e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 1 Nabanita Choudhury Symbiosis School of Economics, Symbiosis International (Deemed) University Sudipa Majumdar Symbiosis School of Economics, Symbiosis International (Deemed) University Ishita Ghosh Symbiosis School of Economics, Symbiosis International (Deemed) University Evaluating Demand Side Enablers for Medical Tourism: Case Study of Medical Tourists from Bangladesh to Kolkata, India. Globalization has brought about transformations in medical infrastructure, with foreign collaborations in ownership of healthcare. The resulting world-class medical services helped India to secure the 6th rank amongst 46 nations. Such demand-pull factors have attracted tourists from across the world to come to India to seek high-quality treatment at affordable costs. The trend has been particularly strong for Kolkata, a preferred healthcare destination for medical tourists from Bangladesh. However, this aspect has been largely ignored in the existing literature. The present research investigates demand-pull and demand-push factors based on the motivations and experiences of Bangladeshi medical tourists. Primary research was conducted through a purposive snowball sampling to interview 207 patients and 11 hospital staff from different Kolkata hospitals. Field observations, telephonic discussions, survey questionnaires, focus group discussions, and in- depth interviews were carried out at outpatient departments, reception desks of diagnostic centers, lodges, and guesthouses where families of international patients stayed for the tenure of their treatment. The key findings of this study provide important policy recommendations for stakeholders and lay down the pathway for future research for cross-border services trade. Keywords: Globalization, Medical Tourism, pull and push factors, Mode 2, Bangladesh, Kolkata. http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 2 Nabanita Choudhury Junior Research Fellow Symbiosis School of Economics, (Department of Symbiosis International (Deemed University)) Senapati Bapat RoadPune – 411004. Tel: 91-20-25672520 Sudipa Majumdar,PhD Professor and Deputy Director Symbiosis School of Economics, (Department of Symbiosis International (Deemed University)) Senapati Bapat RoadPune – 411004. Tel: 91-20-25672520 Ishita Ghosh.PhD Assistant Professor Symbiosis School of Economics, (Department of Symbiosis International (Deemed University)) Senapati Bapat RoadPune – 411004. Tel: 91-20-25672520 Nabanita Choudhury is a Junior Research Fellow at the Symbiosis School of Economics, Pune, India. She completed her Bachelors in Economics from Women Christian College Kolkata and went on to obtain her Masters in Economics from IGNOU, New Delhi. She is engaged in teaching for a long period of time in Undergraduate and Post Graduate Courses. Sudipa Majumdar is a Professor at the Symbiosis School of Economics, Pune, India. She is a Fellow of the Higher Education Academy, United Kingdom. She completed her Bachelors in Economics from Presidency College Kolkata, her Masters in Economics from JNU, New Delhi, and PhD in Economics from IGIDR Mumbai. Sudipa also holds a Post Graduate Certificate in Advanced Statistical Learning from Stanford University, USA, and a Post Graduate Certificate in Higher Education from Middlesex University, UK. Her research has been featured extensively, and she has won multiple academic awards at international conferences. Ishita Ghosh completed her Ph.D. in Economics from the University of Pune. Her research interests include services trade, applications of the gravity model, FDI, regionalism, and geo- economics. She has twenty years of experience in academia and industry. She teaches courses on macroeconomics, international economics, and research methodology. http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 3 Introduction Globalization brought about a remarkable technological transformation, enhancing the process of international medical consultations, telemedicine, medical transcriptions, medical tourism, etc. This has resulted in foreign involvement in the ownership of hospitals and commercial medical practices through collaborative tie-ups. On the one hand, such foreign collaborations had a striking adverse effect in emerging economies like India, leading to a decline in Government spending on healthcare and commensurate growth in private-sector involvement (Davalbhakta et al.,2020). On the other hand, easier access, rising income levels, and reduction in costs of travel and communication provided ease of mobility to both foreign consumers and providers of global healthcare services, which increased the demand for medical tourism. The theory underlying this research comes from global trade in services regulated by the World Trade Organization under the General Agreement on Trade in Services (GATS). According to GATS, services are supplied through four modes, as depicted in Figure 1 below. In the context of the trade of healthcare services, Mode 1 would involve a cross-border supply of services like medical coding, billing, telemedicine, etc. Mode 2 refers to patients traveling to other countries to seek medical treatment and constitutes outbound medical tourism. Collins et al. (2019) explored the factors that influence outbound medical travel from the USA and found that the most critical factors include cost savings, availability of medical procedures, and access to high-quality care. Under Mode 3, the healthcare provider establishes a physical presence in another country through joint ventures, subsidiaries, or franchising arrangements. Since 2015, India has opened up the automatic route permitting 100% FDI in greenfield and brownfield healthcare projects. Mode 4 involves the temporary movement of healthcare professionals to another country to provide medical services. Under Mode 4, doctors, nurses, and medical technicians take up temporary employment and start working in another country (Rueda-Cantuche et al.,2016). Medical travel and tourism fall under Mode 2 of GATS. In Figure 1, India is represented by Country B, in which the Indian healthcare industry would be the supplier of services to foreign consumers in Country A. Empirical studies have determined the main pull factors for medical tourism to be the quality of healthcare service abroad, availability of experienced medical staff, hospital facilities, geographical proximity, competitive pricing, pre/and post-surgery care, and even the ability to combine surgery with a family vacation (Collins et al., 2019; Medhekar et al., 2020). Some of the push factors that compel patients to travel abroad include high medical costs in their home countries, unavailability of surgical treatment, lack of expertise, and long wait times (Drinkert & Singh, 2017) http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 4 Figure 1: Modes of Trade in Services Source: Kuo et al. (2011) The present study is an analysis of medical tourism in Kolkata, the administrative and commercial capital of West Bengal. Given the growing importance of Kolkata as a preferred healthcare destination, this research fills the lacuna in the existing literature with respect to the only existing study on the supply factors of Kolkata's medical tourism (Rai, 2019) based on fieldwork carried out in 2012-2018. Although Rai (2019) focused on hospital facilities and healthcare providers in Kolkata, the author did not mention the major role played by Tata Medical Centre in enhancing medical tourism in Kolkata. The present research makes important updates and extensions to the extant literature. Firstly, this paper delves into the demand side factors of medical tourism in Kolkata, investigating the pull and the push factors based on the motivations and experiences of medical tourists. Secondly, the inclusion of Tata Medical Centre incorporates the missing aspects of the previous study in a significant way. The format of the paper is as follows. Section 2 presents a review of the literature, followed by an overview of the medical tourism scenario in India in Section 3, based on secondary research. Section 4 outlines the research methodology adopted for this study. Key findings of the primary research are presented in Section 5, which gives details of treatments, financial implications, and the satisfaction of medical tourists in Kolkata. This section also includes important field observations based on semi-structured, open-ended interviews and discussions with international patients, family members, and hospital personnel. Section 6 gives the study's recommendations and conclusions along with future research scope. http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 5 Literature Review Medical tourism refers to traveling for medical treatment when a patient is unwell and requires consultation, diagnosis, or surgery (Fetscherin & Stephano, 2016). Medical tourists have been found to travel for services ranging from cosmetic surgery to organ transplantation (Horowitz et al., 2007). A systematic review of the literature by Lunt et al. (2016) reveals the complex and multifaceted aspects of medical tourism that require a nuanced understanding of its determinants, patterns, and socio-economic impacts. Accessibility of information (Henderson, 2003), the presence of qualified medical professionals abroad, and ease of traveling between countries due to globalization (Carrera & Bridges, 2006) have been credited as the main driving forces behind medical tourism. Medical tourism in the USA is influenced by institutional factors such as the West Virginia and Colorado House Bills (Palvia, 2007; Bramstedt & Xu, 2007). Cheung and Saha (2015) used the gravity model of trade to demonstrate the connection between cultural resemblance and tourist demand, while Connell (2013) opined that the growth of medical tourism crucially depends on cost differentials, quality differentials, marketing and promotional efforts between the countries. The Indian medical tourism industry is particularly distinctive in its culture, service delivery principles, and cost structure compared to other Asian medical tourism destinations (Reddy & Qadeer, 2010). Medical tourism in India has the potential to generate additional income and revenue streams, create employment, and stimulate innovation in the Indian healthcare sector (Reddy, 2013; Rai, 2019). However, many disagree with India's efforts to advance globalization and promote itself as a lucrative travel destination. Mathijsen (2019) pointed out that the factors affecting the medical tourism industry are travel preferences, emigration, global marketing, tax advantages, and incentives, especially in Asian countries like Thailand, Singapore, Malaysia, India, and Korea. Other researchers also argue that India does not meet standards for international infrastructure, quality, hygiene, and trust (Wong et al., 2014; Ormond & Sulianti, 2017) India's reputation overseas is primarily due to orthopedic surgery and cardiology. Patients from Canada, the United States, the United Kingdom, the Gulf, Bangladesh, etc., come to India, making it a lucrative medical tourism destination due to its cost-effectiveness. Package deals with airline companies, accommodations, and post-operative vacations are routinely offered to medical tourists traveling to India (Gupta et al., 2015). However, a 2011 study by the Indian Ministry of Tourism highlighted the language barrier, lack of government support, and competition from Singapore and Thailand as major threats to this sector. According to Kalshetti and Pillai (2008) and Turnock (2010), patient safety, psychological and ethnic dissimilarity, political bans, and lack of detailed information were important challenges for medical tourists. Major obstacles arose due to the absence of rigid pricing policies among hospitals and the lack of coordination among multiple industry stakeholders like hotels, hospitals, aircraft operators, etc. (Chakravarthi et al., 2017). The system also has rampant malpractice, like poor transplantation rules (Prasad, 2008). Therefore, there is a need for resource allocation in research and training (Reddy, 2013), along with stricter regulations and assurance of patient safety (Singh, 2019). http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 6 Few studies concentrated on Indian cities as preferred destinations for medical tourism. Sultana et al. (2014) highlighted the choice of Bangalore owing to the reputation of the city's medical facilities, the cost-effectiveness, and the availability of specialized treatments. Rai (2019) provided information about medical tourism in Kolkata, highlighting the need for healthcare providers to adhere to international quality standards and advocating transparency in pricing and treatment. Studies based in Delhi by Malhotra and Dave (2022) and Bagga et al. (2020) found Bangladeshi tourists coming to Delhi seeking cosmetic and plastic surgeries, based on information from websites and social media. Although medical tourism in India has been explored, the importance of Kolkata as a tourism destination for Bangladesh needs to be explored further. The only existing study by Rai (2019) was based on primary research from 2012-2018. Therefore, the present study attempts to bridge the gap by updating the socio-economic trends of Kolkata’s medical tourism since the COVID-19 pandemic. Medical Tourism in India The Medical Tourism Index (2020-21) ranks India at the 10th position among the top 46 countries, and India secured the 6th rank in terms of its quality of medical facilities and services (Press Information Bureau, 2023). According to the Ministry of Tourism, medical travel to India surged from USD 3 billion in 2015 to USD 9 billion in 2020 before the Covid-19 pandemic. Despite the pandemic, India saw almost 200 thousand medical tourists in 2020, generating income of USD 13 billion (Malhotra & Dave, 2022). The lifting of the travel bans in 2021-22 witnessed an influx of patients from Bangladesh, Afghanistan, Nigeria, Nepal, and Bhutan. The Indian medical tourism industry was valued at USD 74.2 billion in 2022 and has been projected to reach beyond USD 400 billion over the next decade (Verghese, 2022) India has emerged as a leading destination for medical tourism, driven by various factors that give the country a competitive advantage in the global market for healthcare services. One of the main pull factors is India's competitive advantage and ability to offer high-quality medical services at significantly lower costs compared to other countries with similar treatment facilities. According to Verghese (2022), bypass surgery in India costs approximately USD 10,000, while the same in the USA costs more than USD 110,000. India has skilled, qualified healthcare professionals, including doctors, nurses, and paramedical staff. This has taken India to the forefront of the globe in medical specialties, including cardiac surgery, organ transplants, and cancer treatment. Cardiovascular treatment and neurological surgeries have had the highest demand from medical tourists in India. Table 1 provides the comparable prices for the common medical procedures in India and some other medical destinations in South Asia that are easily accessible to Bangladeshi patients. The table clearly shows the huge price differentials between the countries, a major pull factor for India http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 7 as a preferred destination for medical tourists in South Asia. According to Kumar and Hussian (2016), medical tourism in Malaysia has been strongly supported by the Ministry of Health, whereby 35 world-class hospitals were selected to attract foreign patients. Konar et al. (2016) noted that the Malaysian cities of Penang and Kuala Lumpur had attracted medical tourists from neighbouring Indonesia due to affordability and proximity, quite similar to the trends of Bangladeshi patients coming into Kolkata. The Thai Government has also been involved in initiating the policy of "Medical Hub" to position the country as a global medical destination (Syah et al., 2022) by offering unique packages to combine medical and leisure tourism. South Korea's medical tourism industry flourished due to its focus on skincare, cosmetics, and plastic surgeries (Dang et al., 2016). In contrast, Singapore focused on its branding as a premium medical destination of clinical excellence to attract high-value-added initiatives in biomedicine and biotechnology (Ebrahim and Ganguli, 2019). Table 1: Prices of Common Medical Procedures in South Asian countries (in USD) Medical Procedure Price in India Price in Malaysia Price in Thailand Price in Singapore Price in South Korea Heart Bypass 7,900 12,100 15,000 17,200 26,000 Angioplasty 5,700 8,000 4,200 13,400 17,700 Valve Replacement 9,500 13,500 17,200 16,900 39,900 Hip Replacement 7,200 8,000 17,000 13,900 21,000 Knee Replacement 6,600 7,700 14,000 16,000 17,500 Source: Sarwal et al. (2021). In recent years, there have been significant investments in healthcare infrastructure, with the establishment of modern hospitals, diagnostics, and healthcare facilities with top-of-the-line medical equipment that meet international standards. Most doctors, surgeons, and nurses in Indian hospitals are fluent in English. In 2022, Prime Minister Narendra Modi set the vision of "Heal in India" to reap the potential of medical tourism as a foreign exchange earner, job generator, and brand ambassador of India's soft power. The Ministry of Tourism has already taken steps to promote India around the globe as a Medical and Health Tourism Destination. Indian Healthcare Federation, a Non-Governmental organization affiliated with the Confederation of Indian Industry, has prepared a guide on select Indian hospitals of the country for health tourism as a part of the Incredible India campaign. Medical and health tourism has been specifically promoted at various international platforms such as World Travel Mart, London, ITP Berlin, etc. A new category of “Medical Visa” has been introduced by the Ministry of Home Affairs since 2014, which can be given for specific purposes to foreign tourists coming to India for medical http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 8 treatment. According to Sarwal et al. (2021), medical visa issuances increased from 184 thousand in 2014 to 697 thousand in 2019. Further, during the Healthcare Leaders' Summit 2022, Union Minister Dr. Jitendra Singh announced that more than 1 million medical visas were issued to foreigners between 2019 and 2022 (Press Information Bureau, 2022). The India Tourism Statistics (2022) figures showed that in 2021, 21.2% of total foreign tourist arrivals into India were for medical purposes, wherein 68.4% of arrivals from South Asia were categorized under Medical Purposes, followed by 61.1% from West Asia and 40% from African countries (Table 2). In terms of the number of tourist arrivals for medical purposes, 77.6% of total arrivals from Bangladesh were for medical purposes, followed by Maldives, Afghanistan, and Iraq (Table 3), which justifies the focus of the present study on Bangladeshi medical tourists. Table 2: Medical Tourist Arrivals into India in 2021 (percentage) Nationality Medical Tourists 1 South Asia 68.4% 2 West Asia 61.1% 3 Africa 40.0% 4 Australasia 21.2% 5 Eastern Europe 17.9% Source: India Tourism Statistics (2022) Table 3: Number of Tourists in India in 2021 – total and medical (numbers) Country Total Foreign Arrivals in India Medical Tourists in India 1 Bangladesh 240,554 186,670 (77.6%) 2 Maldives 26,571 22,798 (85.8%) 3 Afghanistan 36,451 19,538 (53.6%) 4 Iraq 16,213 15,354 (94.7%) 5 Oman 10,174 7,610 (74.8%) 6 Yemen 6,235 4,614 (74.0%) 7 Sudan 6,781 3,906 (57.6%) 8 Kenya 13,373 3,423 (25.6%) 9 Nigeria 5,516 2,912 (52.8%) 10 Tanzania 6,480 2,197 (33.9%) Source: Author calculations based on India Tourism Statistics (2022) http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 9 Methodology The present study is based on primary research with data drawn from international patients from Bangladesh to Kolkata. Purposive snowball sampling technique was used in the first round, where a small population of Bangladeshi patients or their family members were identified and interviewed in the different hospitals of Kolkata. This was done with the help of the hospital staff, medical tourist agents, and travel agencies. In the second round, the sample was expanded through referrals that were sought from the initial participants. A sample of 207 patients from different Kolkata hospitals could be obtained. The leading hospitals and medical centers included in the survey have been listed in Table 4. Table 4: Bangladeshi Medical Tourists surveyed in different hospitals in Kolkata Hospital Frequency Percentage Medinova Diagnostic Services Ltd. 55 26.57 Saroj Gupta Cancer Center & Research Institute 41 19.81 Apollo Hospitals Kolkata 29 14.01 Tata Medical Center 16 7.73 Peerless Hospital 15 7.25 R N Tagore Hospital 14 6.76 Manipal Hospital Kolkata 6 2.90 Columbia Asia 4 1.93 KPC Medical College and Hospital 4 1.93 Disha Eye Hospital 4 1.93 Pulse Diagnostic Centre 4 1.93 Others 15 7.25 207 100 Structured and semi-structured questionnaires were used to carry out interviews, conversations, and discussions with the families and caregivers of the patients and the administrative staff of various hospitals. The questionnaire included demographic details of the patients, their family background, and their perspective of healthcare in India, where their responses to each item were based on a five-point Likert scale ranging from “Extremely Satisfied” to “Extremely Dissatisfied: Each item of the questionnaire was adapted to the present context from an all-India study carried out amongst the hospital staff to study the effect of globalization from the supplier point of view (Ajmera et al., 2015). http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 10 The questionnaire was translated into the local language, Bangla, and the Bangladeshis preferred to converse in their mother tongue. The interviews were carried out at the outpatient departments of hospitals, reception desks of diagnostic centers, and lodges and guesthouses where international patients and their families stayed for the tenure of their treatment. Each interview lasted about 25- 30 minutes. Findings and Analysis The Sample The demographic composition of the sample comprised 135 male patients (65%) and 72 female patients (35%). Out of the total medical tourists surveyed, 48% fell in the age group 31-50 years, while another 38% were more than 50 years of age. Seven children from Bangladesh, aged less than 21 years, were admitted to these hospitals, mainly in the neurology or oncology departments. The parents of the children were interviewed at the hospital premises, and most said that they had sold their personal assets in Bangladesh or had taken bank loans to bring their children for treatment to Kolkata. Almost 80% of the female respondents were housewives and were mainly undergoing treatment for breast cancer. More than half of the male respondents were either businessmen or agriculturalists (Table 5). Table 5: Demographic composition of the sample Frequency (%) Male Female Age Group Upto 10 yrs 4 (2%) 4 0 11 – 20 yrs 3 (1%) 1 2 21 – 30 yrs 23(11%) 17 6 31 – 40 yrs 49 (24%) 28 21 41 - 50 yrs 50 (24%) 30 20 51 – 60 yrs 39 (19%) 28 11 60 years and above 39 (19%) 27 12 Occupation Housewife 57 (27.54%) 0 57 Business 38 (18.36%) 35 3 Agriculture 38 (18.36%) 35 3 Private Jobs 22 (10.62%) 17 5 Government Employee 20 (9.66%) 18 2 Retired 17 (8.21%) 16 1 Unemployed 14 (6.76%) 14 0 http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 11 Student 1 (0.48%) 0 1 TOTAL 207 135 (65%) 72 (35%) Pull Factors The Government of India has made it simple to obtain online medical e-Visas for India for a stay of 60 days from the visitor's entry date. Moreover, it is a Triple Entry Visa, which means that the holder of the Indian Medical Visa can enter three times within the period of its validity of 60 days, and the Medical Visa can be obtained three times per year for purposes of ongoing treatment or follow-up consultations. Family members of the patients who wish to accompany are eligible for a Medical Attendant Visa. This was a major pull factor for medical tourism in India. Based on the primary research carried out for the medical tourists from Bangladesh to Kolkata, the sample included 144 respondents with Medical Visa (70%), 56 with Tourist Visa (27%), and 7 patients who refused to divulge the information (Table 6). The trend in Table 6 indicates that anyone undergoing hospital treatment for their chronic and/or complex medical conditions had valid medical visas. Those with tourist visas came for short stays with prior appointments for preliminary check-ups and consultations as outdoor patients (11 out of 13). It was also found that some respondents traveled to Kolkata on Tourist Visa for consultation and were then recommended that they be admitted to hospital (20 out of 45) for further investigations. These patients could seek help and guidance from the International Support Department of the respective hospitals for the conversion of their visas for a longer duration of stay. http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 12 Table 6: Visa Category and Type of Treatment Type of Treatment Medical Visa Tourist Visa Did not Specify Total First-time check-up 2 11 13 Consultation and undergoing tests 8 20 28 To be admitted to hospital 25 20 45 Admitted to hospital 11 1 1 13 Undergoing treatment 56 0 1 57 Underwent surgery 42 4 5 51 TOTAL 144 56 7 207 Another major pull factor has been the phenomenal growth of specialty and multi-specialty hospitals in the form of private equity funding and venture capital investors. India allowed 100% Foreign Direct Investment in the hospital sector as well as in medical devices, pharmaceuticals, and biotechnology. The Indian Government has also announced increases in public health expenditure to 2.5% of GDP by 2025, along with the implementation of various initiatives to boost medical infrastructure. The Government of West Bengal has also allotted land to upcoming healthcare facilities for different specialties, including cardiology, oncology, trauma care, and organ transplant hospitals. The majority of medical tourists at the Kolkata hospitals were at different stages of treatment for neurology (22.2%), oncology (15.5%), and cardiac complications (14.0%). Amongst the 135 Bangladeshi males surveyed, 41% were undergoing neurological treatment, which was found to be most prevalent amongst 41-50 year males. The second most common treatment amongst the males surveyed was related to cardiac complications, where 51-60-year-olds had the highest frequency in the sample. Among the female counterparts, the oncology department had the highest footfall, and 16% of the females surveyed were undergoing treatment for breast cancer, which was most common amongst the 40-60 age group (Table 7). http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 13 Table 7: Treatment being undertaken by Bangladeshi Medical Tourists in Kolkata Treatment Frequency Male Female Highest Frequency Neurology 46 31 15 41-50 yrs Males Oncology 32 17 15 41-60 yrs Females Cardiology 29 24 5 51-60 yrs Males Haematology 19 12 7 More than 60 years of Males Gastrology 14 10 4 More than 60 years of Males Pulmonary 13 8 5 31-40 yrs Females Ear, Nose, Throat 13 11 2 51-60 yrs Males Others (skin, eye, orthopedic, etc.) 41 22 19 31-40 yrs Males TOTAL 207 135 72 The growing orientation of private hospitals towards foreign clientele has resulted in significant upgradation of their facilities. However, with the increasing footfalls of medical tourists in addition to local patients, there has also been a substantial increase in the workloads of doctors and nurses. Therefore, the satisfaction of the Bangladeshi patients undergoing treatment at the Kolkata hospitals was an important dimension that was included in the present analysis. Responses on a Likert Scale of 1 to 5 were recorded where '1' referred to Extremely Dissatisfied while '5' corresponded to Extremely Satisfied. A mean value of 3 and above signified a positive satisfaction level, and below 3 would indicate dissatisfaction. Table 8 shows that 66% of the respondents indicated positive satisfaction levels; less than 2% expressed dissatisfaction, while the remaining 32% were neutral. Table 8: Overall Satisfaction Levels – based on the Likert Scale Frequency Percentage Extremely Satisfied 42 20.29 Satisfied 95 45.89 Neutral 66 31.88 Dissatisfied 4 1.93 Extremely Dissatisfied 0 0 http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 14 The disaggregated data in Table 9 shows that respondents were most satisfied with the efficiency of the clinic staff (mean = 4.55) and competency of the doctors (mean = 4.24). At the same time, they expressed the lowest satisfaction for special dietary services (mean value 3.10). The results indicate that most Bangladeshi patients found it difficult to communicate with the non-Bengali staff or doctors at the hospitals, indicating the need for interpreter services. The overall scores of the hospitals show that the satisfaction of international patients at Tata Medical Center was the highest. This highlights the importance of including Tata Medical in the present study and significantly contributes to the past literature on medical tourism in Kolkata. Table 9: Disaggregated Analysis of Satisfaction – based on the mean value of the Likert Scale Facilities for patients Mean Medinova Saroj Gupta Apollo Tata 1. Admission process 4.06 3.73 4.07 4.34 4.80 2. Response time 4.22 4.35 4.05 3.31 4.63 3. Competency of doctors 4.24 4.40 3.88 4.45 4.94 4. Efficiency of clinic staff 4.55 4.42 4.24 4.66 4.82 5. Level of communication 4.14 4.27 3.76 4.07 4.42 6. Accommodation facility 3.57 3.85 4.00 3.48 3.12 7. Department coordination 3.23 3.58 3.27 3.00 3.07 8. E-service facilitates 3.67 3.96 3.66 3.83 3.18 9. Transportation facilities 3.49 3.69 3.63 3.76 3.22 10. Interpreter facility 3.83 3.95 3.80 4.07 2.88 11. Forex facility 4.13 4.38 4.34 3.86 3.77 12. Special dietary services 3.10 3.35 3.27 2.45 4.35 13. 24-hours internet access 3.64 3.69 3.27 3.59 4.88 OVERALL 3.84 3.97 3.79 3.76 4.01 Cultural issues also played an important role, including social norms, values, language preferences, and food habits. In medical tourism requiring long-term stays, patients prefer to travel to neighboring countries to avoid culture shock. Therefore, Kolkata proved to be the ideal destination for medical tourists from Bangladesh. Past literature also confirmed this with evidence of American patients traveling to Mexico (Ferguson & Candib, 2002) or the Japanese and the Chinese seeking medical treatment in Taiwan (Liu & Chen, 2013). The same can be seen with Bangladeshi http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 15 medical tourists traveling to Kolkata since they share similar language and food habits. The caretakers strongly reiterated this during our interactions, and interestingly, several Bangladeshi food stalls and kiosks were seen around Peerless Hospital of Kolkata. Kolkata tourist agencies were another pivotal pull factor for Bangladeshi medical tourists. They disseminated information about the healthcare offerings and ensured the flow of international clients for payment of commissions. The agencies provided full assistance in procuring their medical visas, making necessary arrangements for pre-and post-surgical care, providing local transportation for their families during the stay period, and taking care of all their medical requirements. Field observations revealed that almost all hospitals had lodges and hotels in the vicinity that provided accommodation for patients of all ranges of budgets. Major private hospitals in Kolkata had established their own links and offered packages for international patients. For example, Tata Medical Centre collaborated with Coal India Ltd to provide residential facilities for families of outstation and international patients undergoing treatment for critical illness at Tata Medical Center, Kolkata. The ten-storeyed accommodation, Premashraya, had a canteen, library, playroom, prayer room, ATM, etc. However, this was a special facility and should serve as an exemplar to be emulated by other hospitals to provide the demand pull for Kolkata as the preferred destination for medical tourists. Push Factors A dearth of medical facilities and a lack of expertise of doctors have resulted in a lack of confidence in services delivered by hospitals in Bangladesh. This has been the most important push factor that has forced the lower and middle-income Bangladeshis to travel to neighboring countries for their treatment. Kolkata offers world-class treatment at affordable prices and has become the preferred destination for medical tourists from Bangladesh. The data gathered from discussions with the patients and their caretakers revealed various deficiencies in the medical care facilities in Bangladesh that acted as push factors for outbound medical tourists. Firstly, their medical centers offer very low-quality treatment and care as there is gross inadequacy of personnel. Government hospitals and clinics operate with under-equipped laboratories and face severe shortages of medical equipment and medicines. The healthcare system also suffers from poor governance, lack of monitoring or supervision, and extremely centralized service delivery, leading to delays and shortages. Secondly, few private medical facilities with modern facilities are exorbitantly expensive and situated only in the capital city of Dhaka. These hospitals provide high-class healthcare services but are clearly beyond the financial means of most. Thirdly, Bangladesh has a high incidence of non-communicable diseases due to their unhealthy diet, sedentary lifestyles, and high pollution levels. This has prompted the patients to travel outwards since Bangladesh is ill-equipped to handle the high levels of chronic ailments, specific kinds of diseases, general ill-health of women and aged, malnutrition in children, etc. The Covid- http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 16 19 pandemic has worsened the situation manifold. These were strong demand push factors that forced patients from Bangladesh to travel to Kolkata for their diagnosis and treatment owing to its geographical proximity and affordable, high-quality healthcare facilities. Cost of Treatment Despite the affordable pricing, as compared to other South Asian counterparts, the costs of treatment are still beyond the financial means of most families. In many cases, families have been forced to sell their property, spend all their savings, or borrow from others to meet medical expenses abroad. Table 10 shows the costs involved in the treatments that the medical tourists from Bangladesh were incurring in Kolkata. The majority of patients spend less than INR 100,000 for their treatment, which was incurred mainly for their check-ups, consultations, diagnostic tests, and follow-up care. The cost for first-time check-ups and preliminary tests ranges from INR 5,000 to INR 25,000, while consultation charges vary significantly with the nature and intensity of the ailment. For example, cancer treatment, which involves interventions like surgery, radiation, or chemotherapy, costs anywhere between INR 100,000 to INR 1,800,000, depending on the stage of cancer and the level of intervention required. These costs also vary, depending crucially on hospitals and consulting doctors. Table 10: Expenditures on Treatment by Bangladeshi Medical Tourists in Kolkata Frequency Highest Frequency of Treatment Highest Frequency for Type of Treatment Less than INR 50,000 34 (16.4%) Neurology First-time check-up / Consultation INR 50,000 to INR 100,000 66 (31.9%) Neurology To be Admitted to hospital / Consultation INR 100,000 to INR 150,000 18 (8.7%) Oncology Undergoing treatment INR 150,000 to INR 200,000 14 (6.8%) Neurology Underwent surgery INR 200,000 to INR 250,000 17 (8.2%) Haematology Undergoing treatment INR 250,000 to INR 300,000 16 (7.7%) Cardiology Underwent surgery INR 300,000 to INR 350,000 18 (8.7%) Cardiology / Oncology Undergoing treatment More than INR 350,000 24 (11.6%) Gastrology Underwent surgery The majority of patients in our sample needed financial help to meet the expenditures of their treatment. Almost 30% of the respondents had to borrow funds, either from a bank or from their friends and relatives, and this was mainly amongst housewives undergoing treatment for breast cancer or gynecological complications. Another 21% of the sample were forced to sell their personal assets to pay for their travel, stay, and treatment in Kolkata, which was the case amongst http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 17 patients who depended on land and agriculture for their living. Government employees and businessmen were found to fund their treatment out of their past savings and their present salaries (Table 11). Therefore, patients underwent the direct cost of their treatment and the mental stress of their financial burden, leading to further psychological hardships. However, during the course of discussions and conversations, the medical professionals at Saroj Gupta Cancer Center confirmed that they would typically adjust the total costs of treatment and interventions depending on the economic capability and affordability of the patient. Table 11: Funding for treatment of Bangladeshi Medical Tourists in Kolkata Sources of Funds Frequency (%) Mainly Sourced by Borrowings 60 (29%) Housewife Savings 53 (26%) Government Employee / Business Salary 50 (24%) Government Employee Selling Personal Assets 44 (21%) Agriculture TOTAL 207 (100%) 135 (65%) Conclusions and Recommendations The growth of medical tourism has been spurred by globalization and various push and pull factors of a destination. The growing importance of Kolkata as a preferred healthcare destination prompted this research to fill the lacuna in the existing literature, which provides evidence of only one study on Kolkata’s medical tourism (Rai, 2019) that focused on the supply side of Kolkata’s healthcare sector. The present study investigates the demand push and demand pull factors affecting medical tourism of Kolkata using a triangulation method of primary and secondary research along with field observations. To this end, primary research was carried out amongst 207 Bangladeshi medical tourists in some of the leading medical centers in Kolkata. The introduction of e-tourist visas for medical visits was identified as the most important pull factor for easing the entry of Bangladeshi tourists into Kolkata. Subsequently, the provision of e- visa for medical attendants and caregivers was also introduced, along with multiple entries and long-term stay options. Most of our respondents were 40 to 60 years old and were getting treated for neurological disorders, cancer, and cardiac complications. Patients who were undergoing treatment for chronic or complex medical conditions had medical visas and incurred costs anywhere between INR 100,000 to INR 1,800,000, depending on the severity of their ailment and the level of intervention required. Many had taken loans, paid out of their savings, or sold their personal assets for treatment in Kolkata. Lack of health insurance among international patients emerged as a prime concern amongst tourists and could have major business opportunities for the relevant stakeholders in India. http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 18 The major push factors identified were inadequate medical infrastructure in Bangladesh, lack of expertise, and gross shortage of medical equipment. Few high-quality hospitals of international standards were exorbitantly priced and beyond the financial capability of the patients. Therefore, treatment of chronic ailments and life-saving procedures were either unaffordable or not available in Bangladesh, which pushed them to seek treatment abroad and was an important factor for outbound medical tourism in Bangladesh. High-quality healthcare at affordable costs was the major pull factor for India's gaining momentum as a preferred destination for medical tourism. Further, the Ministry of Tourism has been promoting India as a hub for medical tourism, based on the support and impetus provided by Prime Minister Narendra Modi to endorse medical tourism as a foreign exchange earner, job generator, and brand ambassador of India's soft power. The geographical proximity of Kolkata to Bangladesh made it the natural choice for the patients to cross the borders for treatment. Adopting Mode 3 of trade-in services permitted 100% FDI in the healthcare sector in greenfield and brownfield projects, resulting in the formation of state-of-the-art healthcare services across cities, including Kolkata. Such foreign collaborations, along with super-specialty hospitals like Tata Medical Center, have added to the prominence of Kolkata as a viable healthcare destination. The emergence of Kolkata as a viable option for medical tourism is less known to many, and this study provides recommendations for policymakers and stakeholders. There is a need to actively promote the destination, especially through social media platforms and the strong participation of intermediaries like tourist agencies. The role of tour operators needs to be enhanced as a close connection between medical tourists and healthcare providers. Importantly, more hospitals need to acquire international accreditation to become more prominent on the map of medical excellence. As of 2023, only Apollo Hospital in Kolkata has been accredited by the Joint Commission International. Kolkata also has huge potential to build up a strong brand of alternative medicine like wellness, rejuvenation, yoga, Ayurveda, and homeopathy, all of which would help to draw more tourists. The development of Kolkata as a preferred medical destination would also have positive spill-over effects in terms of socio-economic development through job creation, revenue generation, and foreign exchange earnings. These have policy implications for the Centre and the State to improve and understand the needs of international medical tourists and encourage the growth of trade in healthcare services along with strengthening medical legal regulation and enhancing pre- and post-surgery experience in public and private hospitals of Kolkata. Therefore, accreditation of hospitals and doctors should be of high priority, which would help to enhance patient satisfaction and experience. The Indian Ministry of Health and the Ministry of Tourism should work together with the hospitals to build up a network of medical-tour operators, medical- legal services, pharmacies, accrediting bodies, and the logistics sector to provide a positive experience to international patients. The study, therefore, gives important directions to all stakeholders by identifying the levels of satisfaction of medical tourists at the Kolkata hospitals, pointing out the need for a holistic http://ertr.tamu.edu/ e-Review of Tourism Research (eRTR), Vol. 20, No. 1, 2023 http://ertr.tamu.edu 19 approach. It also lays down the pathway for future work to expand the scope of the study by including more viable destinations for inbound and outbound medical tourism in India. References Ajmera, P., Satia, H. K., & Singh, M. G. (2015). Development of a reliable and valid questionnaire considering Indian hospital's perspective of globalization of health in the context of India. 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