The Definition Of Medical Tourism Tourism Essay

Published Date: 23 Mar 2015

This section addresses the various definitions of medical tourism, the attributes of medical treatments and health treatments, the medical tourism market, and the globalization of medical tourism. Reviewing these subjects is vital to have a better understanding of the development of medical tourism.

3.1.1 The Definition of Medical Tourism

There is no specific definition that describes medical tourism (Lee & Spisto, 2007; Garcia-Altes, 2005). Lee and Spisto (2007) have defined medical tourism in a simple context as a "travel activity that involves a medical procedure or activities that promote the well being of the tourist". Medical industry practitioners have defined medical tourism as the act of travelling beyond a home country to receive a healthcare treatment that is either less expensive or more accessible (Kim, Leong, Heob, Anderson, & Gaitz, 2009). The most appropriate definition for medical tourism, illustrated by Bookman and Bookman‟s (2007, p. 1) study, claims that it is "an economic activity that entails trade in services and represents the splicing of at least two sectors: medicine and tourism". Jagyasi (2008) has defined the two terms "tourism" and "medical" individually in order to establish a suitable definition for medical tourism; he also reviews the concepts of tourism and medical treatments and concludes that combining the two definitions to understand the attributes of medical tourism is not enough because the medical tourism industry includes various activities and further procedures that play a primary role in creating medical services for international patients. In this sense, medical tourism can be defined as a "set of activities in which a person travels often long distances or across the border, to avail medical services with direct or indirect engagement in leisure, business or other purposes" (Jagyasi, 2009, p. 1).

3.1.2 The Attributes of Medical Treatments and Health Treatments

In 2006, a report was released by Tourism Research and Marketing (TRAM), suggesting that combining the two terms "medical treatments" and "healthcare treatments" would create a new sector of the medical healthcare sector entitled "medical and healthcare tourism (Lee & Spisto, 2007)." TRAM‟s report explains and places the components of medical and healthcare treatments into four categories: treatment of illnesses, enhancement, wellness, and reproduction (Lee & Spisto, 2007). According to Lee and Spisto‟s study (2007), the treatment of illness represents a wide range of services that vary from a simple healthcare service that can be provided by local health professionals, such as vaccines, therapy treatments, and nutrition to a complex surgical procedure such as a heart transplant. Enhancement procedures represent procedures that are non-disease related, (unless some disease has caused a change in the formation of the human body). However, these kinds of procedures require the work and ability of a skilled and qualified physician who will, for example, conduct a cosmetic procedure such as, breast surgery, facelift, liposuction and cosmetic dental work (Lee & Spisto, 2007). Wellness falls under the heading "alternative healthcare services" such as, spas, acupuncture, aromatherapy, beauty care, facials, exercise and diet, herbal healing, homeopathy, massage, and yoga. These healthcare products are usually operated by professionals who are accredited by local or international organizations and health associations. However, these healthcare activities cannot be determined as medical tourism activities, because most of wellness procedures do not require skilled medical practitioners (Lee & Spisto, 2007).

Reproduction is a new area in medical tourism. Some patients are travelling offshore in search of fertilization procedures. According to Lee and Spisto‟s (2007) study, fertility procedures are illegal in some countries, prompting other countries, like Israel, to provide these surgeries for international patients at attractive costs (Steiner, 2009). Furthermore, birth tourism has been utilized under the category of reproduction tourism, which means that some mothers travel abroad to a foreign country for the purpose of achieving citizenship for their children. As a result, any medical treatments that require the services of trained and qualified practitioners or physicians, licensed facilities, transportation, cultural interaction, and accommodations should be underlined as a form of medical tourism (Lee & Spisto, 2007).

3.1.3 The Medical Tourism Market

Now that we have explained the attributes of medical tourism, identifying the characteristics of the medical tourism market is also essential in order to gain a further understanding of the international market for medical tourism. Cateora and Graham (2005, p. 10), who make distinctions between local and international markets, argue that the international market can be viewed as "business activities designed to plan, price, promote, and direct the flow of an organization's goods and services to consumers in more than one country for profit." In this sense, it can be argued that operating under the medical tourism model, and offering services to patients who are from other countries, can contribute to the benefit of other industries, including those of tourism and travel. The globalization of medical tourism can be explained using Bookman and Bookman's (2007) study: i.e., as a reality that is evolving gradually thanks to the rapid growth of international trading in services such as tourism products, flight tickets, law consultations, etc. Furthermore, Hudson (2009) reviews the two concepts of marketing and international marketing to determine the major factors that drive the globalization of tourism products. Marketing can be described as "the process of planning and executing the conception, pricing, promotion, and distribution of ideas, goods, and services to create exchanges that satisfy individual (customer) and organizational objectives" (Hudson, 2009, p. 12).

According to this idealistic description of the concept of marketing, medical products such as medical tourism packages, medical equipment and medical services can be promoted, transferred and distributed by certain bodies for a particular location with the express purpose of benefitting practitioners, facilitators, medical institutions and patients.

3.1.4 The Globalization of Medical Tourism

The wide expansion of the global market allows some international organizations to be established in order to prevent malpractice and raise awareness of best business practices that sustain incentive growth and respond directly to future demands. For example, the General Agreement on Trade in Services (GATS) was established in 1995 by the World Trade Organization and the Council for Trade in Services. The aim of this agreement is to create policies, standards, and regulations that encourage the development of international trade in services between countries. These foundations create a safe environment for global trade in services, allowing developing countries to benefit from their developed counterparts through the exchange of information, ideas and technology. Therefore, some developing countries such as Jordan, Singapore, and India have recruited skilled physicians who have obtained their degrees in the western world and returned to their home countries to practice their profession (Lambier, 2009). This is a general trend in healthcare and medical education by which developing countries provide physicians and developed countries provide consultations and education in best medical practices. Thus, international patients seeking to travel to developing countries for medical services could be viewed as people seeking adequate medical procedures. However, medical tourism cannot enter the global market, and services cannot be traded safely, unless there is a global market environment that allows trust to be established between developing and developed countries (Bookman & Bookman, 2007). Cateora and Graham (2005) have constructed a framework that demonstrates the environment of the global market. The framework contains three overlapping circles. The inner circle represents the controllable elements that impact a service provider decision (e.g., price, product, promotion, research, and channel of distribution). The second circle represents the internal local environment that has a direct impact on the foreign operation's decisions. These local environmental elements include the competitive structures of the local market, political and legal forces, and/or economic climates. The third circle represents the uncontrollable elements, namely, cultural forces that influence the life style of the local population (i.e. Jordanian citizens like to visit family and relatives on Friday), geography and infrastructure, structure of distribution, level of technology, competitive forces, and economic forces.

These elements cannot be controlled by a service provider because they represent the external market in different countries where foreigners do not have the authority to change their policies, standards, or regulations. To overcome these uncontrollable elements, service providers must work with the requisitions and standards of the external market.

Horowitz and Rosensweig (2007) argue that certain countries, namely those which put confidentiality and privacy as a first priority for patients seeking sex changes, plastic surgery, or drug rehabilitation, offer attractive medical destinations for North American patients who are looking for privacy somewhere outside their home country. In the case of medical tourism, the international market often leads patients to travel abroad to a medical destination in order to receive a medical service for a lower price. Facilitators who work to promote a medical facility at a particular destination should understand the internal medical policies and standards, the international medical policies and standards, and the market policy and standards. Nath (2007) argues that the US market is a highly regulated industry that is full of rules, standards and regulations. In this market, foreign tourism operators and facilitators looking to attract American patients should have an in-depth knowledge of up-to-date medical regulations in order to target the US market. The global medical tourism market (GMT) is a confluence of such factors as medical and healthcare development, information technology and local law, economics and politics. These factors can be considered as barriers for many medical destinations to reaching an external market such as the US, unless these medical destinations modify their medical regulations, standards, and polices to match those regulations existing in the US market. To this end, Jagyasi (2009) suggests that the international community should agree on an organization that is able to develop rigorous international policies and standards to motivate medical facilities around the world to become part of the global medical tourism market.

To adapt and better reflect large, global trends, the development of the medical tourism sector on a greater scale by medical and tourism stakeholders could incorporate more factors that play a primary role in enhancing the medical tourism market at a particular location for promoting extensive medical services (Garcia-Altes, 2005). Some of these factors include lifestyle changes. For example, the rapid growth of the earth's population is prompting the creation of new models of medical facilities and procedures including retirement communities, fitness centers and cosmetic surgeries. These new models of medical and healthcare facilities are being established by local or international investors according to the market demands. Also, what could further motivate patients to travel abroad is to experiment with new tourism models. Medical tourism offers incentive opportunities such as interacting with local culture, visiting historical sites, and visiting relatives and friends. These opportunities could be attractive for foreign patients that are interested to receive adequate medical treatments and visit some tourism attractions. The limitations of domestic medical services, the lack of medical insurance, the length of local waiting lists, and the high costs at home have forced patients to travel abroad in search of adequate medical treatments that offer a high quality of medical service at low costs. For instance, Malaysia has focused on developing the quality of its healthcare, realizing that to enter the global market requires fulfilling certain requirements. To that end the government has initiated a collaboration strategy to promote the medical tourism sector in Malaysia as one piece (Garcia-Altes, 2005). Local health providers and government agencies cooperate together in order to provide excellent healthcare services for foreign patients. On the other hand, hotels have integrated with hospitals and medical facilities to provide incentive healthcare packages at attractive costs, which will play a crucial role in the marketing campaign that will reach new markets in North America and Eastern Europe.

3.1.5 The Service Groups Marketing of Medical Tourism Sector

The service groups that market medical tourism must accomplish specific procedures in order to successfully deliver a medical tourism product to international patients. A medical tourism product can be defined as a medical service enhanced with tourism values for foreign patients and provided by licensed physicians and includes check-ups, health screenings, dental treatments, joint replacements, heart surgery, etc (Bookman & Bookman, 2007). However, delivering a medical tourism product to international patients relies on certain procedures and methods that can be effectively described in the "service marketing triangle" (Zeithaml & Bitner, 2000, p. 16) (see figure 1). The purpose of the triangle is to illustrate three interconnecting groups that work simultaneously to develop, promote and deliver services for the company, the customer, and the provider. Since medical tourism products fall under the services industry, the triangle form can be applied to the medical tourism sector to illustrate the three interconnecting groups that come together to stage a medical product in the global market. In the context of medical tourism, the triangle form represents three interconnected groups: medical facilities, physicians, and foreign patients. Between each group there are three different types of marketing: internal, interactive, and external marketing; all three types of marketing are important for creating and maintaining long-term relationships among one another (Zeithaml & Bitner, 2000).

The first type of marketing is external marketing, which represents how a medical facility makes promises based on what a patient is expecting and what else could satisfy a patient's desire. The goal is to build long-term relationships with patients, and the payoff will be repeated visits to the same medical destination. The second form of marketing represents keeping promises - this type of marketing occurs in the "moment of truth" (Hudson, 2009), when the patient interacts directly with the medical facility and the service at this instant will be produced by the medical facility and consumed by the patient. However, there is a cumulative amount of services provided by the medical facilities and each service adds a new experience that contributes to the patient's overall satisfaction; the payoff will be the desire to do business with the same medical facility. Ultimately, the last form of marketing is internal marketing that represents enabling promises. In this stage of the services marketing triangle, Hudson (2009, p. 16) mentions that "promises are easy to make, but unless providers are recruited, trained, provided with tools and appropriate internal systems, and rewarded for good services, the promises may not be kept." In this sense, the medical tourism sector should be built on solid foundations, on rigorous regulations, quality of care, professional licensing, technological capabilities, infrastructures, connection with international medical institutions, superstructures, and governmental involvement (Garcia-Altes, 2005). Garcia-Altes (2005) argues that achieving these elements is important for providing foreign patients with responsible medical treatments; this means that medical treatments should be subjected to certain laws and standards that eliminate malpractices and protect the patient's rights By being careful and by paying attention to these basic foundations, practitioners and their facilities will build reliable bridges toward sustainable growth by securing and ensuring repeat-visits and referrals and through the cultivation of a world-wide reputation (Garcia-Altes, 2005).

Figure 1: The Services Marketing Triangle of the Medical Tourism Industry

3.2 Medical Tourism Factors

There are several factors (internal and external) that force patients to pursue medical tourism as an alternative medical treatment. For example, American patients are willing to travel offshore to receive medical services that suit their health budgets (Smith & Forgione, 2007). In response to this, several American hospitals participating with the US Senate have established a committee that is obligated to conduct a survey to identify the factors driving American patients to seek medical treatments abroad (US Senate, 2006). These factors were applied in Palvia's work (2007) in two stages. The impact of each factor cannot solely be responsible individually for affecting a patient's decision. Furthermore, these factors (internal and external) impact the patient's decision simultaneously for selecting the most appropriate medical facility. Hence, these factors are categorized into two stages: choice of an international country location, and choice of an international medical facility (Smith & Forgione, 2007).

The first stage includes external factors (see figure 2), represents economic conditions, political climate, social behaviour and regulatory standards. The economic stability of, both the medical facility and the host country are attractive for American patients (Blesch, 2007).

Dubai, for instance, is capitalizing on its own economy by constructing a healthcare city that is ready to respond to the rapid growth in numbers of international patients (Dubai-Healthcare-City, 2010). The city's medical assets and updated technologies are heavily advertised (visit, http://www.dhcc.ae/). In terms of political culture, most patients are only attracted to regions where safety is a high priority in the host country, and where the political system is protected from corruption and violence (Smith & Forgione, 2007). In terms of social behaviour, the local residents perceptions about tourism in general and medical tourism in specific play a primary role for attracting foreign patients. According to Smith and Forgione (2007), foreign patients like to travel to destinations where they can feel welcomed by the local community and travel around the countries without limitations. In terms of regulatory standards, American patients often care about the regulations and laws of the host country (Smith & Forgione, 2007). For example, the US healthcare system provides protection for American patients through its Health Insurance Portability and Accountability Act of 1996 (HIPAA). Therefore, American patients travelling abroad are looking for a similar protection of privacy concerns, something that will provide assurances of confidentiality regarding their medical documents, reports and procedures. In addition, American patients feel more secure with doctors who are covered by insurance companies preventing malpractice. The main purpose of the insurance company is to "cover doctors and other professionals for liability claims arising from the treatment of patients" (Insurance Information Institute, 2007). By law, each physician in the United States is forced to have insurance coverage for liability and malpractice (Insurance Information Institute, 2007).

Internal factors are the second stage in Palvia's work (2007), which represents four factors affecting a patient's choice of an international medical facility. These factors are identified as costs, accreditation, quality of care, and physician training (see figure 3). The first factor is cost. According to some statistics (Insurance Information Institute, 2007), the number of uninsured Americans in healthcare exceeded 46 million in 2005, which means that Americans who are not covered by a health insurance plan will pay a significant amount of money to be medically treated, while insured Americans have access to medical facilities with low fees. However, despite this rapid growth in uninsured American patients, The World Bank has outlined that the medical industry in the United States is excessively expensive and higher than in any other country in the world. For example, the manager of Bumrungrad Hospital in Thailand has estimated charges of medical services in his/her country as costing as little as one-tenth of American fees (Tasker, 2000). The lower costs to medical services in developing countries are cited in Smith and Forgione's study as due, in part, to lower labour costs, lower pharmaceutical costs, and no malpractice insurance costs. The second and third factors in Palvia's work are hospital accreditation and quality of care. Likely the first thing that comes to an American patient's mind is the qualifications or reputation of the hospital. Most American patients are more attracted to hospitals that work with similar standards in the quality of care to the ones in the United States. In many cases, hospitals in developing countries are equipped with advanced technology and trained practitioners that exceed western standards and expectations. The World Bank has conducted a study that clearly shows that healthcare quality in developing countries is "above the minimum acceptable standards in industrial countries" (Matto & Rathindran, 2005). An international health organization such as the Joint Commission of Accreditation for Healthcare Organizations (JCAHO) was established to evaluate and accredit healthcare facilities and organizations in order to improve the safety and quality medical services around the globe (Joint Commission International, 2007).

Palvia's last factor is physician training. A hospital without properly trained practitioners will not be as attractive as a medical facility with skilled physicians for North American patients. Consequently, developing countries provide incentive work opportunities within the medical industry given that they attract international doctors, some of whom are trained in western hospitals. Now, international medical facilities offer complex surgeries that compete with other facilities in terms of costs and quality (Marlow & Sullivan, 2007). Despite this, however, hospitals around the globe are attempting to enhance the communication technologies between medical facilities in order to connect all trained physicians within one network. This plan will help patients in their selection of whom they deem to be the most appropriate physician to preside over their surgery (Smith & Forgione, 2007, p. 27).

Adding to the above factors, Reisman (2010), in his study "Health Tourism", argues that despite the cost and quality of services, there are several factors that motivate individuals to travel abroad seeking medical services. These factors can be categorized into age, gender, race, and income. A study was conducted by Deloitte (2008) that surveyed 3000 Americans between the ages of 18-75 in 2008 and strived to determine how many people are able to take a risk and consider an elective procedure abroad; the study shows that 51.1 per cent of young Americans were willing to travel abroad for medical services, while 29 per cent of over-62s Americans were interested in receiving medical services from abroad. In terms of gender, 44.5 per cent of the males would travel abroad for medical services while 33.3 per cent of the females would do so. Regarding race, the study shows that 56.8 per cent of Asians and 51.1 percent of Hispanics thought that travelling abroad for medical services is feasible, while Caucasian Americans seem to be more conservative than other races with 37.8 per cent saying they would try it. Because many Asians and Hispanics living in North America view medical tourism as a great opportunity to visit relatives and friends back home they were, to a larger extent, more open to travelling abroad. On the issue of income, another study was published by International Medical Travel Journal (2008). The study shows that income can be a primary factor motivating Americans to travel abroad for medical treatments. About 30 per cent of the Americans who stated that crossing a border for medical services is a decent option, had an annual income of US$150,000 or more, while 23.7 per cent of Americans who make US$90,000 and less were not interested in crossing the border for medical services (International Medical Travel Journal, 2008). Such factors (age, gender, race, and income), of course, can impact the patient before he or she takes the first step to cross the border for medical services. Furthering this, Smith and Forgione (2007) determined the factors that impact a patient's choice of medical destination and medical facility (see figure 3).

Figure 3: Internal Factors

Source: (Smith and Forgione, 2007, p. 22)

Outlining the major factors that force American patients to travel abroad for adequate medical services is important for determining in which areas medical tourism has grown. Hospitals and practitioners are tracking the evolution of medical tourism and how this new economic force is impacting the medical industry in the United States. According to 2008 statistics (Medical Tourism Magazine, 2010), the US exported over 750,000 patients. For this reason, North America has been recognized as an attractive market for developing countries like India, South Africa, and Singapore, which are developing their own medical tourism sectors. As developing countries are increasingly involved in the global market of services, each country should implement the basic foundations of a medical tourism sector (economic stability, social stability, and political stability) in order to improve its ability to host even more foreign patients (Hudson, 2009). Therefore, this paper attempts to define all the major factors that motivate foreign patients to seek medical tourism as an alternative medical treatment. Outlining the major factors will help to identify the role of medical tourism stakeholders for developing the medical tourism sector according to these factors that help to make medical tourism more appealing for foreign patients as an alternative medical service.

3.3 Medical Tourism Stakeholders

Medical tourism stakeholders can be identified as serving multi-purposes such as the promotion of medical services through the use of tourism facilities. By combining the medical and tourism sectors and highlighting the area of overlap between the two sectors, a clearer image of the medical tourism sector will be recognized, making it easier for stakeholders to identify a medical tourism network for improving the medical tourism sector. The definition of medical tourism network may vary from one country to another. The medical tourism network contains four stages of evolution: pre-network stage, the start-up stage, expansion stage and mature stage (Lambier, 2009). The pre-network stage represents all stakeholders such as hospitals, hotels, and facilitators, but no collaborative efforts have taken place at this stage. The start-up stage represents cooperative efforts among medical and tourism stakeholders for the purpose of achieving mutual benefits.

The expansion stage represents insurance companies, medical tourism operators, educational institutions, and government bodies which participated in the overall medical tourism network and which can be called a medical tourism network (Lambier, 2009).and finally, in the mature stage, medical tourism stakeholder collaborate among each other on a regular basis.

For instance, Thailand has identified its medical tourism stakeholders by developing a medical tourism network that is based on four elements: suppliers, core activities, service providers and support players. Figure 4 represents the medical and tourism stakeholders, which can be seen in the core activities square. The network among medical tourism stakeholders has been expanded to include the support players like the Medical Research Affiliations and Certification, which help private hospitals obtain accreditation by international organizations such as the Joint Commission International (JCI).

Industry Professional Accreditation Groups can help local doctors meet the minimum American and British standards and gain the relative accreditation. Educational Institutions are considered important players when it comes to providing the medical and tourism industry with a capable labor force. Ultimately, the last group of players within this network is that of the Government Agencies, which includes the ministries of Tourism and Health. In this vein, the government of Thailand has opened fifteen offices abroad to invite international patients to travel to Thailand for the purposes of receiving medical services while visiting their families, tourism attractions, shopping centres, or attending cultural events. In 2004, Thailand was aiming to be known as the "Medical Hub of Asia". Currently, this Asian country is ranked as one of the best medical tourism destinations at the local and international level (Rabindra, 2006).

Some researchers, however, realize that the network among medical tourism stakeholders faces some challenges (Harryono, Huang, Miyazawa, & Sethaput, 2006). First of all, having insurance companies play a part within the medical tourism network will increase the cost of medical services for patients, because private hospitals will be obligated to buy insurance to cover potential malpractice issues. Second, in the network there is no a specific organization that directs medical facilities for improving their medical services in order to target medical tourism market. Therefore, private medical facilities have their own market campaign for promoting their medical services without putting into the consideration how they are going to handle the operation of medical tourism businesses. Therefore, private medical facilities should have direct participations with the medical tourism network for collaborating with other stakeholders such as medical institutions, tourism agencies, facilitators to conduct medical tourism services more professionally.

Also, including environmental organizations within the medical tourism network (MTN) is crucial for private hospitals to convert from being profit-focused organizations to sustainability-focused organizations. Hart and Milstein (2003) have proposed a framework for achieving a sustainable value, meaning a value that provides environmental, social, and economic outcomes. The next section will provide an overview of sustainable development, and the need for implementing sustainability principals to overcome future challenges facing the medical tourism sector.

Figure 4: Medical Tourism Network in Thailand

Source: (Harryono, Huang, Miyazawa, & Sethaput 2006)

3.4 Establishing a Sustainable Medical Facility

Bookman and Bookman (2007), and Dunn (2007), have outlined the importance of implementing a solid foundation for the medical tourism sector to have the ability to host foreign patients. To this end, some developing countries have already initiated plans to develop their medical institutions and facilities in order to provide local residents with adequate health services in the long-term and respond to the future demands of international patients. However, for medical tourism projects to be considered as a community development projects, they should provide community engagement, quality of life for local residents, environmental protection, cultural experiences, and resolve social issues such as poverty, access to health, education and so on (Bookman & Bookman, 2007).

Bookman and Bookman's study (2007) outlines the benefits of medical tourism for developing countries. Medical tourism should not only enhance the everyday life of a local community but should also provide economic stimulation for the local economy by creating work opportunities, accessible health services, and entrepreneurial opportunities. Globally, international healthcare expenditures exceed $56 billion per year, making the medical tourism sector one of the major industries in the world (Bookman & Bookman, 2007, p. 170). In contrast, more than half the world lives on less than $2 a day (Bookman and Bookman, 2007, p. 170). Therefore, it follows that medical tourism, through its positive effects on economies and communities should provide significant benefits to the host countries.

According to Bookman and Bookman (2007), improvement in healthcare at a particular destination relies on its economic development and economic development relies on the basic foundations of the host country. Medical tourism, in turn, can improve and expand the public health system, by providing rooms and capacity for members of the public who need medical treatments; by providing access to treatment involving highly advanced medical technology that increases the quality of health services for local communities; and by attracting and providing skilled physicians to perform complex surgeries for local patients. A successful medical tourism strategy is one that provides results in increasing the quality of life for local residents (Bookman and Bookman, 2007).

To enhance the health and living conditions of local residents, medical tourism facilities should provide skilled doctors to treat the local community. In some cases, local residents cannot afford to be treated in private hospitals; therefore, the government should cooperate with the private sector to give patients opportunities to be treated by skilled doctors through subsidized programs (Bookman & Bookman, 2007). Another positive way to engage the local community within the medical tourism sector is to survey local residents to determine what type of medical tourism or general tourism activities are necessary and sustainable.

McCool and Lime (2001) have conducted research to determine the definition of sustainable tourism. They developed a survey that aimed to answer three questions: 1) How should the tourism industry be sustained? 2) What is sustainable tourism? And, 3) What should tourism sustain? The survey targeted three groups: land management agencies, tourism organizations, and local residents who may benefit from tourism development. As a result, the survey identified the three most important things that the tourism industry should sustain: quality of life for local residents, cultural attractions, and environmental assets. McCool and Lime (2001) suggest that future research should focus on providing more engagement opportunities for local residents to determine what they think tourism should sustain. Some tourism projects put environmental assets as a first priority to be sustained, which might raise some issues such as concerns over delayed construction; other tourism projects designate economic growth as a main thrust toward sustainability, which may also produce concerns over such issues as environmental pollution.

McCool and Lime (2001) determined that a tourism project's benefits should be determined by local businesses, local organizations and local residents. Bookman and Bookman (2007) suggest that the medical tourism sector should be viewed from the local community perspective, otherwise the benefits of this sector will merely serve select groups with the consequence that medical tourism be considered more of an economic project than a community economic project (Hart & Milstein, 2003). There is very little literature that explores medical tourism from a perspective of sustainable development.

Sustainable development has been viewed by tourism developers as an idealistic approach to business, one which requires extra investment, additional employees, and increased amount of time to achieve certain sustainability goals (Hart & Milstein, 2003). However, Hart and Milstein (2003) present four dimensions (internal, external, today, and tomorrow) as a two-by-two, with each dimension in a quadrant (Figure 5). One axis shows the internal and external considerations, while the other represents the today and tomorrow considerations. Each dimension includes different objectives for the company.

The internal, today dimension is for cost and risk reduction (Hart & Milstein, 2003). For example, some hospitals transfer part of their liabilities to third party organizations to reduce risk and costs. The hospital buys insurance coverage that costs $10,000 yearly for the purpose of reducing the risk of malpractice suits and in the meantime protecting the patient's rights (Bookman & Bookman, 2007). Some industries rely on gas consumption which causes pollution and carbon waste, impacting environmental assets like rivers, forests, and parks. However, at least one study shows that "resource efficiency and pollution prevention are therefore crucial to sustainable development" (Hart & Milstein, 2003, p. 58). In other words, reducing the waste of materials by raising awareness about the best practices of electrical consumption, and using recyclable materials instead of raw materials will play primary roles in triggering a social change to protect local environmental assets. For example, in a study conducted by researchers at the University of Maryland, School of Public Health, the most efficient ways for hospitals to reduce cost were determined (Clark, 2011). They discovered that a small amount of planning and management efforts could save hospitals billions of dollars. Ninety percent of the medical waste items were placed in the wrong containers (i.e. hazardous materials containers) and disposed as hazardous materials, while 24 percent only of the total disposed medical items deserve to be processed as hazardous materials. Just by putting disposable items in the appropriate and corresponding containers will take less of a toll on the environment, reduce energy consumption and disposal expenses. Consequently, countless hospitals have initiated green hospital programs for waste reduction.

The external, today dimension represents reputation and legitimacy (Hart & Milstein, 2003). This dimension reflects the idea that the firm follows sustainable business practices that prevent miscommunication and ethical complexities. Working along with stakeholders and following international policies and legislations will enhance the company's overall reputation and draw more community engagement. This dimension is driven by civil society and stakeholders (Hart & Milstein, 2003). Excluding stakeholders‟ opinions will not move the firm forward; instead, the firm will continue to face difficulties as it tries to improve and move forward. For example, Canada has developed First Nations tourism in the Yukon. This tourism program was operated by the Yukon First Nations Tourism Association (YFNTA) to promote aboriginal tourist attractions. Yet, one of the main objectives of the YFNTA is to develop positive working relationships among the YFNTA, local communities, industrial firms, and local government. As a result, local tourism enterprises, entrepreneurs and attractions run by First Nations tend to promote not only the landscape of the Yukon Territory, but also the history and the culture of the First Nations peoples, and this will help transfer these values from one generation onto the next (Hudson, 2009).

Not surprisingly, it is crucial for a firm to be in touch with stakeholders‟ sentiments and views, and the internet is a powerful and suitable communication tool that serves the very purpose of creating networks among stakeholders. Through this technology, stakeholders are now directly connected with the firm's management, which also allows participative opportunities for stakeholders and to share in the company's successes.

The internal, tomorrow dimension represents innovation and repositioning (Hart & Milstein, 2003), which means that the firm should not merely be satisfied with today's payoff, but also develop a deep vision that allows a repositioning of the firm's objectives as to respond efficiently to the market competencies and demands for the future. While the firm generates actual shareholder value, at the same time, it will create tomorrow's products, relative to the customers‟ needs, and remain competitive in the market. This dimension is driven by the desire for new technologies, such as communication technologies, nanotechnologies, information technologies, and renewable energy (Hart & Milstein, 2003). Using reusable materials rather than raw materials will reduce production costs and provide more budget flexibility, making the firm responsive to any changes in the future. Currently, most companies distribute information using the internet, which saves money, energy, and time as it reduces the consumption of paper and reliance on transportation (Hart & Milstein, 2003). This process of information gathering, which has seen countless banks and businesses replace paper records and forms with online equivalents, undoubtedly protects environmental resources for the next generation. Renewable energy consumption will soon become a commonality because of its efficiency and protection of the environment (Christensen, Craig, & Hart, 2001). A study conducted by Hart and Milstein (2003, p. 59) argues that "innovation and technological change are thus the key to the pursuit of sustainable development."

Ultimately, the external, tomorrow dimension reflects the growth path and trajectory: To create a company's vision requires an understanding of what the company is looking to accomplish in the future (Hart & Milstein, 2003). Convincingly, a growth trajectory requires a firm to deliver a product to an existing customer or to enter a new marketplace that has never been discovered before (Hudson, 2009).

The medical facility in any particular destination should have the ability to reform its objectives by responding to unforeseen situations. For example, in the United States, American patients have a desire to travel offshore to seek cheaper healthcare and medical services with a high quality of care and thus the number of American patients who travel offshore for adequate medical treatments is growing quickly (Medical Tourism Magazine, 2010). Consequently, international medical facilities should consider such factors when approaching a new market such as North America; they should study the competitiveness of the market and determine which are the requirements that would make that medical facility as competitive as possible. They should reform their objectives and goals according to the market requisitions. Thus far, however, these four dimensions have not yet been employed by the medical tourism sector as it works toward building a medical facility that speaks more to sustainability; perhaps this has to do with the fact that, currently, most medical tourism facilities are funded and governed by the private sector, a medical facility with a profit-focused model instead of a sustainable model. According to Bookman and Bookman‟s study (2007), at present, the medical tourism sector does not rely on tourism resources, the quality of life of local residents, or public health accessibility; instead, this sector relies on the private institutions for providing medical services for foreign patients, which has a direct influence on the culture of conducting the medical facility toward future goal. Therefore, establishing a network is crucial for motivating private institutions to collaborate among each other for enhancing the market while respecting the social and environmental assets. Singapore, for example, has realized the importance of creating a sustainable value by qualifying local medical staff for providing high quality medical care for foreign patients. As a result, the medical tourism sector in Singapore increased the quality of life for local residents by offering work opportunities within the medical facilities. Singapore has made a great effort to provide the best customer service in the medical tourism industry for foreign patients, making it one of the top medical destinations in the global market (Medical Tourism Magazine, 2010). The quality of medical services is now the main thrust behind the Singaporean medical tourism sector. Hospitals in this country have updated their medical technology to exceed patients‟ expectations, and now boast trained medical staffs from the local community that represent the local culture and deliver tourism values to the patients (Medical Tourism Magazine, 2010).

Figure 5: Sustainable Value Framework

Source: (Hart & Milstein, 2003, p. 60)