Factors Affecting the Satisfaction of Medical Tourists: A Systematic Review

The importance of health has attracted the attention of many countries, driving them to strengthen the well-being of their citizens or transform such initiative into an industrial opportunity; correspondingly, competition in the health industry is currently promoted as a global phenomenon (1). In this regard, the features that advance the globalization of health include the presence of multinational hospitals, prices that are competitive across the world, international quality of global standards, and specialized technologies (2). One of the most important effects of the globalization of health is the emergence of a new form of tourism known as health tourism (3). Among health tourism sub-groups, medical tourism can be regarded as a product of the rapid growth of the health industry (1, 4, 5). Medical tourism is defined as the process in which patients travel to different countries to receive high-quality and suitably priced health care services (4, 6-8). It differs from health tourism in three ways: First, health tourism (health and wellness) services are provided in non-hospital settings, whereas medical tourism services are provided in hospital contexts. Second, in medical tourism, treatment is performed with medicines and surgical procedures, but in health tourism, intervention is implemented through complementary therapies for restoring health. Third, in medical tourism, patients are treated using the existing medical facilities in a hospital (9).

The efforts that some Asian countries, such as Thailand, Singapore, India, South Korea, and Malaysia, exert in promoting medical tourism has enabled them to successfully attract 1.3 million medical tourists from all over the world - a figure that continues to increase (10-12). In 2012, the health tourism sectors in India and Singapore earned $2 billion and $1 million in revenues, respectively (13). Given that the health market is currently a huge and well-developed industry, medical tourism earnings account for a significant proportion of world tourism revenues (14, 15). The health and medical tourism industries alone have been responsible for building a world trade market that is worth $60 billion and grows annually by 20% (16-18). For developing countries, both industries present excellent potential as a means of achieving considerable international earnings and employment with appropriate planning and implementation (19, 20). These industries therefore serve as sources of opportunity for all nations, regardless of developmental level (21).

The rising health care costs in most developed countries have increased the growth of medical tourism (22-24). Aside from increased costs, numerous other factors effectively render medical tourism a desirable option for patients who want to satisfy their health needs. Some of these factors are long waiting lists, high service costs, and lack of access to necessary services and high technology in home countries (6, 25-28). Given the tradability of health care, medical tourism is vulnerable to criticism, thereby encouraging destination countries to endeavor to provide health facilities and services with the highest possible standards to international patients (29, 30).

Features such as service providers (31, 32), medical facilities (33), the behavior of staff with patients (34), waiting time (35), and the quality of service and facilities (33, 36, 37) can affect the satisfaction of domestic and international medical tourists. Satisfaction can be regarded as an important aspect of quality and a key indicator of success in medical tourism. Patient satisfaction is important also because it increases competition among health service providers (38). The key role of satisfaction in the medical tourism industry is likewise reflected in people’s highly responsive practices for achieving their health goals and their demand for appropriate and high-quality services given advances in technology, increased awareness, and increased expectations from health service providers (39, 40).

Patient satisfaction can be analyzed particularly in combination with an examination of different hospital dimensions (41). The feedback that is gained with respect to patient satisfaction can also effectively guide efforts to improve a hospital’s status and strategic plans (42). Additionally, a survey of tourist satisfaction can clarify strengths and weaknesses as well as corrective measures for enhancing the satisfaction of medical tourists (23).

With consideration for the above-mentioned issues, this study was aimed at identifying the factors that affect the satisfaction of medical tourists. The research question pursued in this work was “What are the contributors to the satisfaction of medical tourists?”

In the data extraction process, the variation of studies was high, so in the first stage they were not only excluded by examination of the title, they also needed a review of the abstract. In the final stage, a full text review, a significant number of studies were excluded that could not be identified at the earlier stages for deletion. Therefore, the high accuracy required by the authors. The results of the reviewed studies indicated that many factors can affect the satisfaction of medical tourists. These factors include services provided, manpower, health equipment, physical conditions, costs, and information. The review showed that medical tourists regard the factors associated with the provision of services as more influential in their satisfaction than the other identified factors (47, 48). The review indicated that about 90% of the studies used questionnaires and that many of them were performed in Malaysia, India, and Taiwan. According to the results of the studies, service quality and waiting time are among the factors that are directly related to patient satisfaction and indirectly related to customer loyalty (47-50). The influential factors identified by the studies carried out in Malaysia, India, and America were appropriate interaction with staff (10, 51-53) and feelings of safety in interaction with staff (54). The studies conducted in Taiwan and Romania identified feelings of trust from medical tourists as an influencing factor for the satisfaction of patients (54, 55).

Some of the studies identified factors such as courtesy, accountability, and the willingness of employees to help as influential in the satisfaction of medical tourists (36, 56, 57). Courtesy refers to the display of good faith by employees or politeness in the delivery of services, which increases the confidence of medical tourists with regard to a hospital’s ability to enhance their satisfaction. The studies determined whether hospital employees are consistently courteous and respectful and thus regarded such behavior as one of the factors for assessing the quality of health care and one of the determinants of the satisfaction of medical tourists (10, 51). With respect to tourist communication, language factor was indicated as effectively influencing the satisfaction of medical tourists (57, 58). Another factor that affects the satisfaction of medical tourists, relative to their experience in their home countries, is the waiting time for receiving appropriate services. This factor was revealed as an important aspect of ensuring tourist satisfaction in China, India, Jordan, the United Arab Emirates (UAE), Romania, Germany, and Taiwan (10, 52, 59-62). Waiting time is similarly regarded in Canada and the United Kingdom as an essential motivating factor for travel to other countries for treatment (19, 63). The review also showed the cost of health as one of the most important factors for medical tourists’ satisfaction. In America and the UAE, the developed countries, cost disincentives the acquisition of health services and operations, driving citizens to travel to other nations for their health care needs (1). The same consideration of cost as a significant factor was expressed by medical tourists who traveled to India, China, Germany, the UAE, and Jordan (52, 59, 62, 64). Cost was likewise mentioned as a factor that drives tourists from Canada and the United States comes from developed countries, but not of Africa, Gulf countries. the high quality of health care available in developed nations, but what they seek most is quality service at a low cost (65). A combination of low cost and high service quality therefore attracts tourists.

Yet another factor identified in the review was human resources, with the specific aspects being good relationships with medical staff, their clinical skills, the reliability of physicians as evaluated by patients, the education given to medical tourists, the right to select a preferred provider, and the speed of staff (52, 60, 62, 66-69).

Erdogmus and Babic-Banaszak found low satisfaction with factors such as recommendations during discharge, the clarity of instructions, and the duration of counseling with a health care provider (36, 57). This finding contrasts with that of Tam, who reported that medical tourists are satisfied with the provision of clear guidelines by nurses (33).

Given that medical tourists travel to a distant country for health care, discharge is an important aspect of service provision. In particular, medical tourists seek good counseling at the time of discharge. This factor is interrelated with other determinants of satisfaction because the quality of interactions with medical staff increases the trust and confidence of patients in service providers (23, 50).

As indicated in most of the studies that focused on quality, service quality is key to the satisfaction of medical tourists, In both developing countries and developed countries, because other determinants also affect the assessment of service quality by medical tourists. For example, the provision of appropriate recommendations fosters excellent interactions between tourists and providers, thereby inspiring the former to. Other factors that affect tourists’ quality assessments are communication problems caused by language barriers and the preference of medical tourists for quiet environments in hospitals. Therefore, factors such as high waiting times and high costs in high-income countries that have spawned medical tourists to other countries. But the high quality of health care in both high income countries and low incomes has attracted medical tourists. The quality of services directly affects the value perceived by medical tourists, and such perception, in turn, directly influences their satisfaction, which affects their attitudes and behaviors. Satisfaction is positively related to the loyalty of medical tourists and their return to a destination country (23, 50, 55).

This review identified services provided, human resources, information, costs, health equipment, and physical conditions as influencing factors for the satisfaction of medical tourists. The most important factor from the perspective of tourists are those related to process of service provision, method of service provision, and behavior of hospital staff. With regard to service provision, the quality of services is of considerable importance for medical tourists. So the quality of services from the viewpoint of medical tourists that the additional explanations have been given about how the other factors understood to affect the quality of services. So the quality of services has a direct impact on the perceived value by medical tourists, what medical tourists perceive has a direct impact on the satisfaction of the clients, and the Satisfaction affects patients’ attitudes and behavior. it has a positive relationship in the loyalty of medical tourists and their return. Note, however, that although these factors were identified as positive factors for destination countries, they can also exert negative effects on the satisfaction of medical tourists in their countries of origin. The results of the review can help policymakers and health professionals in destination countries provide the facilities and conditions necessary for the development of medical tourism.