msc ibm thesis

Title: Factors that make Dubai as an emerging Medical Tourism Destination

INTRODUCTION:

“To become the internationally recognized location of choice for quality healthcare and an integrated centre of excellence for clinical and wellness services, medical education and research” (Dubai Health Care City- vision statement)

Medical tourism, wherein patients seek for the enhancement or restoration of their health, by travelling to a different country, is now grown to be a worldwide multi-billion dollar industry. (Amodeo,2010; Goldbach & West, 2010).It's not surprising to see the growth in the travel pattern of patients making trips to developing countries, to get benefits of the less-expensive and affordable rates at high quality and care of medical services. Hence Medical tourism has thus evolved and led to 'globalization of health care'.(Lagace, 2007)

This study examines the role of medical tourism particularly in Dubai, which aims to position itself as a leading medical tourism destination; competing itself with its neighboring countries and established medical tourist destinations like India,Thailand and Malaysia.

In doing so, the study explores the various factors that motivates and are involved in the decision making process; that encourages people to engage in medical tourism and understand the perspective of medical tourist in selecting Dubai as their proposed destination amongst its competitors.

Background of Study:

In 2007, the government of UAE established Dubai Health Authority (DHA) with the primary aim to provide complete strategic oversight of the health sector in Dubai and enhance private sector involvement.

CEO of Health Policy & Strategy sector at DHA, Mrs. Laila Al Jassmi states that, "Dubai and UAE Government are supportive to the development of a sustainable health system; there is an definite concerted effort to identify, encourage and develop health and wellness services that would help attract foreign patients and strengthen our health system."( ) A part of the medical tourism initiate is the Health Care Strategy for 2013-2025 announced to promote Dubai as a favorable medical tourism destination. As Dubai wins the Expo 2020,the health care sector are leveraging on new opportunities to attract patients to this region. The DHA also took an initiative to introduce a special medical tourism visa, which will help overseas patients who wish to have treatment in Dubai take advantage of a three-month medical tourist visa. (GN news)

Taking a global approach, Dubai by investeding mbillions of dollars to create the first of its kind Health Care City. in Dubai It began its operations in 2002 to meet the demand of patient centered health care.Socare. So DHCC mission to attract its residents and medical tourist of neighboring countries and capture the market of exporting patients to other medical hubs like Thailand and India.

The Dubai Chamber of Commerce and Industry suggests that the UAE health care market is expected to reach Dhs 43.7 billion by 2015. Based on statistics by healthcare officials, who spoke about the medical tourism initiative and its implementation, the sector generated $1.6 billion (Dh5.8 billion) for Dubai in 2012.

Patients from developed countries who are unisured, or underinsured or wish to recieve medical treatment ,travel abroad where the cost is low and waiting time is significantly shorter. (Moody, 2007, Awadzi and Panda , 2005). For instance, a spinal fusion procedure that costs US$$41,000 in the US estimates to cost between US$20,000 and us $25,000 in Dubai, depending on patient needs

and requirements. (Patient Beyond Bonders, 2012). Dr Sajay Parasha,a specialist plastic surgeon at the Cocoona Centre for Aesthetic Transformation, Dubai says that, compared to the US and UK, costs for procedures are about 20 to 25 per cent lower for cosmetic surgeries.Table 1.1 compares the cost of medical treatment provided in Dubai with US and Table 1.2 reports the UAE economic health indicators in 2009.

Table 1.1 -Price comparison between DHCC and US.

Source:Patients Beyond Borders,2012

Table 1.2 -UAE Health Care Indicators,2009

Source: WHO,MoH,Alphen Capital Estimates

From Table 1.2 it is clear that despite the low health care expenditure of 2.8%,the government hasve plans to expand the medical tourism in Dubai, tapping the City’s tourist industry which as the city countinuescontinues to offer numerous sights and cultural attractions and activities,-an ideal mix for patient seeking for relaxation along with satisfying health care needs .

Research Aim:

The aim of this research study is to determine factors that make Dubai as a chosen medical tourism destination for medical tourists across the globe.

Scope of the Study:

This study is exclusively focused on foreign medical tourists, who travel away from their home country to seek and receive medical treatments in Dubai Hospitals and healthcare Centres. The questionnaire were distributed to international patients who undertook their treatment in the four famous JCI accredited hospitals in Dubai namely American Hospital, International Modern Hospital, City Hospital and MEDCARE hospital within a duration of three weeks. Convenience sampling was appropriate method used as it as it involved a sample from the part of the population and the total number of population was unknown. The researched focused on determining motivating and decision making factors, and the availability of services that influenced international medical travelers to select the aforementioned four hospitals in Dubai for medical treatment purposes.

Research Objectives:

The objective is to determine various motivating and deciding factors that influence international medical tourist to choose hospital in UAE as their medical tourist destination.Thesedestination. These factors will be identified and ranked to provide points areas of importance which the hospitals can focus on and can be used by Dubai

Government ,Departments involved in Tourism,of Commerceial and Marketing and hospitals to attract more patients visits from different countries.

Research Questions:

The research questions focuses to find answers and solutionsout for the below underlying questions, namely:

Q1.What are the motivating factors thatfactors initiatethat patientinfluence patients to travelto travel abroad and engage in medical tourism in Dubai?

Q2.What are the decision making factors that influence a medical tourist to choose Dubai hospitals as their medical tourism destination?

Q3.What are the medical services patients are looking for that motivates them in selecting motivates in selectingof a destination as a medical tourism destination?

In short, the study is mainly concerned on the motivational , decision making factors and medical services availability factor that are influencing a patient to select Dubai as their medical tourism destination.

It is anticipated that the results from this research will be helpful for both the management of Dubai Health Care providers and gGovernment authorities (such as Dubai Health Authority, Dubai Health Care City, Dubai DeparmentDepartment of Tourism and Commerce Marketing) in promoting Dubai to international medical tourists.

This study focuses only only on Dubai, rather than its UAE as a whole or its neighboring competitors Saudi Arabia and Qatar and or the four three main Asian CompetiorsCompetitors- India, Thailand, Malaysia and Singapore (Choo, 2002) for two reasons. First ,the researcher is residing in Dubai with a working experience of 3 years dedicated toin the health care sector, hence providing an advantage in terms of access to pertinent places and relevant data. Secondly, considering the fact that Dubai as a tourist destination has its own unique established image and as research made on choosing a destination should always be destination-specific (Huybers, 2005). the fact that every destination has its own established image Dubai is a prime candidate to target research on, especially as it continuously aspires and positions itself as a global City, research made on choosing a destination should always be destination-specific (Huybers, 2005).

During the last decade, medical tourism has emerged as a new trend in the healthcare industry, gaining popularity amongst highly industralizedindustrialized countries. Conversely Dubai has a competitive edge and advantage with regards to medical tourism such as the locations of international airports with frequent flights to the various global destination, private medical hospitals, qualified doctors in specialties and plethora of historical tourist, shopping and cultural attraction,s indeed grows to have its share in the medical tourism market.

The following study is structured as:

Chapter 1:The introduction of the study, states the aims, objectives and research questions that are considered defined.Providing an overall view of the researcher intent of this study and the scope of medical tourism in background in Dubai.

Chapter 2:Literature review introduces the definition of medical tourism,.basic concepts of toursim motivation and contribution of authors in their models or frameworks to identify factors related to medical tourism industry. This chapter also presents briefly medical tourism in the GCC with particularly emphasizes on Dubai Healthcare City plan and Strategies of the Ggovernment.Later the chapter also gives an overview of established medical tourism destinations such as India,Thailand,Singapore and Brazil.

Chapter 3:Methodology introduces the approach used, wherein data was collected via questionnaire distributed to four JCI hospitals in Dubai and online survey was sent as a bulk mail to registered patients in the health care providers. Limitations to this study was also discussed.

Chapter 4:Findings from the completed survey of respondents (Nn=65) where analyzed and ranked based on the factors of importance by Rating Average technique.

Chapte5:This chapter concludes by addressing the three research questions ,by testing against the frameworks of the contribution of Crompton (1989),Crooks (2010),Smith and Forgions (),Heug et.el and identify the most important factor that medical tourist choose that motivates them to make a decision to select Dubai as a medical tourism destination. Further research was also mentioned

Abbreviations and Symbols Used in the Study

DHA: Dubai Health Authority

DTCM: Dubai Tourism of Commercial and Marketing

DHCC: Dubai Health Care City

GCC: Gulf Countries Council

JCIA: Joint Commission International Accreditation

N: Sample Size

R.A: Rating Average

LITERATURE REVIEW

Introduction

Medical tourism is an act that involves travelling across international borders to access a broad range of medical services, such as dental, medical and surgical services (Heung, et al. 2010).The goal of most of international patients seeking medical treatments abroad will be to access the highest quality of care, in the most affordable price, from an internationally known - accredited hospitals.

The rise of health care costs in the US & UK and developed countries combined with long waiting times ,has led to patients selecting prominent medical tourism destinations as their choice for undergoing their treatments.

Most of the academic research currently approaches from either the supply or demand perspective and focuses primarily on economic, or marketing aspects of medical tourism industry (Bookman & Bookman , 2007); Connell, 2006; Smith & Forgione, 2007). This study focuses on identifying and ranking the factors that influence the selection of Medical Tourism destinations.

This chapter introduces several research topics ,that have been discussed on the global phenomenon of medical tourism.

Background and History of Medical Tourism

The History of Medical Tourism also termed as health tourism, medical outsourcing , wellness or medical travel dates back as early as 4000 BC where the Greek and Egyptians went to hot springs to bath, to relax and rejunevate( ). travelled from across the world to the Mediterranean to seek the " healing god" at Epidaurus (Chew & Mit, 2007).Thus ,recorded the Epidaurus was the first destination travelled of medical tourism. Also from the West ,people have done pilgrimages to sites that are known for healing properties, like the Shrine of Bath in England.The existence of Roman baths, tourist flocked the towns that offered luxury treatments

and spas. During the contemporary era ,t here has been a growth of medical tourist to South East Asia. (MacIntosh, 2004)

With the surge of health care cost in the late 1980's -1990's ,many American patients started choosing treatments abroad such as dental and surgical procedures. During 1990's the Cuban Government started advertising "sun and surgery" packages including dental and cosmetic procedures, along with spa or "wellness adventures". (Krisen Smith ,p2).

With time, medical tourism industry had emerged and Joint Commission International was formed in 1997 to validate and check healthcare facilities in conformance to international quality standards due to the rise of health provides around the world( ).

In today's era Medical Tourism is a burgeoning field estimated to be $ 60 billion booming industry. (MacReady, 2007).

In recent times, the terminology medical tourism (or medical travel, as preferred by Cohen,2010) is an umbrella term that comprises medical, health and wellness tourism.

Definition of Medical Tourism

Medical tourism is an act the involves travelling across international borders to access a broad range of medical services,such as dental ,medical and surgical services (Heung, et al. 2010).The goal of most of international patients seeking for medical treatments abroad will be to access the highest quality of care, in the most affordable price, from an internationally known - accredited hospitals.Goodrich and Goodrich (1987) define health tourism as the "attempt on the part of a tourist facility or destination to attract tourists by deliberately promoting it's health-care services and facilities, in addition to its regular tourist amenities (p. 127), emphasizing the supply side.Van Sliepen (as cited in Hall, 1992) placing strong emphasis on the demand side, viewed health tourism as comprising of three elements: staying away from home, health as the primary motive, and occurring in a leisure setting.

Gupta (2004),defines medical tourism as the provision of cost-effective medical care to patients in collaborations with the tourism industry. So by travelling to a foreign destination to undergo a treatment, patients also gets the chance of visiting a major tourist destination thus clubbing health care with tourism.Where Connell (2006) explains that medical tourism as a form of popular mass culture whereby individuals travel long distance to obtain medical ,dental or surgical services while being holidaymakers.

Prem Jagayi, Chief Strategic officer, Medical Tourism Association, defines Medical Tourism as "the set of activities in which a person travels often long distance or across the border to avail medical services with direct or indirect engagement in leisure, business or other purposes"( ).

Whether to treat medical tourism and health and wellness tourism as separate two distinct fields is debatable. As Medical tourism is defined as "the process of traveling to another country to receive medical, dental and surgical care" (Humer & DeMicco, 2007, p.76).Whereas Carrera and Bridges (2006) explains health and wellness tourism as " the organized travel outside one's local environment for the maintenance, enhancement or restoration of an individuals' wellbeing in mind and body (p. 447).

Bookman and Bookman (2007) similarly states the medical tourism is most preferred term used in the industry, that "reflects the growing encroachments of medicine even in spa and wellness services " (p. 43).However ,medical tourism with all its breadth is therefore defined as a tourism that includes invasive, diagnostic or lifestyle medical treatments (S.Hudson and X. Li, 2011).

Categories of Medical Tourism

With the rise of health care costs in the US & UK and developed countries compelled with long waiting times ,has led to patients selecting prominent medical tourism destinations as their choice for undergoing their treatments.

This chapter introduces several research topics that has been discussed on the global phenomenon of medical tourism.

Background and History of Medical Tourism

The History of Medical Tourism also termed as health tourism,medical outsourcing , wellness or medical trave dates back as early as 4000 BC where the Greek and Egyptians went to hot springs to bath, to relax and rejunevate.Travellers travelled from acoss the world to the Mediterranean to seek the " healing god" at Epidaurus (Chew & Mit, 2007).Thus ,recorded the Epidaurus was the first destination travelled of medical tourism.Also from the West ,people have done pilgrimages to sites that are know for healing properties,like the Shrine of Bath in England and existence of Roman baths,tourist flocked to towns that offered luxury treatments and spas.During the contemporary era ,there has been a growth of medical tourist in South America & South East Asia. (Mac Intosh, 2004)

With the surge of health care cost in the late 1980's -1990's ,many American patients started choosing treatments abroad such as dental and surgical procedures.During 1990's the Cuban goverment started advesting "sun and surgery" packages including dental and cosmetic procedures, along with spa or "wellness adventures". (Krisen Smith ,p2).

With time ,medical toursim industry has emerged and Joint Commission International was formed in 1997 to validate and check healthcare facilities in conformance to international quality standards due to the rise of health provides around the world.

Prem Jagayi definition of Medical Tourism is "the set of activites in which a person travels often long distance or across the border to avail medical services with direct or indirect engagement in leisure,business or other purposes".

Medical tourism services are either described as 'inbound',orinbound’, or 'outbound', wherein inbound refers to the services provided by the recipient country and 'outbound' relates to those activities that are part of the patients country of origin.

According to Bookman and Bookman (2007), medical tourism services are categorized as: invasive, diagnostic and lifestyle. Invasive procedures include procedures such as plastic surgery,lasik treatments, cancer treatments and hip-joint replacements rely on the state of art machinery Where iInvasive procedures also relates to those treatments performed by medical specialist for non communicable diseases such as dental work. Other such invasive procedure are plastic surgery,lasik treatments, cancer treatments and hip-joint replacements that rely on the state of art machinery. Diagnostic services sector is a booming sector as patients travel for blood screen, bone density testing, healthealth stress trest,lipidtest, lipid analysis and electrocardiagrams to developing countries. A Broad range of services are included in the lifestyle medical toursimtourism category and includes such as wellness, nutrition, weightloss management and anti-aging. The most common is Ayurveda and yoga (in India and Thailand), and acupuncture (in Malaysia, Thailand and Philippines).

Global Medical Tourism

Medical tourism is a US$60 billion global industry with an average growth of 20% (Mac RReady,2007),where developing countries now offering state of the art medical services to meet the global demand of foreign patients. Hence investing in medical history in turn increases the Gross Domestic Product ,encourages positive foreign exchange balances, trade and boost tourism. (Ramirez de Arellano, 2007).

Current status of Global Medical Toursim

The Deloitter Center for Health Solutions (2009) estimated that close to 900,000 Americans will travel outside of the U.S from medical tourism in 2010 alones,a number that Deloitter forecasts will increase to 1.6 million by 2012.. Currently a $50 billion industry (Ontario Ministry of

International Tradte & Investment,2009),the market has tremendous potential .(Ehrbeck, Guevara & Mango, 2008).

Many countries arecountries are recognizing the potential of medical tourism that would boost tourism into their country.Forcountry. For eg.Countries like India, Malaysia, Singapore and Thailand recorded more that 2.5 million medical tourist in 2005. (United Nations Economic and Social Commission for Asia and the Pacific [UNESCAP], 2008).Developing countries like India, Singapore, Thailand, Malaysia, PhilipinesPhilippines, Hong Kong, Jordan, Cuba and United Arab Emirates are emerging as leading medical tourist destinations.

Hence its established that tTravelling abroad for treatment is not a new phenomena, however it is established that where the direction of travel is shifting away from patients travelling from poor to rich countries to access health services ,towards that of patients travelling from rich countries to the poorer nations. (de Arellano, 2007; Whittaker , 2008).

The little academic research that exists primarily focuses on economic, medical or marketing aspects of medical tourism industry and considers them from either the supply or demand perspective(ie, Bookman & Bookman , 2007); Connell, 2006; Smith & Forgione, 2007)

The remainder of the thesis is structured as follows.First......

Goodrich and Goodrich (1987) defined health tourism as the "attempt on the part of a tourist facility or destination to attract tourists by deliberately promoting it's health-care services and facilities, in addition to its regular tourist amenities (p. 127),thus emphasizing the supply side.Van Sliepen (as cited in Hall, 1992) placed stronges emphasis on the demand side and viewed health tourism as comprising three elements:staying away from home,health as the primary motive, and occurring in a leisure setting.

Gupta (2004),defines medical tourism as the provision of cost-effective medical care to patients in collaborations with the tourism industry.So by travelling to a foreign destination to undergo a treatment,patients also gets the chance of visiting a major tourist destination ,thus clubbing health care with tourism.Where Connell (2006)explains that medical tourism is a form of popular mass culture whereby individuals travel long distance to obtain medical ,dental or surgical services while being holidaymakers.

Over 50 countries across have identified medical tourism and introduce policies ,regulations and health laws to consider it as a national industry (Gahlinger,2008).The main reason patients travelling abroad is because of high healthcare, affordablityaffordability ,accessibility or better availability. Patients are influenced by several factors and seek treatment from abroad because of:

Rising costs in healhtcare in developed countries. Traval globallyGlobal Tavel is now available within affordable prices. International Standards of care and technological advancements are available. across. With the wide spread proliferation of internet and communication barriers removesare

removed and it is,it's easier to locate medical centres and treatments overseas. Patients which have no or limited health insurance seek out to opt for medical tourism .

(Medical Tourism Benefits and Advantages,2011)Treatments where pPatients now are now travelling abroadtravelling abroad are not only for cosmetic and dental procedures but also for includes complex procedures such as heart surgery, joint replacement, spinal surgery and more (Lagiewski & Myers, 2008).This creates a necessity to also understand the economic, social, politcal and medical forces that driving and shaping this phenomenon. (Horowitz,et al, 2007)

Subject of debate is whether to treat medical tourism and health and wellness tourism as separate two distinct fields.As Medical tourism is defined as "the process of traveling to another country to receive medical, dental and surgical care" (Humer & DeMicco, 2007, p.76).Whereas Carrera and Bridges (2006) explains health and wellness tourism as " the organized travel outside one's local environment for the maintenance, enhancement or restoration of an individuals' wellbeing in mind and body (p. 447).

In recent times,the terminology medical tourism (or medical travel, as preferred by Cohen,2010) is an umbrella term that comprising medical, health and wellness tourism. Bookman and Bookman (2007) similarly states the medical tourism is most preferred term used in the industry, that "reflects the growing enroachments of medicine even in spa and wellness services " (p. 43).However ,medical tourism with all its breadth is therefore defined as a tourism that includes invasive, diagnostic or lifestyle medical treatments (S.Hudson and X. Li, 2011).

A study of medical tourist in four countries namely India,China Jordan and UAE was undertaken to identify the reasons for seeking out of county care,the level of satisfaction and assess the experience of medical travelers.Wherein cost,doctor reputation ,facility reputation and hospital accreditation were rated and considered as most important factors while selecting a treatment abroad.Additionally long waiting lines ,lack of care and privacy concerns were considered motivations for medical tourist. (Alsharif et al, 2010).The study results of the survey indicate that the most sorted medical procedures in UAE were dental,eye surgery,cosmetic and orthopedic as compared to that of Alternative Medicince,Cardiac,Organ transplantation seen in India and China.

Medical Tourism-Reasons for Growth(Garcia-Altes, 2005) explains that the development of medical tourism is driven by number of factors that are increasing its attractiveness such as social, demographic and economic factors.Such as:

Ageing Populations: Increasing number of older people seek attention for the medical needs such as hip or knee replacement (Lagace, 2007).The aging population is a growing concern to health care infrastructure .

Lifestyle Changes: Living in a world where one gets easily influenced by celebrity and media images, Cosmetic surgery now takes its significant role in the medical tourism niche. (R. Tresidder, 2011)

Tourism Alternatives: Cosmetic surgery is an extension of the services offered by spas,and health clubs.India offered treatments of ayurvedic and alternative medicines to attract a greater potential of medical tourist. (R. Tresidder, 2011)

Nature of generating health systems:The medical treatment is not covered under health insurance policies or the home country may not offer treatment due to economic,political,religious background.For instance ,in US records indicate that 45.7 million people have no health insurance.Thereby by travelling to countries that offer the same treatment has contributed to its growth. (R. Tresidder, 2011)

The literature review shows lack of academic research in medical tourism, there a few researches that have proposed theoretical frameworks that will be discussed here in this study.

Theoretical framework

Smith and Forgione (2007) developed a two-stage model that indicates the factors that influence a patient's decision to seek healthcare services abroad.They argued that country specific characteristics such as economic conditions, political climate, and regulatory policies, influence the choice of destinations; whereas such factors as cost, hospital accreditation, quality of care, and physician training have an impact on the choice of health care facilities.According to this model,it mentions that medical tourist first choose or select a destination and then after making a decision they consider other medical tourism facilities or infrastructure particular to the

destination.(see Figure 1).It generally emphasizes the important factors of medical tourism destinations and health care facilities. (Smith & Forgione, 2007).

Supply and demand model proposed by Heug,Kukukusta and Song are perspectives that indicates the importance of the medical tourist needs when he selects the country,medical facility or doctor.Both the components ,demand and supply supports a medical tourist decision making process,since there is interaction between the two components. (>HUeng>>>>)

The term "demand" refers to those factors that drives a tourists' decision in terms of destination and medical options.It refers to expectation of a certain medical tourist according to his needs that helps him to make a better decision to select a destination. For this ,the tourist is likely to select a amongst the distribution channel in the first stage, such a s via word of mouth,media,friends or internet. However the selection or the criteria's which a tourist decides varies with his needs .For instance a patient choosing cosmetic treatments will be more like to be looking into costs compared to that of organ transplant whose primary concern could be the qualifications and experience of the physician..

On the other hand, the supply side ,comprises of all the efforts, service and medical facilities that a offered and made available at the medical tourism destination. This includes infrastructure, state of art medical services, quality, accreditation ,promotional activities and communication facilities which meets a medical tourist expectations. The supply side of the model is supplied by the private, public and government entities for the medical tourism destination .(Huen,et all, 2010).Thailand is leading in medical health care destinations, with inbound medical toursim of 1 million in 2005 alone (Hutchinson,2005),this has been attributed due to the government bodies such a Ministry of Health and encouraging public and private participation through effective marketing strategies which lead to the success of Thailand in the medical tourism industry.

Quality is noted as an utmost criteria under the demand side of the model.For this there has been a rise of hospital seeking out for attaining international standards of accredition such as the ISO & JCI to compete in the medical tourism industry. (UNESCAP, 2007).

A study was taken among medical tourist in Hong Kong by Ye, Yuen,Qui and Zang (2008) that examined motivations and barrier to medical tourist.A case study approach was taken ,developed a framework if the motivations of medical tourists on the push and pull theory.Their findings were that the motivations of medical tourist differ from those of mass tourism.Medical factors are given more preference than destination attributes.The study also shown various implications for medical tourism destinations,such as marketing programs and initiatives should not only focus on low cost but should highlight other features (Ye et al., 2008).

Another study of medical tourist in four countries namely India, China Jordan and UAE was undertaken to identify the reasons for seeking out of county care, the level of satisfaction and

assess the experience of medical travelers. Wherein cost, doctor reputation ,facility reputation and hospital accreditation were rated and considered as most important factors while selecting a treatment abroad. Additionally long waiting lines ,lack of care and privacy concerns were considered motivations for medical tourist. (Alsharif et al, 2010).The study results of the survey indicate that the most sorted medical procedures in UAE were dental, eye surgery, cosmetic and orthopedic procedures as compared to that of Alternative Medicince, Cardiac, Organ transplantation seen in India and China.(Alsharif et al, 2010).

The research undertaken by Crooks V. et al. (2010) using 348 academic articles,media sources and grey literature for purpose of study and implementation of research,identified themes as decision-making as push and pull factors and motivations which patients decide to leave their country and seek for medical care abroad.Crooks discussed the determining factors,were high cost,lack of insurance in their own country and long waiting time. “Patients can bepulled towards medical tourism hospitals that are renowned for the quality of service,care, and facilities they offer” (Crooks V., et al. 2010:6). “Relatedto this, the religious accessibility of medical tourism facilities and destination nationsis another consideration that can pull patients to one location over another” (CrooksV., et al. 2010:6).Patient decision is also based on the holiday packages and having a vacation in the foreign country during the treament abroad.Additionally ,patient choose hospitals in which employees are friendly and speak a known native language.Also based on the political structure of a country can either motivate a patient to travel to country.

Other decision making factors that is vital is accessing information related to credentials of doctors, as well as “the international marketing of facilitiesand procedures, including their costs, online or via facilitators/brokers,” (Crooks V.,et al. 2010:6).Crooks added that word of mouth is an information source of knowledge ,where a medical tourist learns about the procedure abroad via family and friends.Crooks (2010),also explained about factors motivating patients engagement in medical tourism as: procedure based; travel-based and cost based.Wherein a procedure based the patient wishes to select procedures that are not available or illegal at the home country,such as stem cell therapies.Travel based motivators that have been identified as ease of affordablity of international travel,frequency of flights to destinations,proceeding the applications and smooth visa procedures,presence of package deals and ease of booking serves a motivators to consider for tourist to decide on their medical tourism destination.Additionaly cost and affordabilty were alos discussed a potential motivating factors that engage patients in medical toursim.

Current status of Global Medical Toursim

The Deloitter Center for Health Solutions (2009) estimated that close to 900,000 Americans will travel outside of the U.S from medical tourism in 2010 alones,a number that Deloitter forecasts will increase to 1.6 million by 2012.Currently a $50 billion industry (Ontario Ministry of International Tradte & Investment,2009),the market has tremendous potential .(Ehrbeck, Guevara & Mango, 2008).

Tourist Motivation-Push and Pull Framework

“Motivation is the need that drives an individual to act in a certain way to achieve to the desired satisfaction” (Beerli and Martín, 2004, p. 626). Motivation has been subject of study in various perspectives of physiological, psychological and philosophical approaches (Petre and Govern, 2004:3-14).Similarly in the field of tourism, motivation have been used in better understanding of behaviors and in travel decision making process.

Past literature on tourist motivation introduced to a concept based on motives that are classified as push and pull factors , which is among the most well known theory of push-pull concept (Crompton,1979; Dann, 1977; Epperson, 1983; McIntosh & Goeldner, 1990) ,the analysis of these two factors has been generally accepted in the field of tourists motivation.(Yuan & McDonald, 1990; Uysal & Hagan, 1993).

Dann (1981, as cited in Cooper et. al. 1993: 34) explained the relationship between destination pull and the motivational push, thus pointing out the level of desire (pull) of an individual tourist in response to the pull of the destination or attraction.

Additionally, push factors are identified as those that initiate or motivate the desire to travel; pull factors are those influencing which destination is selected by the tourist.(Page and Connell, 2006). The push factors is the desire to travel to satisfy the needs and wants of a travel ;that urges the traveler to take a vacation, whereas the pull factor is characterized by the various attributes of the destination which leads the traveler to select a destination over another.

The push factors are identified as those that initiate travel desire,while the push factors are explained to be decisive in the criteria of destination choice (Woodside, et al.2008).Crompton’s (1979) identified seven psychological (push) motives and cultural motives namely; (i)escape from a perceived mundane environment, (ii)exploration and evaluation of self, (iii) relaxation, (iv) prestige, (v) regression, (vi)enhancement of kinship relationships, (vii) facilitation of social interaction, and two cultural (pull) motives: (viii) novelty and (xi) education.

Consequently,pull factors as quality of services,facilities and amenities, suitable location were important criteria in destination choice(Awaritefe,2004)The push factors are defined as intrinsic ,compared to the pull factors as extrinsic.Push factors are motives that result in involving in activities that reduce the tourist needs,while Pull factors are characterized by destination forces and knowledge that a tourist acquires about a destination.Push factors consists of the desire to escape, rest and relaxation, prestige, health and fitness, adventure and social interaction.Pull factors includes destination attractiveness ,such as spas, beaches, exotic hotel,recreation and cultural attraction.

Both the factors,push and pull are characterize as relating to two separate decisions made at differant points in time,one former focuses on whether to go,and the latter is on where to go. (Klenosky, 2002).However, few researches have studied to actually show a linkage between the reason why people desire to travel versus where they choose to go.

The push and pull model is defined as a dichotmous approach and is adopted widely in toursimtourism motivation studies.The adopting of push and pull factors as travel motivation is not new.Number of researchers try to differentiate between the two factors and have accepted push factors as motivational factors and consider pull factors as destination attributes.Hence knowledge and understanding of tourist motivations ,contributes to destination marketers to create better plans,strategies, marketing advertisement and campaigns.

To conclude that the push and pull concept has been extensively studied

and widely accepted in by research in tourism literature (e.g., Chan & Baum, 2007; Yoon & Uysal, 2005;Jang & Wu, 2006; Kim, Lee & Klenosky, 2003; Oh et. al., 1995; Swanson & Horridge, 2006) suggesting that is a useful approach for examining underlying motivations of a tourist and decisions making process are influence by these factor.

Concerns about Medical Tourism

Destinations seeking to attract international patients at time face few challenges,which particular needs to be addressed with regards to (i)quality of care (ii)price (iii)legalities (iv)travel.Below each have been discussed in detail.

Quality of care is a primary concern for most medical tourist .Heath care institutions in developing nations are obtaining international accreditions so that they offer services that are as comparable to remaining parts of the world. In 1994, Joint Commission International (JCI) was formed as an international affiliate which accredits US hospitals and health care organizations for compliance with Medicare Conditions for Partipation.By 2000,JCI presents its intial accredition award and published its list of international quality standards for hospitals.In 2007,JCI was accredited by the International Society of Quality in Health Care (ISQua).

Till date,JCI has accredited more than 2000 healthcare organization spanning across 33 countries.However JCI is cited as the quality indicator for many medical tourists.Other known quality ratings include the Trent Accreditaion Scheme (UK),the Internation Organization for Standardization ("ISO"),and the European Society for Quality in Health Care (" ESQH").

In addition,qualification of surgeons also seems to be focused on(Awadzi and Panda, 2005, Mc Dowall, 2006), for example.

Apart from the concern of quality care,patients are also concern about the possibility post-operative complications. (Marlowe and Sullivan,2007).Mac Ready (2007) in response to allegations of post-operative complications proposes a checklist to evaluate medical tourism destinations,such as: facilities and infrastructure, qualifications and certifications of doctors;success and failure rates,mortality and morbidity rates and due diligence.

The second concern for medical tourist is the cost.It's a primary concern on saving their medical expenses which is significance for medical tourist,insurance companies and firms (Marlowe and Sullivan, 2007, McDowall, 2006).In generall ,its research has indicated the costs in the developed countries are 6-8 time more higher compared to the similar treatment in the developing countries. (Awazdi and Panda, 2005, Moody, 2007)

COST EXPLAIN

The third concern is that insurance companies find themselves legally liable for any consequences of treatment provided abroad (Marlowe and Sullivan ,2007).According to Marlowe and Sullivan ,healthcare providers should :(i) not exaggerate and convince people to select and option to travelling abroad to undergo a medical treatment; and (ii)requires a formal statement of their responsibilities for medical malpractice from offshore medical services.

Finally, other cause of concern relates to travel. Travel insurance might be required to cover patients in care of any accidents or difficulties that could occur during the trips. (Marlowe and Sullivan ,2007).Since medical expenses are not tax-exempt for the patients, Hence insurance

companies may find it tough to convince their employees or policyholders to undertake a medical treatment abroad (Marlowe and Sullivan, 2007).

Medical Tourism Destinations

Medical Tourism in Countries Wordlwide

The market for medical tourism is ostensibly driven due to the high demand in the West, where reports indicate medical industry is worth as muc as US$60 billion growing at the rate 20 per cent per annum. (Mac Ready, 20077 :1849)

This section highlights on the medical tourism industry prominent in various countries which are attracting volumes of tourist every year ,making medical tourism a billion dollar industry.

1)India

India boasts about offering varied types of medical treatments such as Ayurvedic therapy, coronary bypass and cosmetic surgery.(Connell,2006).Currently leading as the most sorted destination for medical tourist for its lowest costs for treatments compared to other destinations. The costs are 40% less that offered by other developed countries.A cardiac patient pays US$ 40,000-60,000 in the US,US$ 30,000 in Singapore, US $12,000-15,000 in Thailand,where its available in India within US $ 3,000-6,000.The country is known for its cardiac and orthopedic

procedures ,specialized services in neurolgy,endocrinology,nephrology,urology and organ transplant (Chanda,2001)

Medical Tourism is booming in India ,with an annual growth of 30%, expected to touch US$ 238.7 billion by 2020.Large number of JCI accredited hospitals,experienced and talented professionals,foreign investors,pharmaceuticals and governments are working together to create an images as a Medical tourism destination.

The Indian Goverment has introduced visas for medical tourist called the 'M',and Ministry of Tourism conducts a year long campaign named 'Incredible India' .In 2009,MOT launched a scheme called 'Market Development Assistance' to support financially to differant Medical Tourism Service Providers to participate in fairs,mconference and road shows.Estimates that the annual revenues reached US $2 billion in 2012 with the support of multi speciality private hospitals like The Apollo,Max Health care,Jason Hospitals and Global Hospital. (Horowitz and Rosensweig,2007).

2)Thailand

Thailand is considered as the medical tourism hub of Asia due it its prime location.In 2009,the country recived 1.5 millions foriegn patient visits and by 2014 ,Thailand sets to generate US$ 12.2 billion revenue exclusively from inbound medical tourist.

Patients come from Japan,US,South Asia,Middle East and neighbouring ASEAN countries.The Bumrungrad International Hospital ,is the first hospital in Asia in 2004 to receive the JCI accrediation and currently has 14 such JCI accredited hospitals.The Bumrungrad Hospital is equipped with international restuarants,fast-food outlets,coffee shops thus attracting large number of patients that any other in Asia (Veerasoontorn and Beise-Zee,2010).

The Tourism Authority of Thailand in Octobor 2010,launched a new medical tourism website

namely www.ThailandMedTourism.com provide information related to surgical procedures ,medical tourism providers,packages and promotions ,which is a part of the campaign "E-marketing Campaign for Medical Tourism in Thailand". (KPMG report,2011)Doctors and nurses are trained in Japanese to attract the Japanese market and has earned it international recognition in bone related ailment, cosmetic and reconstructive surgery.(Connell,2006).

Thailand attracts patients due to its beaches,shopping centeres,spas and massages thus trying to tempt international patients with exclusive medical packages offering accomodation and after care environment to recuperate after thier surgery.Thus providing low cost care with extra facilities of airfare and stay creates a perception of a strong medical tourism destination in the patients mindset (Deloitte Developement LLC,2008).

3)Singapore

Consists of 15 JCI accredited ,the largest in Asia providing high quality health care to the foreign tourist.(KPMG Report).The annual increase of patients in 2006-08 estimated more than 16% growth from 555,000 to 646,000 visitors.The country aim to attract 1 million tourist by 2012.Majoity of its patients are flown from ASEAN countries like Indonesia according to Arunanondchai and Flink (2007).

The government promotes medical tourism by providing high quality clinics and hospital backed up with well developed infrastructure. Such as the Parkway Healthcare Group is the one of the largest healthcare group and Raffles Medical Group has huge network of 28 hospital and clinics spread across the country. (Diaz Benavides,2002).Additionally ,English being the common language spoken in Singapore is an advantage for attracting medical tourist.

Apart from the hospitals that are well equipped to treat the patient, the government has developed strategies to attract foreign pharmaceuticals, drug manufactures and biomedical research laboratories to invest in operations in the country.However, Bookman and Bookman (2007) states that the prices for medical treatments are similar to the west and are "priced itself out of the market".

4)Brazil

Brazil has shown a rise in cosmetic surgeries, a destination for cosmoceutical companies and therapeutic equipment to tap the market as there is an increase in demand for procedures such as liposuction, breast augmentation and buttock augmentation. Due to global recession ,brazil lowered its taxes for cosmetic surgery, which will help to attract more foreign medical tourist to undergo the similar treatments.

Brazil has 20 JCI-accredited organizations with developed infrastructure and high quality medicines,the prices are at times higher that U.S making it unattractive for medical tourist.However,Brazil stands out for plastic and cosmetic surgery,rankig itself as the second largest in the word providing state of the art services (Yanos ,2008b),having highest number of cosmetic surgeons per person making.Hence cosmetic surgeries such as nose job or tummy tuck will cost less that $2000 compared to 3000$ in US or 3-4000$ in Dubai.

Further,Herrick (2007) indicates that 9 Brazilian organizations has formed and established the Brazil Health Consortium to market and position the country as a medical tourism destination.

Consideration,Risk and Opportunities of Medical Tourism

Medical Tourism Continuous Growth

Medical Toursim in UAE

Characteristics of Country of Choice

Chapter Summary

Medical Tourism in GCC GCC and UAE Government

Majority of the healthcare providers in GCC are focusing on US $ 50 Billion medical toursim industry,with healthcare services market is projected to expand across the GCC countries growing at annual rate of 11.4% over 2010-15. (Alpine Captial,).Saudi Arabia and UAE are the fasting growing healthcare markets in the region.The governments of the GCC's now seek to attract foreign patients from the West and change the pattern of patients travelling to India,Indonesia,Malaysia by investing large amounts in proving medical facilities,new medical technologies and health concerns.Due to the edge of Low-cost compared to other developed nations,the GCC market is expected to share substiantial market in the global medical toursim space.For example,a heart bypass surgery cost US $ 44,000 in the UAE,which is 66% lesser than compared to US $130,000.Hence,GCC authorities are investing to build state of art healtcare units in the region.Once such development is the Oman City which is a project worth US $ 1Billion solely to build a health care centres.

With the aim in mind,UAE is now positioning itself as the medical hub ,by building modern technology and advanced healthcare infrastructure.UAE Government has developed strategies to attain world class care by getting accredited by Joint Commssion International (JCI),which is internationally approved gold standards for quality and safety for medical facilites.Today UAE government boasts about 35 JCI accredited hospital spread across providing high standards of quality care and excellence.Below is an overview of JCI hospitals accredited in GCC countries, noting that UAE has competition with Saudi Arabia JCI' s hospitals:

TABLE:

Gulf governments are investing in medical education and training programs and acquiring services of international healtcarehealthcare brands.Such as Dubai has attracted Harvard Medical School to be buildt in Dubai Health Care City (DHCC),while Qatar has built a US $2.3 billion specialityspecialty teaching hospital in collaboration with Weill Cornell Medical College in Sidra Medical and Research Centre in Doha. (Grant Thornton, 2009)

THE UAE Government budgeted AED 3billion on healtchhealth care projects and services in 2011-12,wherein in 2011 ,the Ministry of Health (MoH),announced plans to launch 'Wareed' an health information system, that links 14 public hospitals and 68 clinics across Dubai and Northern Emirates through a robust electronic medical records system . (Alphen Capital,2011).

Dubai Healthcaree Plans

It's been 10 years since the launch of Dubai Health Care City (DHCC),by His Highness Sheikh Mohammed Bin Rashid Al Maktoum Prime Minister of United Arab Emirates( (UAE) and Ruler of Dubai, His Highness Sheikh Mohammed Bin Rashid Al Maktoum to "meet the demand for high-quality, patient-centered healthcare" in the middle east by attracting medical tourist from al around the globe .

The DHCC ,the first healthcare freezone is a home of two JCI accredited hospitals ,120 medical medical centers and over 3700 licensed professionals all working to create a center of excellence. The DHCC also includes nine of the largest pharmaceuticals companys, research centers, insurers and education centers all working in a concerted fashion towards the goal in of creating a regional center for quality care. The DHCC has observed an increase in medical tourism in 2011,where out of 502,000 patients about 15 percent where medical tourist compared to one percent of 412,000 patients recorded in 2010.Thus the government is optimistic to establish UAE as a medical tourism destination.

The medical tourism initiative was announced by Sheikh Hamdan Bin Mohammad Bin Rashid Al Maktoum in 2012. Several steps and measures has to taken to bring a collaboration between medical tourism bodies and healthcare authorities such as the DHA, the Department of Tourism and Commercial Marketing (DTCM) and General Directorate for Residency and Foreigners Affairs (GDRFA) .(news)

Dr Ayesha Abdullah, Managing Director of DHCC states that "UAE has strongly established itself as one of the top destinations for medical tourism in the Middle East with Dubai driving the demand for global standard healthcare services, against cost-competitive destinations such as Thailand and India." (exact news)

Dubai has strategically positioned itself in providing niche services and high end tertiary and quality care which makes its standout among the regional players.

According to research from Dubai Chamber of Commerce and Industry the UAE healthcare care is estimated to reach from AED 11.7 billion in 2005 to AED 43.7 billion in 2015.

It is s observed that medical travelers choose cosmetic surgery, dental treatment and hip-replacement due to the lower cost compared to the West. For eg.a Cardiac bypass cost around $ 130,000 in the US and is available for $44,000 only in the UAE.

Today, DHCC is not only in par with international standards and success rates but also with quality of care and accessibility ,and is equipped to become a leading medical tourist destination amongst the GCC countries.

InorderIn order to push medical tourism, the government has released a Health Strategy plan for 2013-2025,with the goals of better health, access ,quality and efficiency. A medical tourism initiative was announced by Dubai Health Authority in 2010,and the Director-General ,Eisa Al Maidour said that the projects will include hosting medical exhibition, participating in overseas exhibitions, encouraging issssn investments and Public Pprivate Patnerships (PPP's).Once such exhibition is the Annual Arab Health Care Conference held in January where health care providers,iI ndustralists ,leading health solution providers help to identify gas in the services and spur investments coming to the city.

To promote medical tourism ,DHCC is also opened specialized centers for oncology and genetic disorders and close the gap by introducing facilities such as rehabilitation, pediatrics and integrated medicine. DHCC has also 50 (Complementary and Alternative Medicine-CAM) licensed professionals offering treatments in areas such as homeopathy, Ayurveda, Unani medicine, Tai chi etc,due to the growing demand of patient choosing CAM.

To cover indepthin-depth news, discoveries and create awareness of DHCC as a center to health care consumers, DHCC has released an guide called "Patient Without Border" in partnership with Health Travel Media which are published in English and Arabic and sold internationally.CEO of Patients Beyond Borders, Josef Woodman quotes states in the introduction that since it is"“Centrally located at the crossroads of Asia, Europe, and Africa, Dubai now boasts 25 American-accredited hospitals, facilities, and programs-nearly half of all the JCI-accredited programs in the UAE,”.Additionaly DHCC with its culturally compatible environment and tourism infrastructure ,it's poised to become a leading medical destination for patients far and near.

Recently Gulf News reported that the DHCC’s plan to position itself as the medical hub for international and regional patients was spurred by increase in the number of patients visiting Dubai for treatment and more investment coming into the city.

Overall,the outlook is positive and the figures show rise in the healthcare industry as more patients are selecting UAE as their preferred place for treatments to avoid long waiting lines and to get quality treatment and care along with the attractive tourist destination with the country has shaped it self.

JCI Accredited Hospitals in Dubai

The following are 4 hospitals in Dubai that are accredited by the JCI that are famous and gaining popularity amongst medical tourist seeking for medical treatment:

1)American Hospital Dubai

The American Hospital was established in 1996, planned and designed to equip itself with American Standards of Healthcare, providing acute care with 143 bed units and proven be a leader in health care in the emirate.

Around 20% of the patients comescome from outside UAE, such as the nearby GCC countries as well as USA and Europe. American Hospital offers multidisciplinary primary, secondary and tertiary medical care that arecare that is amongst the best practices and recognized globally.

AHD (American Hospital Dubai) ,is the first hospital to be accredited by the Joint Commission International Accreditation (JCIA) in 1996 and operates to the standards that all its physicians are North American Board Certified or have acquired Western trained programs.

AHD has expanded to included eastablished Cancer Care centre, Heart Center and Cochlear Impants,in addition to the well establish Knee Joint Replacement and Diabetes centres.The Total Joint Replacement program is the first of its kind in the Middle east (www.ahdubai.com/)

2) International Modern Hospital

Founded by Dr.Hafeez Rahman, world renowned surgeon who has accomplished largest amount of laparoscopic surgeries insurgeries in the world, International Modern Hhospital is a center for Bariatric, Obstetrics and Orthopedics surgeries.

With qualified surgeons, doctors and nurses ,thisnurses, this hospital offers private state of art maternity wing, comforts of a home environment, every suite monitored upon quality comprehensive counseling and full range of services. The worldsworld’s first successful key hole surgery was done in this hospitals.IMH received it first JCI accreditation in 2007,is now have specialized units in Orthopedic and sports centre, where sports players such as the Afghanistan Cricket team and national level players seek any medical treaments.IMH also have department for Cardiology, Dental, Obstetrics, Gynecology and Infertility, Physiotherapy and Ophthalmology.

3) MEDCARE Hospital

Medcare Hospital located in Dubai is new 67 bed premium private general medical facility offerng advanced medical care and emergency services.Withinservices. Within 8 months of its launch, Medcare was able to get accredited by the JCI, thus proving that is has quality standard in healthcare.ThHe hospital covers inpatients and outpatient care with full fledged Emergency department and Surgical Specialties. They have a diagnostic centre equipped with advanced imaging equipments as the MRI,CT Scan and Ultrasound.

Patients receive immediate care by highly accomplished Trauma Surgeons and Neurosurgeons with a specialized Emergency Care department dedicated mainly for any major accidents and is preferred by residents and families in the region

Medcare Hospital International Services Division records patients undertaken treatment from US,UK, Russia and across the Middle East.

Common treatment seeks by International Patients were: Joint Replacement, Spine Surgeries, General Laparoscopic surgeries, Gastric and Bariatric surgeries.

4)The Mediclinic-City Hospital

City Hospital located at Dubai Healthcare city began its operations in 2008 as the first multidisciplinary hospitals. It is, a JCI accredited 210 bed unit, and JCI accredited provides timely treatment in the areas of cardiology, oncology, obstetrics, orthopedics, laparoscopic surgeries trauma and other medical specialites.Is wholly owned by Mediclinic International ,which is among the world's 10 largest private hospital establishments.

Records show that the hospital treated more than 8,600 inpatients (out of which 1200 were recorded from US & Canada) in 2010 and more than 100,000 outpatient visits (figures show nearly 7000 from US & Canada) www.patientsbeyondborders.com.

With qualified staffs of around 400 physician, surgeons and nurses, in the hospital and English as the official language,there is a language board to help patients arrange if required translation services.

Mediclinic offer private VIP floor with own separate entrance,6 deluxe suites, 5 presidential suites and a royal suite, so that patients can enjoy the luxurious comfort and during their stay in the hospital.

The market for medical tourism is ostensibly driven due to the high demand in the West, where reports indicate medical industry is worth as muc as US$60 billion growing at the rate 20 per cent per annum. (Mac Ready, 20077 :1849)

This section highlights on the medical tourism industry prominent in various countries which are attracting volumes of tourist every year ,making medical tourism a billion dollar industry.

1)India

India boasts about offering varied types of medical treatments such as Ayurvedic therapy, coronary bypass and cosmetic surgery.(Connell,2006).Currently leading as the most sorted destination for medical tourist for its lowest costs for treatments compared to other destinations. The costs are 40% less that offered by other developed countries.A cardiac patient pays US$ 40,000-60,000 in the US,US$ 30,000 in Singapore, US $12,000-15,000 in Thailand,where its available in India within US $ 3,000-6,000.The country is known for its cardiac and orthopedic procedures ,specialized services in neurolgy,endocrinology,nephrology,urology and organ transplant (Chanda,2001)

Medical Tourism is booming in India ,with an annual growth of 30%, expected to touch US$ 238.7 billion by 2020.Large number of JCI accredited hospitals,experienced and talented professionals,foreign investors,pharmaceuticals and governments are working together to create an images as a Medical tourism destination.

The Indian Goverment has introduced visas for medical tourist called the 'M',and Ministry of Tourism conducts a year long campaign named 'Incredible India' .In 2009,MOT launched a scheme called 'Market Development Assistance' to support financially to differant Medical Tourism Service Providers to participate in fairs,mconference and road shows.Estimates that the annual revenues reached US $2 billion in 2012 with the support of multi speciality private hospitals like The Apollo,Max Health care,Jason Hospitals and Global Hospital. (Horowitz and Rosensweig,2007).

2)Thailand

Thailand is considered as the medical tourism hub of Asia due it its prime location.In 2009,the country recived 1.5 millions foriegn patient visits and by 2014 ,Thailand sets to generate US$ 12.2 billion revenue exclusively from inbound medical tourist.

Patients come from Japan,US,South Asia,Middle East and neighbouring ASEAN countries.The Bumrungrad International Hospital ,is the first hospital in Asia in 2004 to receive the JCI accrediation and currently has 14 such JCI accredited hospitals.The Bumrungrad Hospital is equipped with international restuarants,fast-food outlets,coffee shops thus attracting large number of patients that any other in Asia (Veerasoontorn and Beise-Zee,2010).

The Tourism Authority of Thailand in Octobor 2010,launched a new medical tourism website

namely www.ThailandMedTourism.com provide information related to surgical procedures ,medical tourism providers,packages and promotions ,which is a part of the campaign "E-marketing Campaign for Medical Tourism in Thailand". (KPMG report,2011)Doctors and nurses are trained in Japanese to attract the Japanese market and has earned it international recognition in bone related ailment, cosmetic and reconstructive surgery.(Connell,2006).

Thailand attracts patients due to its beaches,shopping centeres,spas and massages thus trying to tempt international patients with exclusive medical packages offering accomodation and after care environment to recuperate after thier surgery.Thus providing low cost care with extra facilities of airfare and stay creates a perception of a strong medical tourism destination in the patients mindset (Deloitte Developement LLC,2008).

3)Singapore

Consists of 15 JCI accredited ,the largest in Asia providing high quality health care to the foreign tourist.(KPMG Report).The annual increase of patients in 2006-08 estimated more than 16% growth from 555,000 to 646,000 visitors.The country aim to attract 1 million tourist by 2012.Majoity of its patients are flown from ASEAN countries like Indonesia according to Arunanondchai and Flink (2007).

The government promotes medical tourism by providing high quality clinics and hospital backed up with well developed infrastructure. Such as the Parkway Healthcare Group is the one of the largest healthcare group and Raffles Medical Group has huge network of 28 hospital and clinics spread across the country. (Diaz Benavides,2002).Additionally ,English being the common language spoken in Singapore is an advantage for attracting medical tourist.

Apart from the hospitals that are well equipped to treat the patient, the government has developed strategies to attract foreign pharmaceuticals, drug manufactures and biomedical research laboratories to invest in operations in the country.However, Bookman and Bookman (2007) states that the prices for medical treatments are similar to the west and are "priced itself out of the market".

4)Brazil

Brazil has shown a rise in cosmetic surgeries, a destination for cosmoceutical companies and therapeutic equipment to tap the market as there is an increase in demand for procedures such as liposuction, breast augmentation and buttock augmentation. Due to global recession ,brazil lowered its taxes for cosmetic surgery, which will help to attract more foreign medical tourist to undergo the similar treatments.

Brazil has 20 JCI-accredited organizations with developed infrastructure and high quality medicines,the prices are at times higher that U.S making it unattractive for medical tourist.However,Brazil stands out for plastic and cosmetic surgery,rankig itself as the second largest in the word providing state of the art services (Yanos ,2008b),having highest number of cosmetic surgeons per person making.Hence cosmetic surgeries such as nose job or tummy tuck will cost less that $2000 compared to 3000$ in US or 3-4000$ in Dubai.

Further,Herrick (2007) indicates that 9 Brazilian organizations has formed and established the Brazil Health Consortium to market and position the country as a medical tourism destination.

RESEARCH METHODOLOGY

The primary purpose of this chapter is to determine factors that make Dubai as a chosen medical tourism destination for medical tourist across the globe.

This chapter covers the research framewokr of the study, research questions and hypotheses, relevant data descriptions,data collection methods, limitations and chapter summary.

Research Framework

The study used quantitative marketing techniques to thoroughly identify factors that make Dubai as chosen medical tourism destination,by selecting hospitals in dubai for their medical needs.

Quantitative research methods were originally developed in the natural sciences to study natural phenomena (Hohmann, 2006).The main objective of quantitative research is to develop mathematical models,theories and hypothesis relating to the phenomena. According to Gall,Borg and Gall (1996),the main purpose of using a survey with questionnaires or interviews is to gather and collect data from respondents from a sample to understand their characteristics, experience and opinions in order to estimate the findings of a population that the sample intents to represent. In this way a questionnaire gives an opportunity to collect large amount of data from many participants (Gall, Borg and Gall, 1996;Krathwohl, 1998).

In this study ,the investigation of the research questions for understanding the motivating factor,decision-making factors, and facilities that are important while choosing a hospital for medical treatments as their medical tourist destination through the use of survey questionnaires.

Overview and Justification of research paradigm

Each scientific investigations consist of a chosen research paradigm,which guides the action and creates a road map of the researcher and the method of enquiry (Guba and Lincoln, 1991, Neuman, 2006b).In this study,two research paradigms can be identified: (i) constructivist and (ii) positivist

Constructionism

Is an ontological position based on social phenomena and their meanings are continuously being developed by various social actors.Guba and Lincoln,1991 explains that it's based on the belief that social reality depends on how people attribute meaning to the phenomena around them.

According to (Neuman ,2006b),by considering complex motivations and perspectives of individuals within social contexts only can behaviour be explained.Counstructivists thus show the inter relationships between actors and factors and importance of context. (Guba and Lincoln, 1991).Constructionism is also applied to cultures, where culture is taken as a continuous state of revision and reconstruction.

POSITIVIST:

For the purpose of this study ,a positivism paradigm has been used,where the researcher focuses on facts in deping and testing research hypotheses and frameworks ( Easterby-Smith et el., 2008).

Research Question

While there has been descriptions on the popularity of medical tourism and a growing phenomen,the literature shows a little research on medical tourist decision making ,motivating and influencing factors on this specific field.

The research question to be addressed in this study is:

Research Questions:

The research questions focuses to find out the below underlying questions, namely:

Q1.What are the factors that initiate patient to travel abroad and engage in medical tourism in Dubai?

Q3.What are the services medical tourists are looking for that motivates them in selecting a destination as a medical tourism destination?

Survey Administration and Sampling size:

(Maholtra,1999 , Nueman, 2006b) explains that sampling design involves the following steps: (i) target population, (ii)selecting of sampling frame, (iii)sample size, (iv) survey administration. Each of these are explained in more detailed below:

Relevant Data Description

Target Population:

(Maholtra, 1999, Neuman, 2006b) explains that definition of a target population from a wider population should be in accordance to the relevant parameters of a study and generalizations of any research findings.

For the purpose of this study ,the target population where those medical tourist seeking medical treatments in Dubai from JCI accredited hospitals such as American Hospital,New International Modern Hospital,MEDCARE Hospital and City Hospital.Hence the first criteria in the target population was people who show interest in medical tourism.

This study excludes international respondents who were already living in Dubai and those travelers who fell sick during their trip,but includes those that came only to Dubai primarily for a medical treatment.Due to the economics and time constraints during this study, the target population was limited to those who are proficient in English.

Sampling frame:

In the present study,the sampling frame was based on fundamental parameters noted; (i)interest in medical tourism ,(ii)those undergoing/underwent a medical treatment ,(iii)fluency in English/Arabic. More specifically,the study was meant for prospective medical tourist who contacted travel agencies,health care providers specialized in medical tourism and international patients departments,sales relationship officers of health care units in Dubai.Hence they were many patients who were unable to meet the basic criteria and will be addressed further in the limitations during the scope of the study in the concluding section of this chapter.

Sample and Sample size

According to Roberts-Lombard (2002),convenience sampling is technique where subjects are selected mainly because of their convenient accessibility to the researcher.Hence the sample collection entirely depends on the personal judgement of the researcher.Nevertheless, (Cooper and Schindler, 2006) points out that thirty cases are sufficient for studies in which statistical analysis are to be done.

Survey Administration

(Davis, 2005) describes the survey adminstration as data collection using a survey instrument to collect information related to the research question from a large group of participants.The data for this study was gathered through self-administered questionnaire.The self administered questionnaires are questionnaires that are personally delivered to the respondent but the respondent completes the questionnaire without any interviewer's involvement (Chigamba and Fatoki, 2011).The questionnaire was only distribute to foreign medical tourist that selected Dubai for medical purposes.Hard copies of the survey was also distributed directly to customers of Deparment of T &M,to get feedback of those medical tourist who were visiting on timely basis.This was complemented by web based surveys ,where survey links were sent as blast mails

to email id's registered of international patients of the hospitals and database of the department of Tourism in Dubai...Cover letter.Since,web-bases surveys are the most suitable mode of data collection (Cabanoglu et al., 2001).Help of doctors,staff

Data Collection and Gathering Procedure

This study uses two types of data collection methods for description research: (i)observation (which aims to collect data that can provide prominent description of the situation); and (ii)survey (which frames the positivist paradigm since it aims to collect data to be used to establish findings and testing the theories) (Esterby et al., 1991, Neuman, 2006b, Scanlan, 2002).The objective of this study is to provide findings that can be utilised by policy-makers to enable them to make strategic decision in the scope of medical tourism,survey methods used represent the most right form of data collection.

A survey caters information's by specifying relevant questions to an appropriate number of qualified respondents to explore their attitudes, intentions, and behaviour (Malholtra, 1999,Neuman, 2006a).Appropriate scaling technique for the measurement of each question has to be used (Davis, 2005).Therefore, the survey was designed in a manner to explore the attitudes,intentions of prospective medical tourist regarding their motivations and decision making process in choosing Dubai as its key medical tourism destination.

The entire survey period was conducted over 3 weeks period from November 1st to November 24th 2011.The questionnaire was divided in four sections.The questionnaire were adapted from sources such as (1),A study on medical tourism by Deloitte Center for Health Solutions (2008), (2)Medical tourism decision making model by Smith and Forgione (2008),(3)Crompton's push pull framework and (4) Patient Beyond Borders-A study of medical toursit in four countries (2010)

The questionnaire that were distributed was used the 5-point Likert Scale.The scale showed the importance of each factors viewed by the respondents.

Identified Rate of Scale Very Important 5Important 4Moderately Important 3Of Little Importance 2Unimportant 1

TABLE FOR SCALE

Survey Design:

The questionnaire were divided into 4 parts namely:

Part 1: Question of General Information/Demographics

Part2:Desire to travel for medical treatment

Part3:Decision -making factors

Part 4:Motivating factors

Part1: Consists of demographic aspects of the participant,which were divided 5 elements as Gender,Age,Country of residence,frequency of visit and desired type of medical procedure.

Part 2:Consist of the push factors as identified by Crompton (1987),Crooks et al. (2010) and contribution made by other authors discussed in the literature.Which provides an urge or desire to a medical tourist to seek treatment abroad.The study has identified 10 key push factors which were grouped by Crompton (1989) as (i)escape (ii)self exploratory (iii) relaxation, (iv) prestige, (v) regression, (vi)enhancement of kinship relationships and (vii) social interaction.

Table () present the list of push factors to be considered in this research.

S.No Push factors Attributes

1 Provides you rest and relax physically Relaxation2 A feeling of prestige Prestige3 Offers you a sense of fitness and health relaxation4 Escape from home and mundane environment Escape5 A feeling of Adventure Self-exploratory6 Opportunities for social interaction Social interaction7 Enhances your confidence Kingship

enhancement8 Improves your appearances Kingship

enhancement9 A chance to visit new known place Self-exploratory

10 Visit friends and relatives Social interaction

Part3:Focused on pull factors identified by Crompton (2010) and destination attributes explained by authors that attract tourist to the destination.The pull factors are those deciding factors that makes a medical tourist select a destination of his choice.The study has identified 20 key pull factors contributed by Crompton and selected factors suggested by Crooks (2010) from his research across 348 sources ;Crompton's (1989)push motives are grouped as destination attributes (i)events & activity, (ii) easy access and affordability, (iii)history and culture, (iv)variety seeing, (v)adventure,(vi)natural resources (vii)sight seeing variey,which is adapted from (Mohammed.M , Som. A ,2010) study of pull travel motivations of foreign tourist in Jordan.

S.No Pull factors Destination Attributes

1 Dubai is known for sunshine and beaches Natural resources2 Offers recreational and entertainment

activitiesEvents and activity

3 Destination offers cultural attractions Events and activity4 Cheap airfares to the destination Easy access and

affordable5 History of the location History and culture6 Has good shopping malls Events and activity7 Has a cosmopolitan environment Sightseeing variety8 Sense of luxury Wellness9 Loyalty to the destination Wellness

10 Is a safe and secure destination Easy access and affordable

11 Ease of communicating and no language barriers

Language

12 Offers value for money Easy access and affordable

13 Convenient medical visa is provided Easy access and affordable

14 Religious accessibility Religious

15 Vacation as a part of medical treatment Adventure16 Avoid long waiting time in home country Accessiiblity17 Privacy concern of the procedure Privacy18 Provide good quality of care and service Quality of service19 Credentials of doctors Quality of service20 Offers accommodation to stay Variety seeking

Part 4:Focused on motivating factors as contributed by Smite and Forgione (2007) discussed in the literature and the Supply and Demands model proposed by Heun et al. (2010) where the factors directly or indirectly relate to motivating and influencing the choices of a prospective medical tourist;identifed 25 key motivating factors which are group under 6 attributes: Quality of Care,Potential of Saving,Safety and Security,Hygiene ,Tourism Opportunities and Accessibility.

S.No Motivating factors Attributes

1 Has international standard hospitals with certified doctors and surgeons. Quality of care

2 Has International accreditation like the JCI and reputed hospitals.

3 Has a high success rate of treatments 4 Health care professionals who are fluent in many

languages 5 Coordinate with health care providers at home

country to assure quality of care 6 Guarantee results of treatment and in accordance

to the laws. 7 Equipped with the sophisticated medical

equipment. 8 Fast service and outstanding patient care. 9 Reputed hospital in the country

10 Same medical treatment are much lower cost that home country.

Potential of Saving

11 Desired medical treatment at lower cost that the other destinations.

12 Access to complex procedure that are not available in their country

13 Package promotions on various medical treatments

14 Personalized services or treatment. 15 Has no international conflicts. Safety and

Security16 Provide safe transportation systems e.g bus,

metro 17 Has no epidemic diseases Hygiene18 Has places to visit and tourism opportunities Tourism

Opportunities19 Offers promotions that cover extra services such

as airport pickups and visa extension services.

20 An easy immigration policy Accessibility21 Frequent and direct flights to the destinations 22 Referred by Friends or families /word of mouth 23 No waiting list or delay in treatment 24 Ease of bookings 25 Hospital accept insurance coverage and claims

DIAGRAM

Both primary and secondary data was conducted for the purpose of this study.Wherein questionnaires where used to collect the primary data from the international medical tourist during the time frame that recieved medical treatment at American Hospital,New International Modern Hospital,MEDCARE and City Hospital.On the other hand, this study includes facts and records from reports of hospitals,hospital knowledge bases,articals and journals and website for the secondary data.

The distribution of the questionnaire was with the support of (i)administration staff, international patients officers and concern authorities who were the key contact with foreign patients in the hospital and (ii)travel agencies specializing in medical toursim.Questionnaires were also emailed to current and prospective medical tourist inviting them to complete the online survey .The content of the messages contained primary purpose of the research as well as the confidentiality .

Analysis of the Data:

To data analysis of this research used quantitative analysis.Once the surveying period was over,the results were collected and raw data was imported to MS Excel sheet.The formula that was used to calculate the response and weight age age average of mentioned questions against rankings were done to identify the most important factors were;

Response Rate:

Response Rate = Total No. of Responses / (Sample Size – Ineligible – Unreachable) X 100

Figure 18: Response Rate Formula (Bryman And Bell, 2007, P.104)

Rating Average for each of attributes listed:

Response Average = ({1*(NR) + 2*(NR) + 3*(NR) + 4*(NR) + 5*(NR)} / (Total No. of Respondents) X 100

Figure 19: Rating Average Formula (Akbari, 2010)

NR- Total Number of respondents for each rating scale.

Demographic factors

Studies in the field of tourism and hospitality show little or no significance in the associations between demographics and destination choice (Moshin and Ryan, 2004, Beerli and Martin ,2004).For instance,variables such as age,gender,marital status and incomes were found

to have no significant relationship between the demographic factors and choosing a destination except for income (Moshin and Ryan, 2004).Neverthless, demographic factors were included in this study including country of residence since the survey was published online and promoted and the respondents resided in other countries.

Limitations:

This study was conducted by means of receiving completed questionnaires from international patients of American Hospital,New International Modern Hospital,City Hospital and MEDCARE Hospital as well through online email blasts,hence received many incomplete questionnaires.

Below are problems noted that occurred during the data collection:

Ignorance: Many of the correspondents was not aware of the meaning of medical tourism, so explanation was needed. At times, it was confused by the concept of medical help provided to general tourist and foreigners present during their vacations.

Reluctance: A proportion of the participants, refused to answer or complete the survey. Since they wanted to keep their treatment private and confidential ,thus refused to acknowledge that they were engaged in medical tourism.

Language barrier: The questionnaire could be distribute and completed by only those who were fluent and well versed with English.

Suspicion: This is regarding the doubts respondents had about the real purpose behind the research and the intentions. As well as the identity of the research, since respondents would have felt unsafe in answering about their decisions of seeking treatment via mails.

FINDINGS &RESULTS

This chapter describes on the results and findings from the survey of medical tourist that were seeking their treatment by opting Dubai hospitals for their treatment thereby engaging in medical tourism.The first section explains on the demographics factors of the profile of respondents.Frequencies and percentages described the profile of the respondents based on the procedure selected,age,gender,country of residence and frequency of visit. The second section addressed the finding related to the research questions stated for the purpose of this study.The data was analyzed with the help of an web based response capturing software called Opinionmeter.Wherein the average weight age and ranking of the factors were calculated and later exported to MS.Excel for detailed analysis.The last chapter concludes on the summary of the findings.

A.Demographic Factors:

The demographic questions were included in Part1 of the survey.The international patients were assessed based (i)Procedure selected/seeking (ii)gender (iii)age (iv)country of residence (v)frequency of visit .Table 1.2 presents summarizes demographic characteristics of the respondents.

Table 1.2: Demographic profile of respondents.

Demographic characteristicFrequency (n)

Percent (%)

ProceduresAlternative Medicine 3 4.62%Bariatric 4 6.15%Cardiac 4 6.15%Cosmetic 8 12.31%Dental 10 15.38%Eye Treatment 8 12.31%Laparoscopy 7 10.77%Organ Transplantation 2 3.08%Orthopedic 10 15.38%Oncology 3 4.62%Rehabilitation 6 9.23%

GenderMale 20 30.77%Female 45 69.23%

Age11-20 years 0 0.00%

21-30 years 3 4.62%31-40 years 22 33.85%41-50 years 23 35.38%51-60 years 12 18.46%More than 60 years 5 7.69%

Country of ResidenceAfrica 0 0.00%Cananda 3 4.61%Europe 0 0.00%Russia 0 0.00%South America 0 0.00%South Asia 0 0.00%USA 4 6.15%UAE 0 0.00%UK 1 1.54%Oman 14 21.54%Qatar 16 24.62%Yemen 8 12.31%India 0 0.00%Other Middle East 19 29.23%

Frequency of visitFirst visit 59 90.77%Second visit 6 9.23%More than two times 0 0.00%

The above analysis show that,Respondents (N=65) who completed the questionnaire showed major interest in dental and orthopedic treatment (15.38%) followed by Eye and Cosmetic(12.31%),Laparoscopy (10.77%),Rehabilitation (9.2%),Cardiac and Bariatric(6.15%),Oncology and Alternative Medicine (4.62%) and Organ Transplantation (3.08%).

It is evident that the number of respondents of Females were majority at 69.23% compare to Male respondents at 30.77%.

In terms of the age groups,none of the 65 respondents came from 11-20 age groups.There were 3 respondents (4.62%) who came from the age 21-30 years,22 respondents(33.85%) came from the age group 31-40 years,23 respondents ( 35.38%) came from the age group of 41-50 years, which showed the largest number of response,12 (18.46%) responses came from the age group of 51-60 years and 5 (7.69%) responses came from above 60 years

From the Country of Residence,it is clear that there was no responses came from Africa,Europe,Russia,South America,South Asia,UAE and India.However maximum number of response were from the Other middle east countries (29.23%),followed by Oman (21.54%),Qatar (24.62%) and Yemen (12.31%).Figures show that there were 4 respondents from USA (6.15%),3 from Canada (4.61%) and 1 from UK (1.54%).

Most respondents while answering respondent to be their First Visit (90.77%),few choosed for Second visit (9.23%),and none of the responded had made a visit to Dubai more than two times.

B.Findings Related to the Research Question

Research Question 1.What are the factors that initiate patient to travel abroad and engage in medical tourism in Dubai?

For answering this question ,average weight were calculated to rank the factors in response to the desire that initiate a patient to travel and engage in medical tourism,showing the importance of receiving treatment in the hospital in Dubai.

The respondents (N=65) ranked the factor of offering a sense of fitness and health (R.A= 3.98)as the top most important factor that leads them to engage in medical tourism.Followed by Visiting friends and relatives (R.A =3.78) as the second factor of importance, feeling of prestige (R.A=3.75) as the third important factor and the fourth factor is Improving his appearance (R.A=3.74).The factor of rest and relaxation was rated the fifth (R.A=3.71) ,followed by the factor whether its enhanced the confidence as sixth important (R.A=3.60),and Opportunities for social interaction as seventh important (R.A=3.57).The respondent ranked a chance to visit a new place (R.A=3.40) as the eight factor and the feeling of adventure was ranked ninth in term of importance. (R.A=3.17) and the last factor of importance to the respondents to engage in medical tourism were the feeling of escape from home and mundane environment. (R.A=3.05)

TABLE 1:3

For answering the above questions, respondents had to choose between the scale varying from 5-Very Important to 1-Unimportant amongst 20 decision making and destination attributes

No table of contents entries found. that would influence them in choosing a hospital in as their medical tourism destination.The responses were evaluated by their Rating Average and Ranking of the factors were analyzed below are the findings.

The factors that was ranked No.1 in terms of decision making for a medical tourist is hospitals providing Quality care and service. (R.A=4.95).Credentials of doctors of the hospitals were ranked second by prospective medical tourist (R.A= 4.91).Followed by avoid long waiting times in home country ranked as the third most important factor which influences a medical traveller.(R.A=4.88),hospitals that provided privacy of the procedure as the forth important factor (R.A=4.85) and offers value for money as the fifth important factor (R.A=4.80).Respondents shown influence when a convenient visa is provided as the sixth important factor (R.A=4.72) ,and ease of communicating with no language barriers as the seventh important factors (R.A=4.71).Responded ranked Vacation as a part of medical treatment as eight in impotance (R.A=4.57) ,Cheaper airfares to the destination as ninth in importance (R.A= 4.49) as well as sense of luxury were rated as ninety factor of importance (R.A =4.49),since both received equal number of respondents.The eleventh important factor ranked was safety and security of the destination that influences a patient (R.A.=4.43) and the various offers available for accommodation was ranked as the twelfth important factor (R.A =4.37).Destination that have a cosmopolitan environment was ranked as the thirteen factor of importance (R.A=4.28) and religious accessibility were ranked as well as the thirteen important factor by medical tourist (R.A=4.28).The fifteen factor of importance ranked is the factor that the destination offers recreational and entertainment activities (R.A=3.89) and the destination hold good shopping malls as the sixteen factor rankedv(R.A=3.31),the destination holds cultural attractions as seventeen factors of importance (R.A=3.28).The respondents chosed loyalty to the destination as the nineteen factor that inflenced their decision (R.A=2.65).The last factor of importance were the History of the location (R.A =2.46) which influenced their decision making while selecting their medical tourism destination.

Research Q3:What are the services medical tourists are looking for that motivates them in selecting a destination as a medical tourism destination?

To indentify the motivating factors of medical tourist and the services the choose while selecting a medical toursim destination consists of 25 motivational attributes which are sub divided in 6 factors namely (i)Quality of care (ii)Potential of Saving (iii)Safety and Security (iv)Hygiene (v)Tourism Opportunity (vi)Accessiblity.

Below are the factors ranked based on the priority of Importance selected in the scale of 1-5 by medical travellers.

The motivating factor ranked No.1 in the scale of importance to a medical tourist is No Waiting list or delay in treatment (R.A=4.91).The next ranked important factor is International standards

hospitals with certified doctors and surgeon (R.A= 4.89).The third most important factor is the International accreditation like the JCI and reputed hospitals. (R.A=4.86).Another motivating factor is hospitals providing fast service and outstanding patients care is ranked as forth most important. (R.A.=4.85).The factors ranked 2nd,3rd and 4th all belong to the Quality of care grouping.The fifth important factor that respondents opted is that the same medical treatment are much lower cost than that of home country. (R.A=4.83).Another factors related to potential of saving is ranked as the sixth factor of importance ie. desired medical treatment at lower cost than that of other destinations. (R.A= 4.75)The seventh factor shown to be important is access to complex procedure that are not available in their country.(R.A=4.57). Hospital provinding high success rate of treatments are considered important and ranked eight under motivating factors (R.A.=4.54).The nineth most motivating factor that medical tourist select their destination is the availability of frequent and direct flights to the destination (R.A =4.52).The tenth important factor is the fact that the medical toursim destination is referred by Friends or familers ,or via word or mouth (R.A= 4.45).Another motivating factor is that the hospital must be equipped with sophisticated medical equipment which is ranked as the eleventh factor. (R.A=4.38),with the hospital accepting insurance coverage and claims as the twelfth important factor (R.A=4.35).Ease of booking is yet another important factor under 'Accessibily' that is ranked as the thirteen important factor (R.A=4.32).Additionally,medical tourist opt for an easy immigration policy while selecting their medical tourism desitination which is ranked as fourteen (R.A.=4.15).The fifteen factor is that of healthcare professionals who are fluent in many languages. (R.A=4.11).The sixteen factor is guarantee results of treatment and in accordance to the laws (R.A.=4.06).The seventeen important motivating factors is observed to be places to visit and tourism opportunities (R.A= 3.94).The eighteen factor noted is the presence of promotion offers that cover extra services such as airport pickups and visa extension services. (R.A 3.89).The nineteen ranked important motivating factor for medical tourist is the destination should not have international conflicts. (R.A=3.66).Reputation of the hospital in the country was ranked tweentieth (R.A.=3.52).The fact that personalized services of treatment are offered is ranked the tweentyfirst factor .(R.A=3.40).The factor that there should be a cordination between the health care providers at home country was ranked as tweentysecond factor(R.A=3.18).The tweenty third factor is the destination provided safe transportation systems (R.A=3.11) and no epidemic diseases. (R.A=3.05).The last factor that motivates a medical tourist were package promotions on various medical treaments (2.82).

Conclusion:

This chapter of the study described the data analysis-including modifications made to the questionnaire during the initial phase ,whereby the data collection method principally involved hard copy of survey distributed complemented by Internet survey.

Data gathered from 65 completed questionnaires were included in the analysis.The defined attributes and factors of the research questions were ranked to find their level of importance.

Discussion,Conclusion and Summary

Introduction

Chapter 5 completes this research by stating the findings regarding the testing of the literature framework and models contribute by different authors in the field of medical tourism.The chapter also discussed on the implications of the stud for practitioners.Finally the implication for any future research are also mentioned.

The objective of the study primarily is to determine various motivating ,deciding factors and services that influence international medical tourist to choose hospital in UAE as their medical tourist destination.

Presented below are the research questions that were addressed:

* What are the motivating factors that initiate patients to travel abroad and engage in medical tourism in Dubai?

(Mansfeld, 1992) explains that effective promotion of any tourism destination involves understanding of the perspectives and motivation of the prospective tourist.

The literature indicates a number of factors that influence the motivation levels of a patient to travel and seek treatment from other country. These factors include their attitudes such as issues with cost,waiting time and procedure involved with medical facilities available in home countries (Delinsky, 2005,Awazdi and Panda ,2005).

To identify the motivating factors that patients engage in medical tourism ,this study compared the factors contributed by Crompton (1989) in aspects of psychological or social motives termed as 'push' factors to support the desire to travel to a destination. The results revealed that the 'push factors' is relevant to the motivating factors that engage patients in medical tourism to Dubai.All though all the factors listed are shown to be important by the respondents, sense of fitness and health, visiting friends and relative, prestige and improving appearances are the top four important factors in the list.From the pull factors grouped by Crompton (1989) as (i)escape (ii)self exploratory (iii) relaxation, (iv) prestige, (v) regression, (vi)enhancement of kinship relationships and (vii) social interaction, from this study its identified that 'Relaxation' is the most important psychological factor that urges a medical tourist to travel. There is also a high chance of socially interaction with friends or families that leads to the second factor to travel, followed by the feeling of prestige and enhancement of kinship relations.Thus showing the Dubai ,is successful in attracting patients since its offers a relaxing environment and comfort to it tourist and medical travelers. Where most patients take a vacation

along with undergoing a treatment, thus enabling medical travelers to visit friends, colleagues across the emirate during their visit to Dubai.

* Q2.What are the decision making factors that influence a medical tourist to choose Dubai hospitals as their medical tourism destination?

The literature reveals numerous factors contributing to the decision making process of a medical tourist while selecting a country of his choice for undergoing a treatment.(Crompton, 1992, Hawkin et al. ,2001, Hudson, 1999) mentions that selecting a destination is a multi-step decision making process due to the level of involvement and effort invested by different individuals.

Literature shows that pull factors also known as destination attributes in this study from various sources are more numerous than the push factors.Where the most frequently discussed and identified amongst all the push factors were quality. (Crooks et al, 2010).

To identify the decision making factors that influences a medical tourist to choose Dubai hospitals as their medical tourism destination, this study selected factors suggested by Crooks (2010) from his research across 348 sources and Crompton's (1989)push motives grouped as (i)events & activity, (ii) easy access and affordability, (iii)history and culture, (iv)variety seeing, (v)adventure,(vi)natural resources (vii)sight seeing variey,which is adapted from (Mohammed.M , Som. A ,2010) study of pull travel motivations of foreign tourist in Jordan.

The results indicates that the 'pull factors' is relevant in influencing the patient in selecting hospital in Dubai as their medical tourism destination.

The top five important factors that were ranked by medical tourist in selecting Dubai as their medical tourist destination were: Providing good quality of care and service, credential of doctors, avoiding long waiting time at the home country, privacy concern and offers value for money. It's identified that from the destination attributes quality of service, accessibility, privacy and easy access or affordability were the key areas of interest shown by medical tourist while selecting a destination of the choice. Findings also show that factors such as comfortable in language, medical visa, taking a vacation and feeling of wellness all contributing as influencing or decision making factors while choosing Dubai for treatment.

Thus indicating that Dubai's hospital well furbished as high quality of care,well trained and professional doctors ,along with no delay in treatment contributes to be influencing factors for a medical tourist in selecting their medical tourism destination.

*Q3.What are the services patients are looking for that motivates in selecting a destination as a medical tourism destination?

The literature shows the argument by Smith and Forgione (2007) on country specific characteristics to influence the choice of destinations and factors such as cost,hospital accreditation, quality of care and physician training on the choice of health care facilities (Smith & Forgione, 2007) ,whereas the Heun et al (2010) proposed the Supply and Demand model which directly or indirectly motivates and influence the choices of a prospective medical tourist.

To identify the services patients are looking for that motivates in selecting a destination as a medical tourism destination,the research made use of the above mentioned frameworks that were group under 6 factors namely:Quality of Care,Potential of Saving,Safety and Security,Hygiene ,Tourism Opportunities and Accessibility. (Crouch and Louviere, 2001) suggests that medical tourist assign levels of utility to various attributes which shows more tendency to those attributes to satisfy the tourist needs or motivations.

According to Marlowe and Sullivan (2007)discussed that saving potential is the most important factor in terms of motivation of medical tourist.Such that, medical tourist can sacrifice on other attributes such as quality of care to benefit from saving potential.

The results of the study indicates that the concept of demand model of medical tourism (Heung et al, 2011) and Smith Forgione (2007) is relevant to the demand of medical travel situation in Dubai and motivates a tourist in selecting a destination.

The top five important motivating factors that were ranked by medical tourist in selecting Dubai as their medical tourist destination were: No waiting list or delay in treatment,international standards of hospitals with certified doctors,international JCI accredited hospitals,fast service and outstanding care and same medical treatment with much lower cost that home country.Thus showing the motivation factors group as Quality of care,Accessiblity and Potential of Saving was ranked higher compared to Safety and Security, Hygiene and Tourism Opportunities.

The present study also highlight other motivating attributes such as lower cost of treatment compared to other destinations ,access to complex procedure and high success rate of treatments were respectively the sixth, seventh and eight important motivation attributes when respondents where choosing a medical tourism destination. The factor that there a frequent direct flights to the destination, hospitals were referred by friends and word of mouth, with ease of bookings and insurance covered were other notified motivating factors in selecting Dubai as the medical tourism destination.

Albeit all the factors were important and ranked few medical tourist also show concern for package promotions on treatment, personalized treatments, reputation of the hospital and sophisticated medical equipment which attracted medical tourism is electing Dubai as their medical tourist destination.

Overall, the study shows the Dubai has centered itself in providing High Quality of services to patients, with accredited JCI hospital and qualified doctors, and treatments that affordable compared to the West ,has contributed in attracting a major share of medical tourist from the global market.

Conclusion

Summary

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