The Impact of Medical Tourism Industry for the Hospital Services and Marketing Activities: A Systematic Review

The relationship between the health industry and tourism has produced what is called medical tourism which is one of the largest and fastest growing service industries in the world and is a profitable business for the destination country. To capture the many medical tourists it is necessary to recognize the vital factors that influence the decision of medical tourists to choose the destination country by implementing marketing strategies and good health services. Using Systematic Review with PRISMA method retrieved from online database such as PubMed, and Google Scholar using a keyword “Medical tourism” AND “hospital services” AND “marketing”. The end of this search got 7 journals. India, Singapore and Thailand are the three main medical tourist destinations worldwide with the advantages of each offered. Medical tourism is strongly influenced by patient satisfaction with the quality of health and quality of services. A good marketing strategy plays a very important role in introducing medical tourism to medical tourists. With interesting websites and social media, you can capture patients without considering other factors. Not to forget also patient satisfaction is very influential on the return or absence of patients to do medical tours to the country.


INTRODUCTIONS
Tourism is an important factor for the economy and development of a nation.This dynamic tourism industry can be a major source of income, employment, private sector growth and infrastructure sector development in many countries (Ali Mohammad Varzi et all, 2016).Tourism predicted will become the most profitable industry in the world by 2020.From all of type tourism, medical tourism is regarded as main field of tourism industry in the world, which has been on rise in recent years (Reza AZIMI, 2017).As an industry, medical tourism involves many various components of stakeholders who admit to having the biggest role and want to get a big profit too (HOPE, 2015).Figure 1 shows major participants in medical tourism industry.
According to WHO, medical tourism are type of tourists who choose to travel abroad to get medical treatment.Usually the general actions taken are dental treatment, aesthetic care, elective surgery, and fertility treatment.Medical tourism is often a joint venture between a country' s health agency and its business development, foreign investment, or the immigrant ministry (Bryn Nelson 2014).There are several reasons why people prefer medical tourism, of which there are some people who cannot afford the health costs in their country, some are unable to wait for the health system in their country to provide needed health services, or even no type of health services needed in his country (Melisa Martínez Álvarez et all, 2011) In today' s competitive era, the main goal of health practitioners is to attract as many medical tourists as possible through marketing strategies so that they will continue to return to do medical tourism through service strategy.According to Nahla Mohamed Helmy et all, Medical tourism destinations chosen by medical tourists are usually obtained from searches on the Internet that hold the most important roles and information obtained from the personal experience of their relatives or friends.K. Pollard in HOPE -European Hospital and Healthcare Federation (2015) introduces a model of goal attraction, in which this model includes the factors that determine the final decision for patients who want to do medical tourism.This model consists of 7 factors, namely (1) Geographical proximity, travel time, ease and barriers in reaching the destination, (2) Cultural proximity including language, religion, cuisine, customs and practices, (3) Destination image, reputation of a country and stereotypes, which are hard or even impossible to reverse, (4) Destination infrastructure on country or treatment facility level, (5) Destination environment climate, tourism attractions, facilities compose factors that make the destination more attractive to a patient, (6) Risk and reward, (7) Price.On the other hand, McKinsey, through conducted research, introduce quality drivers as the major ones that influence patient's decision on destination of medical tourism.They cover in order of importance; (1) advanced technology, (2) better quality, (3) quicker access, (4) costs of care.The level of importance is presented in Figure 2.
According to Nahla Mohamed Helmy, 2018, the most important factors that influence medical tourism are wellorganized hospital management, the functioning of quality health centers, the types of services and medical care offered, medical service costs, the natural beauty of the location and a good destination climate, and advertising and promotion activities about medical services offered, and finally, but not least, the safety of the destinations visited.In addition, the image and profile of a country are key factors that influence the choice of medical tourists along with the political environment or political stability without corruption and good rule of law (show in rule 1).

THEORETICAL REVIEW
According to Andrzej Tucki, et all, 2014 based on research, Medical tourism has been developing in a number of countries, such as India, Singapore and Thailand.These three countries are the three main medical tourist destinations worldwide, many of which intentionally link medical care to tourism, so that it can also increase the attractiveness of the coast and other tourist attraction.Another thing that also influences the choice of medical tourism seen by medical tourists is whether the hospital that is intended has been Joint Commission International (JCI) accredited which is the most established medical tourist industry accreditor worldwide.Singapore has the highest number of JCI accreditation providers (18), followed by Thailand (13) and Malaysia (7) (Nicola S Pocock et all, 2011) Medical tourism marketing material used usually from newspapers and web-based sites.The characteristic details of this marketing material result 3 main roles in medical tourism, namely (1) patients seeking health services outside their country, (2) service providers in the destination country who are willing to offer them and (3) medical facilitators connecting them.The fourth is often involved, though not very important in the process, namely the personal physician of the traveling patient who may provide detailed medical history or accommodation and tourist / shopping places when staying longer or is a tour package (show in Fig. 3).

RESEARCH METHODOLOGY
This research was conducting by doing systematic review technique with the PRISMA method to search for journals.Data were retrieved from online database such as PubMed and Google Scholar, with keywords "Medical tourism" AND "hospital services" AND "marketing", the researcher found 10 documents.The researcher limited the journal paper numbers by duplication and years (2013 -2018), Abstract, and Full papper which resulted 7 journal papers.The researcher also used P.I.C.O Model; the population is hospital that applies medical tourism, the intervention is to find out how the hospital services that implement medical tourism and how is the marketing strategy to introduce medical tourism in each country, the comparison is how to apply medical tourism in each country, and the objectives is to increasing the number of tourist visits from various countries to use medical tourism services in the country.

RESULT AND DISCUSSION
Medical tourists usually get more destination country information from the internet.In addition, mouth to mouth and sharing experiences on social media also tend to be powerful marketing tools, as well as information from relatives also plays an important role.Because they believe in the personal experience of their relatives or friends.Unlike other medical tourists, the Gujarat people are very dependent on community opinion and family relations in making medical tourism decisions.The opposite is the Somali people who are very dependent on the internet in seeking information about medical tourism.
Another marketing strategy that can be used according to HOPE -European Hospital and Healthcare Federation, 2015, is to attend, showcase or sponsor medical tourism industry events including conferences, exhibitions, trade shows etc.This event is held throughout the world, presenting high ranking officials who are very influential in the field of medical tourism so that they can foster business relationships that benefit all parties.
Most inbound medical tourists are in the 35-44 year age group (22%), with 18% medical tourists aged between 45 and 54 years and 19% between the ages of 55 and 64 years; 16% are 65 years old.This is different from the demographic profile of those traveling from the UK to seek treatment abroad.Nearly one third (30%) of all UK patients traveling abroad are between 25 and 34 years old, 20% are between 35 and 44 years old and 16% are between 45 and 54 years old.Figure 4 shows medical tourists out younger than those who traveled to England to access medical care (Neil Lunt Et all 2014) (show ih Fig. 4).
According to Heesup Han et al 2015, the quality of health and quality of services felt by patients is very influential on customer satisfaction.Whereas customer satisfaction gives a significant influence on trust in staff and clinics.This trust in staff and clinics greatly influences the return of medical tourists to clinics in the country.
The results of a study conducted in Korea successfully concluded that patient or staff satisfaction is a very important mediator.Overall it can be concluded that trust patient satisfaction with staff, and trust in the clinic play a very significant role as an intention to revisit the clinic and the intention to revisit Korea for medical treatment.Ali Mohammad Varzi et all 2016 in his research showed that patient satisfaction with doctors and nurses is very important, and patients believe that a good medical staff reflects the reasons that patients want to return to the Hospital.Reza AZIMI 2017 in his research revealed that the factors of hospital employees, hospital services obtained the highest value from the patient' s perspective to determine patient satisfaction and made medical tourists want to go back again to do medical tourism in hospitals of Mashhad Iran, while prices, facilities and promotions received low scores.In this case the staff factor gets the highest value (96%), and the price gets the lowest value (66%) in attracting medical tourists.
According to Nahla Mohamed Helmy et all, 2018, the problem of medical tourism faced in Egypt is that there are no standard guidelines for hospitality services offered to medical tourists in Egyptian hospitals.This caused no training in medical tourism services from the Ministry of Tourism or other official tourism associations.In addition, the lack of a marketing strategy to attract medical tourists is still an obstacle too.
India is able to offer the lowest medical tourism prices among all international healthcare providers.Another advantage of the Indian state is that there are many excellent doctors who graduate from UK or USA so English is the language used here, besides that many hospitals in India have passed JCI certification.Singapore has a good reputation for high-quality medical facilities and is famous for providing advanced medical care, including operations such as heart and heart transplants and complex neurosurgical procedures.Thailand has been a pioneer in modern medical tourism and until now still leads in terms of the number of patients treated and in terms of foreign exchange earnings.One of the features of medical tourism offered by this country is flexibility in terms of pricing medical services to accommodate the facilities needed by consumers.In addition, Thailand' s international hospitals have adopted the company' s philosophy to increase customer satisfaction.The cost of medical services is often packaged by staying at seaside resorts, guided tours and nightclubs in Bangkok to attract international patients.(Andrzej Tucki, et all, 2014).
Information about medical tourism, health care providers, or many medical tourist facilitators obtained from the internet (websites or social media) should also be looked at wisely.Do not be fooled by a fake account or website, which can harm the patient himself.We must remember that a decent and "informative" website does not eliminate health tourism from the risks associated with treatment (HOPE -European Hospital and Healthcare Federation, 2015).In terms of regulation, it is necessary to make a special standard by the government in this case the ministry of tourism to make a special guide for medical tourism, where the guidelines establish standards about hospitals that provide medical tourism services.This guideline must be disseminated to all hospitals with medical tourism services (Nahla Mohamed Helmy et all, 2018).

Conclusion
From various research results it can be concluded that patient satisfaction plays a major role in the return of medical tourists to the country to do medical tourism.Patient satisfaction is closely related to hospital services offered.Patient satisfaction in this case is described as the professionalism of medical staff.If all the above factors can be done well, then it can be a reason for medical tourists to always return to the Hospital.
Marketing strategies are also the most important part of medical tourism.It is important for a country to introduce medical tourism at major state events on medical tourism, such as exhibitions or international conferences.Besides that, don' t forget about quality websites and social media to attract medical tourists because most tourists search for information through the internet.Now the goal for medical tourists may not be the one with doctors, technology, and the world' s best prices, but with the most successful marketing strategies.