South Asian Journal of Tourism and Heritage (2009), Vol. 2, No.

Perception of Tourists towards Kerala as a Preferred Alternate Health Tourism Destination: A Study
BINDU V.T.* CHITRAMANI, P.** and BABU P. GEORGE***
Bindu V.T., Lecturer of Tourism Management, Avinashilingam University for Women, Tamilnadu, India Chitramani, P., Ph.D. Reader of Business Administration, Avinashilingam University for Women, Tamilnadu, India *** Babu P. George, Ph.D., Assistant Professor of Tourism Management, University of Southern Mississippi, MS, USA
** *

ABSTRACT
The present paper investigates the perception of medical tourists towards Kerala, India, as an alternate medical tourism destination. Various issues related to tourist satisfaction such as satisfaction with booking and information provision as well as satisfaction with treatment and miscellaneous other facilities are explored. The study identifies the key motivational variables and sources of information used by healthcare tourists. Dimensions of destination preference of Kerala as perceived by alternate medical tourists have also been measured. The paper is concluded with the formulation of a customer retention model for alternate medical tourism. KEYWORDS: Medical tourism, Health resorts, Patient satisfaction, Motivation, Destination performance, and Kerala.

INTRODUCTION The growth of health holidays is fast and notable (Demicco and Cetron, 2006). It is forecasted that medical tourism will earn each of the major players approximately US$2.3 billion, by 2012 (English, Mussell, Sheather, and Sommerville, 2006). Health holiday market is fairly developed in various parts of the world. Typically, medical tourists are residents of industrialized nations; primarily coming from North America or Western Europe. But, more and more, residents of other countries are seeking out destinations where they can both obtain quality medical treatment and enjoy a vacation, at a reasonable price (Richards 2006). Hospitals in developing countries traditionally enjoy a cost advantage over those facilities located in more developed countries. Today, many of these facilities are in the process of upgrading their product/service offerings. We now see the packaging of their products into one all-inclusive offer. This package includes everything from medical treatment to travel and hospitality services. The medical tourism evolution is not restricted to traditional hospitals; a range of alternative healthcare services providers such as ayurvedic, naturopathic, homeopathic, and yogic establishments are also benefiting from this growing trend (Bezruchka 2000). A comprehensive model of medical tourism has been proposed by George and Nedelea (2007) and the same is given in Figure 1. As shown in the model, medical tourists move from their originating regions (their countries of residence) to destination regions (those regions where the care is available). The transit refers to both the actual mode and trajectory of the transportation utilized for this movement as well as any constraining and/or facilitating forces in the travel experience. A destination is a medical tourism destination, not just because of the healthcare facility available there, but also because of the additional provision of destination attractions, both natural and cultural. The core product is the healthcare provided, but tourist comforts do form an important hygiene factor in medical tourism (Messerli and Oyama 2004).
2009 South Asian Journal of Tourism and Heritage

PERCEPTION OF TOURISTS TOWARDS KERALA

69

Figure 1: A Comprehensive model of medical tourism

Patients from various countries are becoming medical tourists to India for low cost and health restorative alternative treatments (Todd, 2005). The medical tourist undergo treatments of a combination of Ayurveda, yoga, Acupuncture, Herbal oil massage, Nature therapies, and some ancient Indian health care methods-such as Vedic care, and alternate health care service. Kerala, a state in South India, has established itself as a prominent destination of world leisure tourism for its natural beauty and cultural assets. Kerala is a perfect hide away with captivating and serene surroundings, friendly and attentive service. The state is also portrayed as Gods own country (National Geographic, 2004). Kerala has sensed the potential for health holidaying based on its centurys old Ayurveda medicinal system. A number of hotels and resorts along with hospitals are offering this treatment. The market for these packages is mainly from Europe and North America. Keralas equable climate, natural abundance of forest with a wealth of herbs and plants are a key to the success of Ayurvedic treatments of Kerala. Ayurveda is one of the greatest gifts the sages of ancient India have offered to man kind and is accepted as the oldest scientific medicinal system. The philosophy of Ayurveda takes a holistic view of health, emphasizing a balanced diet, physical fitness, healthy life style, hygiene and body care for a disease-free long and healthy life. It gives due importance to both preventive and curative aspects of a disease. Many of Ayurvedic tourism development have helped the protection of Keralas Architecture too. In this background, the major aim of the study is to assess the preference of Kerala as a health tourism destination and measure the satisfaction level of health tourists in the selected resorts and thereby suggest suitable strategies for sustainable health tourism growth. The Research Method The Study has been carried out in 3 phases: The first phase focused on the study of selected ayurvedic resorts in Kerala. The second phase focused on a survey to identify the tourist preferences towards Kerala as a health tourism destination and measures the tourist satisfaction. The third phase focused on data analysis and design of strategies based on the observation in the first and second phase. The method adopted in the study is mostly exploratory and analytical. Both primary and secondary data have been used for the study the collection of primary data has been attempted through opinion survey and observations. The secondary data have also been supplemented at appropriate places. The data was collected by Observation of selected Ayurvedic resorts and through opinion survey of 88 tourists across the selected 5 ayurvedic resorts in Kerala. Out of the respondents, 30 were Indians, 11 were Germans, 6 were Americans, 5 were British, 3 each were from Australia, Canada, and France, and the remaining from various other nationality groups. Gender-wise, 62

70

BINDU V.T., CHITRAMANI, P. and BABU P. GEORGE

were males and 26 were females. Most respondents had an annual income of above 4 lakh Indian rupees. Among the respondents, 51 percent were graduates, 32 percent were undergraduates, and 10 percent had technical and/or professional qualifications. The opinion survey was carried out by means of structured self-administered questionnaire. The study was limited to only five Ayurvedic resorts based on the convenience and accessibility of the researcher. In the first Phase the selected five resorts were observed and information were collected. The sample selected for the study came from the following resorts: Kairali, Palakkad Pagoda, Allaphuza Keraleeyam, Allaphuza Ayur Bay, Thiruvanathapuram Somatheeram, Thiruvanathapuram Data Analysis and Discussion The phase I of the study revealed that the major health care programs of the resorts which were highly demanded were: Rejuvenative and Stress Management Programs Anti-Ageing Programs Detoxification Programs Slimming Programs Beauty Care Programs Post Pregnancy Programs Special Packages for Women It was also observed that the resorts had cutting edge facilities. The facilities normally observed were: Full time services of qualified and experienced Ayurveda consultant. Well equipped panchakarma treatment facilities Qualified and experienced Ayurveda therapist Ayurveda Pharmacy Separate treatment rooms for male and female patients Well furnished accommodation Canteen services Special therapeutic diet for patients Clean and Hygienic diet for patients Yoga and meditation hall Medicinal plants garden Library and reading room Telephone and internet facilities Ample parking facilities The respondents whom we interviewed were mostly repeat visitors with a median visit history of 2 in the past. The duration of stay at the resort varied from 1 day to a few months, with a mean of one week duration. The motivations for visit are summarized in Table 1. Table 1: Motivation for health tourism to Kerala Frequency Percent Valid Percent Cumulative Percent Valid Nature Culture Leisure Health Others 19 9 31 25 4 21.6 10.2 35.2 28.4 4.5 21.6 10.2 35.2 28.4 4.5 21.6 31.8 67.0 95.5 100.0

PERCEPTION OF TOURISTS TOWARDS KERALA

71

Frequency Valid Nature Culture Leisure Health Others 19 9 31 25 4

Percent 21.6 10.2 35.2 28.4 4.5

Valid Percent 21.6 10.2 35.2 28.4 4.5

Cumulative Percent 21.6 31.8 67.0 95.5 100.0

Total 88 100.0 100.0 The above table implies that, as expected, health is the most important reason for visiting an ayurvedic resort: but, at the same time, leisure and nature too are extremely important drivers. An insight from this is that ayurvedic resort operators should highlight in their promotional campaigns the leisure and nature opportunities available in Kerala for health visitors and their accompanying companions. The analysis conducted to understand the influence of different media revealed the following result (See Table 2): Table 2: The influence of media Frequency Percent Valid Percent Cumulative Percent Valid Traditional Electronic Media Internet Print Media Personal Sources 3 33 41 11 3.4 37.5 46.6 12.5 3.4 37.5 46.6 12.5 3.4 40.9 87.5 100.0

Total 88 100.0 100.0 This implies the overarching influence of the Internet and is a pointer to those resort operators who are still resistant to the adoption of Information and Communication Technologies for resort marketing. One notable issue is the low influence of traditional electronic media like radio and television. It is much cheaper and cost effective to promote a resort over the internet, compared to the traditional electronic media. This analysis also implies that word of mouth and personal influence is important. One sure way to ensure the spread of word of mouth is to treat the existing patients exceptionally well: this will motivate them to spread positive word of mouth to their kith and kin, and even electronically by giving good reviews of the property. It should also be noted from the results that, despite the proliferation the internet, it is not time yet to write off the print media: it still stands as the biggest crowd puller! Around 78% of the respondents said that they visited the resort in search of natural and herb based preventive medication. The low percentage for curative visits is not shocking: as noted elsewhere, most curative patients who need cure from an existing disease go to an allopathic clinic rather than visiting alternative medical centers. Those curative patients who visit an alternative healthcare resort might be patients suffering from ailments for which there are not definitive cures in the allopathic tradition. The might be individuals who have tried the western medicine in the past and have not got cured. In the phase II, preferences of tourists were studied across 10 dimensions using a 5 point scale( 5-strongly agree,4-agree,3-neutral,2-disagree,1-strongly disagree). Items rated in the dimensions of destination preference were: 1. Kerala as a preferred Ayurvedic destination 2. Preference on Ayurveda over other medical treatment 3. Kerala - an ideal Ayurvedic Destination 4. Kerala - a multifaceted Destination 5. Ayurveda - as preventive and rejuvenative 6. Health and hygiene background 7. Optimum duration

72

BINDU V.T., CHITRAMANI, P. and BABU P. GEORGE

8. Good therapeutic diet 9. First rate transit service 10. Ideally priced Figure 2 given below summarizes this result: Average mean MEAN SCORE 5
Score 4

3 2 1 0 1 2 4 5 6 3 Dimensions of preference 7 8 9 10

Figure 2 Mean scores of dimensions of destination preference The mean score across these dimensions reflect that high preference for Kerala as a health tourism destination. The only dimension that was rated low in preference was price. Later, level of satisfaction of tourists was studied with respect to booking, promotion and awareness, environment, treatment facilities and other facilities and the outputs of analyses are summarized in the graphs given below in Figure 3. The rating instrument had the following options. 1. Easy procedure 2. Fast and accurate confirmation 3. Genuine networks with booking agents The graph (figure 3) shows that tourists are highly satisfied with booking and just satisfied with confirmation and dealings with the booking agents.

BOOKING
MEAN SCORE 5 4 3 2 1 0 1 2 3 SATISFACTION ON BOOKING MEAN SCORE

Figure 3 Patient satisfactions with resort booking The graph (figure 4) portraying satisfaction with information reveals that information accessibility and information clarity need to be improved whereas information provided through travel agent is highly satisfactory. The rating instrument had the following items to respond to: 1. Information provided 2. Information accessibility 3. Information clarity and accuracy

PERCEPTION OF TOURISTS TOWARDS KERALA

73

PROMOTION AND AWARENESS

5 4 3 2 1 0 1 2 3 SATISFACTION LEVEL MEAN SCORE

MEAN SCORE

Figure 4 Patient satisfaction with information provision Environmental factors play a major role in developing customer perceptions of healthcare resorts and hence the same too was studied. The ratings for this question were as follows: 1. Natural and Eco-friendly 2. Clean and hygiene 3. Ambience room and treatment care 4. Ample parking facilities 5. Air conditioned villas/cottages 6. Exotic herbs and vegetable garden

ENVIRONMENT
5 4 3 2 1 0 1 2 3 4 5 6 SATISFACTION LEVEL
Figure 5 Patient satisfactions with Environment In the environment factors there was a relatively high score for nature and eco-friendly surrounding, and clean and hygienic environment whereas guest room ambience, treatment care, parking facilities, exotic herbs and vegetable garden were having mean score between 3 and 4; the latter part needs to be improved. The next issue investigated was satisfaction with treatment facilities.

MEAN SCORE

MEAN SCORE

74

BINDU V.T., CHITRAMANI, P. and BABU P. GEORGE

TREATMENT FACILITIES
4 3.8 3.6 3.4 3.2 3 2.8 1 2 3 4 5 SATISFACTION LEVEL
Figure 6: Patient satisfaction with treatment facilities The ratings for this question were as follows: 1. Full time service of qualified and experienced Ayurvedic consultant 2. Full time service of qualified and experienced therapist 3. Well equipped treatment facilities 4. Certified ayurvedic pharmacy 5. Homely and attentive Tourist satisfaction on treatment facilities given in figure 5 shows the mean score value was between 3 and 4. This implies there exists a need for improvement in the service of the Ayurvedic consultants, therapists, certified ayurvedic pharmacy and personal attentive services. Finally, satisfaction with miscellaneous other facilities in the resort was probed. The graphical output of analysis is presented below in figure 6:

MEAN SCORE

MEAN SCORE

OTHER FACILITIES
5 4 3 2 1 0 1 2 3 4 5 6 7 SATISFACTION LEVEL
Figure 7. Patient satisfaction with miscellaneous resort facilities The ratings for this question were as follows: 1. Special therapeutic diet 2. Herbal and natural accessories 3. Yoga and meditation centre 4. Other entertainment 5. Indoor and Outdoor recreations 6. Fully equipped conference hall

MEAN SCORE

MEAN SCORE

PERCEPTION OF TOURISTS TOWARDS KERALA

75

Library and reading room This analysis reveals that the tourists are highly satisfied with the herbal and natural accessories, yoga and meditation center, and the conference hall. They are only moderately satisfied with other entertainments, indoor, and outdoors recreations, library and reading room facilities. CONCLUSION The study reveals that the most favorable factors for Kerala as health tourism destination are its authenticity, rich ayurvedic heritage with multifaceted attractions. The unique advantage of Kerala ought to be leveraged by the health resorts. Based on our study and the extant literature (Goodrich, 1993; Grnroos, 1984; Mueller and Kaufmann, 2001; Oswald and Henthorne, 1999), we propose the DBSG (Design, Build, Sustain and Grow) customer retention model for the resorts to follow: The design factors include information clarity and accuracy. The build factors are mainly price, able ayurvedic consultant and therapists, treatment care personal attention, indoor outdoor recreation, availability of ayurvedic pharmacy, etc. The sustain attributes should be enhanced by means of the health and hygienic background, prevention and rejuvenation treatment, herbal based treatment, and the transit services offered by the resort. Yoga and meditation services in the resort are some of the sustain factors. These are the main pillars of the health tourism activities. Right presence and proportion of these factors will ensure sustainable growth of the business. Medical tourism presents a great opportunity for alternate healthcare establishments in Kerala to fuel growth by tapping the potential of the international patient market. To attract foreign patients, healthcare providers may consider leveraging on both business and clinical considerations. Also, well coordinated efforts among the travel, hospitality, and healthcare trades are imperative for the sustainable growth of this business. A sincere commitment to these coordinated moves allows each stakeholder to focus on his or her own competencies and may alleviate the level of competition allowing for better long run revenues throughout the entire sector. What we have done is only a preliminary investigation. Further research is suggested in the areas of information access on Kerala and health resorts, pricing, diet, and customer loyalty techniques. A strategic analysis of Kerala as an alternative healthcare destination is the next step. However, given the time and resource limitations within which the present study was carried out, this objective was kept for future researchers to pursue. REFERENCES
Arnould, E. J. and Price, L. (1993). River magic: Extraordinary experience and the extended service encounter. Journal of Consumer Research, 20 (June), 24-45. Bezruchka, S. (2000). Medical tourism as medical harm to the third world: why? For whom? J. Wilderness Environmental Medicine, vol. 12 (11), 7778. Dahanukar, Sharadini & Thatte, Urmila (2000); Ayurveda Revisited, Ayurveda in the light of contemporary medicine, Popular Prakashan, Bombay Demicco, F. and Cetron, M. (2006). Club medic. Asia Pacific Biotech News, 10, 527-531. English, V., Mussell, R., Sheather, J., Sommerville, A. (2006). Medical Tourism. Journal of Medical Ethics, 32(4), 248-248. Green Andrew, (1999) An Introduction to health planning In Developing Countries, Oxford University Press, USA George, B.P. and Nedelea, A. (2009). Medical tourism: An analysis with special reference to its current practice in India. International Journal of Leisure and Tourism Marketing, 1(2), 27-35. Goodrich, J. N. (1993). Socialist Cuba: A study of health tourism. Journal of Travel Research, 32 (1), 36-41. Grnroos, C. (1984). A service quality model and its marketing implications. European Journal of Marketing, 18 (4), 36-44 Joshy,Sunil V. (1997); Ayurveda and Panchakarma, Motilal Banaridas Publishers, Delhi. Menon, Sreedhara A. (1996); A Survey of Kerala History, S. Viswanathan Pvt. Ltd., Madras. Messerli, H. R., Oyama, Y. (2004). Health and wellness tourism - global. Travel and Tourism Analyst, (August), 1-54. Monteson, P. A. and Singer, J. (2004). Marketing a resort-based spa. Journal of Vacation Marketing, 10 (3), 282-287. Murthy, N.A. & Pandey (2000); Ayurvedic Cure For Common Diseases, Orient Paperbacks, New Delhi.

7.

76

BINDU V.T., CHITRAMANI, P. and BABU P. GEORGE

Mueller, H. and Kaufmann, E. L. (2001). Wellness tourism: Market analysis of a special health tourism segment and implications for the hotel industry. Journal of Vacation Marketing, 7 (1), 5-17 National Geographic (2004). http://www.nationalgeographic.com/traveler/index50.html.(22/12/08) Oswald, S. L. and T. L. Henthorne (1999). Health tourism: A niching strategy for marketplace survival in Cuba. Global Development Studies, 1, 3-4 (Winter-Spring), 220-233. Pruthi, Raj(2006), Medical tourism in India, Arise Publishers and Distributors, New Delhi. Ryan, C. (1995). Researching Tourist Satisfaction: Routledge London Sengupta, Kaviraj N.N. (1995); Ayurvedic system of Medicine volume 2, CBH Publications, Nagercoil. Tarabilda and Edward, F.(1998); Ayurveda Revolutionised.: Integrating Ancient and Modern Ayurveda Popular Prakashan, Bombay. Todd, S. (2005). Medical Tourism in India - Save Money & Get a Free Holiday!, http://www.realtykochi.com/html/medicaltourism.htm (11/01/2009)