the need for better healthcare has grown significantly in recent years , which demands an increasing number of countries started promoting medical tourism ( 1 ) .
furthermore , the rising healthcare costs in the us and in many european countries have forced many patients from these countries to seek medical treatment abroad .
there have been a number of published papers analyzing the travel motivation of the tourists , but most of these studies had focused at tourism in general ( 2 , 3 ) . there is very little literature that specifically looks at medical tourism . due to the limited literature and empirical evidence on the topic
, this study believes that , other related studies focusing on the tourist s motivation and criteria of selecting the destination would offer some constructive insights and information on the factors influencing the patients perception in selecting their medical tourism destinations .
moreover , the academic era still lacks in apparent idea and concrete definition of medical tourism . even though , few studies have proposed medical tourism framework ( 46 ) , however , the evidence is not adequate .
realizing the current need to examine closely the perception of medical tourists , this study aims to present the theoretical and empirical literature on medical tourists perception in selecting their medical tourism destinations .
in addition , this study aims to propose a concrete framework for medical tourism , which will significantly contribute to the academic era .
medical tourism may be defined as the deliberate attempt on the part of a tourist facility ( e.g. hotels ) or destination to attract tourists by promoting healthcare services and facilities in addition to regular tourist amenities ( 7 ) .
medical tourism is a form of cost - effective private medical care for patients mostly from developed countries who need surgical and other forms of specialized treatment ( 8) .
another study elucidated medical tourism as the combination of products and services intended to encourage patients in preserving and maintaining their health through a mixture of vacationing and other form of recreational activities in a different location other than home ( 9 ) .
one more study classified medical tourism as the movement of a patient for getting services that help in recovering his illness , outside his own country for a period of time not less than 24 hours and up to one year , and the patient has no intent to work or reside permanently ( 10 ) .
medical tourism usually describes the phenomenon of the people from different countries traveling for medical services to other countries ( 11 ) .
medical tourism refers to patients who travels abroad in order to obtain health services where the motives for going abroad range from lower cost , higher quality , or faster treatment as well as to receive services those are unavailable in their country of residence ( 12 ) .
thus , medical tourism can be defined as a way of obtaining quality treatment in a foreign country with an affordable cost while the patient may also get the pleasure from a beautiful holiday .
further study suggested that , while planning for medical tourism , cost should be an important consideration ( 13 ) .
cost is the main motivating factor among others ( e.g. long waiting time at home ) while patients travel for medical care outside of their home country ( 14 ) .
cost is the only factor for the us patients for preferring medical tourism and the current economic recession has further fueled this escalation ( 15 ) .
as the cost of healthcare in the us is excessively soaring , many employers together with the insurance companies prefer medical tourism as an option in lowering healthcare costs ( 16 ) . to be financially benefitted from this emerging market , a large number of countries around the globe are promoting medical tourism ( 11 ) .
most important thing for these countries involved in medical tourism is that , they offer premium medical services at significantly lower prices , which has become the major motivation for the patients in traveling abroad for the intention of treatment ( 1 ) .
a recent study have found that , surgery is 30% to 70% lower in the countries those are promoting medical tourism than in the us ( 4 ) . in some cases ,
this is up to 80% ( 17 ) ) . a price comparison between u.s . and
other selected countries are provided in table below : in this rapidly growing consumer - oriented health industry , quality has become the integral part . without providing quality services ,
people from rich countries are traveling to less developed countries because of less expensive but high quality medical care ( 18 ) .
one study focused on two major components of the service quality in the health care sector : one is technical or mechanical quality and another is serviceable or functional quality ( 19 ) . in the healthcare industry , technical equipments and other related medical diagnoses systems are core for patients check up for their treatment and functional quality measured by the service offer by the healthcare centers such as services of staffs , nurses , administrations and most importantly the doctors towards the patient and their assistants .
it has been found from different healthcare researches that , patients mostly give priority to the functional quality rather than the technical quality though the technical quality may not be satisfactory ( 20 ) .
however , for the medical patient , the technical quality should be a prime object because the proper treatment of patients largely depends upon the proper diagnoses of the diseases .
service quality works as a suspension bridge , which hangs within customer , and organization , thus , shows the valuable exchange among them ( 21 ) .
service quality is  a global judgment or attitude relating to the overall excellence or superiority of the service  ( 22 ) .
understanding of the customer s requirements has become necessity as this helps the practitioners in developing new approaches to provide improved service quality ( 23 ) .
the service quality in healthcare industry is a vital part for attracting customer as in the healthcare industry , patient perceptions are measured through the quality of services provided by a healthcare centre ( 24 , 25 ) .
thus , delivering quality services to the customers is necessary in order to meet customers perception ( 22 ) .
one of the fundamental barriers in medical tourism is the perception of inadequate quality ( 1 ) .
thus , employing proper marketing strategies and improvements in quality through accreditation from an internationally recognized institution is a key to overcoming this barrier .
this confidence increases if accreditation is accompanied by an affiliation with prestigious hospitals or health care systems in industrial countries ( 26 ) .
the intending medical tourist should check whether or not a hospital is wholly accredited by an international accreditation group , or if it is only partly accredited ( e.g. for infection control ) ( 27 ) .
once healthcare providers are accredited and part of international referral networks , they can be properly rated for risks and consequently , helps in building confidence among the potential medical tourists ( 28 ) .
types and availability of various types of treatments are also an important factor in selection of medical tourism . medical tourism is a procedure that are routinely covered by health care benefits ( e.g. , knee replacement surgery ) and elective cosmetic surgery ( e.g. , abdominoplasty ) , which includes unique travel opportunities ( e.g. , surgical safari ) , or cosmetic dentistry and reproductive tourism ( e.g. , in vitro fertilization ) ( 29 ) .
however , medical tourism is not limited to few specific treatments as a wide range of treatments can be obtained through medical tourism ( 26 ) .
medical tourism involves a wide range of therapeutic treatments ranging from various essential treatments to different sorts of traditional and alternative treatments ( 1 ) .
further study have added that ,  a specialized subset of medical tourism is reproductive tourism and reproductive outsourcing , which is the practice of traveling abroad to undergo in - vitro fertilization , surrogate pregnancy and other assisted reproductive technology treatments including freezing embryos for retro - production  ( 30 ) .
moreover , citizens of england and other european countries are traveling both within the european union and to asia for various medical and surgical procedures , which are not available in their home country ( 31 ) .
 patients generally seek medical care abroad for one of two reasons : either they do not have access to a particular treatment , or they can not afford it , in their own country  ( 11 ) .
american patients travel to foreign locations due to lack access to unproven medical therapies such as stem cell or cytoplasmic transfer therapy ( 32 ) .
access , rather than the cost has been the major factor for the increase of medical tourism ( 33 ) .
lack of access , either because the technology is not available , or is prohibited or illegal in the home country , can lead to medical tourism ( 34 ) .
study conducted on asia have found that , thailand has become increasingly popular destination for a wide range of medical procedures , such as cosmetic surgery , dental work , hip and knee replacements , back surgery and for some unproven medical surgery ( e.g. sex change ) ( 35 ) .
low cost compiled with other factors such as technological capability , government s inventiveness and promotional campaigns in developing healthcare facilities and qualified workforce coupled with the natural resources like beaches , greens have built the confidence of many developed world patients to visit foreign locations for medical procedures .
the ever - increasing media coverage on the satisfaction of the patients who were treated outside the us in the last few years also attracted a large of us patients to seek treatments abroad ( 36 ) .
moreover , due to the tremendous development in ict , information regarding the medical procedures is now readily available and easily accessible .
in addition , internet - based marketing and promotional campaigns by hospitals and travel agencies have boosted the confidence of the foreign patients as they can get their needed information much easily and quickly ( 13 ) .
thus , internet has enabled a significant cost savings for both the patients and the hospitals ( 33 ) . from the above - discussed literature , this study has proposed the following conceptual framework .
medical tourism may be defined as the deliberate attempt on the part of a tourist facility ( e.g. hotels ) or destination to attract tourists by promoting healthcare services and facilities in addition to regular tourist amenities ( 7 ) .
medical tourism is a form of cost - effective private medical care for patients mostly from developed countries who need surgical and other forms of specialized treatment ( 8) . another study elucidated medical tourism as the combination of products and services intended to encourage patients in preserving and maintaining their health through a mixture of vacationing and other form of recreational activities in a different location other than home ( 9 ) .
one more study classified medical tourism as the movement of a patient for getting services that help in recovering his illness , outside his own country for a period of time not less than 24 hours and up to one year , and the patient has no intent to work or reside permanently ( 10 ) .
medical tourism usually describes the phenomenon of the people from different countries traveling for medical services to other countries ( 11 ) .
medical tourism refers to patients who travels abroad in order to obtain health services where the motives for going abroad range from lower cost , higher quality , or faster treatment as well as to receive services those are unavailable in their country of residence ( 12 ) .
thus , medical tourism can be defined as a way of obtaining quality treatment in a foreign country with an affordable cost while the patient may also get the pleasure from a beautiful holiday .
further study suggested that , while planning for medical tourism , cost should be an important consideration ( 13 ) .
cost is the main motivating factor among others ( e.g. long waiting time at home ) while patients travel for medical care outside of their home country ( 14 ) .
cost is the only factor for the us patients for preferring medical tourism and the current economic recession has further fueled this escalation ( 15 ) . as the cost of healthcare in the us is excessively soaring , many employers together with the insurance companies prefer medical tourism as an option in lowering healthcare costs ( 16 ) . to be financially benefitted from this emerging market ,
a large number of countries around the globe are promoting medical tourism ( 11 ) .
most important thing for these countries involved in medical tourism is that , they offer premium medical services at significantly lower prices , which has become the major motivation for the patients in traveling abroad for the intention of treatment ( 1 ) . a recent study have found that , surgery is 30% to 70% lower in the countries those are promoting medical tourism than in the us ( 4 ) . in some cases ,
this is up to 80% ( 17 ) ) . a price comparison between u.s . and
in this rapidly growing consumer - oriented health industry , quality has become the integral part . without providing quality services ,
people from rich countries are traveling to less developed countries because of less expensive but high quality medical care ( 18 ) .
one study focused on two major components of the service quality in the health care sector : one is technical or mechanical quality and another is serviceable or functional quality ( 19 ) . in the healthcare industry , technical equipments and other related medical diagnoses systems are core for patients check up for their treatment and functional quality measured by the service offer by the healthcare centers such as services of staffs , nurses , administrations and most importantly the doctors towards the patient and their assistants .
it has been found from different healthcare researches that , patients mostly give priority to the functional quality rather than the technical quality though the technical quality may not be satisfactory ( 20 ) .
however , for the medical patient , the technical quality should be a prime object because the proper treatment of patients largely depends upon the proper diagnoses of the diseases .
service quality works as a suspension bridge , which hangs within customer , and organization , thus , shows the valuable exchange among them ( 21 ) .
service quality is  a global judgment or attitude relating to the overall excellence or superiority of the service  ( 22 ) .
understanding of the customer s requirements has become necessity as this helps the practitioners in developing new approaches to provide improved service quality ( 23 ) .
the service quality in healthcare industry is a vital part for attracting customer as in the healthcare industry , patient perceptions are measured through the quality of services provided by a healthcare centre ( 24 , 25 ) .
thus , delivering quality services to the customers is necessary in order to meet customers perception ( 22 ) .
one of the fundamental barriers in medical tourism is the perception of inadequate quality ( 1 ) .
thus , employing proper marketing strategies and improvements in quality through accreditation from an internationally recognized institution is a key to overcoming this barrier .
this confidence increases if accreditation is accompanied by an affiliation with prestigious hospitals or health care systems in industrial countries ( 26 ) .
the intending medical tourist should check whether or not a hospital is wholly accredited by an international accreditation group , or if it is only partly accredited ( e.g. for infection control ) ( 27 ) .
once healthcare providers are accredited and part of international referral networks , they can be properly rated for risks and consequently , helps in building confidence among the potential medical tourists ( 28 ) .
types and availability of various types of treatments are also an important factor in selection of medical tourism . medical tourism is a procedure that are routinely covered by health care benefits ( e.g. , knee replacement surgery ) and elective cosmetic surgery ( e.g. , abdominoplasty ) , which includes unique travel opportunities ( e.g. , surgical safari ) , or cosmetic dentistry and reproductive tourism ( e.g. , in vitro fertilization ) ( 29 ) .
however , medical tourism is not limited to few specific treatments as a wide range of treatments can be obtained through medical tourism ( 26 ) .
medical tourism involves a wide range of therapeutic treatments ranging from various essential treatments to different sorts of traditional and alternative treatments ( 1 ) .
further study have added that ,  a specialized subset of medical tourism is reproductive tourism and reproductive outsourcing , which is the practice of traveling abroad to undergo in - vitro fertilization , surrogate pregnancy and other assisted reproductive technology treatments including freezing embryos for retro - production  ( 30 ) .
moreover , citizens of england and other european countries are traveling both within the european union and to asia for various medical and surgical procedures , which are not available in their home country ( 31 ) .
 patients generally seek medical care abroad for one of two reasons : either they do not have access to a particular treatment , or they can not afford it , in their own country  ( 11 ) .
american patients travel to foreign locations due to lack access to unproven medical therapies such as stem cell or cytoplasmic transfer therapy ( 32 ) .
access , rather than the cost has been the major factor for the increase of medical tourism ( 33 ) .
lack of access , either because the technology is not available , or is prohibited or illegal in the home country , can lead to medical tourism ( 34 ) .
study conducted on asia have found that , thailand has become increasingly popular destination for a wide range of medical procedures , such as cosmetic surgery , dental work , hip and knee replacements , back surgery and for some unproven medical surgery ( e.g. sex change ) ( 35 ) .
low cost compiled with other factors such as technological capability , government s inventiveness and promotional campaigns in developing healthcare facilities and qualified workforce coupled with the natural resources like beaches , greens have built the confidence of many developed world patients to visit foreign locations for medical procedures .
the ever - increasing media coverage on the satisfaction of the patients who were treated outside the us in the last few years also attracted a large of us patients to seek treatments abroad ( 36 ) .
moreover , due to the tremendous development in ict , information regarding the medical procedures is now readily available and easily accessible .
in addition , internet - based marketing and promotional campaigns by hospitals and travel agencies have boosted the confidence of the foreign patients as they can get their needed information much easily and quickly ( 13 ) .
thus , internet has enabled a significant cost savings for both the patients and the hospitals ( 33 ) . from the above - discussed literature , this study has proposed the following conceptual framework .
as this is solely a secondary based study , this study have accessed both online and print versions of various academic journals , online databases ( e.g. scopus , directory of open access journals ( doaj ) , econlit , proquest , ebscohost , science direct , web of science ) , newspapers , books and other related materials to collect data for assessing and identification of the main factors regarding the patient s perception and selection criteria by the medical tourists .
however , few data were also considered from this exclusion criteria due to their enormous relativity to this study .
grounded on extant literature , a conceptual model as well as a definition of medical tourism is proposed using data and information covering the main attributes of medical tourist s perception in selecting their medical tourism destination .
this study examined the relations between the key elements of medical tourist s perception and its impact on destination selection .
basing on the theories and other related studies on tourist s perception and motivation has confirmed that , cost , service quality , treatment types and availability ; lack of access to particular treatment and impact of marketing influence significantly the medical tourist s perceptions in selecting the destination .
the findings also help in understanding the fundamental relationships among the variables and enhancing the knowledge for the hospital management to determine where they should concentrate to accomplish their business goals . to be competitive in an ever - increasing healthcare industry ,
hospitals those are promoting medical tourism , need to emphasis on the quality , marketing , and various treatment offerings with relatively lower costs for the procedures .
it can be concluded that customers are the key for the business success of the hospitals .
therefore , it can be suggested that , an effective marketing policy will influence the future customers that , in turn , will enhance the revenue of the hospitals .
there is also an urgent need for quality healthcare for any citizens of the society .
therefore , understanding this need of customers is crucial for the hospital management . failing to meet or exceed customers quality needs is not an option for any health service providers .
therefore , developing a measure that systematically weighs health service quality could significantly contribute towards service improvement .
therefore , further study need to be conducted to test and validate the proposed framework of this study .
nevertheless , this study offers support for the proposed conceptual model and an empirical basis for comparison in future research .
ethical issues ( including plagiarism , informed consent , misconduct , data fabrication and/or falsification , double publication and/or submission , etc ) have been completely observed by the authors .
 background : the need for better healthcare has grown significantly in recent years . in addition , the rising healthcare costs in the u.s . and in many european countries have forced many patients to seek medical treatment abroad , which has created the demand for medical tourism . with little yet known as to the perception of a medical tourist s destination selection , this study aims to explore medical tourist s perception in selecting their destination while going for medical treatment.methods:realizing the current need to examine closely the perception of medical tourists , this study had conducted a secondary study to collect data for assessing and identification of the key factors on patient s perception and destination selection criteria.results:the result confirms the existence of a very strong relationship between cost , service quality , treatment types and availability and marketing impact on the perception of the medical tourists in selecting their medical tourism destination.conclusion:this study offers support for the proposed conceptual model and an empirical basis for comparison in future research . 
Introduction
Literature Review
Cost
Quality
Treatment Types and Availability
Lack of Access to Particular Treatment
Marketing Impact
Methods
Results and Discussion
Conclusion and Limitations
Ethical Considerations