Definition: International inbound tourists (overnight visitors) are the number of tourists who travel to a country other than that in which they have their usual residence, but outside their usual environment, for a period not exceeding 12 months and whose main purpose in visiting is other than an activity remunerated from within the country visited. When data on number of tourists are not available, the number of visitors, which includes tourists, same-day visitors, cruise passengers, and crew members, is shown instead. Sources and collection methods for arrivals differ across countries. In some cases data are from border statistics (police, immigration, and the like) and supplemented by border surveys. In other cases data are from tourism accommodation establishments. For some countries number of arrivals is limited to arrivals by air and for others to arrivals staying in hotels. Some countries include arrivals of nationals residing abroad while others do not. Caution should thus be used in comparing arrivals across countries. The data on inbound tourists refer to the number of arrivals, not to the number of people traveling. Thus a person who makes several trips to a country during a given period is counted each time as a new arrival.
Development Relevance: Tourism is officially recognized as a directly measurable activity, enabling more accurate analysis and more effective policy. Whereas previously the sector relied mostly on approximations from related areas of measurement (e. g. Balance of Payments statistics), tourism today possesses a range of instruments to track its productive activities and the activities of the consumers that drive them: visitors (both tourists and excursionists). An increasing number of countries have opened up and invested in tourism development, making tourism a key driver of socio-economic progress through export revenues, the creation of jobs and enterprises, and infrastructure development. As an internationally traded service, inbound tourism has become one of the world's major trade categories. For many developing countries it is one of the main sources of foreign exchange income and a major component of exports, creating much needed employment and development opportunities.
Limitations and Exceptions: Tourism can be either domestic or international. The data refers to international tourism, where the traveler's country of residence differs from the visiting country. International tourism consists of inbound (arrival) and outbound (departures) tourism. The data are from the World Tourism Organization (WTO), a United Nations agency. The data on inbound and outbound tourists refer to the number of arrivals and departures, not to the number of people traveling. Thus a person who makes several trips to a country during a given period is counted each time as a new arrival. The data on inbound tourism show the arrivals of nonresident tourists (overnight visitors) at national borders. When data on international tourists are unavailable or incomplete, the data show the arrivals of international visitors, which include tourists, same-day visitors, cruise passengers, and crew members. Sources and collection methods for arrivals differ across countries. In some cases data are from border statistics (police, immigration, and the like) and supplemented by border surveys. In other cases data are from tourism accommodation establishments. For some countries number of arrivals is limited to arrivals by air and for others to arrivals staying in hotels. Some countries include arrivals of nationals residing abroad while others do not. Caution should thus be used in comparing arrivals across countries.
Statistical Concept and Methodology: Statistical information on tourism is based mainly on data on arrivals and overnight stays along with balance of payments information. These data do not completely capture the economic phenomenon of tourism or provide the information needed for effective public policies and efficient business operations. Data are needed on the scale and significance of tourism. Information on the role of tourism in national economies is particularly deficient. Although the World Tourism Organization reports progress in harmonizing definitions and measurement, differences in national practices still prevent full comparability. Arrivals data measure the flows of international visitors to the country of reference: each arrival corresponds to one in inbound tourism trip. If a person visits several countries during the course of a single trip, his/her arrival in each country is recorded separately. In an accounting period, arrivals are not necessarily equal to the number of persons travelling (when a person visits the same country several times a year, each trip by the same person is counted as a separate arrival). Arrivals data should correspond to inbound visitors by including both tourists and same-day non-resident visitors. All other types of travelers (such as border, seasonal and other short-term workers, long-term students and others) should be excluded as they do not qualify as visitors. Data are obtained from different sources: administrative records (immigration, traffic counts, and other possible types of controls), border surveys or a mix of them. If data are obtained from accommodation surveys, the number of guests is used as estimate of arrival figures; consequently, in this case, breakdowns by regions, main purpose of the trip, modes of transport used or forms of organization of the trip are based on complementary visitor surveys.
Aggregation method: Gap-filled total
Medical Tourism – The Role of the Destination Brand
An exciting market for medical services is taking shape as more consumers are willing to travel for health and medical care. This market is complex, and little is known about the motivations of those who decide to travel for care. Clinics and hospitals, as well as cities, regions, and countries are investing resources in the hope of realizing some of the anticipated benefits. Most medical tourism investments have not, however, achieved positive Return on Investment (ROI). Empty or only partially used clinics and hospitals which were built to serve medical travelers are a drain on private and public resources and are extraordinarily difficult to support and staff. These very public marketing mistakes also create resistance to further investment. What are needed are tools to better understand why some consumers travel for care, while others will not, and predict market behavior to prevent or reduce investment errors.
The modern healthcare services market continues to grow as seen by the increase in expenditure in both public and private sectors, and rising insurance penetration and premiums. Further evidence of this is price inflation in the sector. Average real growth in spending on healthcare in OECD countries has been 4.0% per year since 1970, with the highest rate 8.2 %. This growth has attracted the interest of investors and governments.
Historically, healthcare services have been produced and consumed locally. The medical travel sector remains an early stage market, but is growing and has captured international attention because of its economic development potential.
Who travels for care?
Until recently, economically advantaged consumers mostly from developed countries have traveled to other developed locations, perhaps outside of their home countries, to consume healthcare and medical services. What is distinct in this more recent medical travel market is the phenomenon of consumers from developed countries traveling to developing countries.
This new medical travel market is motivated by several factors including, the availability of procedures which may not be available where the consumer lives, prompt access, access to procedures which may not be legal or acceptable where the consumer lives, perceived expertise or superiority of a provider in a distant destination, as well as lower healthcare costs in a particular destination. These travelers now represent a sizable market, estimated to be US $30 – 60 billion annually with growth rates of 20 – 30%.
Nations recognize the medical sector and the international medical travel market in particular as an opportunity, and investing in the medical industry as a way to increase gross domestic product (GDP), improve services, generate foreign exchange, create a more favorable balance of trade, and boost tourism. Countries are launching advertising and public relations campaigns to bolster their own international medical appeal, to increase the relative attractiveness of themselves vis-à-vis others and thereby create preference among consumers.
Competitive position is not an accident
The best brands in the world cannot assume that global markets will beat a path to their door. The organizations and individuals behind Apple, McDonald’s, Amazon and Nike understand the critical need to market their products effectively, and have invested heavily to both establish and sustain their brands’ competitive positions. The obvious value of these brands is apparently not so obvious to many business leaders and policymakers in the world that would like to establish themselves as medical travel destinations. Too many attempts are made to establish a hospital, city, a region or even a country as a medical travel destination without considering and / or marketing the brand of the destination. This oversight ignores decades of well-established business principles and research.
What is a “brand”?
A brand is the dominant opinion, or pervasive perception of anything. The perception of a location among the would-be foreign consumers of dental or medical services, i. e. the “destination brand”, plays a critical role in their decision to travel to that location for healthcare. Considering the obstacles and risks associated with the decision to travel for healthcare, it is easy to understand that the perception of the destination, its brand, would weigh heavily in the consumer’s choice. One of the problems in medical tourism and international medical travel is that the role of destination brand in consumers’ choices to travel for care is not yet well understood. We know that it is important, but there have not been objective, reliable measures of destination brand in the context of medical travel.
Destination brand & medical traveler choice
The choice of a medical provider by a consumer is complex. The circumstances may be urgent, such as an emergency, emerging (progressive pain), psychological (self-image) or lifestyle (child bearing) motivations. The range of motivations is broad, from urgent to deliberate. Consideration of a distant destination assumes that consumers deliberate the decision to travel for care, although even in urgent circumstances if local services are not available, sick or injured consumers will seek services wherever they believe these are available or of higher quality. Within this emerging, highly differentiated market of consumers choosing to travel for care, what is not well understood is the role of destination perception – “destination brand” in consumer choice.
The Medical Travel Index
A model to rate and rank destinations based on the measures which medical tourists use to make decisions is needed. Such a model will enable providers and policymakers to successfully plan, position and market a destination to a target audience. Rather than guessing whether consumers will be attracted to a particular hospital or a location, this model creates a way to estimate attraction – or resistance – as a factor in consumer choice. By analyzing, weighting and harmonizing secondary sources such as destination rankings and relevant published indexes, a comparative metric, the Medical Travel Index (Robertson, Stackpole, Geenty, 2015) can be applied to this marketing challenge. The Medical Travel Index scores and ranks countries based on their comparative attractiveness as medical travel destinations, and is indifferent to the country’s marketing messages.
Components of the Medical Travel Index
The Medical Travel index uses five prominent factors to create a nation’s ranking. These factors include a measure of travel and tourism attractiveness, economic freedom, corruption, supply of medical resources and the states’ burden of cost. Each of these is from respected, reliable published sources, then weighted (as shown) and standardized to allow comparison.
The Travel and Tourism Competitive Index quantifies a nation’s ability to attract tourists. This measure is a crucial factor because it approximates the attractiveness of a country’s travel and tourism sector is and is heavily weighted. Also included is the measure by Bloom Consulting, which publishes the annual Country Brand Ranking, based upon data collected by the World Tourism Organization (UNWTO), and is widely respected. These scores were merged to form the “Travel” portion.
The Economic Freedom measure is based upon the The Index of Economic Freedom produced by The Heritage Foundation. This provides an established perspective of a nation’s ability to provide citizens the resources to “…act with autonomy while in pursuit of their economic livelihood and greater prosperity” (Heritage Foundation, 2014).
The Corruption measure was based upon a ranking of Corruption Perception provided by Transparency International, which isderived from global surveys of perceived corruption. This offers insight into how those pursuing medical travel may view different nations (Transparency International, 2013).
The Supply measure is based upon hospital and physician density for each studied nation. The statistics were provided by the CIA World Factbook as well as by the World Health Organization (WHO). Consumers evaluate the relative availability of care by medical practitioners and Supply is a measure of capacity in a destination nation.
The final measure, State Burden, is based on healthcare spending and poverty statistics. Health Expenditures as a proportion of the Gross Domestic Product was provided by The World Bank Group. The poverty data is taken from the CIA World Factbook and measures the population below the poverty line. Consumers may use these to gauge the wealth of a nation’s population and how much of its resources are devoted to healthcare.
Countries & Rankings
Countries included in this initial application of the Medical Travel Index were derived from publications and other documents where the country promoted itself as a medical travel destination (through a cabinet level ministry or a reputable agency) or which were identified in the literature by other authors. Excluded from this analysis were countries which have, based on the best available information, negligible volumes of medical travelers, or have not encouraged medical travelers. Forty-four (44) countries were included in the initial group.
In this analysis, countries such as Germany, France, South Korea and the United States emerge among the most highly rated international medical travel destination brands.
This methodology also produced some paradoxes. Japan and Canada rank very highly, but it is unclear that Japan has been effective attracting many medical travelers. Canada is in the midst of a public debate about whether foreign consumers are inappropriately “jumping the line” on Canadians, and whether this form of medical export should be discouraged.
Other countries, such as Mexico and India, which have aggressively promoted themselves as medical tourism destinations, did not rank as highly as many others; Mexico ranked 29 th and India 43 rd. Economic Freedom, Corruption and State Burden weighed heavily in this comparative ranking. The component scores of the Medical Travel Index can serve as a guide to policymakers as to what needs to be addressed in order to measurably improve their country’s comparative ranking.
This resulting paradox of comparative / competitive ranking can be seen in the Middle East. Israel (20 th ) has done little to promote itself as a medical travel destination, while the United Arab Emirates (23 rd ) is aggressively pursuing various segments of this market.
It should be noted that one of the strengths, and certainly one of the weaknesses of this methodology is that it is based on published data. From the consumer’s point of view, perceived corruption or poverty may not prevent a decision to travel to a particular destination if the situation is desperate enough, or the economics are compelling. In a relatively non-pressurized decision, these factors certainly have greater influence.
What about money and distance?
The Medical Travel Index models and ranks the comparative attractiveness of countries as medical travel destinations, without attempting to adjust for relative economics (e. g. Purchase Power Parity), or distance (travel time). Much more research and analysis is needed for adjustments and refinements to the model to account for these factors.
Globally, the modern healthcare services market continues to grow. Across the developed world, healthcare spending is rising and will continue to do so driven in part by consumer demand. The growing market for international medical care and medical tourism is attractive to developing nations. The need to better understand consumer choice in this complex, medical travel market dynamic led to the development of the Medical Travel Index (Robertson, Stackpole, Geenty, 2015), an objective way of rating and ranking the brands of destinations attempting to attract international medical consumers. This measure is independent of anything the destination says about itself. Further work is necessary to refine the model so that it is more predictive. As the medical tourism and international healthcare markets continue to grow and evolve, additional measures will be developed to more effectively evaluate the impact of destination brand on consumer choice.