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

Vincent C.S. Heung*, Deniz Kucukusta, Haiyan SongSchool 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

Article history:Received 26 February 2010Accepted 18 August 2010

Keywords:Medical tourismBarriersTourism developmentHong Kong

a b s t r a c t

The aim of this study is to determine the factors influencing the development of medical tourism in HongKong. A qualitative researchmethodwas adopted to collect data from representatives of private and publichospitals, 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 arethe main barriers to the development of such tourism. Several strategies for lifting these barriers aresuggested, such as new promotional activity policies, government action to encourage investment in themedical tourism market, and cooperative efforts by the hospitality sector and medical institutions todevelop medical tourism products.

! 2010 Elsevier Ltd. All rights reserved.

1. Introduction

The globalization of healthcare has given rise to a new form oftourism that is commonly known as health tourism. Within thehealth tourism arena, medical tourism is among the fastest growingsectors, andmany countries are nowmaking legal and practical plansto serve it. Reduced transportation costs, higher incomes, knowledgeand technology transfer, and competitive prices all favor travel todistant countries for medical reasons. One of the fastest growingtourism markets in the world, medical tourism now generatesUS$60 billion in business annually worldwide (Jones & Keith, 2006;MacReady, 2007), and the number of countries offering state-of-the-art medical facilities and services to foreign tourists is on theincrease. This international trade in medical services also has hugeeconomic potential for the global economy (Bookman & Bookman,2007), and medical tourism is emerging as a particularly lucrativesector 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, creatinga more favorable balance of trade, and boosting tourism generally.

Many countries have seized the business opportunities thatmedical tourism offers. In 2005, for example, India, Malaysia,Singapore, and Thailand attracted more than two and a half millionmedical tourists (Tata, 2007). Colombia, Singapore, India, Thailand,Brunei, Cuba, Hong Kong, Hungary, Israel, Jordan, Lithuania,Malaysia, the Philippines, and the United Arab Emirates haveemerged as major healthcare destinations, and Argentina, Bolivia,

Brazil, Costa Rica, Mexico, and Turkey are also in the process ofmaking themselves attractive such destinations, particularly in thearea of cosmetic surgery (Singh, 2008). At present, Asia constitutesthe most important medical tourism region (Connell, 2006).

Hong Kong aims to be a center for medical excellence in theregion, and is well-known to deliver high-quality healthcareservices. Hong Kong’s hospitals operate to the highest standards andfeature medical practitioners who are the best in their fields ofspecialization. It is predicted that the annual income generated frommedical tourism in Asia could reach US$4.4 billion by 2012 (Singh,2008), and Hong Kong is well-placed to capture a major share ofthat figure. As noted, India, Singapore, Thailand, and Malaysia arealready actively promoting medical tourism. However, althoughHong Kong is listed as a medical tourism destination, and is knownas a center for traditional Chinese medicine and a hub for cancercare in Asia (Singh, 2008; Teh & Chu, 2006), only limited attemptshave been made to promote medical tourism. Given its reputationfor healthcare excellence, its peaceful environment, and its higheconomic and social welfare status, it is surprising that Hong Konghas no structure or activities in place to promote this emergingtourism sector. With many countries positioning themselves to takeadvantage of this hugely lucrative industry, Hong Kong’s responseappears inadequate.

The main purpose of this study is to investigate, analyze, andexplain the factors influencing the development of medical tourismin Hong Kong based on data gathered from private and publichospitals, government bodies, institutions, and doctors. Its findingswill contribute to the literature by revealing the barriers to thedevelopment of the medical tourism industry. They will also proveof practical value to both Hong Kong and other countries that aretrying to develop this industry. The remainder of the article is

* 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).

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Tourism Management 32 (2011) 995e1005

structured as follows. First, medical tourism is defined, and itsposition in Asia analyzed. Second, the qualitative research meth-odology employed in the study is discussed, and the data collectedare analyzed. Finally, the barriers to medical tourism developmentin Hong Kong are identified and presented in a framework.

2. Literature review

2.1. Medical tourism development

Advances in technology and the spread of information havechanged the nature of exchange, and also the nature specializationand communication among countries. Medical tourism is partlythe result of the globalization of both healthcare and tourism, whichalready constitute major arenas of transnational economic activity(Bookman & Bookman, 2007). Gupta (2004) defines medical tourismas the provision of cost-effective medical care for patients in collab-oration with the tourism industry. The process is usually facilitatedby the private medical care sector, but involves both the privateand public sectors of the tourism industry. Medical tourists can takeadvantage of having medical surgery or treatment while enjoyinga stay in one of the world’s popular tourist destinations. Connell(2006) characterizes medical tourism as a popular cultural phenom-enonwhereby people travel long distances to obtain medical, dental,and surgical services while vacationing. The medical procedures theyobtain include not only elective surgeries such as cosmetic and dentaloperations, but also more complex surgeries that require specialistknowledge and technology (Singh, 2008). Medical check-ups andhealth screening are preventive medical services that are alsoconsidered to fall within the scope of medical tourism.

This tourism sector is making a significant contribution tomany of the world’s economies. The medical tourism industry nowgenerates about US$60 billion worldwide annually, with Malaysia,Thailand, Singapore, and India alone projected to generate morethan US$4.4 billion by 2012 (Singh, 2008). India’s medical tourismbusiness is projected to be worth US$2 billion a year by 2012(Bookman & Bookman, 2007; Singh, 2008), and Singapore hopes toattract onemillion foreign patients annually and push the industry’sgross domestic product (GDP) contribution to more than US$1.6billion. Malaysia expects its medical tourism income to be aroundUS$590 million in five years’ time, and in Thailand and South Koreathe industry is set to generate more than US$4 billion by 2012(Medical Tourism, Asia’s Growth Industry, 2007) According toAwadzi and Panda (2006), many Third World countries see medicaltourism as a gold mine and are promoting it aggressively, thus alsoboosting competition in the industry. These authors also highlightthe importance of ensuring the protection of medical tourists bydeveloping proper guidelines and certification procedures.

The expansion of medical tourism in developing countries oftenresults in changes in the nature of the healthcare services offeredand in hospitals’ physical amenities. According to Cohen (2008),leading hospitals in Thailand have acquired an internationalreputation and a growing number of foreign patients. It has done soby giving its hospitals the appearance of high-class hotels, sepa-rating indoor public spaces from treatment facilities, creatinga cozy atmosphere, prompting staff to be more responsive to clientrequests, establishing constructive relationships between doctorsand patients, and employing state-of-the-art medical equipmentand techniques (Cohen, 2008).

Hume and DeMicco (2007) state that joint partnerships withmedical facilities provide an excellent way for hotels to differen-tiate their services. However, the growth of medical tourism canhave negative effects on the general healthcare system of a desti-nation. Uncontrolled such growthmay place the physical and socio-psychological well-being of the local population at risk (Burkett,

2007; Tan, 2007). Awadzi and Panda (2006) point out that onenegative effect may be the diversion of funds from other areas ofthe economy to medical tourism. Most locals cannot afford e andthus may not welcome e the high-cost services on offer to medicaltourists, although patients from developed countries or regionsmay consider them reasonable.

2.2. Previous studies

Several studies have analyzed the factors and dimensions thatinfluence a country’s medical tourism industry. Smith and Forgione(2007), for example, developed a two-stagemodel of the factors thatinfluence a patient’s decision to seek healthcare services abroad.In the first stage, they identified the factors determining a patient’schoice of destination. In the second stage, they then evaluatedthose determining the choice of a healthcare facility. They arguethat country-specific characteristics, such as economic conditions,political climate, and regulatory policies, influence the countrychoice, whereas such factors as costs, hospital accreditation, qualityof care, and physician training affect the healthcare facility choice.

Caballero-Danell and Mugomba (2007) developed a map thatdocuments medical tourism information collected from the elec-tronic media, newspapers, periodicals, magazines, and academicmaterial. According to their map, the components of the medicaltourism market include consumer benefits, branding, the legalframework, infrastructure, products, targetmarkets, communicationchannels, operators, intermediaries, and social issues. Ye, Yuen, Qiu,and Zhang (2008) examinedHong Kongmedical tourists’motivationby adopting a case study approach that employs push and pullmotivation theory. The results of their study reveal that these tour-ists are mainly concerned with medical matters, rather than desti-nation attributes. The motivational factors that Ye et al. (2008)consider include destination attributes, healthcare quality, promo-tions, companionship, costs, and reputation. Although the lucrativenature of medical tourism has garnered it significant attention,particularly in developing countries, only a few academic studieshave focused on this topic. The aforementioned studies concentrateon specific areas of the medical tourism industry, such as itseconomic, medical, andmarketing aspects, from either the supply ordemand perspective (Bookman & Bookman, 2007; Connell, 2006;Smith & Forgione, 2007). However, no previous research focuseson the factors that influence the development of such tourism.

2.3. Conceptual framework

(a)Heung, Kucukusta, and Song (2010) recently developeda conceptual model of medical tourism to provide a compre-hensive 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. Thelatter represents the factors that affect tourists’ destination choiceand medical treatment options. These are the factors that drive themedical tourist’s decision. The former basically addresses how wella destination is prepared to meet the demands of these tourists.The present study focuses on the supply side of the model, whichconsiders such factors as the current situation of the medicaltourism industry in terms of infrastructure and superstructurefacilities, promotional activities, quality assurance, and communi-cation facilities, all of which are considered significant in attractingmedical tourists. Hence, these supply-side factors were chosen asthe key issues to be addressed in our interviews and in the devel-opment of the study’s interview questions.

Although only a few studies have focused on medical tourism,they have identified most of the key barriers to its development.

V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005996

For instance, according to Smith and Forgione (2007), such factors ascosts, healthcare quality, accreditation, and physician expertise areimportant in medical facility selection, whereas a country’s regula-tory and economic conditions also affect the country choice. Thesefactors are thus considered to be the main barriers to the develop-ment of HongKong’smedical tourism sector in this study. In addition,Ye et al. (2008) also foundpull factors, such as service quality,medicalexpertise, hospital hardware, and the advertisement of thesefacilities, to affect medical tourists’ motivations. The results of thesestudies were considered when formulating the key issues for our in-depth interviews. The factors proposed as barriers tomedical tourismdevelopment are discussed in detail in the following sections.

2.4. Medical tourism in Asia

Medical tourism is relatively new inAsia. The Asian financial crisisof 1997 resulted in significant losses for the region’s businesses,including private hospitals. These hospitals thus began trying to findsolutions to their problems and, accordingly, began to offer new andattractive health packages. Thailandwas thefirst country to enter themedical tourism industry, and it quickly became a hub for cosmeticsurgery. India, Malaysia, and Singapore followed suit, and the fourcounties together attracted more than 1.4 million medical touristsin 2003 (Tata, 2007). Malaysia now attracts 100 000 foreign medicaltourists a year, and Singapore and India are experiencing fast growthin this area as a result of effective marketing strategies. However,Thailand remains the leader in the Asia-Pacific region, attracting400 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, andThailand treated about 1million foreign patients (Hutchinson, 2005).

2.4.1. IndiaIndia is positioning itself as a primary medical destination,

offering everything fromalternative treatments to themost complexmedical procedures (Connell, 2006; Singh, 2008). Many hospitalshave attained Joint Commission International (JCI) accreditation,a U.S. scheme that assures the quality of healthcare in hospitals. Indiahas become renowned for low cost, though advanced, medicalprocedures such as heart surgery, joint replacements, and hipresurfacing, in addition to other relatively simpler treatments.Medical tourists also visit India for such alternative treatments asAyurvedic medicine and yoga.

The country’s medical tourism market is now worth US$333million and is growing by 30% per annum (Chacko, 2006; Nautiya &Dogra, 2005). Themain appeal of itsmedical industry is its low costs.In addition, India has a skilled human resource pool comprisingvery 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 healthcareand tourism components, strategic co-ordination between thetwo sectors is essential. In India, there is co-ordination among thenational government, state governments, and numerous federalbodies to promote medical tourism.

2.4.2. SingaporeSingapore is another leading Asian medical hub, boasting

excellence in quality, safety, and trustworthiness, as well as

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

V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005 997

international accreditation. Like India, Singapore’s hospitals areaccredited by the JCI. Singapore attracts medical tourists fromdeveloped countries such as United States and from neighboringcountries such as Indonesia and Malaysia (Singh, 2008). The Sin-gaporean government strongly supports the sector and hasidentified it as a new growth area. The city state offers complexneurosurgical procedures and highly advanced medical treatmentssuch as liver and heart transplants. To attract additional medicaltourists, Singapore has also signed government-level agreementswith several countries in the Middle East, such as the United ArabEmirates, to offer medical services. These government-led initia-tives have also attracted investors (Tata, 2007).

2.4.3. ThailandMedical tourism is an integral part of Thailand’s tourism and

healthcare industries. As a medical tourism destination, it offers JCI-accredited hospitals and U.S.-certified physicians. The country alsooffers a broad range of medical treatments e from heart surgery toorgan transplants e in modern facilities at much lower prices thanthose inWestern countries (Singh, 2008). The Japanese constitute thelargest proportion of medical tourists to Thailand, although patientsfrom theUnited States, United Kingdom, andMiddle East also come insignificant numbers. Thailand’s competitive advantage in this sector ispricing (Cohen, 2008). Healthcare costs are 50% cheaper than inSingapore, three times cheaper than in Hong Kong, and five to 10times cheaper than in Europe and theUnited States (Kittikanya, 2004).

The Thai government in 2004 published a policy to develop andpromote the country as the leading healthcare provider in Asia by2010 (Tata, 2007). The government’s strategy is to increasemarketing and public relations activities directed at foreigners,improve management, and develop healthcare products andservices. The main medical tourism spots being promoted inThailand are Bangkok, Chiang Mai, Koh Samui, and Phuket.

The Thai Ministry of Public Health also cooperates with the ThaiMinistry of Tourism to promote medical travel to Thailand. More-over, Thailand andMalaysia are in the process of exploring the jointpromotion of medical travel to gain a competitive advantage overother countries. Bangkok’s Bumrungrad Hospital is the leader inthis field, and is considered to be among the frontrunners inmedical travel worldwide (Medical Tourism at BumrungradHospital, 2006). The country’s hospitals offer a variety of facilities,including interpretation in more than 10 languages, and theirquality is assured through JCI accreditation (Singh, 2008).

2.4.4. MalaysiaModern healthcare facilities, qualified medical experts, and low

prices are the chief characteristics of the Malaysian medical tourismmarket. In addition, like Thailand,Malaysia has the advantages of suchphysical attractions as beautiful beaches and resorts. Also likeThailand, the country became involved in medical tourism in 1998 inthe wake of the Asian financial crisis (Connell, 2006). Its governmentleads the effort to market such tourism overseas through variouspromotional activities. According to recentmarket analysis,Malaysia’spatients come from Indonesia, Singapore, Japan, and West Asia. TheMalaysian government also encourages the healthcare industrythrough tax incentives (Leng, 2007), and the low prices of the coun-try’s medical treatments are a major advantage. Thirty-four privatehospitals in Malaysia are engaged in heath tourism, and althoughnone of them is JCI accredited, many have received InternationalOrganization for Standardization (ISO) certification (Yap, 2007).

2.5. Medical tourism development in Hong Kong

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

sector, with public healthcare services provided by the Departmentof Health and the Hospital Authority. The former provides primarycare (preventive and outpatient services), and the latter managesthe public hospitals. The private healthcare sector provides themajority of primary care services. Hong Kong is not only one of theworld’s fastest growing cities, but is also one of Asia’s most populartourist destinations, not least for its numerous shopping centers.According to the latest available figures, 29.5 million tourists visitedHong Kong in 2008 (Hong Kong Tourism Commission, 2009).

Hong Kong has modern medical facilities, and several of itsprivate hospitals have been accredited by the U.K.-based TrentAccreditation Association. A few Trent hospitals can now boastaccreditation from two international bodies, having been accreditedboth by the JCI and under the Trent Accreditation Scheme (TAS).Most private hospitals are moving toward obtaining both types ofaccreditation. The Hong Kong Hospital Authority (HA) also recentlyannounced that another international accreditation agency, theAustralian Council on Healthcare Standards (ACHS), would assessseveral private and public hospitals in early 2010 (Lee, 2009). Toachieve standardization, however, the Hong Kong government aimsto have all hospitals accredited to the same standards in the long run.

Although promotional activities and government support formedical tourism are limited in Hong Kong,many patients, particularlybaby boomers, come from mainland China for healthcare services(Hong Kong Advantages for Medical Tourism, 2007). A few travelcompanies have even begun to attract Chinese mainlanders to HongKong specifically for medical treatment. In terms of the services onoffer, some institutions focus on check-ups and other basic healthcareservices, but Hong Kong is also becoming dominant in the advance-ment of cancer treatment (oncology) using a combination of cutting-edge technology and traditional Eastern therapies (Davis, 2008).

Inskeep (1988) asserts that tourism requires systematic planningif it is to be developed properly, responsive to market demands, andintegrated into an area’s total development pattern. Good tourismplanning leads to tourism development. In other words, if themedical tourism sector is to be developed in a particular region, thenthat region must properly plan for it. In many countries, such asIndia, Thailand, Singapore, and Malaysia, the government has sup-ported medical tourism by establishing special departments,engaging in partnerships with other countries, or launchingpromotional activities. Comparedwith these countries, HongKong isnot currently a key player in the medical tourism market. Althoughthere have been some constructive attempts to boost the sector inHong Kong, the medical tourism concept has generally beenneglected by both the government and the private sector. This studyaims to determine the reasons for this situation and identify thebarriers to medical tourism development that exist in Hong Kong.

3. Methodology

A qualitative research method was adopted in this study. Quali-tative research essentially refers to any kind of research thatproduces findings not arrived at by statistical procedures or quan-tification (Strauss & Corbin,1990). Qualitative methods are generallyemployed when the researcher needs to identify variables that willlater be tested quantitatively or when he or she has determined thatquantitative measures cannot adequately describe or interpreta situation. This study is exploratory in nature because medicaltourism is a newarea that has not yet been fully explored; hence, thegrounded theory approach was employed (Strauss & Corbin, 1998).

3.1. Identification of key issues

The key issues were identified through an extensive review ofthe literature, including previous studies of medical tourism

V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005998

(Bookman & Bookman, 2007; Connell, 2006; Smith & Forgione,2007; Ye et al., 2008) and the theoretical framework developedby Heung et al. (2010). These key issues primarily involve thefactors that influence the development of medical tourism ina country or region.

3.2. Data collection

Qualitative data were collected through in-depth interviewswith hospital representatives, the chief executives and directors ofmedical organizations, and representatives of relevant authoritiesin the healthcare sector. As no definitive list of the institutions orhospitals that engage in medical tourism in Hong Kong could befound, the interviewees were identified through the officialwebsites of the Hospital Authority (HA) and the Hong Kong PrivateHospital Association (HKPHA). There are 56 private and publichospitals in Hong Kong. A letter was sent to the administrators of allof the private and public hospitals listed on these sites and to fivedifferent professional bodies (The Hong Kong Medical Association,The Medical Council of Hong Kong, The Federation of MedicalSocieties 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 theresponse rate, a follow-up letter was sent to those institutionsthat had not responded to the first letter, and an additional tworesponses were received. A third and final letter was sent to theremaining institutions, a further two administrators responded.The final in-depth interview sample thus comprised 12 adminis-trators from medical organizations representing different sectorsof the medical tourism industry in Hong Kong, including privatehospitals, public hospitals, medical associations, and tourismbodies. A semi-structured questionnaire was prepared to guidethe interviews, whose aim was to determine the barriers to thedevelopment of medical tourism in Hong Kong. The interviewquestions were open-ended and mainly focused on the issuessurrounding such development, including infrastructure, super-structure, promotional activities, and medical service quality.The interview questions are listed in Table 1. Two interviewersconducted each interview. One asked the questions, and the othertook notes and audio-recorded the responses. Each in-depthinterview lasted about 60e90 min.

To validate the interview content and clarify any ambiguities,summaries of the interview transcriptswere sent to the intervieweesfor verification. In addition, follow-up questionswere posted to themwhenever clarificationwasneeded. All of the interviewees replied viae-mail to confirm that the content was consistent with their originalresponses except for a few minor changes in wording.

3.3. Data analysis

Data analysis was undertaken in three stages. In the first stage,the raw data were transcribed from the interview audiotapes andprepared for content analysis. These transcripts were reviewed tocheck for data redundancy. The review ended if there was redun-dancy in the information gathered, that is, if no new informationwas obtained (Dunn,1986; Patton,1990). In addition, the notes takenduring the interviews were reviewed, with key words, phrases, andconcepts identified. Finally, content analysis, which is widely used insocial science and management research (Berg, 2004; Neuendorf,2002), was then carried out on the transcribed and verified inter-view 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 cate-gories and to combine closely related categories in which overlapwas found. Two researchers were involved in the coding, and theycarefully interpreted and cross-validated the categories. Followingthe open-coding process, the organizedmaterials were read severaltimes by the researchers, with the content of each interview furtheranalyzed. Each researcher then compared and refined the findingsand developed sub-categories.

In the third and final stage, the researchers employed furthercoding to refine the results of the first two stages. The transcriptswere carefully read again to identify the broad context of the factorshindering the development of medical tourism in Hong Kong.The themes and sub-categories that emerged were subjected tocomparison among the public and private sectors and othermedical tourism bodies. Axial coding permitted the refined sub-categories to be put together to identify the main categories orthemes (Dey, 1998; Strauss & Corbin, 1990) and the relationshipsamong themes to be identified. During this process, the themes andmain categories identified were validated by comparing the infor-mation provided by the different respondents and then furthercomparing the information obtained in the interviews with datagleaned through observation and analysis of secondary documents(Mehmetoglu & Altinay, 2006). Finally, a framework was developedafter revisiting the coded and categorized statements and identi-fying the inter-relationships among them.

4. Findings and discussion

4.1. Interviewees and themes

As previously noted, data were collected through interviewswith hospital executives/representatives and representatives ofhealthcare and tourism authorities. The profiles of the intervieweesare presented in Table 2, from which it can be seen that therespondents were grouped into three categories: public sector,private sector, and medical and tourism bodies. Five of the inter-viewees were hospital chief executives, and three were medicalspecialists. The medical and tourism bodies were represented byone medical doctor, one president, and two senior managers.

The content analysis results revealed specific themes, whichwere grouped and quantified with their associated patterns(sub-categories). Details of the themes and sub-categories thatemerged are listed in Table 3. The theme “policies and regulations”was considered to overlap with some of the factors belonging to the

Table 1Interview 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 specifically 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?

V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005 999

“government attitude,” “investment potential,” and “promotion”themes, the interrelationship among which is depicted by a dashedline. The results of the aforementioned comparison of theresponses given by the representatives of the public and privatesectors and the other medical and tourism bodies are also pre-sented in Table 3. The opinions expressed by each group ofrespondents are shown, along with the number of responses.

All of the respondent groups cited high costs as a major obstacleto the development of medical tourism, ranking it first, followedby the healthcare needs of the local community. Inadequate

promotion of specialized treatments and capacity problems wereranked third and fourth. Government support, regulations onadvertising, and the need for the development of new policies wereother strong factors. These factors are grouped by theme anddiscussed separately in the following sections.

4.2. Framework and comparison with literature

A framework based on the amalgamation of the categories andthemeswas designed to depict the relationships among them. Fig. 2shows this framework of the barriers to the development ofmedical tourism in Hong Kong. It can be seen that costs, expertise/manpower, government attitude, investment potential, infra-structural and super-structural factors, promotion, communication,facilities and attractions, and policies and regulations were iden-tified as the main barriers to such development. The solid arrows inFig. 2 represent the direct influences on the development ofmedical tourism, and the dashed arrows the inter-relationshipsamong the factors. For example, restrictions on advertising, theneed for new policies, and strict medical rules and formalitiesare grouped under the theme of policies and regulations, and canbe understood from the figure to be interrelated.

According to Smith and Forgione’s (2007) two-stage model ofthe factors influencing a patient’s decision to seek healthcareservices abroad, once a destination has been selected, the patientmust choose from among the medical/tourism facilities on offer inthat destination. Some of the barriers identified in this study, suchas costs, laws and regulations, accreditation, and training, aresimilar to those they identified, whereas others, such as facilitiesand attractions, communications, infrastructure, and superstruc-ture, are new. In Caballero-Danell and Mugomba’s (2007) map of

Table 3Results of content analysis and group comparisons.

Themes Sub-categories Public Private Medical andtourism bodies

Rank

Economy Costs are high for medical tourist patients in Hong Kong ++++ ++++ ++++ 1

Infrastructure/superstructure Capacity problems ++ +++ + 4Land scarcity + ++ 7Supportive facilities/establishments for medical tourists and their companions + + ++ 6Physical environment is not suitable ++ 8Separate hospitals are needed for medical tourists + ++ 7

Government attitude More governmental support is needed ++ + + 6Needs of local community (local healthcare problems) ++++ +++ ++ 2New investments should be encouraged + ++ 7Visiting Hong Kong should be facilitated by the government for Chinese patients + 9Privateepublic partnership (PPP) + ++ 7

Policies and regulationsa Restrictions on advertising hinder medical tourism development (promotion) + ++ 7Lack of new policies (i.e., land) and development plans (investment potential) +++ ++ 5Medical formalities (strict rules and regulations) (government attitude) ++ + 7

Promotion Need for an icon or brand name to promote medical tourism + + 8Promotion for medical professionals + + 8Promotion for institutions ++ 8Inadequate promotion on the Internet + ++ 7Hong Kong should promote specialized treatments ++ +++ ++ 3

Investment potential Need for cooperative action between hotels and hospitals ++ + 7Private sector is not interested ++ + 7

Expertise/manpower Medical tourism requires expertise and specialization + + + 7Limited number of specialists + + + 7Manpower deficiency (nursing) + + 8Special training is a necessity for medical tourism + + 8

Language and communication Foreign languages can be a problem ++ 8

Facilities and tourist attractions Lack of tourist attractions as a medical tourism destination + + + 7

+"Number of responses.a Theme constitutes overlapping factors.

Table 2Profile of the interviewees (hospitals, professionals, and institutions).

Industry sector Name of organization Respondent’sposition

Number

Public hospitals Grantham Hospital Top executivea 1Caritas Medical Care Top executive 2Prince of Wales Hospital Medical doctor 3Yan Chai Hospital Senior managerb 4

Private hospitals Hong Kong Sanatoriumand Hospital

Top executive 5

Matilda International Hospital Senior manager 6St. Paul’s Hospital Senior manager 7Baptist Hospital Top executive 8

Medical andtourism bodies

Hong Kong Medical Association Top executive 9Federation of Medical Societies Top executive 10Hong Kong Hospital Authority Senior manager 11Hong Kong Tourism Board Senior manager 12

a Top executives (general managers, hospital chief executives, presidents, andvice-presidents).

b Senior managers (general managers, executive directors, senior projectmanagers, and senior event and product managers).

V.C.S. Heung et al. / Tourism Management 32 (2011) 995e10051000

the market structure of medical tourism, consumer benefits,branding, legal framework, infrastructure, products, target markets,communication channels, operators, intermediaries, and socialissues are identified as the components of the medical tourismmarket. The only common factors between their study and ours,however, are the promotion of medical tourism, the legal frame-work, and infrastructure. The case study carried out by Ye et al.(2008) on the motivations of Hong Kong medical tourists and thebarriers to medical tourism identified some factors similar tothose revealed here, for example, destination attributes, healthcarequality, promotion, companionship, costs, and reputation.However, the two studies serve different purposes in the medicaltourism context.

4.3. Barriers to development of medical tourism

The barriers identified in this study are similar to some of thosehighlighted in the literature as hindering tourism development ingeneral. For instance, Keyser (2002) pointed out that limited accessto financial markets, limited confidence on the part of internationaland domestic investors, complicated taxation requirements andprocedures, limited budgetary allocation, a lack of integration,and limited tourism promotion all constrain the development oftourism in a particular region.

4.3.1. Economy (costs)Although destination attributes and the quality of healthcare

influence medical travel decisions, the primary motivator is

generally economic (Marlowe & Sullivan, 2007). The treatmentcosts for medical tourists are often a quarter to a tenth of the pricethey would pay at home (Adams, 2006). Individuals also travelto distant countries to receive medical treatments that are notcovered by their insurance policies or because insurance coverageis too expensive in their home country. The low healthcare costs inthe countries currently promoting medical tourism represent theirmajor advantage. These costs are relatively high in Hong Kong, andare thus themain 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 andthe cost of medical care, although we do not charge our citizens forhealthcare. We are subsidizing them through our healthy financialproperty market, good economy, and good GDP, but relatively lowtax rate. So, the healthcare system is deemed to be “heavilysubsidized” by public finance. But if you look at the salary structure,we are listed as the second most expensive city in the world, withTokyo as number one.

Hong Kong’s high healthcare costs may be due to its system offinancing healthcare, which is mainly funded by the government, incontrast to countries that have adopted national insurance systems,such as Taiwan, Singapore, and South Korea. A highly subsidizedpublic healthcare system covers everyone, protecting all individ-uals from the significant financial risks that may arise frommajor orprolonged illnesses (Yau & Lung, 2004). It also means that thehospital structure remains the same for decades. In Hong Kong, anincrease in the aging population ratio, rising patient expectations,

MEDICAL TOURISM

DEVELOPMENT

Infrastructure/ Superstructure

• Capacity • Land• Supportive Facilities • Physical Environment • Separate Hospitals

Government Attitude • Public-Private

Partnership (PPP) • Support • Local Healthcare

Needs• Facilitating Visits to

Hong Kong

Facilities and Attractions

Language and Communication

Economy • Costs

Policies and Restrictions

• Advertising Restrictions

• Need for New Policies

• Rules and Formalities

Investment Potential• Cooperative Action • Private Sector Interest

Promotion • Internet• Icon/Brand • Promoting Doctors • Promoting Institutions• Promoting Specialized

Treatments

Expertise/Manpower

• Specialization• Limited Number of

Specialists • Deficient Nursing • Special Nursing

Training

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

V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005 1001

and high-tech medicine and expensive drugs have pushed uphealthcare costs (Yuen, 1999), particularly for private healthcareseekers and non-locals. To control these increasing costs and tolessen some of the government’s burden for medical care, HongKong is moving toward private-sector solutions, such as insuranceprograms.

4.3.2. Infrastructure/superstructureThe sub-categories of capacity problems, land scarcity,

supportive facilities, physical environment, and separate hospitalsare grouped under the theme of infrastructure/superstructure. Amajor problem for Hong Kong’s development as a medical tourismdestination is the insufficient capacity of its public healthcaresystem, which already has to deal with the healthcare needs of its 7million residents. Locals can purchase public healthcare for a smallfee, but there are long waiting lists, especially in public hospitals.For example, the average waiting time to see a specialist is morethan seven months, although the HA is trying to reduce this. Somepatients are able to take advantage of the much more expensivecare in the private market and wait relatively less time. A commonbelief among the respondents was that many hospitals, whetherpublic or private, suffer from an inadequate number of beds.

I don’t think Hong Kong can afford this kind of manpower thatneeded to serve medical tourists. So, it is not that we have nointerest or are not competitive enough.the reality at the momentis that our beds are already full, and we just do not have the sparecapacity (Respondent 8).

Another concern, particularly among the hospital executives,was the scarcity of land and the relatively high land costs. Landscarcity and a high population density render the expansion ofexisting hospitals impossible.

They [medical tourists] need extra beds, and everything is so costlythere is no way that they would be able to recuperate before havingto leave Hong Kong.that’s the major difference [with otherdestinations]. In Hong Kong, there is no room and the governmentis 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 insufficient supportfacilities in Hong Kong, particularly for companions or familymembers accompanying medical tourists. Hospitals would need toprovide special facilities and services (perhaps with the attributesof a five-star hotel) for both patients and their companions. Inaddition, to attract medical tourists, Hong Kong must offer muchmore than shopping attractions to complement medical services.

And the family coming along with the patient.the patient may beadmitted to a private hospital, and the room may be good enoughfor him or her to stay for an initial check-up or surgery, but whatabout the family? (Respondent 4)I think what we are missing is.say, you go to Thailand. Thailand iswell known for its spas, and people want to go to the spa after-wards. You know, have cosmetic surgery and then go and spendtime under a banyan tree, or whatever. You enjoy some luxury aswell as undergoing surgery (Respondent 6).

The respondents from the public sector stated that separatehospitals would need to be built for medical tourism in Hong Kong:

We would like to see separate facilities rather than the samehospitals, with some being for medical tourism and the rest for thelocal population. We would prefer a separate infrastructure, maybea separate hospital totally devoted to medical tourism (Respon-dent 12).

4.3.3. Government attitudeAlmost all of the respondents mentioned that government

support is needed for the development of medical tourism:

The point is that the government keeps saying “develop medicaltourism,” but neither the government nor the tourism industry hashelped us to do it (Respondent 5).

According to the interviewees, the Hong Kong government needsto ease the problem of land scarcity by making more land available.Also, in addition to hospitals’ insufficient capacity, the main focus oftheHA is the needs of the local community. In a sense, the healthcareneeds of the local community hinder the development of medicaltourism, as Hong Kong’s hospitals and healthcare professionals arebusy addressing those needs. The interviewees thus pointed out thatthe government must encourage investment in such tourism,for example through privateepublic partnership (PPP) initiatives.Considering theburdenof the public sector healthcare inHongKong,PPP may represent a good strategy for the government.

The overall concept that we support is PPP, and we have it ona number of levels for the building of hospitals. Potentially, we havefour pieces of land, and land is a very expensive commodity in HongKong. We also have staff arrangements. We are exploring thesemodels right now to see which PPP model would suit Hong Kongbest as we move forward (Respondent 12).

4.3.4. Policies and regulationsRegistered medical practitioners are not allowed to advertise in

Hong Kong to attract more patients, in accordance with the regu-lations of the Medical Council of Hong Kong (Medical Council ofHong Kong Guidelines, 2008). This situation has resulted in inad-equate promotional activities on the part of hospitals and practi-tioners. The Internet is the main tool by which prospective medicaltourists seek information about the qualifications of foreignmedical professionals. Many private hospitals in countries thatpromote medical tourism thus provide detailed information abouttheir services, together with promotional packages, on the Internet.

The Hong Kong Medical Council has very strict rules on so-calledadvertisements. You cannot advertise anything other than yourbasic qualifications, and advertising on the Internet is still notallowed. You can only give details of your basic qualifications andthe services you provide on the Internet, but not in a newspaper ora magazine (Respondent 3).

In addition to ethical considerations, medical doctors are alsobound by the laws and official regulations constituting the legalframework that regulates medical practice. Unlike many of thecountries that promote medical tourism, Hong Kong law restrictscertain treatments and surgeries, which limits the medical prod-ucts that can be made available.

Overseas patients seek different things. For example, people who livein the United Kingdom, and because of the law are not allowed toundergo an organ transplant, go to India to do it. The reason whyIndia is their first choice is probably because of the weaker legalenvironment. There is no obstacle to doing something that is againstthe law in the United States or the United Kingdom. But in HongKong we follow common law and UK law, so it would affect thosepeople in the sameway. I think thatmedical tourism can’t be appliedin Hong Kong because we don’t have the flexibility (Respondent 4).

4.3.5. PromotionIn countries such as Greece, South Africa, Jordan, India, Malaysia,

the Philippines, and Singapore, the government actively promotesmedical tourism. The governments of these countries sometimes

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even include such tourism in their national tourism marketingcampaigns. A hospital or medical center with an iconic brand needsto be established and promoted in Hong Kong. Such a developmentwould support the generation of medical tourism products,because promotional activities are usually shaped by the productsthemselves.

We need to build a brand with an image. Hong Kong itself hasa good medical reputation, but we need to have an iconic type oforganization that patients can easily recognize (Respondent 1).

Clearly, Hong Kong’s legal and regulatory restrictions onmedicalservice-related promotional activities, such as the promotion ofspecialists and other doctors, medical institutions, and specializedtreatments via the Internet or other media channels, hinder itsdevelopment as a medical tourism destination.

4.3.6. Expertise/manpowerThe sub-categories of clinical expertise and specialized treat-

ments, limited number of specialists, shortage of nurses, and theneed for special training are grouped into the theme of expertiseand manpower. Undoubtedly, gaining access to superior medicalexpertise is one motive for medical tourists seeking specializedtreatments, and some of the respondents noted that Hong Kongneeds more specialists.

The number of doctors, especially specialists, is few. There is limitedcapacity, unlike in Thailand, where there are thousands of doctorswho can concentrate on medical tourism. So, if we want to havemedical tourism, then we need more specialists in specific areasand also highly trained nursing staff and other health professionalsrelated to those specialties (Respondent 2).

A shortage of medical manpower, both in terms of specialistsand high-quality nurses, thus constitutes another barrier to thedevelopment of medical tourism in Hong Kong. The provision oftop-quality healthcare services requires both high-quality nursingstaff and good post-operative care (McCallum & Jacoby, 2007).The qualifications for nurses involved inmedical tourism need to beclarified, and programs that will result in better nursing caredeveloped (Ben-Natan, Ben-Sefer, & Ehrenfeld, 2009). The need fortrained nurses is as significant as that for specialists. The Hong Konggovernment recently announced that 60 additional senior-yearplaces would be provided for nursing degree programs in the2010e11 academic year. The HA has also re-opened some of itsnursing schools and provided additional training places in 2009e10(Hong Kong Government, 2009).

4.3.7. Investment potentialMedical tourism’s investment potential can be divided into the

two sub-categories of private-sector interest and cooperativeaction. The bulk of medical tourism is served by the private sectorin such countries as Australia, Thailand, the United States, and theUnited Kingdom, especially in terms of analyzing available oppor-tunities, leading development, and formulating strategies. For thisreason, the governments in these countries can concentrate theirefforts on public hospitals and doctors (Teh & Chu, 2006). Medicaltourism activity remains largely in the private sector, with large-scale specialist hospitals that generally operate for profit. As suchtourism develops in a destination, the demand for private hospitalsincreases, and more qualified doctors are needed, many of thembeing drawn from the public sector (Gupta, 2004). The situation inHong Kong is different, however, as the private sector is not activelyinvesting in medical tourism for several reasons, including the lackof available land, the government’s attitude, and, possibly, generalsatisfaction with existing business and economic conditions.

Up to now, the private sector has been quite happy focusing itsbusiness on local people because they charge a lot, and local peoplecan pay. So what is the payoff in focusing on foreigners?(Respondent 2).

In some countries that promote medical tourism, hospitalsengage in cooperative activities with hotels. For example, Thailand’sPhuket-based Bangkok Hospital Phuket has been collaborating withnine hotels since 2006. The interviewees in this study suggested thatsimilar cooperative activities, such as partnerships between hotelsand hospital investors, should also be encouraged in Hong Kong:

I think Bumrungrad Hospital in Thailand works with hotels to offerpackages. As far as I know, this has not happened in Hong Kong(Respondent 6).

4.3.8. Language and communicationTo provide medical services of an international standard,

medical tourism destinations need to hire medical staff who canspeak foreign languages. Although Hong Kong’s official languagesare Cantonese and English, language difficulties may representa barrier for some international patients.

Hong Kong doctors do not speak Putonghua well. Their English isOK, and they can even communicate effectively with people fromother Asian countries. But Putonghua? I doubt it (Respondent 3).

4.3.9. Facilities and attractionsDespite its good hotels, restaurants, and thousands of shops,

another major constraint to medical tourism in Hong Kong is thelack of natural attractions and facilities. Unless medical tourists areobliged to undergo a specialized treatment or complex surgery inHong Kong because it is not available elsewhere, and such treat-ment or surgery is their sole reason for undertaking a trip to HongKong, the general tendency is to prefer to obtain treatment ina relaxing environment. Hong Kong thus needs to provide facilitiesand services that provide relaxation and recreation, not only forpatients, 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 themedical tourism industry, both in Hong Kong and elsewhere. Thefollowing suggestions are recommended to lift the barriers thathinder the development of medical tourism in Hong Kong.

# Costs. Costs in Hong Kong are high. Instead of focusing on cheapmedical tourism products, Hong Kong could target higher-income medical tourists by focusing on specialized treatmentsor complex surgery that require a high level of expertise.A primary target market could be high-income groups frommainland China.

# Capacity. Designated hospitals are needed to overcome thecurrent lack of capacity. New medical establishments such asmedical centers and hospitals could be completely devoted toand promote specific areas of expertise/medical tourism prod-ucts, such as Chinese medicine, cancer treatment, or cosmeticsurgery. Due to land scarcity, these specialized or branchhospitals would need to be located in the outer regions of HongKong, where there is more available land. The Hong Konggovernment recently identified four suitable sites inWong ChukHang, Tseung Kwan O, Tai Po, and Lantau, and invited

V.C.S. Heung et al. / Tourism Management 32 (2011) 995e1005 1003

expressions of interest from the market to develop privatehospitals (Hong Kong Government, 2009).

# Government support. Governments can support medicaltourism in many ways, although they must also ensure thatmeasures are in place to prevent the healthcare needs of thelocal community from being compromised. Capacity problemscan be solved by encouraging local and foreign investment inthe healthcare sector, which can be facilitated by the appro-priate easing of regulations. The government should alsosupport PPP to eliminate the financial, technical, and opera-tional risks of new medical tourism investments and projects.

# Travel facilitation. The government should make it easier formedical tourists to visit Hong Kong. Although Hong Kong hasno visa limitations for individuals from many developedcountries, new policies are needed to facilitate the entry ofmainland Chinese patients seeking medical services.

# Policies and plans. To encourage investors and boost investmentin medical tourism, new policies and development plans areneeded. For instance, the land policy should be reviewedto encourage new hospital development. Area and heightrestrictions could be made more flexible, and land could begranted a discounted premium for hospital development.

# Investment. Policies aimed at decreasing the expense of setting upmedical tourism facilities, such as tax deductions and financialsupport 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 bymedical institutions and specialists could be supported by theHong Kong Tourism Board and the HA, and medical tourismpromotion 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 modernmedicine could be promoted as a distinct medical tourismproduct in Hong Kong. The establishment of an institution thatcarries an iconic brand name, similar to Bumrungrad Hospitalin Thailand, could aid such promotional activities.

# Internet. Many countries engage in online promotions to attractmedical tourists. Such promotions are particularly effective in thisarena because prospective medical tourists or intermediaries(medical travel agents) initially search the Internet to collectinformation. Government support for the online promotion ofmedical services could help medical facilities to offer more reli-able information than is available on existing healthcarewebsites.

# Communication skills. Although Hong Kong boasts a largenumber of English-speaking medical staff, it is important formedical tourism patients that there is a good level ofcommunication across the entire treatment and recuperationprocess. In addition, the language barrier is not confined toEnglish, although the demand for other languages will dependupon the target market. If that market is mainland China, thenit makes sense to employ staff who speak Putonghua (theofficial language of China, often called Mandarin in English).

# Facilities. Hong Kong requires better collaboration between thehealthcare and tourismsectorsdue to the inadequatebedcapacityin hospitals. Hospitals and hotels could collaborate to serve theneeds of medical tourists and their companions. A separate insti-tution charged with planning, organizing, and tracking medicaltourism in Hong Kong would be helpful in this regard.

5.2. Conclusion

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

Nevertheless, it appears that neither the government nor the privatesector has been sufficientlymotivated to developmedical tourism inHong Kong due to the barriers identified in this study, despite itsadvantages comparedwith other countries that do promotemedicaltourism. The chief barriers include a lack of active governmentsupport, high costs, and the healthcare needs of the local commu-nity. Section 5.1 recommends a number of actions that could betaken to promote the development of Hong Kong’s medical tourismindustry, and suggests ways to overcome the barriers to thatdevelopment. Hong Kong does appear to be moving forward in thisregard, as indicated by the recent announcement that the govern-ment has already assigned a few parcels of land for the developmentof specialized medical services and invited expressions of interestfrom foreign investors.

5.3. Study limitations and directions for future research

Although this study has identified the main barriers to thedevelopment of medical tourism in Hong Kong, certain limitationsshould be noted. The main limitation is the small number ofrespondents surveyed. Reaching a large number of healthcareprofessionals, such as hospital executives, proved extremely difficultdue to their busy schedules. As this study focuses on the supply sideof medical tourism industry, further studies should be conducted togather data from potential medical tourists so as to obtain infor-mation from the demand perspective, and to determine the basicneeds of these tourists. Detailed comparisons between two or moredestinations would also be beneficial in investigating the medicaltourism phenomenon more thoroughly.

Acknowledgements

This study was supported by The Hong Kong PolytechnicUniversity under research grant number G-YX1G.

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