Medical Tourism's Impacts On Health Systems In The Philippines - An Essay.

Background to Medical Tourism

Discuss about the Medical Tourism for Potential Impacts on Health Systems in the Philippines.

This research project will explore the Medical Tourism, specifically, the research will analyse and outline the impact of medical tourism on the health system in the Philippines. The research will be conducted by reviewing current and relevant literature and similar research projects for concepts and ideas about medical tourism. This research intends to add to the body of knowledge of medical and its effects on general health services in a country. 

In this Section the research will first, establish the objectives of the research, second, introduce the background to the research, third, develop a research question, fourth, outline the significance and the justification of the research, fifth, establish the research methodology/design  and finally, outline and time-frame of the research. 

According to Carrera and Bridges (2006) medical tourism is “the organised travel outside one’s local environment for the maintenance, enhancement or restoration of the individual’s well-being in mind and body”. Due to the growth of popularity of medical tourism and as the rising cost of medical procedures, people from Western countries seeks medical treatment, surgical care, cosmetic surgery and dental treatment to developing countries, mostly in Asia for cheaper medical alternatives. There are many reasons for medical travel. Most of these are from the problem in a country’s health system; one reason is lack of insurance or underinsurance, second is excessive waiting times, and inadequate local healthcare infrastructure. (DOT, 2009).

Deloitte (2008) estimated that the world medical tourism market in 2008 was around US$ 60 billion and that it is expected to grow to US$ 100 billion by 2010. Herrick (2008) also estimated that around 6 million people a year worldwide will travel for medical care by 2010. In Southeast Asia, the health sector is expanding rapidly, (Pocock and Phua, 2011). Countries like India, Thailand, Singapore, Malaysia and the Philippines are constantly promoting their country as a medical tourism destination. Medical tourism is nothing new – it has existed in different forms for centuries (Hancock 2006; Goodrich 1994). According to World Health Organization, in 2000, U.S. spent 13.2 percent of the GDP on its health care, by 2007 this went up to 15.7 percent (WHO, 2010). And will continue to increase in 2019 by 19.3%. (Truffer et al., 2010).

Made up of 7,107 islands and situated in Southeast Asia, the tropical Philippines have all the essentials for the growth of medical tourism. People from other nations mainly from the US and Europe chose the Philippine for low cost treatment, diversity in treatment procedures, qualified medical practitioners and friendly and hospitable natives allows for a rewarding and memorable tourism experience. (Dr. Prem, n.d.). In 2004, former president Gloria Macapagal- Arroyo created the Philippine Medical Tourism Program (PMTP) which aims to develop the communications, logistics and health wellness industries in the Philippines. (Picazo, O., 2013). The National Competitiveness Council (NCC) was created under the executive order 571 issued in October 2006, making tourism focused on Health Wellness and Recreation (HW&R), to be promoted and developed as globally competitive industries. (Zuellig, 2011). Medical tour packages are now being offered that takes care of everything from visas, airfares, and accommodation and hospital costs for treatment.

Medical Tourism of World

This research will investigate if PMTP’s have any effect on the general medical health services offered to the local population in the Philippines.

What are the key influences of medical tourism on the general health system?

In addressing the above research questions, the objective of this research can be stated as:

• To analyse the potential impacts of medical tourism on the general health systems in the Philippines and make recommendations to the various organizations associated with the medical tourism. 

Although medical tourism is gaining popularity and has become a potential source of foreign revenue to most developing countries, the concept of travelling to another country to receive medical services and further care than one’s own country has driven economic growth for several of these developing countries. However, there is limited literature that is focused on understanding the influences and impacts of medical tourism in most developing countries (Jotikasthira, N., 2010).  In this particular study, which will examine the potential impacts of medical tourism in the Philippine’s health systems, the number of studies about the topics is also limited. Therefore, this research aims to explore further literacy studies on the potential impacts of medical tourism in health systems in the Philippines, and in the process, examine the medical tourism industry as a whole in the Philippines.

This study aims to provide the healthcare and tourism industry in the Philippines and other developing countries. Nakra (2011) indicated in an article that the medical-tourism industry has introduced new business models and are bringing about significant changes in the way governments around the world deal with financing hospitals, recruiting physicians, reimbursing health-care providers, and building adequate health-care systems for current and future generations. (Nakra, 2011). Currently, there are more than 40 governments around the world who are involved in supporting medical tourism and that number is growing rapidly each year. (Nakra, 2011).

This study will follow a qualitative and interpretative approach to evaluate the potential impacts of medical tourism in health systems in the Philippines. The use of qualitative approach will aid in understanding the knowledge and opinions of key informants, tourism and medical experts (Koutra, 2009).

This research paper will utilise secondary data, specifically drawing information from published articles, journals and medical tourism books, and government historical research. Additionally, information will be collected from research articles, research journals, e-journals, books, blog posts, and Philippine government websites.

Research Methodology for this study will be explained further in Section 3, which describes the specific research methodologies that will be used to investigate the research topic and provide explanations to the research questions.

The Philippines as a Medical Tourism Destination

The researcher implemented “authentic strategies and techniques outlined in an appropriate methodological procedure to achieve the objective oriented outcomes in a proactive manner”. The primary purpose of the study is to examine the potential impacts of medical tourism in terms of Philippine health systems. The researcher would seek a deep insight to opt for “philosophy of objectivism and Interpretivism” as the chosen research philosophy (Wahyuni, 2012). The “deductive research approach” would set an outline for the selected research philosophy. The research strategy would comprise of “qualitative data analysis” and the implementation of “case study approach” would serve as the “chosen research design”. The researcher would implement a “qualitative and interpretative approach” to illustrate the effects of medical tourism on the health care sector in the Philippines.

 The researcher would not select “primary data sources and quantitative data analysis” due to the College’s lack of ethics committee. The application of “qualitative data analysis” with the aid of “secondary data sources” would assist the researcher to acquire knowledge and opinions of key informants, tourism and medical experts. The “secondary data” would be gathered from the “various books, journals, blogs, post, e-journals, historical research journals, magazines, Philippine government websites and previous work of other researchers” (Al, 2013). The researcher would implement “simple random sampling techniques” for the particular selected research topic.

The chosen research philosophy would take active participation in acknowledging the information enhancing activities outlined in the methodological section. There are several applications of research philosophy for conducting the research philosophy in a proactive manner.

Objectivism and Subjectivism

In the context of ontological aspects, there are mainly two types of research philosophy “Philosophy of Objectivism and Subjectivism”. The “philosophy of objectivism” emphasizes on data that illustrates the truthfulness of a statement. Likewise, the “philosophy of subjectivism” is more about individual beliefs and ignores factual data (Harrison and Reilly, 2011). The researcher selected the “philosophy of objectivism”, as the potential impacts of medical tourism in the health care sector of Philippines could not be justified through information based on individual beliefs.

Positivism and Interpretivism

The application of epistemology illustrates the inclusion of two philosophies with likes of “positivism and Interpretivism”. The “philosophy of positivism” usually aims to acquire specific information through scientific application of measureable outcomes. The “interpretative philosophy” seeks a deep insight to consider qualitative application of data through the implementation of thematic frame (Allwood, 2012). Since the particular research topic ignores “primary data sources and quantitative data”, the researcher did not choose the “philosophy of positivism”. The researcher opted for the “interpretative philosophy” due to its involvement with “secondary data source and qualitative data analysis”.

Research Question

The “research approach” provided the outline for the “chosen research philosophy”. Research approaches are usually of two types- “Deductive approach and inductive approach”. The “deductive approach” took active participation in evaluating specific information through implementation of appropriate theories and models from the “secondary data sources”. “Inductive research approach” usually develops “new theories and models” from the “emerging data”. The “deductive research approach” assisted in setting the “research hypothesis” in context of the chosen research philosophy (Bryman and Bell, 2015). The accumulation of specific data from generalized information assisted the researcher in successful intervention of the research study. Relatively lower financial budget and restricted time duration stopped the researcher from selecting the “inductive research approach”. The “chosen research approach (Deductive approach)” would help the researcher to acquire specific information within limited time and financial investments.

The researcher usually implements two types of research strategy- “Quantitative and Qualitative research Strategy”. In case of the “quantitative research”, strategy the researcher takes active participation in acquiring “numeric data from statistical analysis”. The viewpoints are taken from the respondents participating in the research study. The “quantitative research strategy” is in association with primary collection of data. In terms of “Qualitative research strategy”, the researcher seeks a deep insight to assume an interaction between the theory and research and therefore reflects upon the valuable implications drawn from the secondary data sources (Creswell, 2013). The researcher selected the “qualitative research strategy” has it enhances the overall quality of the chosen research topic by providing enriched information and data. Since, the topic is very much dependent on “secondary resources”, the research could not consider “primary data sources”, and therefore had to ignore “quantitative research strategy”.

The “research design” reflected upon the “guidelines” needed by the researcher for identifying the potential impacts of medical tourism on the health care sector in the Philippines. The research study of the particular company aimed to achieve the objective oriented outcomes and with the assistance of the chosen research design, the researcher would discuss the superiority of the research study. The “case study based- research design” would investigate specific areas of the selected topic by entailing its standpoint (Hammersley, 2014). The “case study based research design” would also assist the researcher acquire specific information in relation to the chosen research topic. The researcher opted for the “case study based research design”, as it serves as one of the best guidance for acquiring specific information about the trend of medical tourism over the years along with the concurrent incidents.  

Research Objective

Research limitation in this research has been identified below:

• Due to the college’s lack of an ethics committee, primary data is not feasible to this research paper.
• Since there are only fifteen (15) weeks to conduct this study, time is limited.
• On the grounds of using secondary data, this research study may not be reliable and the source of the information may be questionable, especially if the data is not verified.
• Insufficient information about medical tourism discussion in the Philippines.

• Although, the secondary data will be based on the case studies following qualitative approach which can be outdated and may involve false decision making as the present scenario would represent other information or factors that could influence the research (Brymen & Bell, 2015).
• The non-involvement of the primary data based on the present scenarios may cause a certain degree of loss to the study as it will not be able to provide the empirical analysis of medical tourism on the health systems in Philippine.

Below Table is the propose time table to complete the research paper.

Assignment	Date of Submission
Research Brief	01 April 2016
Assignment 1: Literature Review & Research Proposal	05 April 2016
Assignment 2: Field work and data collection	24 April 2016
Assignment 3: Data analysis, testing of hypothesis & observations	15 May 2016
Assignment 4: Research Paper Report and Presentation	28 May 2016
VIVA Presentation	13–17 June 2016

In this Section the research first, introduced the background to the research, second, established the objectives of the research, third, developed a research question, fourth, outlined the significance and the justification of the research, fifth, established the research methodology/design  and finally, outlined and time-frame of the research.

The research question developed in this Section will be utilised in the literature review to further develop a conceptual model of the key influences that medical tourism have on the general medical health services. 

“Medical tourism is understood as travel abroad with the intention of obtaining non-emergency medical services. This practice is the subject of increasing interest, but little is known about its scope.” This Section will focus on the literature review of the foregoing key subtopics in order to investigate the potential impacts of medical tourism in health systems in tourist destinations. This Section will specifically review the five major areas surrounding the research topic; First definitions of medical tourism, second the globalisation and its effects, third factors influencing choice of destination and finally medical services.

Finally, by reviewing the medical tourism the research will be able to develop a conceptual model of the key influences that medical tourism has on the general medical health services.

Lee and Spisto (2007) have defined medical tourism as “travel activity that involves a medical procedure or activities that promote the well-being of the tourist”. Bookman and Bookman’s (2007) claims that, medical tourism is “an economic activity that entails trade in services and represents the splicing of at least two sectors: medical and tourism”.

Destinations or countries that choose to pursue such medical tourism openly promote their health-care services and facilities, in addition to their other conventional tourism attributes (Marlowe and Sullivan, 2007). Because medical tourists travel for care, medical tourism includes a “tourism” aspect, that is, the consumption of “services associated with travel, such as transport, lodging, and hospitality” (Stackpole & Associates, 2010).

Even though, medical tourism recently became popular, Goodrich (1994) mentioned that for centuries different forms of medical tourism have existed. Medical tourists travel to around the globe for treatment. Lately, people from developing countries are seeking higher quality of medical treatment to developed countries (Awadzi and Panda, 2005). However, a reversal in contemporary trend is taking place. An increase of number of patients from developed countries are traveling to developing countries such as in South East Asia, to receive medical treatment. Figure 1 shows some of the medical tourism destinations in the world.

Justification for the Research

Figure 1 Countries that promote medical tourism Source: Medical Tourism Index

This shift of the trend is due to high costs of medical treatment at their home country, lack of medical insurance and other limitations of the health-care systems in Western countries (Marlowe and Sullivan, 2007, MacReady, 2007, Deloitte, 2008, McDowall, 2006).

Goodrich and Goodrich (1987, p.217) defined health tourism as promoting health care facilities and services by a tourist destination to attract tourists. Another definition by Tabacchi, is closely associated with wellness tourism. (Gill and Sigh, 2011). Wellness tourists often procure a service containing physical fitness, health nutrition, meditation, beauty care and relaxation. (Mueller and Kaufman, 2011). People who travel long distances outside one’s health care to obtain restoration of health while simultaneously being holidaymakers. (Connell, 2006; Carrera and Bridges, 2006).

According to a report by Medical Tourism (2005), medical tourism is described as a form of travel from one’s place to destination at which surgical treatments and medical is provided. Additionally, in a recent definition by Marsek and Sharpe (2009), medical tourism is “the practice of travelling abroad in search of high-quality, low-cost medical care”.

There are contradicting views of experts about the impact of medical tourism on general health system of the countries involved. As Mattoo and Rathindran supports the idea that it has positive impact on the general health system of host country. They argue that host countries generate a huge revenue from foreign patients and they can use that revenue to improve the health facilities for residents, secondly, when private investors see that more foreign patients are coming to the country they make investments in the health field to attract incoming foreign customers towards their practices, which can also be used by residents. While Chinai and Goswami are in other camp, they argue that workforce distribution can have a negative impact on resident’s health care.

In nations that have long waiting lists for certain procedures, medical tourism provides a mechanism to clear backlogs by sending patients to foreign countries without expanding local capacity. Currently, the British National Health System is sending patients to nearby countries for this purpose, and more distant medical tourism destinations may be used in the future. Although this idea has not been explored, there may be novel opportunities to use low-cost offshore medical destinations to provide care for unfunded low-income patients while simultaneously relieving the burden on domestic healthcare facilities and philanthropic organizations.

Research Methodology

The above definitions indicates that the “medical tourism industry” has established new “business models” and are creating noteworthy changes in the approach taken by the  governments around the globe pact with financing health care systems, recruiting trained physicians, compensating health-care providers, and constructing sufficient “health-care systems” for present and future generations. Therefore, from the definitions it is clear that poor countries are promoting the health care business so that developed countries can obtain the low cost services. The definitions support the fact that Philippines is one of the few countries that is expanding in terms medical tourism. The impact on the country’s medical tourism is affected by the demand for low cost services by the developing countries (Connell, 2006).

According to Mahun (n.d., p 46-47) “globalisation refers to the act of investing into markets internationally, beyond national and domestic locations, to establish business, thereby increasing product from one location to another”.

The growing globalisation is linked with the growing demand for health services based on the demographic change that is not only coupled with epidemiological change but also the requirements of the people for more and better health services. The services offered by the coupled health services manifests the role of increasing international trade in health services and products via patient flows across border on different health systems (Horowitz, Rosensweig & Jones, 2007).

Globalization affects the international levels of global health contexts such that the impact can be notified by the impact on health outcomes. However, this can be well elaborated by the globalization of diseases that had led to a rise in communicable disease rates (Martin, MacLachlan, Labonté, Larkan, Vallières & Bergin, 2016).

The health systems in the globalization context refer to the regulation as well as service availability, organization and delivery of the health systems. The maximum impact has been referred to the undersupply of the specialists resulting in liberalization of markets and the other being the global migration pattern (Aluttis, Bishaw & Frank, 2014).

Globalization on medical tourism has evolved as the new global business has identified the basic factor that assesses equity as well as impact on health care. The globalization has resulted in expanding health care sectors, generating supplementary revenue by further improving quality and with providing access to health services indifferent countries. Conversely, it has lately become a threat to various health systems due to internal brain-drain from public to private hospitals and upholding health disparities in targeted countries (Hadi 2009).

Research Methods

The global increase in medical tourism can be manifested by the travel of wealthy patients to more developed countries for more advanced treatment. However, the study relates globalization to destinations where medical tourism is operational. The countries like Thailand, Singapore, Malaysia as well as Jordan, Turkey, Mexico, Cuba and Philippines have treated and yet have generated earnings through the types of services they offer (Connell, 2013).

Philippine Medical Tourism Program (PMTP) has developed the communications, logistics and health wellness industries in the Philippines. This reflects the fact that this country has surveyed the international market and recognised the effects of globalisation. This phenomenon is determined by marketplace forces and takes place outside of the vision and power of the prearranged healthcare system. “Medical tourism” presents significant issues and challenges. Moreover potential opportunities are also an important concern. This tendency will have rising effect on the healthcare landscape in industrialized and emergent countries around the earth. The patients’ sense pressed to stabilize their health requirements alongside other considerations, and health issues may be subordinated to other concerns. Modern technology aids latent medical tourists to examine and arrange healthcare anyplace in the globe from their residence processor directly or with the recommendation and support of a “medical tourism agency.”

The destinations play a key role in undermining the new angling phenomenon of the globalisations. As far as the results are concerned on the literature, the role of developing countries have been playing an important factor is causing a drift in the medical tourism. The growing trend in the developing countries is because the tourist from the developed country let their treatment done in cheaper prices, transport sites, government policy and the actual quality of skills that the management possess. On the other hand, the tourist attitude and service cost also proves to be an important determinant of competitiveness in destination (Sultana, Haque, Momen & Yasmin, 2014).

The choice of a destination is a high-involvement decision associated with a high level of risk (Jang and Cai, 2002). Prospective tourists typically apply significant mental effort in making a destination decision in order to reduce the level of perceived risk (Zaichkowsky, 1985, Hawkin et al., 2001). Several authors have noted that the choice of a destination is primarily determined by the tourist‘s motivation to travel; in other words, a destination is chosen to satisfy the particular motivation of a given tourist (Mansfeld, 1992, Um and Crompton, 1990). In the case of medical tourists, the motivation is to find the desired medical treatment of requisite quality at lower cost. The whole destination choice process in medical tourism is therefore determined by these two parameters of quality and cost.

“It has been previously in the study that people from other nations mainly from the US and Europe chose the Philippine for low cost treatment, diversity in treatment procedures, qualified medical practitioners and friendly and hospitable natives allows for a rewarding and memorable tourism experience. The literature review thus supports the actual fact of the research. Destination environment climate, facilities, tourism attractions, composes factors that craft the destination extra attractive to a patient. The use of website advertising in the present is the most frequent basis of information to health travellers. Geographical proximity, ease, travel time, and blockade in reaching the location. Destination image, stereotypes and reputation of a nation are the factors that contribute to the selection of the location. They affect patient’s perception of a specific treatment competence. Destination infrastructure of a country or cure facility level also counts into this matter.”

When analysed on the globalisation factor for the services offered, the effectiveness is elaborated by the service quality that is offered by the countries in potential travel and tourism. Moreover, the study rests on the distribution costs and service as the chief factors for the medical tourism. Conversely, customer satisfaction is based on the competitive factors of quality service and labour force that are skilled and are able to offer the same quality with consistency to every human being that demands to take up the service. However, the five major dimensions that help in evaluating the nature of services is given by five measures of quality namely reliability, tangibility, responsiveness, assurance and empathy (SERVQUAL model) (Sultana, et al., 2014).

In terms of Philippines the kind of medical service provided influence the choice of medical services in the country. The National Competitiveness Council (NCC) was created under the executive order 571 issued in October 2006, making tourism focused on Health Wellness and Recreation (HW&R), to be promoted and developed as globally competitive industries. Medical tour packages are now being offered that takes care of everything from visas, airfares, and accommodation and hospital costs for treatment. This reflects the fact that demands the medical services and requirement in terms of expansion in the field the country has promoted various services. Moreover, the country has lived up to the expectations of the patients in terms of the quality, facility, assurance and tangibility of medical services.

Survey indicates that “competent doctors”, “rapid medical treatment” and “superior health treatment facility”, are the peak three factors previous to deciding the location for the medical trip abroad. “Quality in healthcare” is a construction of cooperation connecting the patient and the healthcare bringer in a compassionate environment. “Healthcare service quality” is dependent on personal factors of the “healthcare service provider” and the individual who seeks help and factors relevant to the healthcare system and wider environment. “Healthcare quality” can be enhanced by compassionate visionary leadership, education, proper set up, and availability of resources, training, employees and processes, effective management of resources and association and cooperation within providers.

This Section on the medical tourism literature to investigative the potential impacts of medical tourism in health systems in tourist destinations. The Section specifically reviewed the four major areas surrounding the research topic; first the definition of medical tourism, second the globalisation and its effects, third factors influencing choice of destination and finally medical services. Finally, by reviewing the medical tourism the research was able to develop the following conceptual model of the key influences that medical has on the general health services.

In this section the literature review was done in order to understand the various actual and conceptual meaning of medical tourism. The review reveals the fact that medical tourism is an industry that promotes the health of the tourist involving medical procedure. Moreover, the various determinants of medical tourism have been reviewed in this section which involves definition, globalisation, factors influencing choice of destination and medical services. “The reviewing of the medical tourism helped in developing the following conceptual model of the key influences that medical tourism that medical tourism has on the general medical health services.”

Figure 2 Conceptual Model for the Research

Finally, the above conceptual model will be used in the next Section to further review the current medical tourism in the Philippines.

The purpose of this study is to explore the potential impacts of medical tourism on the health systems in the Philippines. This Section will first, discusses the research method of collecting data, second the research will utilise the conceptual model develop in the literature review to compare current industry practices with theory. Any Gaps will allow the research to further develop an understanding of the potential impact of medical tourism on the general health systems in the Philippines.

There are usually two types of “data sources (Primary and secondary)” implemented by the researcher while conducting a study in a successful manner.  “Primary data” involve the direct viewpoints of the respondents participating in the study. The viewpoints provide specific information about the context of the study. The “secondary data” are gathered from the “various books, journals, blogs, post, e-journals, historical research journals, magazines, Philippine government websites and previous work of other researchers” (Hammersley, 2014). As per the “nature of the research topic”, the researcher would not include “primary data sources”. However, due to its commercial application “secondary data sources” could be manipulative by nature.

“Sample size” refers to the “number of respondents” required by the researcher to conduct “the research study” in a proactive manner. The researcher would analyse the potential impacts of medical tourism in the health care sector of Philippines over the last 10 years. The researcher would consider several medical hospitals across the globe as a benchmarking process. The researcher would select the “simple random sampling methods” for reducing the biases from the “random sampling methods” for the “current sampling methodology” (Bernard, 2011). The “simple random sampling techniques” would give a better analysis and calculation of the various factors influencing the medical tourism sector in Philippines over the past 10 years.

“Data Collection methods signify the specific area from where data would be acquired in order to enhance the overall standard of the selected research topic in a successful manner”. There are usually, two types of data collection methods- “Quantitative and Qualitative collection methods”. Since the researcher could not include “primary sources of information” for the particular research topic, the researcher did not adopt “quantitative data collection methods” (Bryman and Bell, 2015). The researcher would select the “qualitative data collection method” for gathering practical information about the selected research topic. Furthermore, the implementation of qualitative data collection procedure enhances the overall quality of the selected topic in a proactive manner.

The questionnaire is utilized to gather data and essential information to close the after-effect of this exploration. The survey was sent to the online clients to get to their recognition about "variables affecting the potential effects of restorative tourism in the social insurance area of Philippines". Poll finding can be tended to as take after way.

In addition, the next question is identified with components those mirrored the clients to pick or buy therapeutic tourism administrations in Philippines. (Gravetter & Forzano, 2011).

The above graph says that different elements and devices are drawing in the clients to purchase wellbeing tourism. In this, 30% member underpins that promotion of the Philippines wellbeing tourism item is assume a noteworthy part to pull in the clients. Also, 16% members' reacted that price and cost, 8% bolster quality administrations and 10% reaction differing scope of items or components draw in them (clients) towards the wellbeing tourism items. Then again, 20% clients reacted that big name underwriting and sends out backing or remark on wellbeing tourism item pull in them to buy the Philippines human services administrations. Moreover, 12% clients perceived shield from sicknesses and give best care administrations arrangement as component that pulls in them to purchase the wellbeing tourism administrations. Additionally, just 25% clients decide brand notoriety and great picture of Philippines social insurance associations pull in them to pick the nation's wellbeing tourism administrations. (Bryman, 2012).

The next question was associated with the appraisal of the client base and information about the wellbeing tourism items and administrations and its effects on client purchasing conduct.

The above graph demonstrates that the greater part of the clients around 82% are acquainted with the Philippines wellbeing tourism items and administrations. Moreover, just 8% answered adversely and 10% did not give any answer with respect to they think about the administrations offers by the Philippines nation identified with the wellbeing tourism. (Thomas, Nelson, & Silverman, 2011).

In addition, the above outline identifies with the client recognition in that 36% take an interest answered that that Philippines government special promoting and showcasing methodologies upgrade mindfulness in the middle of the client and impact their purchasing conduct of wellbeing tourism item or administration. What's more, 30% additionally give a comparable answer however 4% were unbiased in light of this inquiry. Moreover, 18% were differ and 12% were emphatically couldn't help contradicting this announcement that Philippines government limited time promoting and advertising methodologies to make mindfulness and impact clients purchasing conduct for the wellbeing tourism. In this way, this reaction relates that Philippines government diverse limited time promoting and advertising methodologies fill in as a positive strategy for the wellbeing tourism to improve mindfulness and draw in the clients. (Speziale, Streubert, & Carpenter, 2010).

The next question was connected with examine of the limited time promoting and advertising technique that draw in the clients for the Philippines wellbeing tourism. In this, diverse limited time strategies are proposed by the clients that pull in them to buy the association's item. 

On the basis of participant response, it is found that the majority of the clients are pulled in by the online and online networking advancement as 26% select this alternative. Besides, 16% clients answered that compelling ads, 10% direct showcasing, 12% individual offering, and 14% deals advancement devices draw in them for buy Philippines wellbeing tourism. Furthermore, 8% takes an interest answered that UTC plans, 10% open connection and 4% bolstered to other limited time promoting and advertising devices pull in clients towards the Philippines wellbeing tourism. (Punch, & Punch, 2005).

The above graph shows the view of the members about the part of Philippines social insurance associations successful limited time promoting and advertising techniques to tie the clients to buy their wellbeing tourism items and administrations. In this, 68% client answered emphatically bolster and 20% clients answered contrarily that Philippines social insurance associations limited time promoting and showcasing devices tie the clients to buy wellbeing tourism items and administrations. Moreover, 12% took an interest were impartial to react to this inquiry. Maxwell, 2005).

At the same time, next question is connected with clients' reasoning about the late Philippines human services associations special promoting and showcasing techniques as they are sufficient to keep up its position in the worldwide focused market or not.

In the context of this question, the customer/client reacted has been plotted in the above outline, which is identified with adequacy of late Philippines human services associations limited time publicizing and advertising methodologies to get by in the global business sector. In this, 42% members reacted emphatically that late showcasing and limited time publicizing methods of the Philippines human services associations are helping it to stay in the worldwide aggressive business sector. Moreover, 36% clients reacted adversely that late limited time publicizing and advertising instruments of the Philippines social insurance associations are not helpful of it to make due in the global business sector because of rivalry expanding in the overall business sector. Additionally, 22% clients were answered impartial reaction to this inquiry. (Gerrish, & Lacey, 2010).

The next question 8^th was alluded to the assessment that there is any prerequisite of change in the current limited time publicizing and showcasing procedures of the Philippines medicinal services associations.

The above chats represents that the Philippines medicinal services associations is required for changes in its late showcasing and special promoting techniques. In reacted to this inquiry, 44% member answered decidedly and 42% were answered contrarily that the Philippines human services associations required changes and change in its present showcasing and limited time techniques to upgrade its execution and development in the worldwide aggressive business sector. Also, 14% clients were impartial in reacted to this scrutinize the Philippines medicinal services associations requires alteration in its late advertising and limited time techniques. (Daymon, & Holloway, 2010).

The next question evaluation of the customers’ recognitions identified with part of Philippines government support on the social insurance association's development and achievement in the worldwide business sector.

The greater part of the clients trusted that Philippines government backing of the wellbeing tourism division contributes into the development and achievement of human services association as 72% were reacting decidedly to this inquiry. What's more, 16% clients were accounted for adversely that the present Philippines government support not useful of the healing facilities. Additionally, 12% clients were impartial on the reaction to this scrutinize implies they didn't think about this subject. (Zikmund, 2003).

The reactions were given by the clients is successful to discover the arrangement of this examination. On the premise of clients reacted of the survey, it predicts that Philippines government showcasing and special publicizing systems assumed significant part in the development and accomplishment of medicinal services associations in the focused worldwide business sector.

The medical tourism in Philippines undeveloped as there are more potential opportunities in other developing countries because of lack of expertise (McKenzie, 2014). The results highlights that Philippines has been more involved in the marginal activity of the medical transplant tourism than the tourism attracting holiday makers. Philippines with other countries like Singapore as well as Thailand have experienced an internal brain drain in the medical tourism industry. The health worker flows in Philippines has been from public to private sector due to the inefficiency of the government. The brain drain occurs from public to private sector movement of the killed and expertise to the private sectors due to less payment. Moreover, the local employment remains loose, since several locals opt for better options abroad with more salary structure. (Bradby, 2013).

The medical practises in the Philippines are not done by the natives of the Philippines rather specialists are the foreign doctors and health managers from the different countries that are called to create reciprocal relations with the tourists who come to Philippines to get treated. Although, the medical tourism market of the Philippines is not advanced. The medical specialists in Philippines are not outwardly qualified to response to the concerns of medical tourist from the developed countries (Hodges, Turner & Kimball, 2012). Although, with less medical assistance on the major health issues and with no proper medical specialists, the medical tourism in Philippines has lowered irrespective of the number of health care systems (Holtz, 2012). Thus such a condition affects adversely to the health of the patients. Although the country is developing in terms of the medical sector, there are still certain lags that need to be made. There is a positive economic impact of the country’s medical tourism which contrasts the negative impact on the country’s health care system.

The Philippines medical services ranks low when compared with all developing countries. The public and private medical sector lacks the required resources that are needed to fill the large income gaps that are experienced in the health sector in Philippines. Moreover, the study formulates that the medical services infrastructures needs to be revitalized as the country is not affluent to promote its services to international patients as a ways of bolstering tourism in health sector Thus, it can be said that healthcare system of Philippines is getting negatively affected due to the reduced number of medical practitioners and poor infrastructure especially in the public sector. (Porter, De Vera, Huang, Khan, Qin & Tan, 2008).

The medical facilities in Philippines are borne by the nature of the technology in the public as well as private sector such that the natures of the facilities offered in Philippines are more expensive as the government does not charges and fees. However, the irony lies in the fact that best practise is only offered in the public health medical sector. The nature of the responsibilities in Philippines is way above the standard costs because of the shortage of medical personnel that not only generates a question of getting treated properly but also possess the rise in medical costs in Philippines Therefore, it is obvious that the public health sector seeks more advantages than the private sector.  (Heung, Kucukusta & Song, 2010).

Philippines is highly sufficient in providing medical services with lack in personnel to the tourist because the Philippine health system not only possess the threat of loss of money for travellers but also raises the question of getting treated properly or not. The nature of medical practices raises a question of costs that are low than the developed countries. Nevertheless, Philippines receive treatments from top private hospitals to meet the needs of the tourists from abroad. Although there are facilities to provide medical aid to the foreigners, there are negative impacts on the health of the locals due to the rise in the medical tourism. (Heung, Kucukusta & Song, 2010).

Table X Current Practice compared to Theory

Theory Discussed in Literature	Current Practices in the Philippines	Possible Gaps
Globalisation of the Industry	Employment of highly skilled medical practitioners from the international market.	Internal brain-drain from public to the private sectors
Choice of Destination	Two factors considered high quality and loss cost treatment	High level of risk in the investing money.
Choice of Services	Medical tour packages, airfares, cheaper treatments, accommodation are offered	Customer satisfaction level due to the competitive market

In this Section the research will utilise the Table X developed in Section 3 to analyse the possible gaps between current medical tourism practices in the Philippines and the theories developed in the literature (conceptual model). This Section will first, review the methods of data analysis, second globalisation of the industry, choice of destination and finally choice of services. This analysis will further develop the recommendations of how to manage potential impacts of medical tourism on the general health systems in the Philippines and make recommendations to the Government. 

The analytical procedure serves as the identical aspects of “Quantitative and Qualitative research”, by which the researcher may significantly “categorize, summarize and evaluate” the important areas of the research topic in accordance to the “subject matter of the body”. Upon implementation of the “analytical procedure”, the researcher would get a better idea about the potential impacts of medical tourism in the health care sector of Philippines (Bryman and Bell, 2011). Since the researcher did not opt for implementation of “primary data sources for quantitative analysis”, the researcher did not select the “statistical tools” in the terms of “Tables, Charts, Mean, Mode, Median and STDEV”.

Instead, the researcher opted for tools such as “content analysis approach and thematic frames”. The “content analysis approach” assisted the researcher to develop the overall quality of the selected research topic by collecting authentic and relevant information. The thematic frame analysis helped the researcher to identify the “factors influencing the potential impacts of medical tourism in the health care sector of Philippines”. The thematic research serves as one of the most common analytical tools for quantitative data analysis. The thematic analysis takes active participation in illustrating the occurrence of a particular phenomenon in association with specific sets of research questions (Bryman, 2011). The thematic format focuses upon “pinpointing, examining, and recording patterns (or "themes") within data”.

Thematic analysis is utilized as a part of this subjective exploration study to unravel the examination issued through creates topics by coordinating arrangements of coding with the survey meeting information. In topical examination, the specialist is empowered to investigate and adjusting subjects to gathered essential information with respect to the elements sway on therapeutic tourism in the human services part of Philippines. The procedure of topical investigation gives the adaptability of the scientist to highlight subject and inquiries amid the distinctive meetings (Bendat, & Piersol, 2011). The specialist has figured three fundamental subjects or codes on the premise of gathering information through studying of various journals and literature review.

Major Themes	Perceived Benefits	Key issues
Positive image of health care sector contribute into medical tourism	Create trust with customers	Confusing consumers about the product’s true country-of-origin
Health care services and costs considered by the customers during purchase services	Willing more to pay if health care services is better	Customer preferable cost and quality so they prefer best health care services and products
Better promote the health care services by the government	Create awareness in people that encourage customers for medical tourism	Require more affords and huge funds to promotion campaign

(Source: Punch, & Punch, 2005)

On the premise of the produced powerful topics or codes, the analyst investigations and consolidates information with significant subject in regards to the present circumstances of the general population for buy medicinal tourism administrations. It can be broke down that constructive or great picture of the medicinal services administrations in the general population mind that assumed significant part in impact client buy states of mind and purchasing conduct for therapeutic tourism administrations. The solid certainty among the general population urge them to perceived logo amid buy therapeutic tourism administrations, so they likewise ready more to pay for better social insurance administrations. Also, some client, for example, high wage class clients favoured quality and low salary class individuals costs, so they may not willing more to pay for medicinal tourism administrations, in the event that they have other global restorative tourism choices. The information broke down additionally discover that the administration better advance the restorative tourism administrations to make mindfulness in individuals that urge them to purchase Philippines therapeutic tourism benefits rather other nation administrations. (Pickard, 2013).

The data was collected from reviewing of various literature and journals. Through the study it was analysed that there are variables that affect the potential restorative tourism. According to a report, the “Department of Tourism in Philippines” estimates around 1, 00,000 visitors in the country have been classified into medical tourist. According to a study, the expansion of medical tourism can help in elevation of the nation’s health care system by increasing the generation of tax revenues which can be later used in the betterment of the local health care system. This can also contribute to the provision of jobs to the medical professionals so that they do not obtain for employment abroad (Connell, 2006).

“The reputation of a nation and stereotypes, which are hard or even impossible to undo, can improve the reputation of the country. They influence patient’s perception of a particular treatment facility.” Destination infrastructure on country or treatment facility level also contributes in this regards. Theme analysis reflects that if the infrastructure, facility and services of the health care system proceed by maintaining the quality of the services and improving the condition of the health care system it will attract medical tourists. Once the reputation of the country develops in terms of a good health care provider then it will contribute to medical tourism positively. If quality services are provided to the foreigners it will help in gaining their trust on the nation.   

In the Philippines, the government is a bureaucrat associate in the industry. According to a literature review, the administrator “Philippine Medical Tourism program,” a public-private joint venture, has made substantial hard work to attract “transplant tourists” into the nation’s highly developed medical facilities. Philippines began bit behind for the intercontinental patient commerce but are catching up rapidly. Its international healthcare marketplace is predicted to develop with a “CAGR” of nine percent for the time of “2012 – 2015.”

As discussed by Connell (2006), there was trend observed in the medical tourism i.e. the developed countries have tendency to travel in the developing countries to avail for medical treatment depending on the standard services. According to the studies the patients from the developed countries generally like to obtain medical services from those nations which provide them with high quality facilities at a cheaper rate than their own country. For example, countries such as England, USA, have high medical cost and people faces difficulty in availing such medical options. Patients from these countries tend to travel in developing countries with cheaper medical cost. The patients from abroad remains ready to pay more if the service is good and satisfaction level is high. But there exist an issue that can hamper medical tourism. When a customer does not compromise in the cost, then they expect best quality service. Therefore meeting up to their satisfaction level remains a challenge (Connell, 2006).

In terms of Philippines the treatment offered are versatile in nature involving orthopaedics treatment surgery, LASIK cardiac care, dental treatments and cancer therapy. This country offer special itineraries which is available for both the international and the domestic patient who are ready to combine treatment with leisure. Moreover, there is availability of medical equipment and the Filipino doctors are well trained with western medical orientation. “In Philippines, one can get medical treatments at surprisingly low costs. Apart from the surgical procedures, the medications which are required during the recovery process also cost less in this country. The living cost in Philippines is also very low when compared to foreign countries. So, even if the accommodation and transportation costs are added, the total treatment cost for visitors will be very much lower than their home country. One can choose from the many health care packages, which includes travel, accommodation, and hospital services. For getting best facilities, you will have to find the right hospitals to provide the exact services that you require.”

It is the government and other authoritative bodies of the country that contributes to the promotion of the medical tourism. The main objective of the Philippines government is to ensure that the country’s is internationally competitive through accomplishment of quality values in both public and private segment. Using the various media such as websites, television advertisement, and other modes the government does the marketing of the health care system in order to attract the medical tourist. The advertisement facilitates to develop an awareness in the general public which leads to the promotion of the medical tourism. The promotional events require huge amount of affords and funds. Such funds can help in the campaigning and marketing events. This can be a big and reflective issue in terms if the medical tourism.

According to Penney et al., (2011), in Philippines, a forum was designed to foster the discussion related to the public national health priorities. The “Board of Investment” in terms of the discussion urged not to give investment privileges or special tax to those services that are business oriented.  As a result the board adopted the service that exempting the tax from the private hospitals and added extra thirty beds. The National Competitiveness Council (NCC) was created under the executive order 571 issued in October 2006, making tourism focused on Health Wellness and Recreation (HW&R), to be promoted and developed as globally competitive industries. (Zuellig, 2011). Medical tour packages are now being offered that takes care of everything from visas, airfares, and accommodation and hospital costs for treatment.

Philippines social insurance associations pull in them to pick the nation's wellbeing tourism administrations. (Bryman, 2012). Philippines government limited time promoting and advertising methodologies to make mindfulness and impact clients purchasing conduct for the wellbeing tourism. In this way, this reaction relates that Philippines government diverse limited time promoting and advertising methodologies fill in as a positive strategy for the wellbeing tourism to improve mindfulness and draw in the clients.  Bearing in brain that the government has had approaches, research teams, marketing forums and a puzzling history of bureaucrat organizations as as long ago as 2004, an account that carry up the similar solutions as preceding ones goes a extended way to elucidate why “inbound medical tourism” has a extensive way to visit in the Philippines.

Analysis of the secondary data it has been observed and concluded that there are various factors that contributes as a factor that impact on the Philippines medical tourism sector. The strategies adopted by the government have positively resulted in the growth and success of the health care and medical tourism sector.  The Philippines could attract more medical tourists if it could reduce the cost of air travel, improve air links, cut airport fees, build a transport infrastructure, improve tourist safety and security, deal with consumer concerns about the quality of healthcare, market better, and decide what niche it can target. So says the latest official report on medical tourism. Literature review reveals that although there are still areas to conquer by the nation in terms of the health care sector, the country has evolved within a short span as one of the trusted nations in terms of medical tourism. When the themes were analysed in concerned of Philippines, it was observed that the country has been used as an option by many foreign countries since it provide cost effective services with high quality medical facilities. Moreover, Philippines are well known for certain therapeutic surgeries which are not so popular in many countries (Penney et al., 2011).

Theory Discussed in Literature	Current Practices in the Philippines	Gaps	Possible Recommendations
Globalisation of the Industry	Hiring of medical expertise from the international market	Internal brain-drain from public to private sector	Higher salary structure can retain the medical practitioner
Choice of Destination	Two practices are involved high quality and low cost treatment	High level of risk in investing money	Pursue negotiations of public insurance portability for international medical travel and retirement
Choice of Services	Provision of medical packages, airfare, accommodation, etc.	Customer satisfaction level in the competitive market	Improve the transparency between the customer and medical policies.

Recommendations and Conclusions

The gaps can be improved through certain improvements. The recommendations to fill the gaps are as follows:

1. Improve international connectivity by eliminating the common Carriers Tax and Gross Philippine Billing tax on foreign airlines.
2. Development and implementation of national and destination masterclass and predict property rights of investors with Tourism act 2009.
3. Enhancement of mobility for travel and tourism Enterprises.
4. Pursue negotiations of public insurance portability for international medical travel and retirement.

Thus,  it can be concluded from the above report that medical tourism is a growing field in the developing countries of the world. The facilities and  services provided by the countries are grabbed by the developed countries to receive low cost and high tech services. One of such developing country is Philippines which have developed and designed this field effectively in order to promote medical tourism. Although the impact of medical tourism on the health care system is highly affected by globalization, choice of services and destination choice, the gaps can be removed by certain effective improvements in plans and policies. 

References:

Connell, J. (2006). Medical tourism: Sea, sun, sand and… surgery. Tourism management, 27(6), 1093-1100.

James, P. T. (2012). The impact of medical tourism on Thai private hospital management: informing hospital policy. Global journal of health science,4(1), 127.

Manuel, C. R. Medical tourism: a growth strategy: a multi-dimensional view on medical tourism. Makati City: Asian Institute of Management, Dr. Stephen Zuellig Center for Asian Business Transformation; 2011.

Penney, K., Snyder, J., Crooks, V. A., & Johnston, R. (2011). Risk communication and informed consent in the medical tourism industry: a thematic content analysis of Canadian broker websites. BMC medical ethics,12(1), 17.