1. Introduction
Several countries have benefited from international medical travel in terms of increased GDP, improved healthcare infrastructure, attracting foreign currency, promoting tourism, and, more importantly, checking the brain drain of skilled medical professionals [
1,
2]. However, the reason behind this phenomenon is the unavailability of certain types of treatments such as bypass surgery, cancer treatment, transplantations, eyecare in a home country, or treatment that is available with low quality or at a very high price. International medical travel is defined as “the citizens of source country travel to foreign destination hospitals with the sole purpose of obtaining necessary medical procedures and treatment”. Many researchers disagree with using the term “medical tourism” for a journey performed solely in search of medical treatment, as the term otherwise mainly defines the phenomenon of north-to-south travel where receiving health and medical care was combined with leisurely activities. Researchers argue that the majority of individuals traveling outside the country for treatment are needy patients who have the sole motivation to receive the required treatment [
3,
4].
International travel for medical services in the sub-Saharan region of Africa has been growing rapidly in the last decade [
5]. Although the specific figures are not available on the number of travelers traveling outside the country for medical needs, general figures can provide a broad picture of the size of international medical travel in sub-Saharan Africa. According to Crush and Chikanda [
6], more than 2 million patients mainly from sub-Saharan Africa traveled to South Africa between 2003–2008 at an average of 400,000 per annum. In the year 2010, an average of 3000 Nigerians traveled to India for medical purposes each month, spending around USD 200 million for medical care [
5]. In 2016, Africans spent USD 6 billion on receiving medical treatment abroad, in which Nigerians alone spent USD 1 billion [
7]. Although most of the travelers visited India on social visas, India issued 18,000 medical visas to Nigerian patients alone in 2012 and received USD 260 million as revenue [
8]. Movement of the patients outside the country intensified in East African countries due to the perception of low-quality services at home and less proactive marketing. Based on estimation, 100,000 East Africans travel to India annually due to high cost of treatment in their home country [
9].
Sub-Saharan African medical travellers are the largest contributors to the Indian medical travel industry in terms of numbers and revenue [
10]. However, despite being the largest group of visitors, Africans face different kinds of problems in India. African visitors faced incidences of harassment and violent attacks while visiting India, which were covered by the world media [
11,
12,
13]. In reaction to the incidences against Africans in India, local newspapers in African countries quoted general public reaction and found that citizens willing to visit India were concerned about the incidences happening in India [
14]. In this situation, it has become very significant to understand the travel-related decision-making of sub-Saharan African medical travellers. As sub-Saharan Africans are the largest group of medical travelers to India, ignoring their concerns and issues will be insidious for the Indian medical travel industry. Evidence from the previous studies shows that medical travelers tend to change their preferred destination over a period of time [
15]. Although specific reasons were not available, one or the combination of few factors such as deterioration in service quality, increased cost, personal safety and security, uncomfortable journey, and travel documentation could trigger the change in behavior. According to Prakash, Tyagi [
10], issues raised by the medical travelers, who visited India, such as hidden cost, food quality, accommodation, and travel documents, need to be taken care of, otherwise India may lose its competitive advantage. The main objective of the study was to identify and analyze the role of different factors in travel decision making which will help managers to understand the future travel behaviour of African medical travellers.
Many researchers [
3,
16,
17] have made calls to understand the decision making of medical travellers by investigating the influential role of different factors. Although few quantitative empirical studies are available in the context of medical travel and travellers behaviour [
18,
19], these studies were performed on leisure travellers, therefore, it cannot reflect the views of actual medical travellers. In leisure travel, plenty of studies have been undertaken to understand the decision making process of travellers based on the travel motivations, perceived risks, travel constraints, destination image, and visit intention [
20,
21,
22,
23]. The studies proved that these variables have a direct and indirect role in the development of perceptions and visit intention among the travellers. This study was in the direction to investigate the role of travel motivations, perceived risks and travel constraints in the formation of destination image and the effect of the two components of destination image, i.e., medical and non-medical on an intention to visit India among the sub-Saharan African medical travellers.
4. Discussion and Implications
The study found that those medical travellers who perceived high physical-health risks possessed negative perceptions of the destination image based on medical attributes. Physical-health risks were measured based on facing health-related issues, getting sick due to contaminated food and drinking water, and contracting infectious diseases. The image of many medical travel destinations is weak in terms of hygienic conditions, pollution, infectious diseases, physical injuries, and safety and security [
3,
67,
68,
69]. The findings of this study support the arguments by researchers on the perception of risks. Many western governments release their travel advisories periodically and warn their citizens about contracting infectious diseases such as malaria, Japanese encephalitis, cholera, typhoid, hepatitis, tuberculosis, and poor air quality, and physical injuries due to accidents while travelling to countries of Asia and Latin America. Most of the well-established medical travel destinations are in this region. Western governments also advise those citizens who have existing medical conditions to take extra care of their health while travelling to emerging countries [
70,
71,
72,
73]. The Governments of Canada, America, and the UK have issued special travel advice to medical travellers about health-related issues at medical travel destinations such as blood-borne infections like HIV, hepatitis-B due to infected blood transfusion, acquiring malaria from local blood banks, contact with multi-drug resistant bacteria in hospitals, and illegal organ selling. Although the situation related to the prevalence of infectious diseases, physical injuries, and hygiene is no better in most of the medical travel source countries than the destination countries, a wide range of sources of information such as medical travel blogs, forums, websites, and travel advisories from western governments may create health-related worries in the minds of most medical travellers, especially when they are already suffering serious medical conditions. The medical travel destinations and the hospitals providing services to medical travellers should take initiatives to reduce the physical-health related concerns to increase the confidence of medical travellers. The marketing managers must take initiatives to spread positive images about destinations in terms of safe food and drinking water and about the measures taken for the prevention of infectious diseases and physical injuries to reduce the perception of physical-health risk among medical travellers.
The results also found that the perceived service quality risk among medical travellers was negatively related to the perception of the destination on medical and non-medical attributes. Service quality risk was measured based on unsatisfactory medical service that fails to meet expectations and is not value for money. However, descriptive analysis shows that the mean value of the variable service quality risk was 2.65 (SD = 1.31), which means that most of the respondents consider service quality risk related to medical travel destination as being low. The literature on medical travel argued that the high-quality medical service provided by the hospitals at the medical travel destination is the most important factor that pushes the majority of the medical travellers to travel to foreign country [
3,
5,
6,
74]. However, a negative perception of non-medical attributes is a concern for medical travel destinations. The findings of this study support the arguments of previous studies that issues such as hidden cost, food quality, accommodation, and travel documents need to be addressed for the continuous growth of medical travel [
10]. Medical travel destinations must emphasise maintaining and improving the quality of medical and non-medical services offered to medical travellers and highlight them in the marketing and promotional materials to attract more medical travellers.
The results of the study reveal that the destination risks of the medical travellers were negatively related to the medical attributes of the destination. Destination risk was measured based on crime and safety, political instability, racist attacks, and prejudice among the local population. Destination risks have not been given due consideration in medical travel literature. However, most medical travel destinations are middle or lower-middle income countries and rank low on the social progress index [
75]. Medical travellers face different kinds of crime and safety issues at the destinations such as the sexual assault on female foreign patients at hospitals, fraud, and opposition to medical travel by nationalist groups [
76,
77,
78,
79]. The most alarming aspect of the finding is that problems and issues not related to medical services are damaging the image of the destination based on medical attributes. Safety and security, crime, and political unrest are issues that have damaged the tourism industry of many countries. Medical travel destinations should also keep in mind that the medical traveller could be more vulnerable to destination related risks as they reside in one place for long periods to complete the treatment. Medical travel destinations must take these issues seriously and find solutions to tackle them for the continuous arrival of medical travellers.
The findings also revealed that those medical travellers who perceived travel constraints also perceived the destination negatively based on medical and non-medical attributes. The study provides interesting findings on the travel constraints of medical travellers. The perceived travel constraints were measured based on stress and anxiety felt, difficulty to find companion, the arrangement of money, the arrangement of travel documents, and flight connectivity from the home country. As far as anxiety and stress are concerned, managers must identify the factors which lead to stress and anxiety among medical travellers. More positive information should be spread among potential medical travellers about the medical and support services that will lead to a reduction in stress Managers also need to identify the issues and problems faced by travellers and work on reducing and correcting those problems so that negative word of mouth can be reduced. For the issue of finding a companion, the destination should develop a supporting mechanism that minimises the need of having a companion. Kangas [
15] found that finding a suitable companion to travel abroad was a difficult task for medical travellers. She found that the head of the household who was also the earning member of the family and main decision-maker could not accompany the patient due to work commitments and arrangements of money to finance the trip. Therefore, travellers need a companion to travel with them who can take necessary decisions if needed while the patient receives treatment [
80]. Destinations must develop a mechanism that can reduce the need to take crucial decisions by the patient at the time of receiving treatment. Detailed communication before arrival between the hospital and the patients about the procedure, treatment, expenses, and other support services will reduce the need for taking spontaneous decisions at the destination.
Studies of medical travellers have found that the arrangement of medical travel documents and flight connectivity from many source countries is a major issue faced by medical travellers [
3,
10]. Due to the tedious process which requires a lot of paperwork, most medical travellers visit the destination countries on tourist visas which can sometimes complicate their treatment. A tourist visa allows visitors to stay for a shorter period (in some cases for 15 days only), and sometimes medical procedures force travellers to stay for longer periods. In this case, receiving a further extension of the visa gives can be troublesome, especially when patients are undergoing treatment. For example, the Government of India recently took measures to provide e-visa to health travellers from more than 150 countries [
81,
82]. However, this relaxation does not include those who want to travel to receive medical treatment. Flight connectivity from many source countries such as the sub-Saharan region is another issue to which governments must take care to attract more medical travellers from this region.
The findings suggest that medical travel destinations should also focus on the risk perceptions and travel constraints of medical travellers instead of just promoting medical services to international patients. It is true that the main criterion for selecting a destination by foreign patients is the quality and cost of medical services. However, at present, many countries are developing their healthcare infrastructure to attract foreign patients by providing quality medical care at low cost and the criterion to choose a destination will include factors such as vulnerability to different kind of risks and ease of travel. Destination marketing managers should develop their marketing strategies that provide solutions to risk perceptions and travel constraints of medical travellers. At the same time, destinations must develop policies and measures that reduce the possibility of getting harmed at the destination for medical travellers.
5. Conclusion, Limitations, and Future Recommendations
The study contributes to the body of knowledge in two ways. First, the study was performed on actual international medical travellers, as most of the previous quantitative empirical studies [
19,
20] were performed on potential medical travellers. Therefore, this study provides useful insight into the travel behaviour of actual medical travellers. Second, the study conceptualised and integrated different factors in a single framework that are crucial in the travel decision-making of medical travellers and empirically tested their relationships. Based on the path coefficient values, it was found that physical-health risk (β = −0.139, p < 0.10), service quality risk (β = −0.128, p < 0.05), and destination risk (β = −0.233, p < 0.05) had negative relationship with destination image based on medical attributes, whereas, service quality risk was negatively associated (β = −0.138, p < 0.10) with destination image based on non-medical attributes also. Travel constraints were negatively associated with both destination images based on medical and non-medical attributes. It was found that physical-health risk and destination risk have no relationship with destination image based on non-medical attributes. The empirical evidence of the study suggests that perceived risks and travel constraints of medical travellers negatively affect their perception about the destination on different aspects such as quality of medical services, quality of support services, culture, physicians’ skills, medical facilities, etc. and influence their travel behaviour. The destination and hospitals providing services to foreign patients must understand the perceptions of medical travellers. The study suggests that destinations and hospitals should be aware of the types of risks and constraints medical travellers face so that their future behaviour can be understood better.
Although the study has considerable practical implications, the study has several limitations. The study was performed on sub-Saharan African medical travellers visiting India. Therefore, care should be given in generalising the study findings to medical travellers from other regions. The study used non-probability convenience sampling due to the lack of a sample frame which limits the generalisability of the study findings. The study sample was skewed toward male respondents. 73.5% of the study respondents were male which means that the findings of the study could be biased towards male medical travellers. Future studies could be performed on medical travellers travelling from other parts of the world, and the findings can be compared to develop a better understanding of the travel behaviour of medical travellers. As this study could not provide equal representation of female medical travellers, future studies can use a more balanced sample of male and female participants so that the results can be generalised for both genders. Future studies can be performed on the different decision-making stages of international medical travel to examine if information sources and other personal factors play a role in the perception of risks and constraints.