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Journal of China Tourism Research
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/wctr20
An Exploratory Study of Factors Influencing
Chinese Outbound Medical Tourism
Kei Wei Chia & Yi Ming Liao
To cite this article: Kei Wei Chia & Yi Ming Liao (2020): An Exploratory Study of Factors
Influencing Chinese Outbound Medical Tourism, Journal of China Tourism Research, DOI:
10.1080/19388160.2020.1780177
To link to this article: https://doi.org/10.1080/19388160.2020.1780177
Published online: 16 Jun 2020.
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An Exploratory Study of Factors Inuencing Chinese
Outbound Medical Tourism
Kei Wei Chia and Yi Ming Liao
School of Marketing and Media, Asia Pacific University of Technology and Innovation, Kuala Lumpur,
Malaysia
ABSTRACT
China has experienced rapid economic transitions in the past few
decades, accumulating high demand for accessible, aordable, and
ecient healthcare services both within the country and abroad.
The purpose of this study was to explore the factors inuencing
Chinese mainland outbound medical tourism. Data was derived
from interviews with 10 respondents. The thematic analysis quali-
tative method was employed to identify respondents’ views on the
factors inuencing Chinese outbound medical tourists to seek
medical services. A total of seven themes were identied and
classied under two dimensions (quality of medical service and
convenience). This study provides empirical evidence regarding
the factors inuencing Chinese outbound medical tourists by draw-
ing on interviews with potential Chinese medical tourists. The
insights and implications derived from the results are discussed.
中国游客出境医疗旅游因素之探索性研究
摘要
在过去的几十年中, 中国经历了快速的经济转型, 对国内外可进入
性, 可负担, 高效率的医疗服务需求也在不断增长。本研究的目的
是探索中国人选择出境医疗旅游的影响因素。本研究的数据来自
对10位受访者的访谈, 进而采用主题分析方法来确定影响受访者
选择出境医疗旅游的因素。本文总共确定了七个主题并将其分为
两个维度 (医疗服务质量和便利性) 。本研究通过对潜在中国医疗
游客的访谈, 为影响中国游客出境医疗的因素提供了证据, 见解和
启示。
ARTICLE HISTORY
Received 13 June 2019
Accepted 1 April 2020
KEYWORDS
China outbound tourism;
healthcare; factors; medical
tourism
关键词
中国出境旅游; 医疗卫生
保健; 影响因素; 医疗旅游
Introduction
Today, people travel without borders to seek medical treatment (De Arellano, 2007). In
fact, the number of people traveling abroad for medical services has increased rapidly in
recent times (Tseng, 2013). In 2018, approximately 150 million overseas trips were made
by Chinese tourists (Cheng, 2019). Chinese mainland tourists, meanwhile, spent about
258 USD.0 billion on tourism, which is close to 20% of the world’s total tourism
expenditure (UNWTO, 2018). It was reported that China’s health expenditure equaled
RMB4.6 trillion (Deloitte China, 2017). It was also estimated that there are approximately
CONTACT Kei Wei Chia ckeiwei@gmail.com , Kuala Lumpur 57000, Malaysia
JOURNAL OF CHINA TOURISM RESEARCH
https://doi.org/10.1080/19388160.2020.1780177
© 2020 Informa UK Limited, trading as Taylor & Francis Group
500,000 outbound Chinese medical tourists who spend more than 10 USD billion
annually seeking medical treatment in Southeast Asia and Western countries (Global
Growth Market, 2018). The number of such tourists is expected to reach 1,000,000 by
2020. Therefore, many medical tourism countries pin their eyes on the Chinese market to
target affluent people who are willing to fly abroad for medical treatment.
China’s medical tourism industry is growing fast. Several first-tier cities such as
Beijing, Shanghai, and Guangzhou have shown great enthusiasm for the development
of the medical tourism and have continued to learn from developed countries. Today, the
demand for medical services is extremely high, such that some are willing to travel abroad
to seek better medical services. Despite increased awareness of health issues, it is only in
recent years that a substantial body of medical research in China has emerged. However,
research has scarcely been concerned with studying why Chinese medical tourists travel
abroad to seek medical services (Pan & Chen, 2014). Prior studies have largely concen-
trated on wellness tourism (Huang & Xu, 2014; Kucukusta & Heung, 2012; Lo et al.,
2013), with only a few studies focusing on Chinese outbound medical tourism (Pan &
Chen, 2014; Ye et al., 2011;. Yu & Ko, 2012). Consequently, this study sought to
contribute to filling this void by examining the motivations of Chinese medical tourists’
overseas travel to seek medical services.
Though researchers from developed countries and different disciplines have carried
out empirical studies on medical tourism, little is known about this phenomenon in
developing countries such as China. In addition, most medical tourism studies in China
have been quantitative in nature. In order to advance the knowledge in this area, this
study employed a qualitative survey. The findings were extended to the global context
and conclusions were drawn to understand the importance of the factors driving
potential Chinese medical tourists to seek medical treatment abroad. Besides this purely
academic purpose, the study aimed to provide a starting point for future comparisons of
medical tourism in other parts of the world.
Literature review
Medical tourism
Medical tourism has become a significant niche in the tourism industry as more humans
travel beyond boundaries to seek healthcare treatments (Connell, 2006; Rodrigues et al.,
2017). To date, there is no universally accepted definition of medical tourism, since
various countries and researchers define the term differently (Helble, 2011). Nevertheless,
medical tourism is always associated with health tourism and is a subset of health tourism
(Heung et al., 2010). Although there is no widely accepted definition of medical tourism,
in this study, medical tourism refers to ‘all the activities related to travel and hosting
a tourist who stays at least one night at destination region for the purpose of maintaining,
improving, or restoring health through medical intervention (Musa et al., 2012, p. 527).’
On the other hand, Altın et al. (2012, p. 1004) defined health tourism as ‘the travel of
individuals from their residences to other places with the purpose of receiving treatment.’
It is also ‘a form of outsourcing medical services to medical centres in countries in which
costs of services are lower than in the home country (Pan & Chen, 2014, p. 108).’ In some
countries, such as Malaysia, the economic contribution of medical tourism is evident.
2K. W. CHIA AND Y. M. LIAO
Foreign medical tourism has several competitive advantages because foreign medical
institutions provide world-class professional services and treatments. One of the unique
selling points of Malaysia as a foreign medical tourism destination is that the healthcare
system is supported by the Malaysian government. This ensures quality and compliance
to safety standards and regulations. Additionally, medical experts are well-trained and
medical equipment meets international standards. In developing medical tourism, Ulaş
and Anadol (2016) highlighted several contributors to the growth of medical tourism.
These include an aging population, the development of international healthcare stan-
dards, increased insurance coverage, cooperation between insurance companies and
healthcare institutions, the establishment of mediatory agencies between international
patients and hospital networks, marketing communication efforts, and government
publications targeting medical tourists’ support.
Medical tourism in China
In China, the demand for medical tourism has seen tremendous growth (Pan & Moreira,
2018). Medical tourism was initially incorporated by the Chinese government who saw
a need to reform the healthcare system. It then expanded rapidly over the next few years
when Hainan become the hub of medical tourism destination in China to boost domestic
medical tourism (Bloomberg News, 2017). Meanwhile, foreign investment penetrated the
Chinese healthcare industry, establishing more than 100 clinics in first-tier cities. In the
late 2000s, the Chinese government reformed the healthcare system with the aim of
achieving comprehensive healthcare coverage by 2020 (Yip et al., 2012). This reform
included efforts to improve insurance policies, public hospitals, and the essential drug
system. Previously, China’s ‘One-Child’ policy drove some Chinese couples to travel to
Hong Kong to give birth (Yip et al., 2012). Today, the abolishment of the policy allows
Chinese couples to consider a second child; however, age is a major concern as most
couples are above 40 years old (Aliman, 2018). Thus, countries like Malaysia are taking
this opportunity to help Chinese couples with their fertility concerns, given that the
success rate (approximately 66%) for In Vitro Fertilization (IVF) treatment in Malaysia is
above the world average (50%).
Furthermore, advanced medical resources in mainland China are highly limited and
concentrated in selected public hospitals across the country. Common healthcare pro-
blems in China include long waiting lists (Cao et al., 2011; Sun et al., 2017; Sun et al.,
2016; Wee, 2018), poor medical service quality (Eggleston et al., 2008; Meesak., 2017),
overcharging (Fang, 2008; Hui, 2010; X. Liu et al., 2000), medical corruption (Cao, 2015;
Tam, 2011; Xu, 2014; Y. Zhang et al., 2014), low responsiveness (Eggleston et al., 2008),
and lack of specialist services. The Chinese public also frequently complain about medical
corruption (Y. Zhang et al., 2014). It was reported that 1,100 medical staff in one city in
China were found to have taken bribes amounting to 3 USD.34 million (Yan, 2013). Low
wages are the main cause of such misbehavior (i.e receive bribery from patients) among
Chinese doctors in public hospitals (Cao, 2015). These negative factors have increased the
intention of Chinese patients to seek medical treatment abroad and thus reveal a medical
business opportunity.
From an institutional standpoint, before the 1980s, public hospitals covered approxi-
mately 90% of inpatient and outpatient services (Yip et al., 2012). This imposed a huge
JOURNAL OF CHINA TOURISM RESEARCH 3
burden on public hospitals and caused inefficiencies (Liu et al., 2017). Subsequently, the
2003 SARS (severe acute respiratory syndrome virus) outbreak pushed the Chinese
government to reform the healthcare system. From a supply perspective, in 2015, the
number of private hospitals exceeded public hospitals, accounting for roughly 58% of the
total number of hospitals (Ren & Zhan, 2017). Following this, China has planned to add
89,000 new hospital beds and 140,000 medical personnel by 2020 (Stanway, 2017). This
medical expenditure was influenced by the national income and the government’s public
healthcare reforms (Y. Wu & Jacobson, 2015). In addition, the demand for medical
services in the country is extremely high due to several issues, such as the aging
population, urbanization, and infectious diseases. Overall, with its rapid economic
growth, the supply and demand for healthcare services in China are not balanced (Liu
et al., 2017).
As medical tourism continues to grow, scholarship in the area is more expedient.
Therefore, assessing the motivations and needs of medical tourists continues to be
popular among medical and tourism scholars. Studies have adopted diverse vantage
points and contexts to draw insights in the quest to understand the motivation of
medical tourists. Recently, medical tourism studies have portrayed a much more
inclusive perspective on tourist motivations. Pan and Moreira (2018) studied the
motivations, deterrents, and needs of Chinese outbound medical tourists. The
findings indicate that the availability and quality of medicine, a well-regulated and
supervised market, advanced technology, and the quality of care are key motivations
for medical tourists to go overseas. Meanwhile, high cost, risk to individual health,
lack of information, absence of a companion, and lack of time are restrictions to
outbound medical tourism. In addition, the authors highlight that intermediary
agencies, health insurance, and clear information are perceived as important needs
by medical tourists.
Factors inuencing medical tourism
There are a multitude of reasons patients travel to seek medical treatment abroad. The
choice of medical tourism destination is influenced by a tourist’s travel motivation, which
can be explained using push and pull factors. In tourism studies, push factors refer to the
intrinsic desires of human beings, such as to escape from a busy routine or to seek
adventure and novelty (Jurowski et al., 1993). On the other hand, pull factors refer to the
elements that cause people to recognize their needs, such as people, cost, image, facilities
and so on. Previous literature has reported the factors that influence the choice of
a medical tourism destination: 1) political climate, 2) economic condition, 3) regulatory
standards, 4) cost, 5) accreditation of hospitals, 6) quality of services and facilities, 7)
physicians expertise, 8) long waiting time, 9) travel opportunity, 10) illegal or untested
procedures, 11) privacy, 12) insurance. Pan and Chen (2014) identified eight motives
explaining Chinese citizens’ participation in medical tourism. Besides, Tseng (2013)
found that a lack of health insurance, high costs, inaccessibility, and unfamiliar language
and culture are factors that influence people’s medical travel abroad. In the US, Singh
(2013) found that low cost, governmental policies and laws, and high-quality healthcare
services are important determinants that influence the choice of destinations. Meanwhile,
Drinkert and Singh (2017) investigated the push and pull factors of perceived quality
4K. W. CHIA AND Y. M. LIAO
based on post medical travel experience. They reported that price, timeliness of service,
privacy concerns, and availability of local medical services influence US citizens to seek
medical treatment abroad.
Long waiting times reduce patient satisfaction (Xie & Or, 2017), particularly in public
hospitals. This is because a long waiting time is often associated with poor quality and
poor management (Sun et al., 2017; Sun et al., 2016). A study conducted on Malaysian
public hospitals showed that a typical medical process takes more than two hours while
the actual consultation with a doctor is only about 15 minutes (Pillay et al., 2011). This is
similar to China, where the patient registration time is far longer than the consultation
time (Cao et al., 2011). Accordingly, Zarei et al. (2018) identified seven factors that attract
medical tourists to seek niche medical tourism services, such as sex reassignment
surgeries (SRS) in Iran. The factors are religion, quality and standards, marketing and
advertising channels, attractions, ease of travel and stay, restrictions on availing medical
services at home, and services. Likewise, Zolfagharian et al. (2018) stated that domestic
medical costs, patient privacy concerns, medical restrictions, and foreign destination
desirability are important considerations when choosing medical treatment abroad. In
Malaysia, Musa et al. (2012) utilized quantitative methods to examine travel behavior
among inbound medical tourists in Kuala Lumpur. They identified the factors (i.e. cost,
facilities, cultural & religious similarity) that drove medical tourists to visit Kuala
Lumpur for medical treatments and found that, on average, medical tourists spent
about RM26, 800.00 including medical fees, airfare, and accommodation.
In selecting a medical tourism destination, there are various concerns to be addressed.
For example, the quality of healthcare is not guaranteed or safeguarded by the govern-
ment (Burkett, 2007). In addition, there is always a debate on the legal issues pertaining
negligence in medical services in some developing countries (Herrick, 2007; Whittaker,
2008). Medical travelers also experience several difficulties in the course of booking their
out-of-country care. Obtaining visas and registering for treatment are the most fre-
quently encountered problems, particularly in China and Jordan. Language and com-
munication, moreover, pose particular challenges for medical travelers to China.
Notably, the travel experience is valued as a more significant factor than costs by the
Chinese (Nielson, 2017).
Methodology
Although there is substantial literature documenting medical tourism, limited research
has been devoted to understanding potential medical tourists in particular (Kim & Um,
2016; Lunt & Carrera, 2010; Wu et al., 2016). The purchasing decisions of potential
customers is different from existing customers and has been frequently precluded in
scholarly works (Mahmoud & Hine, 2013). In recent years, however, scholars have
gradually realized the need to understand potential medical tourists’ purchase intentions
and expectations (Cham et al., 2016; Guiry et al., 2013; Wang, 2012). For example,
learning the perceptions of potential customers would help organizations attract new
customers and expand sales (Lin & Huang, 2015). Therefore, this study used potential
medical tourists as the unit of analysis. In this study, potential medical tourists were
defined as tourists that have not received any medical services before but exhibit the
intention to seek medical services in the future. This study was qualitative in nature and
JOURNAL OF CHINA TOURISM RESEARCH 5
adapted Lam et al.’s (2011) study to examine the influencing factors for Chinese medical
tourists to seek medical treatment abroad. Interviewees were asked the following
question:
(1) What are the factors influencing your intention to seek medical treatment abroad?
Surveying the entire population of China would be impossible; therefore, choosing the
right sample is crucial. In a qualitative study, there are no standards or requirements
surrounding the sample size to reach data saturation (Hagaman & Wutich, 2017). This is
because arriving at data saturation is far more important as long as the sample size can
justify it (Francis et al., 2010). An in-depth interview with 10 to 20 participants may thus
be adequate to obtain rich information for further analysis (Guest et al., 2006; Wang,
2012). Similarly, Francis et al. (2010) proposed at least 10 interviews or the ‘10 + 3ʹ
criterion, where three more interviews should be added if saturation is not met.
Generally, saturation is usually reached between eight and 16 interviews (Namey et al.,
2016).
Data collection
This study endorsed the use of a telephone to conduct semi-structured interviews.
Sturges and Hanrahan (2004) suggested that there are no significant differences between
interviews conducted face-to-face and over the telephone. In fact, telephone interviews
bring several benefits to research and researchers. First, it is cost saving and eliminates
the need for distant travel for interviews (Musselwhite et al., 2007; Sturges & Hanrahan,
2004). Second, the telephone allows an interviewer to cover more geographic areas (Ang,
2014). Third, it is flexible, such that interviewees or interviewers can determine the best
interview times and interviewees can be called multiple times at their convenience
(Cachia & Millward, 2011; Musselwhite et al., 2007). Fourth, it protects the anonymity
of interviewees especially when discussing sensitive topics (Greenfield et al., 2000). Fifth,
more honest data can be obtained through telephone communication (Trier-Bieniek,
2012). Telephone interviews also produce quality textual data like face-to-face interviews
(Cachia & Millward, 2011). In this study, all the interviewees chose to schedule
a telephone interview during their leisure time (e.g. after work and weekends). This
indirectly created a ‘safe location’ that did not interrupt the interviewees’ personal space
(Hanna, 2012).
This study used purposive sampling, where only interviewees who fulfilled the
study criteria were selected. The criteria for participation in the study were that
interviewees had to (i) be at least 18 years old and (ii) have the intention to travel
abroad to seek medical services in the next three years. The data collection for the
study was conducted by the second author. Potential interviewees were recom-
mended by the researcher’s network of friends and acquaintances. Fifteen potential
interviewees were then contacted through phone and were briefed on the purpose of
the survey before being invited to participate in the survey. Interviewees were clearly
informed that participation in the study is voluntary and that they could stop the
interview at any time. Due to time constraints and confidentiality issues, some
potential interviewees were either rejected or were unable to participate.
6K. W. CHIA AND Y. M. LIAO
Therefore, a final total of 10 interviews were secured. Upon agreement, the
researcher scheduled and conducted interviews with each interviewee at a time of
their choosing (e.g. after work, weekend, or night). Data collection took place
between September 2018 and October 2018.
The interviewees were assured that the information provided by them would be
kept confidential. An interview guide was utilized with a combination of open-
ended interview questions to guide the discussion (Pine & Qi, 2004). During the
telephone interview, interviewees were encouraged to give as much information as
possible without reservations. Ambiguous answers were probed by the researcher as
well. Each interview took approximately 40 minutes, which was recorded with the
interviewee’s permission. Upon completion, all interviews were transcribed.
Data analysis
In a qualitative study, when the saturation stage has been reached, data collection can be
concluded (Suri, 2011). Thus, upon reaching saturation, this study followed the process
of analysis suggested by Christou et al. (2018), Poland (1995, 2003), and Ho et al. (2017).
First, the data was transcribed in Mandarin and translated into English, and then back-
translated to check for consistency. All the data were transcribed, interpreted, and
translated by the researchers together to reduce bias. Prior to running the thematic
analysis, the transcribed scripts were read numerous times to get a feel of the data as
a whole, as prescribed by Walls et al. (2011). In order to protect the anonymity of the
interviewees, each interviewee received a pseudonym or code to be used in data analysis
(i.e. R1, R2 . . . R10). Then, the researchers used frame analysis to analyze the data, where
emerging topics were classified into interrelated themes based on a coding structure. This
study referred to the coding procedure suggested by Strauss and Corbin (1998) to identify
themes and categories. Accordingly, key themes and sub-themes were drawn from the
transcripts and were compared with previous studies. This study then presented the
outcomes in a similar arrangement to other studies (e.g. Christou et al., 2018; Sharpley &
Jepson, 2011).
In qualitative research, validity refers to the ‘appropriateness’ of a method in
answering a research question (Leung, 2015). This study employed a qualitative
interview method to answer its research questions and promoted validity of the
findings by allowing interviewees to speak freely based on their knowledge. Using
this method, interviewees’ statements could be clarified and monitored, while the
direct interaction between interviewees and the researcher secured more accurate
data. The issue of reliability in producing the same result consistently is extraneous
to this study because reliability has no relevance in qualitative research (Lincoln &
Guba, 1985; Stenbacka, 2001). Stenbacka (2001, p. 55) explained that ‘the concept of
reliability is even misleading in qualitative research. If a qualitative study is dis-
cussed with reliability as a criterion, the consequence is rather that the study is no
good’. This is supported by Patton (2002), who asserted that reliability in
a qualitative inquiry is a consequence of validity, which lies in the ability and skill
of researchers.
JOURNAL OF CHINA TOURISM RESEARCH 7
Findings
Characteristics of interviewees
The interviewees were from seven different cities across China (see Table 1). The age of
the interviewees ranged from 28 to 55, with an average age of 38. In terms of gender, there
was an equal distribution of males and females. Among the interviewees, eight were
professional workers and two were a student and a housewife, respectively. In choosing
a medical tourism destination, interviewees said they would consider South East Asia,
East Asia, America, and Europe.
Themes and extracted framework of the study
Based on the results, seven themes were grouped under two dimensions (see Table 2), i.e.
quality of medical service and convenience. The dimension of quality of medical service
comprised the themes of quality of treatment, quality of customer service, and quality of
equipment, while the dimension of convenience consisted of the themes of cost, travel
distance, language, and climate.
Quality of treatment
Recently, the quality of medical treatment in developing countries has become as good as
in developed countries. Unsurprisingly, all the respondents claimed that the quality of
medical treatment is the utmost important factor when seeking medical services abroad.
One interviewee (R3) was more confident in the quality of medical treatment overseas as
he said, ‘The quality of medical treatment abroad is better than China and that is why
Table 1. Demographic profile of interviewees.
Respondent City Occupation Age Gender Travel intention Code
1 Shenzhen IT operations staff 32 M Regular medical
checkup
R1
2 Shenzhen IT developer 30 M Regular medical
checkup
R2
3 Ganzhou Accountant 28 F Vaccination and immunization services R3
4 Nanning Student 28 F IVF R4
5 Ganzhou Wealth manager 36 M Cosmetic dentistry R5
6 Shenyang Freelancer 42 F IVF, cosmetic surgery R6
7 Shanghai Housewife 46 F Eye surgery R7
8 Wuhan CEO 35 M Vaccination and immunization services R8
9 Ganzhou Self-employed 50 F Herniated disc surgery R9
10 Shenzen Self-employed 55 M Regular medical checkup R10
Table 2. The themes emerged from the findings.
Factors Sub-factors Description
1.Quality of medical service Quality of treatment
Quality of customer service
Quality of equipment
Cost
Good quality
Waiting time
Advanced
Cheap, affordable
2.Convenience Travel distance
Language
Climate
Close, near
English, the same language
8K. W. CHIA AND Y. M. LIAO
I choose to go abroad instead of here in China.’ Another interviewee (R4) agreed that ‘The
medical standards and quality are trustworthy in Malaysia, especially the In-Vitro ferti-
lisation treatment. In addition, medical tourism in Malaysia receives support from the
Ministry of Health and the Malaysian Medical Tourism Council.’ It was observed that
interviewees appeared more confident in foreign medical treatment than in Chinese
medical treatment. Three interviewees explained their views in the following manner:
My husband’s friend participated in medical tourism in the USA. He told us it was a great
experience and the healthcare quality is very good. I feel eager to do my medical examina-
tion in a well-organized hospital in the USA and to experience the local culture. (R7)
I have been suffering from lumbar disc disease for many years. I was referred to many
hospitals in China and spent a lot of time and money, but the treatment seems ineffective.
Therefore, I consider going overseas to try better medical treatment. (R9)
I am not confident about the healthcare system in China. Some doctors have been accused of
giving wrong diagnoses. I guess the healthcare system in China is still in the infancy stage.
(R10)
Compared to developing countries, some interviewees (R1, R4, R6) were more favorable
toward seeking medical services from developed countries. One interviewee (R1)
explained that the chances of treatment success are greater in developed countries.
Below is a comment reflecting this:
We should choose to go to developed countries for healthcare treatment because the success
rate is higher.
Quality of customer service
There was strong agreement among interviewees that the quality of customer service is an
important factor in choosing medical tourism abroad (Singh, 2013). Several interviewees
concurred that they find the quality of customer service as a vital consideration which is
somewhat lacking in China. One interviewee (R5) provided this answer:
Compared to developed countries, both the medical service level and the customer service
level in China are largely lagging.
Another interviewee (R8) noted that some countries provide one-stop medical services to
patients. His comment is illustrated as below:
I heard that Bangkok’s medical tourism service is very good; it provides one-stop travel
service, medical inspection, surgery, and recuperation. I don’t think China has this type of
service.
This was supported by another interviewee (R4), who said ‘Foreign hospitals are custo-
mer-oriented and they are very professional in meeting the customer’s needs and wants.
I don’t think I will get the same treatment in China.’ Another interviewee (R9) echoed the
same sentiment this way:
I went to visit my daughter in Malaysia six months ago. She took her father to experience
a medical service and I found it very good. I remembered when we first arrived at the
hospital, it was huge, clean and felt like a hotel. The nurse at the front desk greeted us
JOURNAL OF CHINA TOURISM RESEARCH 9
politely and led us to the health testing centre. The waiting area was excellent, equipped with
a wireless network, TV, and reading materials. I felt that I was being taken care of by the
staff.
One interviewee (R1) highlighted that, ‘Privacy protection in foreign countries is better
than in China.’ This is interesting, considering that the Chinese government has recently
formulated new regulations to protect patients’ personal information.
Quality of equipment
Most interviewees agreed that the quality of equipment is another important factor. Some
interviewees stated that medical equipment overseas is better and more advanced than
China. For example, two interviewees clarified:
In China, public hospitals own most of the expensive and advanced medical equipment.
However, the waiting time in public hospitals is extremely long. There are many private
hospitals overseas where the technology and equipment are better than China. So, it is worth
going overseas instead of waiting in the country. (R8)
In China, most of the advanced medical equipment are directly imported from overseas,
which I feel is more reliable and trustable. I am more confident in foreign medical equip-
ment than local Chinese equipment, to be honest. (R1)
This was supported by an interviewee (R7) who remarked, ‘I believe advanced equipment
gives a more precise and reliable reading; so I will consider travelling overseas.’ Another
interviewee (R2) also agreed that ‘Foreign medical equipment is more advanced.’
However, for one interviewee (R10), most medical equipment is standardized. He
shared that:
I feel that China’s technology is advanced because we have a hospital that incorporates AI
and robotics in diagnosing patients. For me, since medical equipment in China is normally
imported from foreign countries, it makes no difference. Guess what, the equipment parts
are from China!
Cost
Cost was frequently cited by the interviewees as a key consideration in medical travel.
Previous studies have highlighted that cost is a determining factor for outbound medical
tourism (Heung et al., 2010; Yu & Ko, 2012). For example, J. Y. Yu and Ko (2012) showed
that cost influenced Chinese medical tourists’ travel decisions to Korea. This finding
suggests that interviewees are aware of the high treatment cost in China. One interviewee
(R4) explained:
In terms of expenditure, domestic treatment cost is high while the cost of medical tourism in
Thailand and Malaysia is affordable. Compared to other countries, the medical service in
Malaysia is basically only half the price of the service in China, and the quality of treatment
is world-class. So, why pay more for the same service in China?
A similar view was echoed by another interviewee (R6) who perceived that ‘The price of
medicines and the cost of medical treatment in specialist hospitals are relatively expensive
in China, so some consumers prefer to go overseas.’
10 K. W. CHIA AND Y. M. LIAO
The findings suggest that potential medical tourists are looking for better healthcare
quality at more affordable rates than Mainland China, which is considered expensive. For
example, one interviewee (R9) described:
I will choose to travel to Malaysia instead of China. The reputation of the healthcare system
in Malaysia is good and the cost is affordable and reasonable.
Travel distance
The interview findings further reveal that travel distance influences the motivation of
interviewees to seek medical treatment overseas. Most of the interviewees (R4, R6, R10)
acknowledged that they prefer to travel short distances to places such as Taiwan, Korea,
and Southeast Asia. One interviewee (R2) gave the following explanation:
I want to travel to Southeast Asia because it is very close to China. It is just a few hours
journey from Shenzen by flight. I can’t imagine flying to Europe or the USA; it is tiring, and
I would have no mood to enjoy my medical tour.
Another interviewee (R4) said, ‘I will choose medical tourism in Malaysia because it is
close to China and it is convenient to do anything there.’ The same sentiment was shared
by an interviewee (R6) who said, ‘I would like to go to Malaysia because the travel distance
is very close.’ One interviewee (R3) divulged that a shorter travel distance would allow her
to bring her children along. She shared her views this way:
I would like to go to Thailand or Malaysia because they are near and I am afraid of taking a long-
haul flight. If it is near, I can bring my children for a summer vacation. It sounds very good to
me!
Language
Language barriers may pose significant problems for non-English speakers, including
Chinese tourists. The interviews revealed a similar finding, where language was found to
influence medical tourism destination choice (Heung et al., 2010; Pan & Chen, 2014).
One interviewee (R7) felt that traveling to a non-Chinese speaking country would be
challenging. She elaborated:
Due to differences in language, there are problems that cannot be ignored. For example,
some medical terms are alien to me; I am not a professional medical doctor, I don’t even
understand what it means. Therefore, I hope the medical personnel will at least explain the
medical procedure in simple terms or in a language I familiar with to avoid
miscommunication.
Another interviewee (R9) had a similar view, stating that ‘I hope I can consult the doctor
in Mandarin as I am afraid a translator would translate the wrong information and
confuse me.’
In contrast, some interviewees (R7, R4) commented that language is not a barrier
because many medical personnel from Thailand and Malaysia speak their language
(Mandarin), which makes communication easier. To illustrate, one interviewee (R4)
JOURNAL OF CHINA TOURISM RESEARCH 11
believed that ‘There is no language barrier because there are many Chinese doctors in
Malaysia, and they can speak my language (Mandarin and Cantonese).’
Climate
Adding to earlier studies, climate is a unique theme that emerged from this study. Each
country has its distinct climate, which may influence tourism destination selection. The
findings revealed that many interviewees stressed the importance of local climate condi-
tions. Some interviewees preferred warm weather and sunshine in Southeast Asia, while
some interviewees preferred cooler weather in Japan and Korea. However, most inter-
viewees (R1, R2, R3, R4, R10) preferred to travel to a place where the climate is temperate,
such as Southeast Asia. One interviewee (R1) explained why climate is particularly
important. He explained that:
The climate should be pleasant; if it is too hot, it will affect our travel mood.
Another interviewee said, ‘Compared to China, I prefer to travel to Southeast Asia
because the weather is more comfortable for me.’ This was supported by an interviewee
who commented, ‘As long as the climate is good, the family can relax and enjoy the medical
tourism service.’
Discussion
The demand for medical tourism is growing, which is beneficial to both suppliers and
consumers. Cross-border medical tourism expands consumers’ choice of medical
services and travel range. Furthermore, it enables more people to enjoy high-quality
medical services at lower prices. Consistent with previous studies (Heung et al., 2010;
Horowitz et al., 2007; Lunt & Carrera, 2010), this study found that quality of treatment
is an important attribute for potential medical tourists. Meanwhile, this research
confirms that customer service quality is another critical influencing factor for out-
bound medical tourism, as per the view espoused by previous studies (Chen et al., 2013;
Turner, 2007).
There are many private hospitals in China with somewhat mature operation modes.
However, most of the interviewees believed that the technology, equipment, and services
in the mainland are still lacking. Given the difficult accessibility and low utilization of
high-quality medical equipment in China, many interviewees viewed high-quality med-
ical equipment as an influencing factor to go abroad. This is supported by earlier research
findings that the quality of equipment influences the decision to travel abroad for medical
treatment (Cohen, 2008; Veerasoontorn et al., 2011; Yu & Ko, 2012). This study’s
findings further suggest that cost is an influencing factor, whereby the comparatively
affordable cost of medical treatment abroad is a pull factor for Chinese mainland tourists.
This mirrors previous research on similar medical tourism contexts (e.g. Han & Hyun,
2015; Moghimehfar & Nasr-Esfahani, 2011; Yu & Ko, 2012). Additionally, medical
patients now prefer to travel short distances to get medical treatment. As Connell
(2013, p. 1) stated, medical tourism ‘is now seen as relatively short distance, cross border
and diasporic.’ Similar to earlier studies, this study posits that distance plays an important
role in choosing an international medical tourism destination (Hanefeld et al., 2015;
Heung et al., 2010; Moghimehfar & Nasr-Esfahani, 2011; Zhang et al., 2013).
12 K. W. CHIA AND Y. M. LIAO
In this study, some interviewees perceived language to be an important consideration. In
particular, interviewees preferred to travel to Southeast Asia because there are fewer language
barriers there, as it is convenient for Chinese medical tourists to communicate with medical
personnel in their native language (Mandarin). Accordingly, studies have highlighted the
importance of hiring medical staff who can speak foreign languages because it reduces
miscommunication (Han, 2013; Heung et al., 2010). Finally, interviewees said they would
like to travel to a place with a pleasant climate such as Thailand or Malaysia. Thus, an ideal
climate is an important consideration in planning a medical trip (Jabbari et al., 2013; John &
Larke, 2016; Singh, 2013; Yu et al., 2011). Given the strategic location of Southeast Asia,
climate conditions in the region are deemed suitable compared to many countries.
Theoretical and managerial implications
This study sought to contribute to the understanding of the factors influencing potential
Chinese medical tourists to seek medical treatment abroad. From the theoretical perspec-
tive, the study established a framework of factors to identify medical motivations. Notably,
this study revealed that climate is a contributing attribute, which has seldom been identified
in previous studies. Although the study of medical tourism is not new, findings in this study
can help practitioners improve their marketing strategies. From a managerial viewpoint,
foreign medical service providers should be aware of the factors determining the purchase
decisions of Chinese mainland medical tourists. This is because when potential Chinese
medical tourists plan their medical treatment abroad, these factors can be leveraged to
influence their decisions. Thus, medical service providers should develop strategies that
focus on these factors to attract customers. Specifically, they should place greater emphasis
on the quality of medical services and customer service. Accordingly, different marketing
strategies should be deployed to attract medical consumers. Given the convenience of
online tools as an information source, medical marketers may consider fully utilizing social
media to promote their medical services.
Limitations
Given its exploratory nature, this study is subject to a few limitations that should be
addressed in future studies. First, this study bears the inherent shortcomings of the
qualitative approach, where the findings were taken from a small number of interviewees
through purposive sampling within the researcher’s personal network. Future studies
should consider using the quantitative method to validate these findings, especially with
a larger sample size. Second, the findings may not be generalizable to all Chinese
Mainland citizens as the interviewees were mainly from the Southern part of China.
Future studies on this topic should cover citizens from different parts of China. Finally,
this study did not consider the potential effects of respondents’ socio-demographic
background (e.g. gender, age, income level) on foreign medical tourism intention, as
the respondents were solely based on the researcher’s personal network. Future studies
should consider these variables to obtain a better picture of medical tourism
consumption.
JOURNAL OF CHINA TOURISM RESEARCH 13
Disclosure statement
No potential conflict of interest was reported by the author.
Notes on contributors
Kei Wei Chia is Lecturer in School of Marketing and Media at Asia Pacific University of
Technology and Innovation, Kuala Lumpur, Malaysia. He completed his Ph.D. in 2017, from
Universiti Putra Malaysia. He has authored and coauthored many articles in refereed and profes-
sional journals including Tourism Management, Journal of Hospitality & Tourism Research and
International Journal of Business and Society, Tourism and Hospitality Research. His current
research interests are in the area of island tourism, medical tourism, rural tourism, heritage
tourism, and sustainable tourism (E-mail: dr.chia@apu.edu.my).
Yi Ming Liao was born in Ganzhou, Jiangxi, China. She obtained her Bachelor’s degree in Gannan
Normal University. After graduation, she earned her MBA in Asia Pacific University of
Technology and Innovation, Malaysia. She is currently a CEO in one healthcare company
registered in Hong Kong SAR, China.
ORCID
Kei Wei Chia http://orcid.org/0000-0002-6216-2772
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