities. Overseas promotional activities by
medical institutions and specialists could be supported by the
Hong Kong Tourism Board and the HA, and medical tourism
promotion could become part of a national tourism campaign.
Together with state-of-the-art medical facilities and services,
the combination of traditional Chinese medicine and modern
medicine could be promoted as a distinct medical tourism
product in Hong Kong. The establishment of an institution that
carries an iconic brand name, similar to Bumrungrad Hospital
in Thailand, could aid such promotional activities.
Internet. Many countries engage in online promotions to attract
medical tourists. Such promotions are particularly effective in this
arena because prospective medical tourists or intermediaries
(medical travel agents) initially search the Internet to collect
information. Government support for the online promotion of
medical services could help medical facilities to offer more reliable information than is available on existing healthcare websites.
Communication skills. Although Hong Kong boasts a large
number of English-speaking medical staff, it is important for
medical tourism patients that there is a good level of
communication across the entire treatment and recuperation
process. In addition, the language barrier is not conned to
English, although the demand for other languages will depend
upon the target market. If that market is mainland China, then
it makes sense to employ staff who speak Putonghua (the
ofcial language of China, often called Mandarin in English).
Facilities. Hong Kong requires better collaboration between the
healthcare and tourism sectors due to the inadequate bed capacity
in hospitals. Hospitals and hotels could collaborate to serve the
needs of medical tourists and their companions. A separate institution charged with planning, organizing, and tracking medical
tourism in Hong Kong would be helpful in this regard.

5.2. Conclusion
The analysis and discussion contained herein suggest that Hong
Kong has been an Asian medical destination for more than 30 years.

Nevertheless, it appears that neither the government nor the private


sector has been sufciently motivated to develop medical tourism in
Hong Kong due to the barriers identied in this study, despite its
advantages compared with other countries that do promote medical
tourism. The chief barriers include a lack of active government
support, high costs, and the healthcare needs of the local community. Section 5.1 recommends a number of actions that could be
taken to promote the development of Hong Kongs medical tourism
industry, and suggests ways to overcome the barriers to that
development. Hong Kong does appear to be moving forward in this
regard, as indicated by the recent announcement that the government has already assigned a few parcels of land for the development
of specialized medical services and invited expressions of interest
from foreign investors.
5.3. Study limitations and directions for future research
Although this study has identied the main barriers to the
development of medical tourism in Hong Kong, certain limitations
should be noted. The main limitation is the small number of
respondents surveyed. Reaching a large number of healthcare
professionals, such as hospital executives, proved extremely difcult
due to their busy schedules. As this study focuses on the supply side
of medical tourism industry, further studies should be conducted to
gather data from potential medical tourists so as to obtain information from the demand perspective, and to determine the basic
needs of these tourists. Detailed comparisons between two or more
destinations would also be benecial in investigating the medical
tourism phenomenon more thoroughly.
Acknowledgements
This study was supported by The Hong Kong Polytechnic
University under research grant number G-YX1G.
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