Government authorities seeking greater transparency, want to know precisely how their support will make a difference to the local and national economy. In the past 8 years, many health tourism cluster organizations have been loosely organized for the oft unspoken strategic purpose of co-opting large conference stand rentals that would otherwise be too costly for individual hospitals and clinic exhibitors and sponsors. The basis of the strategy is to connect with potential buyers and buyers’ agencies and to market the destination under some common symbolism or logo image. Few have developed the required infrastructure to operate effectively, efficiently and deliver return on PPP investment. Many have been abandoned or continue to limp along after initial budget allocations have been spent without adequate results.

Organizations operating on the ground want a better understanding of what works best and most efficiently so that they can optimize their efforts and program portfolios. Governments, communities, and other stakeholders—including targeted program participants—are also showing ever-increasing interest in long-term results.

Few large regional non-governmental organizations today have an effective means of measuring effectiveness, or developing measurable objectives for the regional or national medical tourism clusters. Most organizations measure short-term indicators—such as the number of coordinated referrals, number of calls inbound to a call center, number of closed sales through the call center, or the number of measurable calls to action executed through a website -- all of which are relatively easy to track but which produce few if any cash results.

Some organizations also measure their efforts’ direct short-term effects, such as improved positioning for the destination as a medical or dental tourism hub. Most organizations, however, lack a rigorous, systematic approach to gauging long-term impact, whose measurement poses far greater challenges.

For a health and wellness tourism regional or national cluster to improve the situation of public and privatized clinics seeking to grow their medical tourism business, or to increase brand recognition and reach across national and regional borders, cluster participants and their communities must afford each organization empowerment through staff capacity development programs and the provision of health care services to domestic and international visitors alike.

The cluster must be designed so that through established processes, it can produce and then quantify precisely that economic and social impact. Working in partnership with The Mercury Advisory Group, clusters and their government supporters have worked together for several years, exchanging knowledge across the social sector.

Mercury Advisory Group has been awarded consulting projects to remediate several failed and failing clusters. As a part of the project, we developed a highly effective approach to impact assessment, one that comprehensively measures the long-term effects of its efforts and provides valuable insight into how regional and national medical tourism clusters might further improve the impact of its programs and publish externally verified, credible data.

Measuring Impact
Medical tourism cluster organizations strive to do more than simply sell excess capacity of medical services to foreigners. More sophisticated PPP clusters aim to ensure that the long-term impact of the cluster’s work with stakeholders and their communities is as significant and sustainable as possible. The organizations also seeks to continually improve its effectiveness.

Our client clusters recognized soon after the formation consultants left that they had spent a lot of money on a logo and that they lacked a clear understanding of the operational and sustainable strategy to do more than attend conferences and pay for brand recognition sponsorships. They lacked the sustainable operational infrastructure to function as a business cluster, and had no shared destination experience product to sell, nor the means to sell anything through the cluster.

As such, long-term results of its efforts to achieve those goals were never realized - only expenses. With this in mind, we sought to develop a robust approach and methodology for measuring long-term impact, focusing on the clusters’ core work in organizational development, training and capacity development, jobs creation and empowering future business leaders from local communities to effectively manage and operate the public-private partnership for health tourism and produce local tax revenues to sustain marketing, operations, quality and safety accreditation and training.

Through the provision of shared services and economies of scale, the health tourism cluster organization strives to provide quality care, brand destination awareness and reputation, and community pride and jobs creation for skills at every level.

Mercury Advisory Group’s assessment methodology evaluates two elements of the programs’ long-term impact:

• the non-financial (or all-around) impact on the individual cluster or PPP stakeholders and the community, and
• the financial and other impacts on society.

The determination of the long-term impact on individual participants is based largely on information gleaned from interviews of program participants by Mercury’s external researchers and others who are willing to share unbiased, credible data. This is supplemented by qualitative research conducted through focus group discussions with participants and community leaders.

The outcomes are assessed along the following six dimensions:

1. Livelihood. What are the participants’ employment and income status, and do stakeholder organizations possess sufficient resources to assure organization survival and development?
2. Care. Do cluster participants have strong, stable relationships that provide ongoing social, emotional, physical, and material support to their local communities as well as international and domestic visitors?
3. Capital. Does the cluster organization have the required capital to operate and market their services, brand and continue brand growth and development?
4. Scalability. Does the health or wellness tourism cluster have the ability to scale up or down depending on the needs of the market and sudden opportunities?
5. Education and Skills. Are staff and managers well-prepared for future employment as the cluster grows in sophistication and operations? Preparation requires, for example, the availability of relevant education or training and the ability to regularly attend classes either face-to-face or online or by directed independent study.
6. Protection. Are cluster participants and their customers safe from abuse, exploitation, corruption?

Each dimension is tracked using a number of related indicators. The health and wellness tourism PPP programs’ long-term impact on the local community is similarly assessed using a variety of indicators. These include, for instance, the following:

1. Community Awareness. Are local stakeholders able to render affordable healthcare to local citizens? Some PPP clusters have been organized as special economic zones with tax incentives as long as they do not “cannibalize” market share of local private community-based health centers. As such, locals are prohibited from using the PPP cluster facilities within the special economic zone. This reduces the ability to use local end-user testimonials and social media feedback to influence other purchasers going forward.
2. Community-Based Support Systems. Does the community receive benefit from the existence of the PPP where technology and other system advantages could alleviate waiting times and supply or augment certain missing or scarce health services not found elsewhere in the public health system?
3. Progress Toward Sustainability. Would activities related to the programs continue the cluster withdrew from day-to-day involvement in the health and wellness tourism community?

Mercury Advisory Group expert consultants gather information through field interviews and focus group discussions with critical stakeholders in the community and supplement with case studies and desktop research.

Societal Benefits from Health & Wellness Tourism Cluster Operations
The health & wellness tourism cluster or PPP programs’ long-term financial impact on society is gauged by the programs’ social return on investment (SROI), a comparison of the programs’ total costs and benefits to society. The calculation of societal benefits is based on easily quantifiable elements. The most important of these elements are the present value of staff and manager projected lifetime incomes and earning capacity, skills transferability, and the present value of projected long-term financial benefits to the communities where the clusters are established; the programs’ direct financial benefits to the community, including the local spending of the cluster on office supplies, rents, parking, mass transit, gasoline taxes, personal income taxes, etc; and the savings in government social spending resulting from access to timely care interventions for locals without buying additional or redundant cutting edge technologies already present in the private sector health facilities, purchased at wholesale government fee schedules. It also measures the ability of cluster employees to support themselves and their families financially. The calculation is supplemented by a number of sensitivity tests to ensure that the picture that emerges is realistic.

Testing the Approach on the Ground
To date, Mercury Advisory Group has conducted and completed pilot projects on 4 continents to test its impact-assessment approach. The proof of concept results were highly encouraging in all cases.

The approach proved feasible in the field. Despite the pilots’ limited sample size, the approach provided critical insight into the programs’ performance and long-term impact—essentially answering all of the questions that the organization had posed. In some instances, we were able to identify that the cluster would not survive and was not creating community benefit and would not be able to do so without significant reinvestment or donor funding. In others, we were able to determine that in hindsight, the cluster had spent precious financial resources heading straight to selling strategies by sending on conference mega-stands, travel costs and sponsorships to create brand awareness of a logo design, without having developed a product deliverable underneath the cluster banner.

For some (very few, actually) health and wellness tourism clusters, the news on their programs’ long-term impact was highly encouraging. Most of these happen to be established within the USA as integrated health delivery schemes, accountable care organizations, independent practice associations, management services organizations, and physician hospital organizations and healthcare co-ops. Among the most salient findings was that a convincing majority of cluster established within the past 8 years by one common consulting firm—almost 90 percent—were failing to produce anticipated results on at lease four of the least six dimensions considered. Some had never even considered these objectives part of their mission. Moreover, local stakeholders indicated that they were disappointed in or didn’t find value in the organization’s work in their communities. Some expressed outright remorse at early strategic decisions and leadership.

Further, the programs’ SROI was compelling where successful, with a $1 investment yielding benefits to society of $4 or more using conservative assumptions. In fact, the programs’ true impact is even higher than these figures indicate, since the SROI calculation only includes easily quantifiable elements (and excludes such things as the multiplier effects of program participants’ increased incomes on society); valuable but indirect societal benefits, such as corresponding improvements in health care access and lowered technology procurement costs and crime rates, are not considered.

Conclusion
An effective measurement of SROI galvanizes health and wellness tourism national and regional cluster creation and PPPs with management viewing the results as both motivation and a mandate for carrying its work forward. The findings also identified potential areas of future improvement for the organizations that can be applied to the more than 150 countries seeking to build a health and wellness tourism sector.

One way in which the PPP or cluster organization can focus more on vocational training to meet the requirements of the local labor market and increase participants’ employability is to partner with educational institutions (high school, vocational training, community colleges and universities) to use the PPP or cluster as a learn laboratory for internships and local research centers that produce primary data, evaluate secondary data and produce industry statistics and value-based reports for stakeholders, decision makers, local authorities, researchers and the media.

Encouraged by the way its methodology performed in the pilots, Mercury Advisory Group plans to apply it to other locations in which the firm’s consulting assignments are awarded. We are certain that as we go further with this approach for the health and wellness tourism sector, we will learn lessons to help us help our clients to create a lasting impact for more and more health and wellness tourism destinations throughout the world.

Mercury Advisory Group is currently conducting assessments in five additional locations—mainly in the USA and in parts of Africa, Europe, the Caribbean and Asia—that are scheduled to be completed in 2017. We continue to receive strong interest in our ability to help health and wellness tourism clusters to reorganize with better goals, objectives, missing infrastructure and organizational process. We will use the results from these assessments to continue to publish best practices and increase our clients’ programs’ effectiveness through the Center for Health Tourism Strategy and further optimize Mercury’s client services portfolio.

The Mercury Advisory Group SROI impact-assessment methodology affords its experts and clients a unique and powerful lens for understanding the long-term effects of health and wellness tourism cluster and PPP programs. Core elements of the methodology are broadly applicable to other organizations operating in the social sector and could prove highly valuable to those organizations.

One additional lesson learned through a hospital construction feasibility projects in both Northern and rural West Africa was that SROI impact can be measured even when medical tourism is not contemplated and the intention is a project solely for the use and improved health access for locals.

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If you would like to discuss how Mercury Advisory Group's impact assessment can benefit your health and wellness tourism cluster or PPP organization or local health services outlet in 2017, please feel free to contact me. +1.303.823.4662.