Development Strategies for Taking Thailand’s Health Healing Tourism Business into the Global Market

As a business, medical tourism seems to offer a wide range of products/services to potential customers, especially those from overseas. In this regard, the Thai government has adopted a policy to promote Thailand, as the medical hub of Asia, capable of providing world-class health care. The purpose of this study, therefore, is to analyze the development strategy of the medical tourism business using a combination of methods, both qualitative and quantitative in nature, to achieve this objective. The sample for this study consisted of 310 foreigners undergoing medical treatment in private hospitals in Bangkok, and the data collected from these respondents is presented in statistical form through the use of Path Analysis. The strategies pertaining to the development of medical tourism consist of demand strategies, supply strategies, research framework strategies (such as the perceived potential of the medical tourism industry for providing quality service), appeal, management of relevant public services, and service quality strategies, including those relating to strong and weak points. Furthermore, using path analysis to determine the relationship between public management, the quality of the hospital’s service, and the appeal of the country’s amenities that affects foreigners’ perception of the country’s potential regarding health facilities. It was found that the most important factor was the quality of the service provided, while the second most influential variable was appeal.


Introduction
Health-related tourism serves as a product presented to consumers, particularly to foreigners, who turn into paying attention to this product which is at the travel, the main aim of which is to maintain tourists' health.The places providing this type of health healing tourism service will consist of private hospitals with the acceptable potential and standards.Some provide a comprehensive service and are able to accommodate and provide a wide range of services to foreigners from numerous countries, in addition to high medical standards and a host of other amenities.These include foreign patient service centers, interpreter services, belongings services, an embassy contacting service, airport pick-ups, point-to-point transportation service, e-mail communication, coordination with international insurance services and so forth.Since the cost of medical treatment in foreign countries is rather high, foreigners turn their attention to the medical services offered in Thailand, which can be regarded as a form of export that generates revenues that will have an important role to play in the country's future.At present, Thailand is trying to promote its health healing businesses to become the main medical hub of Asia.Therefore, any study of the strategies involved in the development of the medical tourism business should prove useful to those involved in this field, either at the policy-making level or at the commercial level.
2.5.To study the development strategies related to the medical tourism business 2.6.To study problems and obstacles and to offer pertinent suggestions

Theoretical Framework
Health-related tourism is one of the most frequently examined topics in the hospitality tourism field because it plays an important role in the survival and future of tourism products and services.It also significantly influences the choice of destination, the consumption of products and services, and the decision to return.The study consists of an independent variable (perceived potency) and three dependent variables (attractiveness, public management, and service quality).Kaosa-ard (2006) studied the tourism potency which consists of: (1) Attractiveness of tourism sources which there are 12 sub-items in consideration such as historic places and culture and beaches, (2) Public managing, 10 sub-items in consideration such as visa permission, immigration, customers, communication, (3) Service quality, 10 sub-items in consideration such as rapidness, honesty, cleanliness etc.The details of perceived potency, public management, service quality, and attractiveness are as follows:

Perceived Potency
Perception is the process of attaining awareness or understanding of the environment by organization and interpreting sensory information (Pomerantz, 2003).Health perception is an important outcome associated with health related quality of life.Various correlates of perceived health have been identified.Our estimated model was theory-based, developed from existing research identifying the following correlates of health perception: physical function, co morbidities, socioeconomic status, social support, age, and prior health perception.The number of co morbidities and physical function were found to have the strongest influence on health perception (Cree et al., 2001).Wilson and Cleary (1995) described a model where in physiological and psychological symptoms affect functional status, which affects general health perceptions and quality of life.Concepts pertaining to characteristics of the individual (e.g., motivation and values) and characteristics of the environment (e.g., social support) were also included in their model.General health perceptions are associated with physical, mental and social health domains (Ware et al., 1995).

Public Management
New Public Management (NPM) in the public sector has become an international trend within the OECD countries during the past 20-30 years (Pettersen, 2003;Brorström et al., 2008;Groot et al., 2008;WHO, 2000).NPM is a specific management philosophy used by governments.In particular,the following have been found to deal with issues of NPM in general and in particular within the health care (Peyton, 2009).Private management was in the subsidiary position of Singaporein hygienic standard which marked up to percentage of 16.36.Singapore's public management is the highest potential in many areas especially public health, pollution (Kaosa-ard, 2006).

Service Quality
According to the definition of Zeithaml et al. (1990) service quality is customers' perception of how well a service meets or exceeds their expectations and it is judged by customers, not by organizations.Berry et al. (1988) defined service quality as "conformance to customer specifications." Sohail, (2003) and Parasuraman et al. (1985) defined service quality as the difference between predicted or expected service (customer expectations) and perceived service (customer perceptions).The interactive nature of service process results in the consumers' evaluation of quality immediately after the provision and performance of that service.Empirical evidence exists that shows that the true impact of service delivery changes in terms of customer perceptions can only be assessed longitudinally (Bernhardt et al., 2000) and that customers' assessments of service quality are relatively constant and subject to slow change (Bolton & Drew, 1991;Douglas & Connor, 2003).Research has shown that delivering quality service has significant relationship with customer satisfaction perception (Boulding & Statelin, 1993;Johns et al., 2004;Kara et al., 2005), customer retention (Reichheld & Sasser, 1990), loyalty (Boshoff & Gray, 2004;), costs (Wilson et al., 2008), profitability (Rust & Zahorik, 1993;Zeithaml et al., 1996), service guarantees (Kandampully & Butler, 2001) and financial performance (Buttle, 1996) of service businesses (Sohail, 2003).One of the key issues company decision makers is facing is how to assess and monitor customer service effectiveness (Pearce et al., 2002).Parasuraman et al. (1988Parasuraman et al. ( , 1991Parasuraman et al. ( , 1994) ) found a positive and significant relationship between customers' perception of service quality and their willingness to recommend the company.
Performance not only separates one firm from others, it also creates loyal customers who spread favorable "word of mouth" (Youssef, 1996).

Attractiveness
This study examined the relationship between the attractiveness of the physical environment of healthcare facilities and patient perceptions of quality.Further examinations of the way outpatient-practice environments impact patient and staff perceptions and how those perceptions impact behaviors and medical outcomes are suggested (Becker, 2008).While Arneil and Devlin found a relationship between physical attractiveness and perceived quality of care (Powers & Bendall-Lyon, 2003).This study examined the relationships between the attractiveness of the physical setting and the actual and the perceived waiting times, quality of care, anxiety, and staff-patient interaction for patients in an outpatient facility.The study reported here seeks to test whether the relationship between physical attractiveness of ambulatory-waiting environments and perceived quality of care holds up when actual patients rate their quality of care in the ambulatory waiting areas where they are being treated (Becker, 2008).The tourism attractiveness around Mekong region 2 is friendliness, tourism sources, culture, natural, worthy spending, and cheap food.From Gap Analysis, it was found that Thailand marked the most attractive in tourism sources, cultural tourism andnatural sources such as beach, waterfalls, and mountains.Thailand has attractive prominent points in warm greeting, worthy spending, night time color and cheap and affordable cost of touring.However, it was lower than Cambodia in historical area and was lower than Singapore just only two areas, namely, amusement park and health tourism (Kaosa-ard, 2006).

Hypothesis Testing
Due to the variable relationship of the research framework and the structural equation obtained from the literature review, the research hypotheses are as follows:

Methodology
The sample in this study consisted of 310 foreigners who used the medical services in private hospitals in Bangkok.Purposive sampling was conducted to choose a number of private hospitals to interview patients or their relatives who used their medical services.The data collected consisted of both primary and secondary data.The primary data came from a questionnaire survey and in-depth interviews from administrators, doctors, specialists, hospital marketing departments, tour companies, medical sales representatives, health service providers, etc.The secondary data was collected from both private and the public sectors, including text-based sources such as textbooks, domestic and international journals, and thesis.With regard to the data analysis, the study used a five-point Likert scale indicating five levels of satisfaction: 1 = very dissatisfied, 2 = dissatisfied, 3 = neither satisfied nor dissatisfied, 4 =satisfied, 5 = very satisfied, in addition to frequency, percentages, mean scores, standard deviation, and path analysis as the main statistical approach.Thestudy consists of an independent variable and dependent variables as follows:

Results
The study demonstrates the marketing situation regarding medical tourism, the potential demand and supply, foreigners' behavior pertaining to the use of health services, the causal relationship between public management services, hospital service quality, and overall appeal that affects foreigners' perception regarding the potential of the Thai medical tourism industry.It also examines the development strategies of the medical tourism business, in addition to discussing the problems and obstacles involved and offering a number of pertinent suggestions.The details are as follows.

Market Situation
After the economic crisis in 1997, the Thai Baht declined in value and medical expenses in private hospitals became cheaper.Therefore, foreign customers visited Thailand for medical treatment.An increasing number of customers with high purchasing power flew to Thailand from Japan, Europe, and the Middle East for treatment in private hospitals.

Analysis of Demand and Supply
In terms of potential demand and supply, the demand side requires universal standard service, worthiness, safety and security during the patient's stay, superior service, expert health care, as well as the need on the part of patients to receive the requisite service, understanding, and sympathy.Conversely, on the supply side, there is a need for the potential of health services, the ability to serve and provide standard services, natural tourist attractions, a one-stop service and facilities, etc.

Characteristics of Sample
 Sex: Most of the sample groups were males, who constituted 54.84 percent, while females constituted 45.16 percent. Age: Most of the respondents (39.68 percent) were over 60 years of age, followed in descending orderby those less than 55-60 year old (16.13 percent) and those less than 30 years old (3.55 percent). Education: Their level of education was mostly that of a bachelor degree, (40.32 percent), followed in descending order by those with an educational qualification lower than a bachelor degree (35.48 percent), and those with a master's degree (16.13 percent).Those with a Ph.D. degree constituted the lowest number (8.06 percent). Occupation: Most of them were managers/ administrators, (16.13 percent), followed in descending order by those who were housewives/business owners (15.16 percent) and students are the lowest (7.10 percent) (Table 1).Nationality.Most of them (10.32 percent) were Saudi Arabian followed by citizens of UAE (10 percent).Represented the least were Nepalese (0.97 percent) (Table 2).

Analysis of Foreigners' Behavior Regarding the Use of Health Services
Most of the respondents (14.52 percent) used the health service for the treatment of a heart condition, followed in descending order by those who came for medical treatment for their kidneys (12.58 percent); and for ophthalmology (12.26 percent), while the lowest percentage (0.97 percent) sought sex-reassignment surgery / procedures, (Table 3).Most of them (34.52 percent) took responsibility for their own expenses, while the family paid for the expenses in 25.81 percent of all cases, with the lowest percentage (17.42percent) having their bills paid by their company (Table 3).Regarding the use of the hospital's services, most of the sample group (40.65 percent) used the service once.The majority (29.49percent) had learned of the hospitals from the internet, and most (54.42 percent) were accompanied by their relatives/families (see Table 4).

Reason for Selecting a Particular Hospital
Regarding the hospital's attributes as an element in the selection of a particular hospital, one of the main factors reported by the majority of (17.74 percent) of the respondents was the expertise of the physicians (see Table 5).

Public Management
With regard to the level of satisfaction with the use of public services, the main factor cited by the majority of the respondents in the sample group was their satisfaction with the ease of entry into the country ( = 3.76) (Table 6).
x The services were accompanied by tangibles.Sampling groups were satisfied with documents and various forms that were clear and easy to be understood being a major priority 1 (X = 3.85). For reliability, it was found that sampling groups were satisfied with the physicians' capability to perform up to international standards, this being a major priority 1 (X = 3.91). Regarding responsiveness towards service recipients, it was found that the respondents were satisfied with the promptness in providing the service requested, this being a major priority 1 (X = 3.86). Regarding the assurance service recipients experienced, it was found that the sampling groups were satisfied with the experience and capability of the teams of physicians they encountered during a lengthy period treatment, considering this as a major priority 1 (X = 4.00). Regarding empathy, it was found that the recipient's feelings were considered to be a major priority 1 (X = 3.65).

Attractiveness/ Main Appeal
Regarding the matter of the appeal, in considering each individual item, it was found that members of the sample group were satisfied with the physician's level of expertise, cutting-edge medical technology and procedures, considering these a priority 1 (X = 3.90) (Table 8).Sampling groups were satisfied with doctors' expertise in the treatment of specific diseases, this being considered a major priority 1 (X = 3.90) (Table 9).From equation 1, it was found that the recognition of the potential health rehabilitation of private hospitals, whose services foreigners came to use, was directly influenced the most by service quality, having a direct causal influential value of 0.4289 (t -test = 9.1708).The second most influential variable was attractiveness, which yielded a direct influential value of 0.4209 (t -test = 9.0377).The last was public management, with a direct influential value 0.1256 (t-test = 2.9595).The coefficient of (R 2 adj ) of the variable was capable of predicting potential recognition with regard to health rehabilitation of private hospitals whose services foreigners used at a percentage of 87.8.From equation 3, it was found that service quality was directly influenced by public management, with a direct influential value of 0.8576 (t-test=29.2630).In addition, the predictive coefficient value (R 2 adj ) of the variable was able to predict service quality at 73.5 percent.From testing the hypotheses, it was found that the recognition of the potential health rehabilitation of private hospitals, whose services foreigners came to use, was directly influenced the most by service quality.The direct causal influential value was 0.4289, having an indirect influence of 0.2370, while the predictive of coefficient (R 2 adj ) of the variables was able to predict the perceived potential of medical tourism by a percentage of 87.8%.The second most influential variable was attractiveness, having a direct causal influential value of 0.4209, while public management had a direct influence of 0.1256 and an indirect influence of 0.3678 (Table 10).
Attractiveness: This was directly influenced by service quality, with adirect causal influential value of 0.5633, followed by public management, with a direct causal influential value of 0.3732, and an indirect influence of 0.4830.The predictive coefficient value (R 2 adj ) of the variables was able to predict attractiveness by a percentage of 81.6 (Table 10).
Service quality: This was influenced by public management, yielding a by having direct causal influential value of 0.8576.The predictive coefficient (R 2 adj ) of the variable was able to predict service quality by a percentage of 73.5 (Table 10

Development Strategies
Medical tourism strategies require information to ensure a state of readiness concerning the medical needs of foreign patients who might otherwise have to wait a long time in their own countries for medical treatment, competitive prices in Thailand compared with those countries, as well as an understanding of their customs and culture.On the demand side, it requires a high level of expertise in marketing, good strategic planning in this regard, marketing as a leader because of the high degree of competition, IT utilization, international marketing initiatives, customer penetration by overseasagencies and insurance companies, good financial support and good internal management.Demand strategies consist of export and service initiatives, while supply strategies consist of the potential and state of readiness of hospitals, doctors, dentists, pharmacies, nurses, and related personnel as well as technological equipment, expertise in a comprehensive range of treatments, etc.Otherwise, the strategies included in the research framework are foreigners' perception regarding the potential of the Thai medical tourism industry, public management, service quality, and attractiveness, including the strengths and weaknesses of this sector.

Perceived Potency
Strategies in recognizing the potential health rehabilitation of private hospitals, whose services foreigners came to use, are required to construct representative networks in many countries and to carry out marketing for letting foreigners to recognize about service quality and hospital attraction by activities such as export promotion, fairs or product exhibition fairs.Regarding medical and health areas in foreign countries, arrange seminars providing knowledge about requisition of expense concerning medical treatment and arrangement of business negotiation activities between Thai private hospitals and target groups in foreign countries.Apart from those mentioned, it is necessary to learn exporting strategies and marketing strategies.

Service Quality
Physical and mental service quality are bodies of measurement point of service quality such as modern technology, good reputation of the medical team, friendliness etc.In addition, having complete service in every department, providing facilitation, assistance, support, clarification, enthusiasm in providing services throughout saving of money and time.shouldbe considered.

Attractiveness
From the study, it was found that the first three levels of attractiveness in the health service are: (1) Specialist of doctors and technological equipment, (2) Hospital standardization and goodtreatmentreputation, (3) Expense in treatment.Therefore, attractiveness strategy should brought the prominent points as mentioned to serve as a selling point.

Public Management
Public management provides clear policies, planning in advance and supporting in time which is an important role for business development.Because customers weigh the importance to facilities, safety, communication and public utilities which are factors affecting to service quality and attractiveness.

Obstacles
There are many obstacles in developing Thailand as a medical hub such asashortage of human resources in the field of medicine, problems relating to public relations and cooperation, including a lack of advanced planning and proactive strategies, as well as the inability to communicate, and the development scattered and improper linkage.

Implications and Recommendations
With regard to the policy pertaining to the development of medical tourism in Thailand, both the positive and the negative effects of such a policy need to be taken into consideration.In terms of the positive effects, it requires an increasing number of healthcare institutions that are on a par with international standards.On the negative side, it diverts resources and personnel from within the Thai healthcare system, affects the prices of health services and affects the quality of healthcare available to the Thai public.Policy and practice should be undertaken in a parallel manner to ensure that they are consistent with each other, reducing any conflicts that might occur between two policies, thereby resulting in success, to the benefit of the nation, in a win-win situation.
Public policy implications are: With regard to the policy pertaining to the development of medical tourism in Thailand, both the positive and negative effects of such a policy need to be taken into consideration.In terms of the positive effects, it requires an increasing number of healthcare institutions that are on a par with international standards.On the negative side, it diverts resources and personnel from within the Thai healthcare system, affects the prices of health services and affects to the quality of healthcare available to the Thai public.Policy and practice should be undertaken in a parallel manner to ensure that they are consistent with each other, reducing any conflicts that might occur between two policies, thereby resulting in success, to the benefit of the nation, in a win-win situation.

4. 1 .
Public management affects foreigners' perception regarding the potential of the Thai medical tourism industry 4.2.The quality of the service provided by private hospitals affects foreigners' perception regarding the potential of the Thai medical tourism industry 4.3.Attractiveness affects foreigners' perception regarding the potential of the Thai medical tourism industry 4.4.Public management affects overall attractiveness 4.5.Private hospitals' service quality affects overall attractiveness 4.6 .Public management affects the service quality of private hospitals An integral promotional central agency should be established  Determination of service standard should be established  Marketing public relation should be made aggressively  Coordinating centers should be established  The promotion of health related tourism should be made a continuous policy at the national level  Marketing research should be conducted  The public sector should provide the requisite coordination and determine clear directions

Table 1 .
Number and percentage classified by characteristics of the sample

Table 2 .
Number and percentage of patients classified by nationality

Table 3 .
Number and percentage classified by medical services used

Table 4 .
Frequency of use of hospital service

Table 5 .
Main reason for choosing specific hospitals

Table 6 .
Satisfaction with government services

Table 7 .
Quality of hospital service

Table 9 .
Potential readiness to provide treatment The quality of the service provided by private hospitals affects foreigners' perception regarding the potential of the Thai medical tourism industry