iv

TAHAP PENGETAHUAN PELANCONGAN KESIHATAN DI KALANGANPENDUDUKMALAYSIA

ABSTRAK

Pelancongan kesihatan semakin popular di. kalangan masyarakat antarabangsa.

Walaupun, secara relatifuya pelancongan kesihatan barn bertapak di Malaysia tetapikewujudan industri mendapat perhatian selepas berlakunya krisis ekonomi pada tahun1997. Produk pelancongan kolam air panas merupakan satu bentuk pelancongankesihatan terawal di Malaysia. Industri ini juga berkembang dengan pertambahanbilangan hospital-hospital swasta di bandar-bandar utama yang menawarkan rawatan

kesihatan Moden dan tradisional semasa melancong. Oleh itu, kerajaan Malaysiaoptimistik dengan perkembangan ini dan ia telah dimasukkan dalam Rancangan MalaysiaKe-9 (RMK9) sebagai salah satu sumber potensi pendapatan ekonomi negara. Tambahanpula, negara-negara jiran seperti Singapura, Indonesia dan Filipina aktif mempromosipelancongan kesihatan di negara masing-masing, Oleh itu, Malaysia juga tidak

ketinggalan menyertai industri ini dan bersaing dalam pasaran pelancongan kesihatan.

Objektif utama kajian ini untuk mengenal pasti tahap pengetahuan rakyat Malaysiaterhadap pelancongan kesihatan dengan menggunakan model pemasaran . Dapatan kaj ianmenunjukkan bahawa tahap pengetahuan responden berada pada aras sederhana dan

kebanyakan responden mengaitkan pengetahuan pelancongan kesihatan dengan produkdan servis yang diterima. Walau bagaimanapun, responden menunjukkan sikap positifuntuk mencuba produk dan perkhidmatan yang disediakan oleh industri ini. Oleh itu,promosi melalui iklan dalam bahasa tempatan, maklumat yang mencukupi dan tepatboleh meningkatkan tahap kefahaman orang rarnai. Maklumat perkhidmatan yangberkualiti, kemudahan infrastruktur dan pakar yang diiktiraf boleh meningkatkanpersepsi positifmasyarakat tempatan dan pelancong antarabangsa.

v

ABSTRACT

Medical tourism is increasingly becoming popular and the competitions are growingamong choices for global community. Health tourism is relatively new in Malaysia,however the emergence of this industry was started since the year 1997. One of theearliest forms of health tourism that of visiting mineral or hot springs has also existed in

Malaysia for some time. Recently, the development of health tourism has been extendedwhen there are more and more private hospitals and medical centers offering their

healthcare services especially in major cities. Therefore, Malaysia is optimistic over the

growth prospects on health tourism and it is also included in the Ninth Malaysia Plan

(RMK-9) as one of the possible area in generating revenue for the nation economic.

Furthermore, other neighbouring countries such as Singapore, Indonesia and Philippineare now actively promoting health tourism, there is a need for Malaysia to be competitivein providing the highest quality for healthcare services in order to position itself as the

leading health tourism in this region. Basically, this research objective is identifying the

level of knowledge on health tourism amongst the local residents by using the marketingmodel namely AIDA Model. The research findings found that most of the respondentspossess a moderate level of knowledge and they recalled it to the products or services

offered by service providers. Furthermore, the respondents also presented a positiveattitude to engage in health tourism experience, mainly through their interest and desire.

The promotion via advertisement might be suggested to enhance the knowledge and

provide sufficient information for the local residents. The advertisement should be

published in local language and the information delivered to public should be true and

presented in ethical manner. So, public are not being cheated with the untrue story.Another significant aspect of information needed which makes the local residents

believed that health tourism is safer by providing sufficient information on service

quality, supported with good infrastructure and handle by well-trained staffs. The qualityof information disclosure by service providers will enhance the demand amongst localand international medical tourists as well.

TABLE OF CONTENTS

PageDeclaration

AcknowledgementAbstrak

Abstract

CHAPTER 1

11

111

IV

V

INTRODUCTION

1.1

1.2

1.3

1.4

Introduction 1

3

5

5

Problem Statement

Objectives of Study

Significant ofStudy

CHAPTER 2 LITERATURE REVIEW

2.l . Background of Study

2.1.1 Development ofHealth Tourism 6

2.1.2 Malaysia's Health Tourism 9

Development

2.1.3 Definition ofAwareness 17

2.2 Previous Study ofHealth Tourism 18

CHAPTER 3 RESEARCHMETHODOLOGY

3.1 Theoretical Model 23

CHAPTER 4

CHAPTERS

List ofTables

List of Figures

Bibliography

Appendix

3.2 Method ofResearch 25

DATA ANALYZING AND DISCUSSION

4.1 Data Analyzing4.1.1 The Respondents' Profile 26

4.1.2 The Respondents' Knowledge of 28

Health Tourism

4.1.3 Affect of Interest on Selection 30

Criteria

4.2 Discussion

4.2.1 Health Tourism Knowledge4.2.2 SWOT Analysis4.2.3 Strategies for Malaysia

CONCLUSION AND RECOMMENDATIONS

45

48

51

54

CHAPTER 1

INTRODUCTION

1.1 Background

Health tourism is relatively new in Malaysia (9th MP Report, 2006). However,

one of the earliest forms ofhealth tourism that of visiting mineral or hot springs,

has also existed in Malaysia for some time. This form of health tourism is

similar to the trend which can be traced back to Neolithic and Bronze ages in

developed countries such as Switzerland, Germany, Italy and other Europeans

countries (Chan, 2008; Gracia-Altes, 2005; Norhanim Abdul Razak, 2007). This

tourism segment has been identified as one of the new growth areas with

potential to increase the flow of foreign currency which contributing directly to

the current account of balance of payments for Malaysia (Bernama, 15 March

2009; 9th MP Report, 2006; Chong Wei Yee, Boey Tuck Sai and Nancy

Vathsala, 2006; Chee, 2007). Its potential is also seen in terms of it linkages with

both the health and tourism industries. It is anticipated that through a multiplier

effect, it will have spill over to secondary and tertiary sectors and produce

2

cyclical waves of economic expansion (Chee, 2007; Bookman, 2007; 9th MP

Report, 2006; Mohamad Taha bin Arif, 2002).

Nowadays, there are more and more private hospitals and medical

centres offering their healthcare services in this country especially in majorcities such as Kuala Lumpur, Penang and Malacca. As the standard of livingin the country increase, there are more Malaysians who can afford to seek

services from these private health accommodations. At least for the last ten

years, these private hospitals and medical centres have also expanded their

services to cater for foreign health tourists (patients). According to the

Association of Private Hospitals of Malaysia, there are now 35 private

hospitals and another 76 healthcare facilities that have been recognized bythe Ministry of Health, Malaysia for the promotion of health tourism with a

combined bed availability of6,781 beds and 3,303 beds respectively (APHM,

2003).

Malaysia has some of advantages that could led to the growth in

health tourism such as the capability to produce high quality services at low

prices, a favourable exchange rate, short waiting time for surgery, a strong

referral network in target market and horizontal integration. Other factors

such as the quality of care and numbers of professional licensed facilities (9thMP Report, 2006), the existence of 224 state-of-the-art private hospitals

nationwide which are easily accessible from domestic local airports with

efficient international flight connections, facilitatory arrival procedures and

the existence of supportive government led to this optimistic development

(Garcia Altes, 2005). In addition to the above advantages, Malaysia is now

increasingly faced with tough competition from her competitors especially

from countries in the same region such as Singapore and Thailand.

A little academic research has been done on this particular market

segment. Due to that reason, a recent study found that the understanding of

health tourism industry in Malaysia among those who were involved directly

3

in tourism sector and tourism education was not been well defined and

understood (Chan, 2008). Since as a market segment has enormous potentialfor further expansion, a strong believe that an increasing of health tourism

awareness must be a trigger for a benefit ofall in this country.

1.2 Problem Statement

Malaysia is optimistic over growth prospects on health tourism and it is also

included in the Ninth Malaysia Plan as one of the possible area to generate

revenue for the nation economic (RMK-9). This is because Malaysia has

great advantage to develop the health tourism industry due to a few reasons.

Malaysia has the skill manpower in the medical field and some of the best

facilities in this region. By referring to research done by Association of

Thailand Private Hospitals (ATPH) in the year 2006, it shows that high-tech

medical hardware in Malaysia is better than other countries in this region

(ATPH, 2006). Furthermore, the medical cost in Malaysia is still relatively

cheaper than other neighbouring countries.

However, other countries (namely, Singapore Thailand and India) in

this region are also actively promoting health tourism in their countries.

Therefore, there is a need for Malaysia to be competitive in providing the

highest quality of healthcare services in order to position itself as the leading

health tourism in this region. But before being competitive, the players,

stakeholders and environment should be ready with adequate information.

However, we found that there is lacking in work on the awareness among

Malaysian on this particular tourism market segmentation and supported with

the lacking in the number ofexisting literature and research which is provide

the information regarding health tourism awareness among public.

Most of the previous studies discussed on the definition of health

tourism (pollock & Williams, 2000; Goodrich, 1987 & 1993), the

4

relationship between tourism and health treatment activities (Gracia­

Altes,2005;Didaskalou & Nastos, 2003;Ross,2001) and economics growth

(Lee & Chang, 2008), development on health tourism (Lancaster,2004;

Vajirakachon, 2004; Percivil & John, 2005;Herrick,2007;Poon, 1983 &

1993), the competitiveness of the health care industry (Dwyer & Kim,2003;

Weiermer & Steinhauser,2003; Kim & Db, 2004; Crouch & Ritchie, 1999)

and potential of health tourism industry (Kazemi, 2007; Salem Salemeh

Harahsheh,2002).

From Malaysia perspective, the researches concentrated on the

definition of health tourism(Palany, 2008; Chan, 2008, Gracia-Altes, 2005;

Ministry of Health, 2002) development of the medical tourism industry

(Melaka State Government, 2003; Chee,2007; Nurhanirn Abdul Razak, 2007),

guidelines to be successful in the market (Chong, Boey and Vathsala, 2006).

Chan (2008) and Gracia-Altes (2005) found that the understanding level of

health tourism industry is still relatively low and not well defined amongst

Malaysian, but this industry is potentially to emerge (9th Malaysia Plan,

2006). Therefore, it is very important to achieve a high level of awareness

because this will enable change individual mindset and then affected human

behaviour. Consequently, the information from public knowledge on this

matter is expected to affect in terms of creating the potential participants use

the products (services), future entrepreneurs in the industry and health care

policies .Therefore, there are several questions that may arise in identifying

the awareness level of health tourism amongst Malaysian:

1. To what extent health tourism knowledge and interest to participate in

health tourism products or services amongst Malaysian?

2. What are the factors influence the health tourism development

amongst Malaysia?

5

1.3 Objectives ofStudy

The research aims to accomplish two objectives:

1. to determine the level of knowledge about Health Tourism among

local residents.

2. to identify the internal and external factors working behind the

surge inflow of the health tourists from developed and developingcountries to Malaysia.

1.4 Significance of the study

The contribution of this study is to extent the literature on health tourism

industry. In addition, this research will enhance awareness among public

regarding the alternative health treatment and create new business

opportunities for SME entrepreneurs. The research finding on the industry

profile is expected to be used by other stakeholders who are interested to

promote and deliver the information of new attractive health tourism placesto the public.

6

CHAPTER 2

LITERATURE REVIEWS

2.1 Background of Study

2.1.1 Development ofHealth Tourism

Health Tourism is about leisure, recreational and educational activities removed

from the distractions ofwork and home that uses tourism products and services

that are designed to promote and enable customers to improve and maintain their

health and well-being (pollock & Williams, 2000). At a glance, various aspects

such as geographical location, technology advancement, attractive exchange rate,

modernization in healthcare system, quality of human capital, amongst others,

would contribute to the success of this type of tourism segment. Nevertheless, this

issue should be carefully handled as health tourism is a segment of tourism which

requires careful and efficient coordination between the many government

ministries, agencies or departments and private industry.

The relationship between health and tourism has been deep-rooted in many

cultures such as British, French and American cultures since the early days, when

travellers went places far from their home for medical treatment (Didaskalou &

Nastos, 2003). Historically, health tourism was based on curative treatment where

7

the notion of 'health' is viewed as "merely an absence of disease (pollock &

William, 2000). Over the years, health tourism has evolved from medical care

oriented to health promotion. The range ofhealthcare segments has been vastly

expanded and now includes the curative, wellness and fitness programmes

(Ross, 2001). In the old days, wealthy patients from developing countries

travelled from afar to developed countries for high quality medical care duringtheir vacation. Recently, waves of patients from developed countries have been

travelling to places like India, Brazil, Thailand, and Malaysia for medical

procedures ranging from face lifts to knee replacements to cardiac bypass

surgery (Lancaster, 2004). At the same time, there are also growing numbers

of healthy people from developed countries who are travelling for high quality

rejuvenation and wellness therapy services at affordable prices. Cities in these

countries have opened up private hospitals that cater specifically to foreignersand that are often staffed by Western-trained physicians (CBS Broadcast,

2005). These hospitals offer relatively cheaper prices to the patients comparedwith what they would pay for similar services in their origin country. On their

visit, they do not come to get only curative treatment or therapies but also as a

pleasurable break away from home.

The combination of healthcare and tourism seems to be an emerging

niche market that is projected to have great potential in the tourism industry

(Herrick, 2007). Many reasons have been suggested for this, including long

waiting lists, high cost of care, and lack of medical insurance or under

insurance in the source countries (Gracia-Altes, 2005). The demand for health

tourism has been flourishing all over the world especially in the Asia-Pacific

region (percivil & John, 2006). As a result, more and more countries including

ASEAN countries are offering and promoting their health products and

services to foreigners. Some of the countries that have made inroads in the

health tourism sector include Malaysia, Singapore and Thailand.

8

Besides depending on bounteous natural resources, the host tourism countries

had been faced a transformation of tourism demand. Increasingly, tourists

(customers) have been taken away from traditional mass tourism demand

prototypes to the new era of tourism (poon, 1989 and 1993). Among the

critical factors that have been identified as affecting the transformation of

tourism demand are firstly, technology in general and information technology

in particular where by the global information revolution has obliged tourism

(enterprise) to act local and think global. Secondly, customers have become

much more sophisticated and discerning and tourists more demanding in

requesting high quality product and value for both their money and time.

Finally, with the advent ofedu-entertainment, customers are increasingly using

their leisure time at destinations to learn and explore about other cultures,

history and customs (Dimitrios Buhalis, 2001). Thus today, holidays are not

only regarded as relaxation or an opportunity to escape from the daily routine,

but also as a personal development opportunity to developed new skills,

interests and hobbies. The holiday maker wants to enjoy his holiday

thoroughly. This has resulted in an increasing special interest in holidays

devoted to sports or other hobbies, natural, health, adventure, religion and

other goals.

The above scenario describes the global competition that has emerged in the

health care industry. Most countries tried to offer the best healthcare services

and products in the health tourism segment. Those who have a higher

competitiveness will strive for bigger market share. To examine the challenges

and prospect of this segment, first there is a need to understand the

competitiveness of tourist segment destinations. To do this, all basic

determinants that constitute competitiveness should be considered. A firm

should adapt itself to the uncertain industry environment, understanding the

changing needs of customers and responding to new market entries (Dwyer &

Kim, 2003; Kim & Oh, 2004). Resource wealth is not enough for the tourism

industry's success. Sharing the tourism vision among all stakeholders, having

managers who develop an appropriate management and marketing strategy and

9

a government that supports the tourism industry with an efficient tourism

policy also important (Doris & Tania, 2008, Porter, 1980). The most

significant goal is the health tourism segment's (and in general, tourism

sector's) ability to add value to its products and services, customers,

employees and owners (Crouch& Ritchie, 1999).

2.1.2 Malaysia'sHealth Tourism Development

Today, Malaysia's health tourism is seen as one of the main components

within the 10 tourism sub-segments that have led to an increase in the number

of visitors to the country over the last few years. Malaysia is very optimistic

over growth prospects in health tourism and this segment is included in the

Ninth Malaysia Plan as one of the potential areas to generate revenue for the

nation's economy (9th MP Report, 2006). This is because Malaysia has many

advantages to develop the health tourism industry. These advantages can be

categorised as internal (firm-specific efforts) and external (industry analysis)

determinants for competitive advantage (Spanos & Lioukas, 2001). Malaysia

has the skilled manpower in the medical field and some of the best facilities in

this region. Furthermore, the costs of health tourism services in Malaysia are

relatively cheaper than compared other neighbouring countries (Table 1).

10

Table I

Competitive Prices for Quality Service

Procedure U.S. Malaysia Thailand Singapore

Heart Bypass 70,000-133,000 12,000 22,000 16,300

Hip Replacement 33,000-57,000 7,500 12,700 12,000

Facelift 10,500-16,000 6,400 5,000 7,500

Gastric Bypass 35,000-52,000 12,700 13,000 16,500

All prices in US Dollars

Source: Information from Patients beyond Borders, Taiwan Edition, p. 7 in Reader's Digest,January, 2009.

Before the arrival of modem medicine, Malaysians had been dependent

on traditional herbs for their medical treatment requirements (Melaka State

Government, 2003). An abundance of healing herbs are easily found in the

jungles in this country and many more remain to be discovered even though there

have been efforts to commercialize the production of such herbs. However,

western (modem) curative practices were started in Malaysia during the

Portuguese invasion. This was evidenced by the opening of the first hospital

named Royal Hospital and followed by the Pauper Hospital in Malacca (Melaka

State Government, 2003). After that, the Dutch took over Malacca and they also

continued the work of the Portuguese. During the British occupation, civil,

military and prison hospitals were built. All these early hospitals set up by the

colonialists in some way helped pave the way for the existing healthcare system

in this country (Norhanim Abdul Razak, 2007).

During the Asian financial crisis of 1997, the Malaysian ringgit dropped

rapidly before it was pegged to the U.S. Dollar at RM3.80 and affected every part

of the healthcare sector. The purchasing power of local patients for healthcare

provided by the private sector was badly reduced and they reverted to the public

healthcare sector for their needs. Many private hospitals were closed, downsized

or cut back their benefits for employees. The price of imported pharmaceuticals,

medical supplies and medical equipment rocketed. In the prevailing economic

climate then, private hospitals could not comfortably survive (Chee, 2007).

11

In 1998, Malaysia introduced health tourism as a response to the crisis

in its search for new and sustainable growth areas. Private hospitals increased

efforts to attract foreign patients. Despite the setback, foreigners have been

seeking medical treatment in Malaysia since long ago. For example, from

hundreds of years ago, Malacca has been known as a place which offers a

healthy and wholesome environment to those recuperating from an illness.

Records show that the Portuguese built a hospital at the foot of St Paul's Hill

called The King's Hospital in the 1500s. A charming story was recorded by

literary figure Munshi Abdullah on how the founder ofmodem day Singapore,

Sir Stamford Raffles, while in Malaysia recovering from an illness in 1807

(NST, January 25, 2002).

Meanwhile, the government of Malaysia has recognized the important

of health tourism as a mechanism for the country's economic growth.

Consequently, the National Committee for the Promotion of Medical and

Health Tourism was formed by the government in 1998 was chaired by the

Director General ofMinistry of Health (MOH). This committee comprised of

members from Ministry of Tourism (MOT), Association of Private Hospitals

ofMalaysia (APHM), Malaysian Association of Tours and Travel Agencies,

Malaysian Airlines and 35 selected private hospitals. Each subcommittee has

specific tasks such as identifying suitable source countries for promoting

health tourism; drawing up tax incentives; fee packaging; accreditation

guidelines; and advertising guideline (MOH, 2002). Overall, the main

committee is responsible in formulating a strategic plan, promoting a 'smart

partnership' between government, healthcare facilities, travel organization and

medical insurance group, and forging strategic alliances and linkages with

renowned overseas centers of excellence for mutual benefits (MOH, 2002). In

2001, the name of the committee was changed to National Committee for the

Promotion ofHealth Tourism (Chee, 2007). Prompted by this, the Ministry of

Health has taken an effort ''to change the mindset of Malaysians, from a

society that is focused on looking for a cure when sick, to embrace the

preventive concept ofwellness in daily life. (palany, 2008).

12

In the several years intervening, much has been achieved by these

subcommittees. The Malaysian government has organized a number of road

shows and marketing promotion efforts. Malaysian External Trade

Development Association (MATRADE) and Tourism Malaysia are the

government bodies tasked with this responsibility. From year 2001 until 2005,

among the countries targeted for promotional efforts were United Arab

Emirates, Bahrain, Saudi Arabia, Myanmar, Vietnam, Indonesia and China

(APHM, www.hospitals-malaysia.org).

The Malaysian government also encourages the development of health

tourism through various tax incentives for the healthcare industry. Tax

incentives available include industry building allowance for building hospitals,

exemption from service tax for expenses incurred on medical advice and use of

medical equipment, deduction for expenses incurred in pre-employment

training, double deduction for expenses incurred on promoting services

(exports) and use of information technology. Moreover, the National

Committee for Health Tourism has proposed further incentives, including

exemption from taxes the revenue earned from foreign patients in excess of

five percent (threshold) of the total revenue for the hospital, and double

deduction for money spent on accreditation and reinvestment allowance in

relation to accreditation requirements (MOH 2002: 110).

Since these policy steps were taken, the Malaysian health care system

has undergone steady growth despite the existence ofmarket players actively

promoting health tourism in this region like Thailand and Singapore. However,

these recent years has seen the steadily growth ofMalaysia health care system

supported by tourism activities that have helped Malaysia to position itself as

one of the premier destinations for health tourism. In 2006, hospitals in

Malaysia were estimated to host 296,687 foreign patients, earning revenues of

RM 203 millions. Malaysia expects to earn RMl.2 billion from medical

tourism by 2010 (Financial Times, 2005).

13

Table 2 illustrates the potential of this tourism segment by showing the

number ofpatients and income under the Health Tourism Program in Malaysiafrom 2002 to September of2008.

Table 2

Number ofPatients and Income under Health Tourism Programs.

Year 2002 2003 2004 2005 2006 2007 200S-until

Sept

Number of 84,585 102,946 174,189 232,161 296,687 341,228patients

Income 35.9 58.9 105.0 150.9 203.7 253.84

(RMMillion)

282,000

222.25

Source: Association ofPrivate Hospitals Malaysia.

"'Figures in brackets is an annual changes

Even though it is almost 10 years since the health tourism industry was

actively promoted by government in partnership with industry, it that the

understanding of health tourism industry among Malaysians is still relativelylow and has not been well defined and understood (Chan, 2008; Gracia-Altes,

2005). In addition, the availability of statistics on medical (or health) tourism

is poor (Chee, 2007; Norhanim Abdul Razak, 2007). The number of research

efforts carried out in this particular area is also limited. In the case ofMalaysia,

health tourism initiatives are still very much government driven and lack

sufficient information for the formulation of effective policies and strategies.Not only government, but private hospitals and other stakeholders too need

information to analyze the sustainability of their business ventures. One of the

most prominent disadvantages is that there are no legal means to compel them

to do so (Chee, 2007).

14

In comparison with the neighbouring countries, Malaysia is considered

as a late entrant to the health tourism industry. Malaysia has only been

promoting health tourism since late 1998. Singapore has been well known for

quality medicine and state-of-the art medical care since the 1980s (Chee,

2007).The Singapore health system is ranked as the best in Asia and amongst

the best in the world (http://www.mcos.com/). In the meantime, growth in the

medical tourism sector in Thailand since the early 19th century has been largelyled by the private sector. The Tourism Authority of Thailand (TAT) has been

promoting Thai traditional healthcare including massage, herbs and authentic

Thai food as a segment in health tourism (Vajirakachomt, 2004). Thus, they

are the closest competitors for Malaysia. In order for Malaysia to be

competitive in providing a high quality of healthcare services and to position

itself as one of the leading health tourism providers in this region, Malaysianeeds to come out with certain measurements of the effectiveness of health

tourism efforts. It can help to measure how effective and competitive Malaysiain providing not only quantity but quality of services as well. Reliance on price

competitiveness, skilled manpower or even the best facilities in this region is

no longer the most important factors. Therefore, in a globalize economy all

competing countries must be able to reshape production conditions and change

theirmarketing strategies.

The health tourism sector has huge potential for growth and has been

expected to earn RM2.2 billion in 2010. But, there are root problems in the

Malaysia healthcare system that needs to be resolved. Through the years, the

massive and sustained haemorrhage of senior, experienced staff from the

government service to the private sector due to more highly remunerative

privileges in the private sector have created serious problems for the provision

of general healthcare for the Malaysian public that is dependent on the public

health system. As more and more leave, those who are left behind face an ever

increasing workload (Chee, 2004). According to the 9th Malaysia Plan (2006),

the country continued to face shortages ofmedical personnel in all categories.

To alleviate these shortages, the public healthcare system recruited 871 foreign

15

doctors and dentists and a total of 873 retired specialists, doctors and dentists

were re-employed on contract basis. Private sector specialists were also

recruited on session basis in public hospitals and general practitioners were

encouraged to serve in public health clinics. In addition, dental officers and

pharmacists were required to serve three years compulsory service (9th MP

report, 2006). Thus, the growth of the lucrative private health care system

questioned the effectiveness of the public healthcare system in serving the

local populace. At the same time, the situation also raised doubt on the

multiple roles played by Ministry of Health as a regulator in a mixed public­

private healthcare system which needs to be functionally integrated.

Another problem that arises in positioning Malaysia as a top health

tourism destination is the marketing approach adopted. The tagline Malaysia -

'Truly Asia' is no longer unique as other countries in the region are becoming

more multiracial and multicultural. It is almost parasitic in nature, clinging to

the image ofAsia as a whole which, for some people, means it gives Malaysia

no identity of its own. Despite this, the Malaysia - 'Truly Asia' tagline was

cited as helping the country gain equity amidst similar markets inundated with

similar services (The Star Online, Dec 27, 2008). One of the questions to be

asked is how do we monitor and track the effectiveness of this brand to ensure

it continues to achieve fresh and effective communication over a period of time?

While most of the top destinations have their medical or health tourism

taglines, the general tagline Malaysia - 'Truly Asia' which is also used for

tourism in general does not reflect to the uniqueness of health tourism offered

in Malaysia (e.g. Malaysia, Truly Asia. Your next destination .....and take

advantage of its modern private healthcare facilities.). There are some

examples given for several countries which offer health or medical tourism

such as 'Singapore, A leading healthcare hub in Asia' (besides 'Uniquely

Singapore'), Thailand - Sun, sand and surgery (besides 'Amazing Thailand'),

'India - A global health destination' (besides 'Incredible India'), or 'MIT'­

Medicine in Taiwan. What is the appropriate tagline for health tourism 10

Malaysia?

16

Apart from the above challenges, Malaysia still has many others

potential resources that are not yet fully explored and developed. For instance,

Malaysia has identified many natural hot springs and health spas with potential

for health tourism promotion yet have not been marketed as health tourism

products (Norhanim Abdul Razak, 2007). Even though, Malaysia is one of the

12 mega-biodiversity nations in the world (Mohamad Taha, 2002). Thus, the

outlook for Malaysia's herbal industry is bright but requires putting energy,

time and resources necessary to scale up our efforts towards ensuring

availability, accessibility, acceptability and affordability of safe and high

quality Traditional or Complementary Medicine practices and products, and to

facilitate the integration of Traditional or Complementary Medicine into the

national healthcare system, Malaysia can come out with new alliances and new

initiatives that can make a difference to health tourism in Malaysia.

Other than the above mentioned potential of health tourism products, a

study conducted by Samsudin et al. (1997) indicated the potential development

of hot springs in Malaysia. The research revealed 9 hot springs having a high

potential for development. There were 14 hot springs having medium potential

and 17 hot springs having Jow potential for development. Researcher

suggested the development process should include more hot springs by

working parallel with capitalizing on existing surroundings and attractions and

developing commercial tourist activities that serve the health tourism industry

such as health spas, outdoor recreational canters as golf courses.

In conclusion, such efforts will also offer various opportunities to the

locals such as promote the set up of new businesses, training facilities,

research and development centers such as in biotechnology fields and provide

employment for skilled or unskilled workers. To position Malaysia as the

regional health care centre, Chong, Boey and Vathsala, (2006), enumerates six

factors that are essential to embark health tourism business opportunity. They

are first, increase the pool ofmedical specialists and health personnel; second,

upgrades the medical facilities; third, maintain or improve further service

17

quality; fourth, be more competitive in cost; fifth, aggressive promotional

activities; finally, plan out strategy or guideline involving the standard of

safety. In conclusion, the researchers undoubtedly that Malaysia will succeed

in promoting health tourism in this region.

2.1.3 Definition ofAwareness

The knowledge of health tourism become significant in response to the

statement by MOH in changing mind setting among Malaysian to look for

preventive than cure actions. Therefore, awareness components play an

important role to change the mindset. According to Meager et al. (2002), there

is a significant difference between the meaning of words knowledge and

awareness. The term awareness is defined in the following way:

"Awareness occurs when an individual is sufficiently informed about a subject

for him/her to be conscious of its existence and its broad subject matter."

(ibid., p. 11)

This is opposed to the definition ofknowledge, which is the following:

"Knowledge requires a theoretical orpractical understandingofa subject."

(ibid., p. 11)

Meager et at (ibid., p.12 ) claim that:

"It is possible to demonstrate awareness without having any substantive

knowledge ofa subject, but not vice versa."

The definition ofawareness as given byWordNet (2006) is the following:

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Awareness, consciousness, cognizance, cognisance, knowingness -- (having

knowledge of; "he had no awareness of his mistakes"; "his sudden

consciousness of the problem he faced"; "their intelligence and general

knowingness was impressive")

The awareness is here described as the consciousness and knowingness,

as defined by Meager et a1. (2002). We could now conclude that a clear

definition of health tourism awareness does not exist. From the above

definitions, awareness of health tourism is most often connected between

knowledge and participation in health tourism packages.

2.2 Previous Studies ofHealth Tourism

A lack of previous research has been found regarding awareness in health

tourism. Most of the studies discussing on definition, purposes, trends in

demand, type of treatments, development and challenges. Traditionally,

"health care tourism" is closely associated with curative treatment. However,

this phrase remains illusive until today as the concept of health tourism

represents different ideas to different people. In these recent years, the scope of

health care tourism has widened with the rapid advancement of health care

system and the development of the tourism sector. Health tourism does not

only limit to curative treatment for travellers. It also includes the aspects of

''wellness'' and "fitness".

Jonathan Goodrich has addressed in his studies issues related to health

tourism (Goodrich & Goodrich, 1987; Goodrich, ] 993). According to

Goodrich, health tourism may be defmed as "the deliberate attempt on the part

of a tourist facility (e.g. hotel) or destination (e.g. Baden, Switzerland or Bath,

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England) to attract tourists by promoting health-care services and facilities in

addition to regular tourist amenities (Goodrich, 1993:37). The author has

provided a listing of health-care services provided by such tourist facilities or

destinations as listed by Goodrich (1993:38).

1. Medical examinations in the hotel (cholesterol levels, diabetes, blood

pressure, etc.)

2. Vegetarian or special diets

3. Tran vital injections and vitamin-complex treatment.

4. Daily exercise programs

5. Yoga

6. Acupuncture

7. Thermal swimming pools (indoor and outdoor).

8. Underwater massage (balneotherapy)

9. Body massages.

10. Cellulite treatments (cellutron).

11. Saunas.

12. Hydrotherapy.

13. Fango packs (mud).

14. Special stop-smoking programs.

15. Various baths (e.g., eucalyptus bath, and Turkish bath).

16. Herbal wraps and herbal teas.

17. Use of sun-bed under supervision.

18. Sessions on muscle development and relaxation techniques.

19. Beauty treatments, such as facials, cream packs, face peeling, etc

Goodrich through his research has conveyed the motives of travellers in

acquiring "curative properties and relaxation" or "to be cleansed physically

and spiritually" when going to rivers and mineral springs or when bathing in

the following rivers: the Nile, the Ganges, the Yangtze, and the Jordan River.

Hembry (1990) has written about the ancient English individuals' motives

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behind visiting Bath in England, which is to be able to enjoy the healthy

benefits of bathing in warm springs and mineral waters. The mentioned supply

components are believed to offer a 44 cure for diverse health problems such as

skin infections, poor digestion, and rheumatism (Goodrich, 1993). As a

response to a more health-conscious market segment, many cruise lines and

hotels have complemented their already existing exercise facilities with fitness

and wellness seminars and programs (Goodrich, 1993).

Weiermair and Steinhauser (2003), discussed on the need for new

tourism clusters due to big socio demographic shifts, health awareness and

changes in a consumer behaviour and value in five alpine provinces, Austria.

The purpose of the study was to recommend an ideal starting point for what

may be called "Alpine Wellness". The research used Porter's Clustering

Model and Diamond Model as a base of discussions. The local customers,

related industries and new technologies or innovative companies were

identified as driving factors of clustering. Meanwhile, productivity

enhancements, increases in innovations and new business formation were

summarized as the effects of clusters. A cluster strategy places all public and

private stakeholders in the position of being producers and suppliers to one

another. The value chain was developed to demonstrate how tourism can

generate benefits to the economy beyond the tourism sector through linked

industries. Finally, Porter's Diamond Model was used to characterizing and

identifying a cluster which includes all relevant market forces and factors of

competitiveness.

Another study done by Kazemi (2007) was considered on medical

tourism discussion in Iran and surveying the potentiality and effective factors

which are important for attracting medical tourism industry in Iran. The

methodology used in this study was triangulation method (both qualitative and

quantitative method). Purposive sampling was chosen for this research;

judgment sampling - because sampling the members are selected from the

population based on judgment and proceeding knowledge for medical tourism