South Asian Journal of Tourism and Heritage (2009), Vol. 2, No.

Perception of Tourists towards Kerala as a Preferred

Alternate Health Tourism Destination: A Study

BINDU V.T.* CHITRAMANI, P.** and BABU P. GEORGE***

*
Bindu V.T., Lecturer of Tourism Management, Avinashilingam University for Women, Tamilnadu, India
**
Chitramani, P., Ph.D. Reader of Business Administration, Avinashilingam University for Women,
Tamilnadu, India
***
Babu P. George, Ph.D., Assistant Professor of Tourism Management, University of Southern Mississippi,
MS, USA

ABSTRACT

The present paper investigates the perception of medical tourists towards Kerala, India, as an alternate
medical tourism destination. Various issues related to tourist satisfaction such as satisfaction with booking
and information provision as well as satisfaction with treatment and miscellaneous other facilities are
explored. The study identifies the key motivational variables and sources of information used by healthcare
tourists. Dimensions of destination preference of Kerala as perceived by alternate medical tourists have also
been measured. The paper is concluded with the formulation of a customer retention model for alternate
medical tourism.

KEYWORDS: Medical tourism, Health resorts, Patient satisfaction, Motivation, Destination performance,
and Kerala.

INTRODUCTION
The growth of health holidays is fast and notable (Demicco and Cetron, 2006). It is forecasted
that medical tourism will earn each of the major players approximately US$2.3 billion, by 2012
(English, Mussell, Sheather, and Sommerville, 2006). Health holiday market is fairly developed in
various parts of the world. Typically, medical tourists are residents of industrialized nations;
primarily coming from North America or Western Europe. But, more and more, residents of other
countries are seeking out destinations where they can both obtain quality medical treatment and
enjoy a vacation, at a reasonable price (Richards 2006). Hospitals in developing countries
traditionally enjoy a cost advantage over those facilities located in more developed countries.
Today, many of these facilities are in the process of upgrading their product/service offerings. We
now see the packaging of their products into one all-inclusive offer. This package includes
everything from medical treatment to travel and hospitality services. The medical tourism
evolution is not restricted to traditional hospitals; a range of alternative healthcare services
providers such as ayurvedic, naturopathic, homeopathic, and yogic establishments are also
benefiting from this growing trend (Bezruchka 2000). A comprehensive model of medical
tourism has been proposed by George and Nedelea (2007) and the same is given in Figure 1.
As shown in the model, medical tourists move from their originating regions (their countries of
residence) to destination regions (those regions where the care is available). The transit refers to
both the actual mode and trajectory of the transportation utilized for this movement as well as any
constraining and/or facilitating forces in the travel experience. A destination is a medical tourism
destination, not just because of the healthcare facility available there, but also because of the
additional provision of destination attractions, both natural and cultural. The core product is the
healthcare provided, but tourist comforts do form an important hygiene factor in medical tourism
(Messerli and Oyama 2004).

© 2009 South Asian Journal of Tourism and Heritage

 PERCEPTION OF TOURISTS TOWARDS KERALA 69

Figure 1: A Comprehensive model of medical tourism

Patients from various countries are becoming medical tourists to India for low cost and health
restorative alternative treatments (Todd, 2005). The medical tourist undergo treatments of a
combination of Ayurveda, yoga, Acupuncture, Herbal oil massage, Nature therapies, and some
ancient Indian health care methods-such as Vedic care, and alternate health care service. Kerala, a
state in South India, has established itself as a prominent destination of world leisure tourism for
its natural beauty and cultural assets. Kerala is a perfect hide away with captivating and serene
surroundings, friendly and attentive service. The state is also portrayed as “God’s own country”
(National Geographic, 2004). Kerala has sensed the potential for health holidaying based on its
century’s old Ayurveda medicinal system. A number of hotels and resorts along with hospitals are
offering this treatment. The market for these packages is mainly from Europe and North America.
Kerala’s equable climate, natural abundance of forest with a wealth of herbs and plants are a key
to the success of Ayurvedic treatments of Kerala. Ayurveda is one of the greatest gifts the sages of
ancient India have offered to man kind and is accepted as the oldest scientific medicinal system.
The philosophy of Ayurveda takes a holistic view of health, emphasizing a balanced diet, physical
fitness, healthy life style, hygiene and body care for a disease-free long and healthy life. It gives
due importance to both preventive and curative aspects of a disease. Many of Ayurvedic tourism
development have helped the protection of Kerala’s Architecture too. In this background, the
major aim of the study is to assess the preference of Kerala as a health tourism destination and
measure the satisfaction level of health tourists in the selected resorts and thereby suggest suitable
strategies for sustainable health tourism growth.
The Research Method
The Study has been carried out in 3 phases:
• The first phase focused on the study of selected ayurvedic resorts in Kerala.
• The second phase focused on a survey to identify the tourist preferences towards Kerala as a
health tourism destination and measures the tourist satisfaction.
• The third phase focused on data analysis and design of strategies based on the observation in
the first and second phase.
The method adopted in the study is mostly exploratory and analytical. Both primary and
secondary data have been used for the study the collection of primary data has been attempted
through opinion survey and observations. The secondary data have also been supplemented at
appropriate places.
The data was collected by Observation of selected Ayurvedic resorts and through opinion
survey of 88 tourists across the selected 5 ayurvedic resorts in Kerala. Out of the respondents, 30
were Indians, 11 were Germans, 6 were Americans, 5 were British, 3 each were from Australia,
Canada, and France, and the remaining from various other nationality groups. Gender-wise, 62
70 BINDU V.T., CHITRAMANI, P. and BABU P. GEORGE

were males and 26 were females. Most respondents had an annual income of above 4 lakh Indian
rupees. Among the respondents, 51 percent were graduates, 32 percent were undergraduates, and
10 percent had technical and/or professional qualifications. The opinion survey was carried out by
means of structured self-administered questionnaire. The study was limited to only five Ayurvedic
resorts based on the convenience and accessibility of the researcher. In the first Phase the selected
five resorts were observed and information were collected. The sample selected for the study came
from the following resorts:
• Kairali, Palakkad
• Pagoda, Allaphuza
• Keraleeyam, Allaphuza
• Ayur Bay, Thiruvanathapuram
• Somatheeram, Thiruvanathapuram
Data Analysis and Discussion
The phase I of the study revealed that the major health care programs of the resorts which were
highly demanded were:
• Rejuvenative and Stress Management Programs
• Anti-Ageing Programs
• Detoxification Programs
• Slimming Programs
• Beauty Care Programs
• Post Pregnancy Programs
• Special Packages for Women
It was also observed that the resorts had cutting edge facilities. The facilities normally
observed were:
• Full time services of qualified and experienced Ayurveda consultant.
• Well equipped panchakarma treatment facilities
• Qualified and experienced Ayurveda therapist
• Ayurveda Pharmacy
• Separate treatment rooms for male and female patients
• Well furnished accommodation
• Canteen services
• Special therapeutic diet for patients
• Clean and Hygienic diet for patients
• Yoga and meditation hall
• Medicinal plants garden
• Library and reading room
• Telephone and internet facilities
• Ample parking facilities
The respondents whom we interviewed were mostly repeat visitors with a median visit history
of 2 in the past. The duration of stay at the resort varied from 1 day to a few months, with a mean
of one week duration.
The motivations for visit are summarized in Table 1.
Table 1: Motivation for health tourism to Kerala
Frequency Percent Valid Percent Cumulative Percent
Valid Nature 19 21.6 21.6 21.6
Culture 9 10.2 10.2 31.8
Leisure 31 35.2 35.2 67.0
Health 25 28.4 28.4 95.5
Others 4 4.5 4.5 100.0
 PERCEPTION OF TOURISTS TOWARDS KERALA 71

Frequency Percent Valid Percent Cumulative Percent

Valid Nature 19 21.6 21.6 21.6
Culture 9 10.2 10.2 31.8
Leisure 31 35.2 35.2 67.0
Health 25 28.4 28.4 95.5
Others 4 4.5 4.5 100.0
Total 88 100.0 100.0
The above table implies that, as expected, health is the most important reason for visiting an
ayurvedic resort: but, at the same time, leisure and nature too are extremely important drivers. An
insight from this is that ayurvedic resort operators should highlight in their promotional campaigns
the leisure and nature opportunities available in Kerala for health visitors and their accompanying
companions.
The analysis conducted to understand the influence of different media revealed the following
result (See Table 2):
Table 2: The influence of media
Frequency Percent Valid Percent Cumulative Percent
Valid Traditional Electronic Media 3 3.4 3.4 3.4
Internet 33 37.5 37.5 40.9
Print Media 41 46.6 46.6 87.5
Personal Sources 11 12.5 12.5 100.0
Total 88 100.0 100.0
This implies the overarching influence of the Internet and is a pointer to those resort operators
who are still resistant to the adoption of Information and Communication Technologies for resort
marketing. One notable issue is the low influence of traditional electronic media like radio and
television. It is much cheaper and cost effective to promote a resort over the internet, compared to
the traditional electronic media. This analysis also implies that word of mouth and personal
influence is important. One sure way to ensure the spread of word of mouth is to treat the existing
patients exceptionally well: this will motivate them to spread positive word of mouth to their kith
and kin, and even electronically by giving good reviews of the property. It should also be noted
from the results that, despite the proliferation the internet, it is not time yet to write off the print
media: it still stands as the biggest crowd puller!
Around 78% of the respondents said that they visited the resort in search of natural and herb
based preventive medication. The low percentage for curative visits is not shocking: as noted
elsewhere, most curative patients who need cure from an existing disease go to an allopathic clinic
rather than visiting alternative medical centers. Those curative patients who visit an alternative
healthcare resort might be patients suffering from ailments for which there are not definitive cures
in the allopathic tradition. The might be individuals who have tried the western medicine in the
past and have not got cured.
In the phase II, preferences of tourists were studied across 10 dimensions using a 5 point scale(
5-strongly agree,4-agree,3-neutral,2-disagree,1-strongly disagree).
Items rated in the dimensions of destination preference were:
1. Kerala as a preferred Ayurvedic destination
2. Preference on Ayurveda over other medical treatment
3. Kerala - an ideal Ayurvedic Destination
4. Kerala - a multifaceted Destination
5. Ayurveda - as preventive and rejuvenative
6. Health and hygiene background
7. Optimum duration
72 BINDU V.T., CHITRAMANI, P. and BABU P. GEORGE

8. Good therapeutic diet

9. First rate transit service
10. Ideally priced
Figure 2 given below summarizes this result:

Average mean
MEAN SCORE
5

Score 4

3
2
1
0

1 2 3 4 5 6 7 8 9 10
Dimensions of preference
Figure 2 Mean scores of dimensions of destination preference
The mean score across these dimensions reflect that high preference for Kerala as a health
tourism destination. The only dimension that was rated low in preference was price. Later, level of
satisfaction of tourists was studied with respect to booking, promotion and awareness,
environment, treatment facilities and other facilities and the outputs of analyses are summarized in
the graphs given below in Figure 3. The rating instrument had the following options.
1. Easy procedure
2. Fast and accurate confirmation
3. Genuine networks with booking agents
The graph (figure 3) shows that tourists are highly satisfied with booking and just satisfied with
confirmation and dealings with the booking agents.

BOOKING
5
MEAN SCORE

4
3
2
1 MEAN SCORE
0
1 2 3
SATISFACTION ON
BOOKING

Figure 3 Patient satisfactions with resort booking

The graph (figure 4) portraying satisfaction with information reveals that information
accessibility and information clarity need to be improved whereas information provided through
travel agent is highly satisfactory. The rating instrument had the following items to respond to:
1. Information provided
2. Information accessibility
3. Information clarity and accuracy
 PERCEPTION OF TOURISTS TOWARDS KERALA 73

PROMOTION AND AWARENESS

MEAN SCORE
4
3
MEAN SCORE
2
1
0
1 2 3
SATISFACTION LEVEL

Figure 4 Patient satisfaction with information provision

Environmental factors play a major role in developing customer perceptions of healthcare
resorts and hence the same too was studied. The ratings for this question were as follows:
1. Natural and Eco-friendly
2. Clean and hygiene
3. Ambience room and treatment care
4. Ample parking facilities
5. Air conditioned villas/cottages
6. Exotic herbs and vegetable garden

ENVIRONMENT

5
MEAN SCORE

4
3
MEAN SCORE
2
1
0
1 2 3 4 5 6
SATISFACTION LEVEL

Figure 5 Patient satisfactions with Environment

In the environment factors there was a relatively high score for nature and eco-friendly
surrounding, and clean and hygienic environment whereas guest room ambience, treatment care,
parking facilities, exotic herbs and vegetable garden were having mean score between 3 and 4; the
latter part needs to be improved.
The next issue investigated was satisfaction with treatment facilities.
74 BINDU V.T., CHITRAMANI, P. and BABU P. GEORGE

TREATMENT FACILITIES

MEAN SCORE
3.8
3.6
3.4 MEAN SCORE
3.2
3
2.8
1 2 3 4 5
SATISFACTION LEVEL

Figure 6: Patient satisfaction with treatment facilities

The ratings for this question were as follows:
1. Full time service of qualified and experienced Ayurvedic consultant
2. Full time service of qualified and experienced therapist
3. Well equipped treatment facilities
4. Certified ayurvedic pharmacy
5. Homely and attentive
Tourist satisfaction on treatment facilities given in figure 5 shows the mean score value was
between 3 and 4. This implies there exists a need for improvement in the service of the Ayurvedic
consultants, therapists, certified ayurvedic pharmacy and personal attentive services. Finally,
satisfaction with miscellaneous other facilities in the resort was probed. The graphical output of
analysis is presented below in figure 6:

OTHER FACILITIES

5
MEAN SCORE

4
3 MEAN
2 SCORE
1
0
1 2 3 4 5 6 7
SATISFACTION LEVEL

Figure 7. Patient satisfaction with miscellaneous resort facilities

The ratings for this question were as follows:

1. Special therapeutic diet
2. Herbal and natural accessories
3. Yoga and meditation centre
4. Other entertainment
5. Indoor and Outdoor recreations
6. Fully equipped conference hall
 PERCEPTION OF TOURISTS TOWARDS KERALA 75

7. Library and reading room

This analysis reveals that the tourists are highly satisfied with the herbal and natural accessories,
yoga and meditation center, and the conference hall. They are only moderately satisfied with other
entertainments, indoor, and outdoors recreations, library and reading room facilities.
CONCLUSION
The study reveals that the most favorable factors for Kerala as health tourism destination are its
authenticity, rich ayurvedic heritage with multifaceted attractions. The unique advantage of Kerala
ought to be leveraged by the health resorts. Based on our study and the extant literature (Goodrich,
1993; Grönroos, 1984; Mueller and Kaufmann, 2001; Oswald and Henthorne, 1999), we propose
the DBSG (Design, Build, Sustain and Grow) customer retention model for the resorts to follow:
The design factors include information clarity and accuracy. The build factors are mainly price,
able ayurvedic consultant and therapists, treatment care personal attention, indoor outdoor
recreation, availability of ayurvedic pharmacy, etc. The sustain attributes should be enhanced by
means of the health and hygienic background, prevention and rejuvenation treatment, herbal based
treatment, and the transit services offered by the resort. Yoga and meditation services in the resort
are some of the sustain factors. These are the main pillars of the health tourism activities. Right
presence and proportion of these factors will ensure sustainable growth of the business. Medical
tourism presents a great opportunity for alternate healthcare establishments in Kerala to fuel
growth by tapping the potential of the international patient market. To attract foreign patients,
healthcare providers may consider leveraging on both business and clinical considerations. Also,
well coordinated efforts among the travel, hospitality, and healthcare trades are imperative for the
sustainable growth of this business. A sincere commitment to these coordinated moves allows
each stakeholder to focus on his or her own competencies and may alleviate the level of
competition – allowing for better long run revenues throughout the entire sector. What we have
done is only a preliminary investigation. Further research is suggested in the areas of information
access on Kerala and health resorts, pricing, diet, and customer loyalty techniques. A strategic
analysis of Kerala as an alternative healthcare destination is the next step. However, given the time
and resource limitations within which the present study was carried out, this objective was kept for
future researchers to pursue.

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