Views of Indonesian consumer towards

medical tourism experience in Malaysia

Harriman Samuel Saragih and Peter Jonathan

Abstract Harriman Samuel Saragih is

Purpose – Indonesians are known for their unique behaviour and willingness to travel abroad for based at School of
healthcare treatments. More than half of the healthcare ‘‘tourists’’ who travel to Malaysia come from Business and Economics,
Indonesia, followed in numbers by those in India, Japan, and China, Libya, the UK, Australia, USA, Universitas Prasetiya
Bangladesh and the Philippines. Malaysia is also geographically located near two Indonesian main Mulya, South Tangerang,
islands, i.e. North Sumatera and North Kalimantan. These reasons contribute to making Indonesia one of
Indonesia. Peter Jonathan
the most productive healthcare consumers in Malaysia. This study aims to examine these Indonesian
is based at Universitas
consumers’ through the use of behavioural lenses to examine their medical tourism experiences in
Malaysia, its neighbouring country. Pelita Harapan, Tangerang,
Indonesia.
Design/methodology/approach – The theory of planned behaviour is used as the basis of these
analyses and hypotheses development. In total, 7 variables and 18 indicators that built both the
exogenous and endogenous variables were developed from previous literature. Through a purposive
sampling technique, the authors collected 200 samples of individuals where each respondent must at
least have been to Malaysia once for medical treatments related to a general check-up, cardiovascular,
cancer, orthopaedics, nervous systems or dental problems. A partial least squares – structural equation
modelling analysis was carried out to examine both the measurement model and the structural model.
Findings – Behavioural belief positively affects the attitude of Indonesian patients and their intentions to visit
Malaysia for medical treatment, i.e. attitude, subjective norms and perceived behavioural control. Results
show that as individuals, Indonesians have a strong belief that undergoing medical treatment in Malaysia will
be more favourable than having that same medical treatment in Indonesia. The study also shows that people
who are considered important to patients, e.g. family members or relatives, significantly influence their
intention to visit Malaysian medical institutions. The authors also found that patients’ resources and
capabilities – e.g. financial strength, supporting infrastructures and time availability – are essential factors for
Indonesian patients to choose medical tourism and to visit Malaysia as their venue for medical services.
Research limitations/implications – The results of this study are consistent with the previous research,
which has shown that attitude, subjective norms and perceived behavioural control positively affect visit
intention. The results also suggest new interesting theoretical findings that Indonesia’s medical tourist
intention to visit Malaysia is most strongly caused by subjective norms followed by individual attitudes
and perceived behavioural control, all reasons that are identical to Japanese medical tourists’ visiting
South Korea for similar purposes. Indeed, there are similar behavioural practices and beliefs among both
Indonesian and Japanese medical tourists, despite the gap existing in these two countries’ economies.
Practical implications – The study proposes two managerial implications using its findings. First, this
study can be a basis for the Malaysian medical tourism business to better understand Indonesian medical
tourists’ behaviour when visiting their country. The study explicitly suggests that it is both collective and
individual beliefs that drive Indonesian patients, who have the sufficient resources, to visit Malaysia because
of better quality and affordability available there compared to Indonesian medical services. Second, this
study raises a fundamental question about Indonesian stakeholders in the medical industry. In the near
future, this type of medical tourism behaviour will, without a doubt, affect the Indonesian economy at large.
Originality/value – The contributions of this study are twofold. First, compared to previous studies that Received 19 April 2018
focussed specifically on the developed countries, this study focusses on Indonesian consumers’ point of Revised 20 November 2018
view as an emerging country towards Malaysia’s medical tourism business. Second, this study provides Accepted 3 March 2019
quantifiable insights on the Indonesia-Malaysia medical tourism phenomenon, which previously has been The authors of this study are
frequently discussed, but only using a qualitative exploratory approach. largely benefited from the
Keywords Malaysia, Medical tourism, Indonesia, Planned behaviour assistance of Research Office,
Universitas Prasetiya Mulya,
Paper type Research paper BSD.

DOI 10.1108/JABS-04-2018-0135 VOL. 13 NO. 4 2019, pp. 507-524, © Emerald Publishing Limited, ISSN 1558-7894 j JOURNAL OF ASIA BUSINESS STUDIES j PAGE 507
 Introduction
Health is an essential and valued aspect for everyone. There are people who are willing to
travel abroad and pay a significant price for better medical treatment. In Indonesia, this is a
common thing to do. Many Indonesians, in fact, frequently do travel outside of Indonesia to
seek medical treatments. Indonesia Services Dialog has reported that the number of
Indonesian medical tourists reached 350,000 in 2006 and rose to 600,000 by 2015 (Purba,
2017). The number of expenses incurred by those Indonesian people seeking medical
treatment abroad also reached Rp 18.2tn (the equivalent of US$1.3bn). As reported by
Meikeng (2014), more than half of the healthcare “tourists” who go to Malaysia come from
Indonesia (56.76 per cent), followed by those coming from India, Japan, China, Libya, the
UK, Australia, the USA, Bangladesh, and the Philippines. Edelman.ID (2018) added that the
regulation of the Indonesian healthcare sector, which prevents foreign doctors from working
within the country makes it more necessary for middle and upper-class people with high
buying power to choose neighbouring countries as a venue for their medical treatments.
This is due to the fact that medical treatments and services in Indonesia seem to be
unequally distributed in terms of quality and price differences (Purba, 2017; Pramudito,
2017; Pambiago, 2012). In addition, Malaysia is geographically located near two of the
Indonesian main islands, i.e. North Sumatera and North Kalimantan. These reasons
contribute to making Indonesia one of the most productive producers of healthcare
consumers in Malaysia.
Based on the above reasons, medical treatment has become one of the most emerging
business sectors, particularly in Malaysia, a neighbouring country to Indonesia. To create
more delightful experiences of healthcare services for Indonesia’s prospective patients,
attempts have been made by Malaysian medical institutions to provide added-value
services for those who do seek medical treatment in a non-local country, e.g. shuttle
services from the airport or a local city tour. This integrated experience of medical treatment
and tourism experiences outside one’s home country is known as medical tourism (Hunter,
2007). However, we also found that related studies on behavioural attitudes well-supported
by robust statistical justifications among Indonesian consumers’ on the Malaysian medical
tourism point of views have not been undertaken.
On the one hand, judging by the expected increase in the number of Indonesians travelling
abroad for medical treatment, especially to Malaysia (430,000 and 600,000 in 2017) that the
medical tourism industry in Malaysia can, indeed, affect Indonesia’s economy. Based on
the given data, Indonesia will become the largest contributor to the medical tourism
industries in Malaysia compared to such tourism in other countries (IMTJ, 2017). On the
other hand, there is also opportunity for Malaysia to advance the medical tourism
experience and seek out even more Indonesian medical treatment seekers.
Applying these explanations, this study examined the numerous factors’ influencing
Indonesian tourists to seek medical treatment in Malaysia, using the theory of planned
behaviour (TPB) (Ajzen, 1985; Ajzen, 1991). Researchers used this conceptual framework
as the basis of this research model since that this same framework has been extensively
used by multiple studies to test and predict human behaviour, particularly in the tourism,
hospitality and healthcare industries (Lam and Hsu, 2006; Han et al., 2010; Quintal et al.,
2010; Sparks and Pan, 2009; Lee et al., 2012). Variables discussed in this study included:
behavioural beliefs that affect one’s personal attitude, normative beliefs that influences
one’s subjective norm; control beliefs on the perceived behaviour control of an individual;
which eventually will predict the intention of an individual to perform a specific action.
Judging by several reports of medical consumers in Indonesia, TPB is indeed contextual
and can be the basis of our analyses. For example, the Indonesian public is more confident
that medical treatments abroad will provide better treatment results. This view is related to
more sophisticated technology, complete hospital facilities, and better medical service

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quality in Malaysia (Purba, 2017; Tempo.co, 2013) especially in cardiology, orthopaedics,
neurology, and dental care (IMTJ, 2017; Khan, 2017). This actual example can be
described using behavioural and attitudinal beliefs as part of the TPB. Also, BBC Indonesia
(2011) has stated that some Indonesians seek treatment abroad on the advice of others
who are special to them. This choice can also be described using the normative belief and
the subjective norm found in TPB.
To achieve the objectives of this research, this paper is organised into five sections. First,
the current phenomenon regarding Indonesian medical consumers’ behaviour and
Malaysia’s medical tourism industries is presented. Then, a literature review is carried out to
describe the theoretical development of TPB and medical tourism. In this second section,
the key hypotheses are also formulated along with the variables and the indicators.
Subsequently, this discussion is followed by methodology. The fourth section presents the
findings and discussions based on use of the statistical inferences from the data collected
from the questionnaire. Finally, the conclusions, as well as the limitations of the study are
presented.

Literature review
Medical tourism experiences in Malaysia
Since the nineteenth century, people have travelled to countries for relaxation or healing
purposes (Hunter, 2007). Europeans and Americans also travelled during the eighteenth-
and nineteenth-centuries to gain medical cures for ailments, for example, tuberculosis
(Pickert, 2008). According to Hunter (2007), medical tourism can be described as “the
integration of features of the medical industry and the tourism industry at a travel
destination.” The Medical Tourism Association (2018) defines the term as when people
travel to another country to receive medical care – for example, surgical, dental, and
medical care – usually because of more affordability and better access to care or a higher
level of quality of care. In this study, we synthesise these explanations to create our
definition of medical tourism, i.e. the integrated experience where one travels to seek
medical treatment services at a specific destination, a decision that may be triggered for
various reasons, e.g. access, affordability or better quality.
Medical tourism in Malaysia started with the decolonisation of Malaysia away from the
British Empire in 1957 (Ormond et al., 2014). However, Malaysia, along with its surrounding
countries, such as Thailand, started to seriously promote its medical tourism industry
following the debt crisis in South East Asia in 1998 to regain its own economy (Moghavvemi
et al., 2017). This was a significant move taken by the Malaysian government, and Malaysia
is now one of the most sought after countries in the world for its medical tourism. It has
achieved numbers as high as 882,000 with revenue of RM 777m (Macleod, 2017), 850,000
visitors in 2015 with revenue of RM 900m (IMTJ, 2016), 860,000 visitors in 2016 with revenue
of RM 1bn (The Star, 2017), and finally, 1 million visitors in 2017 with revenue of RM 1.3bn
(Macleod, 2017).
In addition, Malaysia was chosen “Destination of the Year” for three consecutive years in
2014, 2015, 2016 for medical tourism (MHTC, 2017). The Malaysian medical tourism
industry has the most medical tourists from other countries, including those from Singapore,
Bangladesh, China, India, Japan, Africa, and Indonesia, and Indonesian tourists are now
half of the total medical tourists coming to Malaysia (IMTJ, 2017). Because of the significant
number of Indonesian visitors’ visiting Malaysia for medical treatment, Malaysia has also
formed a strategic partnership with certain Indonesian companies, such as CIMB Niaga
Bank, PT Admedika, Antavaya Tour, and Golden Rama Tours to facilitate these visitors
regarding medical insurance, the tour, and financing (IMTJ, 2017). The article continues by
reporting that most of these patients are usually seeking cardiology, orthopaedics,
neurology, oncology, and dental treatments.

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 There have been several studies completed that discussed the medical tourism
experiences in Malaysia and how it is relevant for Indonesian patients by using various
approaches. Meghann Ormond is a particular researcher who conducted an extensive
analysis of Indonesian behaviour towards Malaysian medical tourism. Ormond et al. (2014),
for example, discussed Indonesian medical tourism experiences in Malaysia using the intra-
regional tourism, south-south migration, and regional alliances concepts. Using a qualitative
semi-structured interview, Ormond’s study provided insights regarding how the informal
market mechanisms of medical travel among Indonesians going to Malaysia has
contributed to more formal and sustainable ways to undertake medical travel business.
Continuing the above study, Ormond (2015b) investigated how Indonesian consumers
perceive medical tourism – or as the author implied “international medical travel” – through
the lens of political consumerism, health advocacy, and social movement theory. The study
offered interesting insights into how the issues pertaining to regulation, quality, access, and
affordability are central to Indonesian consumers. The study also suggested how the
present Indonesian healthcare services could impact that nation’s economy in the future.
Another report by Ormond (2015a) reported on ways that transportation and infrastructure
could facilitate the healthcare treatment of Indonesians who frequently travel to Malaysia.
Using a qualitative approach to query medical specialists in Kuching (both in private and
medical sectors), six Indonesian medical travel agents in Pontianak, and six private hospital
administrators in Kuching and Pontianak, her study focussed on precisely illuminating how
the Malaysian healthcare services – according to Indonesian patients – and their quality
compared to that of the Indonesians. One patient, indeed, confessed that compared to the
Malaysian healthcare services, the local hospital in Pontianak was both rather expensive
and ineffective.
From this discussion, it is clear that the Indonesian public feels more confident if they
undergo medical treatment abroad and believe they are more likely to recover due to the
more sophisticated technology, more complete hospital facilities, and better medical
service; especially for cardiology, orthopaedics, neurology, and dental in Malaysia (Khan,
2017; Purba, 2017; Tempo.co, 2013; IMTJ, 2017). However, this study also argues that it is
crucial to gain a more profound understanding of this medical tourism, built on robust
statistical investigations, so as to better understand why the Indonesian people visit
Malaysia for medical tourism purposes.
Even though several studies have examined this issue, Indonesia as one of the emerging
countries with a high proportion of middle classes and rising buying power can contribute to
the literature by providing a different point of view, than that of the more developed
countries, such as Japan or Korea (Lee et al., 2012). Our study, therefore, aims to provide a
more robust understanding regarding Indonesian medical tourist behaviour through several
hypotheses rooted in a combined theoretical and statistical approach. It is expected that
the result of this study will provide a more quantifiable exposition on actual Indonesian
consumer behaviour when experiencing medical tourism in Malaysia than has been already
presented from the qualitative point of view (Ormond, 2015b; Ormond, 2015a; Ormond
et al., 2014).

Theory of planned behaviour

Ajzen (1985) first introduced TPB as a theory aimed to predict human social behaviour. This
theory is the expanded version of the theory of reasoned action previously developed by
Fishbein and Ajzen (1975). The difference between the two is that the TPB also considers
perceived behaviour control as a determinant of any behavioural intention. This new
concept is also considered more robust than the previous theory, as it also considers such
factors as resources, time, and opportunities, all of which are non-volitional (Lee et al.,
2012). The TPB has also been applied to previous medical tourism studies

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(Ramamonjiarivelo et al., 2015; Seow et al., 2017; Lee et al., 2012). However, to our
knowledge, there has been no study as yet that focusses specifically on Indonesian –
Malaysia medical tourism experiences using TPB. This intention is, thus, determined by a
few different factors, such as one person’s attitude towards a behaviour, the subjective
norm, and the ability to control behaviour. Therefore, several key variables are included in
this revised theory, i.e. behavioural belief, attitude, normative belief, subjective norm, control
belief, perceived behaviour control, and visit intention.
Behavioural belief comes from the two words, “behavioural” and “belief”. Behavioural is the
adjective form of behaviour, and behaviour is “any observable overt movement of an organism
taken to include verbal and physical movements “(Bergner, 2010). It is also any physical activity
that is observable. Behavioural belief is the perceived consequence of performing a certain
behaviour, whether that consequence is positive or negative, and the subjective values or
evaluations of those consequences (Ajzen, 2015). Lee et al. (2012) explained that behavioural
belief is a personal subjective view that is taken when performing a specific behaviour that will
lead to a specific consequence. Behavioural belief is also the subjective probability, wherein an
object has a particular attribute (Fishbein and Ajzen, 1975), as, for example, when a person
believes that when he/she is doing exercises, that activity may reduce the risk of heart disease.
In this example, doing exercise is the object, and reducing the risk of heart disease is the
attribute. In conclusion, then, the definition that this study will use to measure the conceptual
definition of behavioural belief is the definition offered by Ajzen (2015) due to the fact that the
researcher feels this definition is the most complete when compared to the other definition.
Attitude is “a mental or neural state of readiness, organised through experience, exerting a
directive or dynamic influence on the individual’s response to all objects and situations to
which it is related” (Allport, 1935). Seow et al. (2015) defined attitude as a personal judgment
of being in favour of or opposed to an action to perform a specific behaviour. Another
definition by Borkowski (2005) states that attitude is an individual’s mindset or tendency to act
in a way, caused by one’s experience and temperament. He continued by arguing that
attitudes help us see how to observe and behave in a situation. Attitudes may include one’s
feelings, thoughts, actions, and also the evaluation or emotional reaction of a person. The
examples of an attitude are, “I dislike arrogant people”, “He makes me angry”, and “John does
not like working in this place”. In conclusion then, the definition by Borkowski (2005) is the
definition that will be used here to measure the conceptual definition of attitude.
Fang et al. (2017) stated that normative belief refers to the “beliefs of an individual that are
accepted by specific people or groups and dictate whether behaving in a particular fashion
is appropriate” (p. 3). Trafimow (2001) argued that normative beliefs are the beliefs of
individuals on the thinking of people whom they considered important for whether these
individuals should or should not perform particular behaviours. There are two general uses
for normative beliefs. The first is to aid the prediction of variables, such as a subjective norm
and intention; the second is to provide information when performing an intervention
regarding what efforts should be focussed on for that intervention (Trafimow, 2008).
Trafimow stated that two factors can increase the importance of normative beliefs, i.e. group
identification and priming the collective self.
Terry and Hogg (2000) concluded that norms would have stronger influence for an
individual when he/she identifies with the group strongly, so the stronger and important a
group is to the individual, the stronger will be the normative belief of that individual. The
second aspect is priming the collective self, which is the influence of norms that can be
increased when the collective self is primed, compared to the private self (Trafimow and
Finlay, 1996). Collective self is a memory that contains thoughts of the individual about
group membership (Trafimow, 2008). In conclusion, the definition of normative beliefs by
(Fang et al., 2017) is the most definitive and latest definition compared to other definitions,
at least in the researcher’s opinion. This definition will, thus, be used to define the
conceptual definition of normative beliefs here.

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 Subjective norm is defined as a view of others that are considered to be important to an
individual and these views influence an individual’s decision making (Ajzen, 1991).
Subjective norm is the influence of others’ opinions on one’s decision making (Han et al.,
2010). It is rather similar to normative beliefs; only subjective norm extends the motivation to
comply with that of an individual (Lee et al., 2012). Subjective norm is usually influenced by
the social pressure from others to behave and comply with those people’s views (Ham
et al., 2015). They noted that there are two types of subjective norms, descriptive and
social. Descriptive norm is defined as the real undertaking of behaviours or the activities of
others, while social norm shows how an individual should behave based on the perception
of other people and their opinions. An example of the descriptive norm is “My relatives
would go to other countries for medical treatment”, and an example of the social norm is
“My parents would want me to travel to Malaysia for health treatment.” In conclusion, the
definition that the researcher will use to define the conceptual definition of the descriptive
norm is the by Ajzen (2015), as the researcher feels it is the most definitive definition and
clarifies the difference between the subjective norm and normative beliefs.
Lee et al. (2012) stated that perceived behavioural control is the perception of an individual for
how easy or difficult it is to perform a particular behaviour. Ham et al. (2015) stated that
perceived behavioural control is defined as “the perception of one’s abilities and sense of
control over the situation and is defined as a combination of locus of control – belief about the
amount of control that a person has over events and outcomes in his life – and self-efficacy
(perceived ability to perform the task)”. Self-efficacy is defined as an individual’s belief in the
ability to succeed in a situation or task (Bandura, 1977). Therefore, the difference between
perceived behavioural control and self-efficacy is that perceived behavioural control focusses
on the perception of the difficulty of an individual, while self-efficacy focusses on the ability of
an individual to succeed in performing a specific behaviour. The definition proposed by Lee
et al. (2012) will be used here to define the operational definition of perceived behavioural
control, as this researcher feels that it is the simplest and easiest definition to understand
compared to the others.
Lee et al. (2012) proposed that control belief is the perception of an individual of the availability
of resources or the opportunity needed to perform a particular behaviour. Consistent with
Ajzen (2002), control belief is one’s beliefs in the factors that could facilitate or hinder one’s
behaviour. These control beliefs may be based in part on prior experience with the behaviour,
but they will usually also be influenced by second-hand information about that behaviour, the
experiences of acquaintances and friends, and other factors that may increase or reduce the
perceived difficulty of performing that behaviour examples of control beliefs are “Having a
medical treatment in Malaysia is cost-effective” and “I can communicate with foreign
healthcare providers and get them to perform the needed procedures”. In conclusion, the
definition that will be used to define control belief in this research is the one Lee et al. (2012)
offers, as it is the most relevant definition to address the topic of this current research.
Behavioural intention is the likelihood of performing a behaviour as perceived by an
individual (Glanz, 2015). Another definition of behavioural intention is the probability that an
individual will engage in a given behaviour (Armitage, 2001). Intention to visit or travel
intention is the willingness of a potential visitor to visit a certain destination (Chen and Tung,
2014). In this paper, the behaviour being predicted is travel intention, which is the
evaluation of a visitor based on the cost and benefits of other alternative destinations
(Abubakar, 2016). The definition of travel intention used to define the conceptual definition
in this current research will be the one offered by Chen and Tung (2014).

Hypotheses development
A study by Lee et al. (2012) on Japanese perception towards Korean medical tourism
showed there is a positive relationship between behavioural belief and visit intention to a
medical tourism business. Based on previous studies on the intention to visit a specific

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country destination, behavioural beliefs will have a positive relationship with attitude.
Therefore, we expect that in the medical tourism context this hypothesis can be defined as:
H1. Behavioural belief is a positive predictor of attitude to travel to Malaysia for medical
treatment.
The relationship between an attitude and an intention has been studied previously and seen
as demonstrating that attitude and intention have a positive relationship. For example, a
study by Seow et al. (2015) stated that attitude has a positive relationship with visitor travel
intention, especially in the medical tourism industry when the study was conducted in
Malaysia and aimed to target other nationalities, such as Indonesia, Singapore, and
Japanese visitors. Another study also stated that attitude has a positive relationship with
visit intention, whereas this study was conducted on attracting Japanese tourists’ visit
intentions to Korea for medical treatment (Lee et al., 2012). This hypothesis can be defined
as:
H2. Attitude is a positive predictor of the intention to travel to Malaysia for medical
treatment.
Based on previous studies, normative beliefs have a positive relationship with the subjective
norm. Lee et al. (2012), for example, reported that normative beliefs have a positive
relationship with the medical tourism industry. Thus, another hypothesis can be offered as:
H3. Normative belief is a positive predictor of the subjective norm to travel to Malaysia for
medical treatment.
Previous studies have further proposed that if a parent or a spouse does not want an
individual to perform a specific action, for example, a medical visit to another country, then
that intention will be relatively low (Seow et al., 2015; Seow et al., 2017). Moreover, Lee et al.
(2012) stated that there is a positive relationship between subjective norm and visit
intention. Therefore this hypothesis can be stated as:
H4. Subjective norm is a positive predictor of intention to travel to Malaysia for medical
treatment.
Studies have also shown that control beliefs have a positive relationship with perceived
behavioural control. Lee et al. (2012) also stated that control beliefs have a positive
relationship with perceived behavioural control in a study conducted in South Korea on the
medical tourism intention of Japanese visitors. Therefore, this hypothesis can be stated as:
H5. Control belief is a positive predictor of perceived behavioural control to travel to
Malaysia for medical treatment
Lee et al. (2012) further noted that perceived behavioural control has a positive relationship
with visitors’ travel intention in medical tourism in a study conducted in Korea to attract
Japanese visitors. Other studies have also stated that perceived behavioural control has a
positive relationship with visit intention, where a study was conducted in Malaysia regarding
international visitors’ travel intention to Malaysia for medical treatment (Seow et al., 2015;
Seow et al., 2017). Therefore, the hypothesis can be stated as:
H6. Perceived behavioural control is a positive predictor of travel intention to travel to
Malaysia for medical treatment.

Methodology
This study used structural equation modelling (SEM) as the basis of its analysis. It is a
technique capable of analysing patterns of relationship between latent constructs and their
indicators, latent constructs with each other, and for measurement error directly. SEM allows
an analysis between several dependent and independent variables directly (Hair et al., 2006).
This study tested the structural and measurement model. The former is a relationship between

VOL. 13 NO. 4 2019 j JOURNAL OF ASIA BUSINESS STUDIES j PAGE 513

 the latent variable, while the latter is the relationship between indicators with a latent variable.
The structural model was also used to conclude whether a hypothesis was supported, by
looking at the t-statistic and the p-value. This study used a confidence interval of 95 per cent.
There are two types of SEM, i.e. variance and covariance (Hair et al., 2014). The difference
between variance and covariance SEM is their estimation objectives. Covariance-based
SEM focusses on minimising a discrepancy between the empirical and theoretical
covariance matrix, while variance-based SEM focusses on determining construct scores as
linear combinations of observed variables, wherein a specific criterion of interrelatedness is
maximised (Henseler, 2017).
This study uses partial least squares (PLS)-SEM instead of control beliefs (CB)-SEM, as
PLS-SEM is more suitable when the study is predictive, and a particular study has yet to
have been studied intensively by previous researchers (Hair et al., 2006). SmartPLS is one
of the software programmes used for testing variance-based modelling. To analyse the
data, this research uses SmartPLS software, Version 3.0. In this research, there are seven
variables including their conceptual and operational definitions. A Likert scale is used to
measure attitudes by expressing agreement or disagreement with a particular event or
object (Sekaran and Bougie, 2013). In this research, we use the five-point Likert scale to
measure all the variables (1 = strongly disagree and 5 = strongly agree). Personally
administered methodology and electronic questionnaires were used as the data collection
technique. As this research is conducted with people that speak in Bahasa Indonesia, we
also carried out back-translation procedures.
Back translation is one method often used to deal with the complexities in translating an
instrument from one language to another to attain validity in translation and avoid language
bias (Brislin, 1970). Brislin defined the steps in back translating an instrument. The first thing
to do in back-translation method has a bilingual person translate the instrument into another
specific language. The second step is to have another bilingual person translate it from the
target language to the original language of the instrument. The person translating it should
have never seen the original language. The third step is comparing the original instrument
to the back translation and modifying it for any discrepancies. Thus, when adapting the
questionnaire from Lee et al. (2012), we translated the original version (English) to Bahasa
Indonesia and then translated it back to the original language with only minor modifications.
The conceptual, as well as the operational definition is exhibited here in Table I below.
The sample frame chosen as representative of the population in this research will be
Indonesian patients who have gone to Malaysia for medical treatment at least once. This
frame was chosen as the subjects who had received medical treatment in Malaysia already
experienced the services, possess the most information needed, and will avoid producing
biased results. Considering the wide range of medical-related services that are available in
Malaysia, this study limited the cases for analysis to any of the following six treatments:
medical check-up, cardiovascular, cancer, nervous systems, dental or orthopaedics. Those
who had not been to Malaysia for medical tourism purposes wee not considered for further
analysis (Table II exhibits the respondents’ profiles).
In this research, the number of samples taken for pre-test were 30 respondents (Johanson
and Brooks, 2010). Hair et al. (2006) asserted that a good sample for research is that acquired
by some indicators times 10 when using PLS-SEM. SEM is a statistical technique capable of
analysing the patterns of relationships between latent constructs and their indicators, latent
constructs with each other, and measurement error directly. From the preliminary test, nine
indicators were deleted out of 27. Therefore, 18 indicators were used in this research, making
180 the minimum number of respondents that should be reached. Based on this preliminary
test, we then collected 200 respondents for the hypotheses tests.
To analyse the data, this research used SmartPLS software, Version 3.0. A variable is
considered reliable if it has a Cronbach’s alpha of > 0.6, and composite reliability of 0.7

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 Table I Questionnaire instrument used in the study
Variable Conceptual definition
Behavioural Perceived consequences of
belief performing a behaviour,
whether it is positive or
negative, and the subjective
values or evaluations of
these consequences
Attitude An individual’s mindset or
tendency to act in a way,
caused by one’s
experience and
temperament
Normative Beliefs of an individual that
beliefs are accepted by specific
people or groups and
dictate whether behaving in
a particular fashion is
appropriate
Subjective The view of others that are
norm considered to be important
to an individual and their
views influence an
individual’s decision
making
Control beliefs Perception of an individual
regarding the availability of
resources or the opportunity
needed to perform a
behaviour
Perceived Perception of an individual
behavioural regarding how easy or
control difficult to perform a
behaviour
Travel Intention to visit or travel
intention intention is the willingness
of a potential visitor to visit a
destination
Note: This table describes how the questionnaire was formulated in this study using relevant sources to justify the conceptual and
operational definition
when using PLS-SEM (Hair et al., 2006; Sekaran and Bougie, 2013). This research tested
the construct validity as it can testify how well the results obtained from the use of the
measure fit the theories for which the test was designed (Sekaran and Bougie, 2013). The
convergent validity test for construct validity can be determined by looking at the average
variance extracted value of > 0.5 (Huang et al., 2013). While the discriminant validity test
Operational definition Sources
Traveling to Malaysia for medical treatment would allow Ajzen (2015)
me to save medical costs.
Traveling to Malaysia for medical treatment would allow
me to enjoy the extra care and services in a clinic
Traveling to Malaysia for medical treatment would allow
me to receive treatment that I need immediately
Traveling to Malaysia for medical treatment would allow
me to receive treatment from highly trained
professionals
Traveling to Malaysia for medical treatment would allow
me to enjoy a tourism experience while there (shopping,
visiting attractions, etc.)
I think going to Malaysia for medical treatment is Borkowski (2005)
desirable
I think going to Malaysia for medical treatment is
pleasant
I think going to Malaysia for medical treatment is
favourable
I think going to Malaysia for medical treatment is wise
I think going to Malaysia for medical treatment is
enjoyable
My family thinks I should travel to Malaysia for medical Fang et al. (2017),
treatment Lee et al. (2012)
My friends think I should travel to Malaysia for medical
treatment
My close acquaintances who have had previous
medical treatment in Malaysia think I should travel there
to receive medical treatment as well
My doctor thinks I should travel to Malaysia for medical
treatment
People who are important to me would want me to travel Ajzen (2015), Lee
to Malaysia for medical treatment et al. (2012)
People who are important to me would travel to Malaysia
for medical treatment
People who are important to me would think that I should
travel to Malaysia for medical treatment
Visiting Malaysia for medical treatment is cost-effective Lee et al. (2012)
Information about specialists for medical treatment in
Malaysia is easy to find.
Language is not a barrier when visiting Malaysia for
medical treatment
Visiting Malaysia for medical treatment seems safe
Whether I travel to Malaysia is completely up to me Lee et al. (2012)
I am confident that if I want, I can travel to Malaysia any
time
I have resources, time, and opportunities to travel to
Malaysia for medical treatment
I am willing to travel to Malaysia for medical treatment Chen and Tung
I made plans to travel to Malaysia for medical treatment (2014), Lee et al. (
I made an effort to travel to Malaysia for medical 2012)
treatment
VOL. 13 NO. 4 2019 j JOURNAL OF ASIA BUSINESS STUDIES j PAGE 515
 Table II Demographic profile of study respondents’
Frequency Percentage (%)

Age
17-25 10 5
26-35 15 7.5
36-45 14 7
46-55 92 46
56-65 67 33.5
>65 2 1
Occupation
Student 9 4.5
Private employee 31 15.5
Lawyer 3 1.5
Business owner 115 57.5
Other 42 21
Income/month (in thousand IDR)
< 10.000 9 4.5
10.000-20.000 15 7.5
20.000-30.000 17 8.5
30.000-50.000 29 14.5
50.000-100.000 60 30
> 100.000 70 35
Visits
1-3 times 97 48.5
4-6 times 73 36.5
7-10 times 25 12.5
>10 times 5 2.5
Patients’ previous related health issues (Respondents can choose more than one)
Medical check-up 160 51.95
Cardiovascular 73 23.70
Cancer 11 3.57
Nervous system 24 7.79
Dental 1 0.32
Orthopaedics 36 11.69
Other 3 0.97
Note: This table presents the respondents’ profiles who participated in this study

can be tested using the Fornell–Larcker test and the cross-loading indicator test, SEM
allows for a direct analysis between several dependent and independent variables (Hair
et al., 2006). The t-critical value must be higher than 1.96, and the p-value shall be smaller
than 0.05, given that the confidence interval used in this current research was 95 per cent.

Findings
Based on the preliminary test, nine indicators were deleted, as these indicators did not fulfil the
validity and reliability criteria. Having deleted these items, behavioural belief, normative beliefs,
and perceived behavioural control were acceptable variables for this study, as they had
Cronbach’s value within the acceptable range. Subjective norm, visit intention, attitude, and
control beliefs were also considered reliable, as the Cronbach’s alpha values were higher than
0.8. By looking at these factors, all variables were considered reliable, as they passed the
reliability and internal consistency tests. Every variable was considered to be reliable if it had a
value over 0.6 for Cronbach’s alpha and 0.7 for composite reliability. The variables attitude and
control beliefs were also considered acceptable, as they had values above 0.6, but below 0.8.
For composite reliability, all the variables were considered satisfactory as they all had a value
above 0.7. The Fornell–Larcker validity test also showed that all variables are valid. The validity
and reliability test results are exhibited in Tables III and IV.

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 Table III The reliability test results
Variable Indicators Loadings Cronbach’s alpha AVE Composite reliability

Attitude A1 0.921 0.792 0.827 0.906

A2 0.899
Behavioural beliefs BB1 0.843 0.843 0.761 0.904
BB2 0.923
BB3 0.849
Control beliefs CB1 0.907 0.767 0.811 0.895
CB2 0.894
Normative beliefs NB1 0.883 0.813 0.729 0.889
NB3 0.888
NB4 0.786
Perceived behavioural control PBC1 0.919 0.817 0.846 0.916
PBC2 0.920
Subjective norms SN1 0.944 0.899 0.832 0.937
SN2 0.875
SN3 0.917
Visit intention VI1 0.915 0.895 0.827 0.935
VI2 0.889
VI3 0.923
Notes: This table presents the SmartPLS results of the measurement model. All of the indicators show
that the questionnaire instrument is reliable to use

Table IV Fornell–Larcker validity results

Behavioural Control Normative Perceived behavioural Subjective Visit
Attitude beliefs beliefs beliefs Control norms intention

Attitude 0.911
Behavioural Beliefs 0.707 0.872
Control beliefs 0.612 0.63 0.900
Normative beliefs 0.697 0.614 0.584 0.854
Perceived Behavioural
Control 0.539 0.582 0.622 0.579 0.920
Subjective norms 0.661 0.604 0.68 0.759 0.483 0.912
Visit intention 0.718 0.623 0.751 0.699 0.553 0.715 0.909
Notes: This table presents the SmartPLS validity test results of the questionnaire used in this study. The results in this table show that all
variables are valid

Table V Hypotheses test

Hypotheses Path coefficients t-statistics Result

H1. Behavioural beliefs ! attitude 0.707 19.772 Supported

H2. Attitude ! visit intention 0.373 5.802 Supported
H3. Normative beliefs ! subjective norms 0.759 17.65 Supported
H4. Subjective norms !visit intention 0.389 5.394 Supported
H5. Control beliefs ! perceived behavioural control 0.623 12.645 Supported
H6. Perceived behavioural control ! visit intention 0.164 2.296 Supported
Notes: This table presents the SmartPLS result of the hypotheses tests. The indicators show that all
the hypotheses are supported.

In Figure 1, it can be seen that all the offered hypotheses were supported. The H1 was
supported, as it has critical t-value of 19.77. Also, the H2 was considered as supported, as it
had a critical t-value of 5,802. This finding means that attitude is a positive predictor for
Indonesian patients’ visiting Malaysia for medical treatment. The H3 states that normative

VOL. 13 NO. 4 2019 j JOURNAL OF ASIA BUSINESS STUDIES j PAGE 517

 Figure 1 PLS algorithm results for the measurement and structural model

belief is a positive predictor of subjective norms, and it is also supported as it has a critical
t-value of 17.65. The H4 states that subjective norm is a positive predictor for Indonesian
patients’ visit intention to Malaysia for medical treatment was also supported with its critical
t-value of 5.39. The findings also support the H5, which states that control belief is a positive
predictor of perceived behavioural control as its critical t-value is 12.64. Finally, the H6 stated
perceived behavioural control is a positive predictor for visit intention is also considered
supported due to its critical t-value of 2.29. The PLS algorithm result is offered in Figure 1.
H1 states that behavioural belief is a positive predictor of attitude, and it is supported and
consistent with the findings from previous researchers (Quintal et al., 2010; Lee et al., 2012;
Han et al., 2010). In the Indonesian context, the Indonesian patients perceived that
travelling to Malaysia for medical treatment gave them a higher chance of getting cured
(Purba, 2017), receiving a better medical quality (Pramudito, 2017), and the price
differences were not significant, especially when travelling to Malaysia for medical treatment
also included visiting tourist destinations in Malaysia (Pambiago, 2012).
H2 states that attitude is a positive predictor for patients’ intention to visit Malaysia for
medical treatment was also supported and accordingly so from previous researchers
(Chien et al., 2012; Seow et al., 2015; Seow et al., 2017). This finding can be explained as
when a belief is considered favourable by an individual, then it is most likely that a specific
action will be positively executed by that individual (Ajzen, 2015). This finding reflects the
notion that Indonesian patients travel to Malaysia for medical treatment because of their
positive perceptions of Malaysia’s health services. They prefer Malaysia over other places
for medical treatment, and they also see travelling to Malaysia for medical treatment as a
wise choice. Based on the journal that this research replicated, people will travel for medical
treatment based on their favourable perceptions of costs and better services in a country.
These perceptions eventually lead to their intention of visiting a certain country for medical
treatment (Lee et al., 2012).

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H3 states that normative beliefs are a positive predictor of subjective norms. It was
supported accordingly as previous researchers determined (Lee et al., 2012; Ajzen, 2015;
Han et al., 2010). Normative belief is the beliefs of an individual that are accepted by
specific people or groups. They dictate whether behaving in a particular fashion is
appropriate (Fang et al., 2017). The subjective norm is the view of others who are essential
for an individual and their views also influence an individual’s decision making (Ajzen,
2015). These influential people can be friends, family or a doctor, especially in the medical
context. It is possible, as based on phenomena occurring in Indonesia, that some
Indonesian patients have travelled to Malaysia based on their friends’ who also went to
Malaysia for medical treatment and their recommendations for medical treatment (Perkasa,
2016). This phenomenon is highly relevant to the questionnaire that states “My friends think
that I should travel to Malaysia for medical treatment” and “People who are important to me
would travel to Malaysia for medical treatment”.
H4 states that the subjective norm is a positive predictor for Indonesian patients on visit
intention. It was supported and agrees accordingly with the previous researchers as well
(Seow et al., 2015; Seow et al., 2017; Lee et al., 2012; Ramamonjiarivelo et al., 2015). This
finding means that Indonesian patients travel to Malaysia for medical treatment after people
whom they consider important to them told them to go. Just as stated previously, the
phenomena, where Indonesian patients travel to Malaysia for medical treatment based on
their friends or family’s recommendations, are highly relevant to this questionnaire. For
example, Indonesian patients travelled to Malaysia for medical treatment based on their
friends’ recommendations, especially from those who had already gone for medical
treatment in Malaysia (Perkasa, 2016).
H5 states that control belief is a positive predictor of perceived behaviour control, and it was
supported and accordingly agrees with the previous studies (Lee et al., 2012; Ajzen, 2015).
Control belief is one’s beliefs regarding the availability of resources or opportunities that are
required to perform a specific behaviour (Lee et al., 2012). In this context, control belief is
related to the risk (accident-free) and cost-effectiveness when travelling for medical treatment.
These findings are highly relevant related to phenomena that happen to Indonesian patients.
For example, some Indonesian patients have confessed that travelling to Malaysia for medical
treatment enabled them to save up to 20 per cent of costs compared to Indonesia and they
even received free consultation fees days after they had their treatment (Perkasa, 2016). In
terms of the safeness of traveling to Malaysia for medical treatment, some Indonesian patients
have claimed that it is safe, as the excellent services they received included assurances that
their privacy would be strictly kept from when they experienced a pick up from the airport to
the hospital, and a return to the airport to depart from Malaysia (Tarigan, 2017).
H6 states that “perceived behavioural control is a positive predictor for visit intention is also
supported and is in accordance with the findings of previous researchers (Lee et al., 2012;
Seow et al., 2015; Seow et al., 2017). It can also be said that Indonesian patients have
relatively abundant resources and the more abundant the resources are, the easier it is to
act. Having conducted a statistical examination to test the hypotheses, the following section
is particularly interesting as it discusses the visit intentions of Indonesian medical tourists to
Malaysia compared to intentions found in previous studies.

Discussion
It was discovered that subjective norms, attitude, and perceived behavioural control are
essential variables that positively influence Indonesian medical tourist intention to visit
Malaysia for medical treatment. This result is consistent with the previous study carried out
by Lee et al. (2012) on Japanese patients that visit Korea for medical purposes. Looking at
the path coefficients for these three variables, this study delivers parallel results to those for
the Japanese patients.

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 Subjective norms are considered as the variable that has the most substantial impact on
visit intention among Indonesian patients, and it is similar to the Japanese. It can be
inferred, therefore, that those who are closely related to a patient can significantly reinforce
their intention to visit a particular country. This person can be a family member, close
relatives, or inner circle friends. Thus, it is fair to suggest that this “collectivist” behaviour
plays a crucial role in shaping one’s decision to undertake medical travelling behaviour
(Bagozzi et al., 2002; McAuliffe et al., 2003).
The second most influential factor that contributes to visit intention among Indonesian medical
tourists is also parallel to that of the Japanese. An attitude that results from previous individual
experiences is also a significant factor and one that positively influences the intention among
Indonesian patients and their visit intentions to travel to Malaysia for medical treatment. We
argue that in the Indonesian context, attitude is constructed not only solely by “individual”
experiences but also by exposure to other actors, e.g. relatives, media, and/or family
members who might have experienced poor medical treatment services in healthcare-related
institutions (Purba, 2017). Massive promotional campaigns from these institutions can also
affect patients’ perceptions and shape their behaviour to ultimately visit Malaysia for medical
purposes (Tempo.co, 2013), thus increasing the attitude belief of a patient.
Perceived behavioural control was found to be the third most potent factor that leads to visit
intention to Malaysia. We argue that this finding is caused by the “sacrifices” that a patient must
compensate for when undergoing medical tourism. There are two key aspects, namely, financial
resources and time availability. Despite the country’s efforts to reduce poverty, 20.78 per cent of
the population still remains vulnerable to poverty (Worldbank, 2018). It can, thus, be reasonably
inferred that only a certain proportion of Indonesians can afford to travel to Malaysia.

Concluding remarks
To conclude then, subjective norms, attitude, and perceived behavioural control positively
affect travel intention for Indonesian patients to travel and receive medical treatment in
Malaysia. Indonesian patients who travel to Malaysia for medical purposes are shown to be
driven by collective norms, that is, the opinions of close relatives or family members.
Individual experiences in local medical institutions are also a contributing factor for visit
intention. Finally, patients’ resource availability – e.g. money and time – has also been
predicted to influence their decisions to visit Malaysia for medical treatments, compared to
those resources for those who remain in Indonesia.
Even though this study achieved its objectives, certain limitations still existed in this
research. First, the scope was limited, as the study was conducted only in Jakarta and the
Tangerang area in Indonesia. Second, this study limited its analysis to particular medical
treatments. Third, this study used PLS-SEM as the basis of its analysis, and it mainly used to
identify key driver constructs. Hence, several proposed recommendations can be offered
for future positive research avenues. First, further investigation is needed in other main cities
on the different islands, thereby increasing the sample size, for a more exhaustive
explanation of the Indonesian behavioural perception towards Malaysia’s medical tourism.
Second, taking into account other medical treatments could provide more variable data.
Third, we suggest that future scholars interested in this field should carry out a CB-SEM
analysis and confirmatory theory testing on the proposed model.
Theoretically, the results in this study are consistent with the previous work, which has shown
that attitude, subjective norms and perceived behavioural control positively affect visit
intention. Our results also suggest interesting theoretical findings that Indonesia’s medical
tourists’ intention to visit Malaysia is strongly caused by subjective norms, followed by
individual attitudes and perceived behavioural control, indeed identical findings to those
Japanese medical tourists’ visiting South Korea for similar medicinal purposes. Thus, there
seems to be identical behavioural practices and beliefs among the Indonesian and the

PAGE 520 j JOURNAL OF ASIA BUSINESS STUDIES j VOL. 13 NO. 4 2019

Japanese medical tourists, despite the gap between the economic situations of these two
countries.
Therefore, we propose two managerial implications as a result of our findings. First, this
study can be the basis for the Malaysian medical tourism business and better understand
Indonesian medical tourists’ behaviour when visiting the country. The study explicitly
suggests that it is collective and individual beliefs that drive Indonesian patients, with
sufficient resources, to visit Malaysia because of better quality and affordability than that
offered by Indonesian medical services. Second, this study raises a fundamental question
for stakeholders in the Indonesian healthcare industries. In the near future, this type of
travelling behaviour for medical treatments will, without a doubt, affect the Indonesian
economy at large. Considering the massive number of transactions that have been
recorded for medical tourism in Malaysia, relevant stakeholders in Indonesia should take
appropriate actions if the country wants to provide better access, higher quality, and
positive affordability that can positively compare what its neighbouring countries can offer.

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About the authors

Harriman Samuel Saragih is an Assistant Professor of Management in Prasetiya Mulya
Business School. He holds his PhD from the School of Business and Management,
Bandung Institute of Technology. In addition, he serves as Program Manager for Bachelors

VOL. 13 NO. 4 2019 j JOURNAL OF ASIA BUSINESS STUDIES j PAGE 523

 in Branding Studies. He also teaches Strategic Executive MBA, serves as Associate
Consultant in Executive Learning Institute, and Consultant in BVDI Prasetiya Mulya. He
received the BPPDN Scholarship from the Indonesian Ministry of Research, Technology
and Higher Education. He is an Editorial Board Member in International Journal of
Innovation Science (Emerald Publishing). His primary research interests are in the field of
case research method, collaborative innovation, creative industries, and consumer
behaviour. His articles have been published in the Emerald Emerging Markets Case
Studies, Heliyon, Journal of Management Development, International Journal of Business
Innovation and Research, Asia Pacific Journal of Marketing and Logistics, and International
Journal of Innovation Science. Harriman Samuel Saragih is the corresponding author and
can be contacted at: harriman.saragih@pmbs.ac.id

Peter Jonathan is an International Business Management Graduate from University of Pelita

Harapan. Currently, he works as Product Specialist at Orang Tua Group, a major local food
and beverage company in Indonesia. Prior joining Orang Tua Group, he was a former
employee of Siemens Indonesia and served as a Business Development Analyst. His main
interests sector of industry are in healthcare, energy, and food & beverages.

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