image of Which Destinations Will Benefit from a Tourism Boost through Health Tourism Destination Growth?

This past week, I made an observation while completing my research for a client project to develop a health and wellness tourism strategy. I had the occasion to review statistics from the World Tourism Organization, Yearbook of Tourism Statistics, Compendium of Tourism Statistics and data files (Private Sector & Trade: Travel & tourism) and examine number of arrivals and international expenditures from tourism between 2014 and 2017 for the country I was researching and the surrounding region.

I happened upon this graph (below) that indicated that several of the countries including the one I was focused on had almost "flat" arrivals growth in the period from 2014-2017.

As I worked on the client's strategic plan and road map, I noticed something odd about the comparative data shown in the tables above. The data presented were very different than I expected. My expectations came from my experience in the other listed countries along with my knowledge of the market and direct observations. The data presented in the statistical tables seemed inaccurate by a significant amount. But I couldn’t put my finger on exactly what was “off” or why it didn't make sense to me. So, I kept digging to find the reason for the discrepancy, rather than simply accept it and base my output on their data and simply cite the source to point a finger of blame if it turned out to be wrong. After all, blame is unimportant, really. The client isn't paying for a report that isn't right. The client is paying me to produce a tool that works to achieve their objectives. Exoneration for a useless output was irrelevant.

Mired in the muck of statistical data

The problem I encountered as I attempted to analyze the data became more evident, the more I continued to dig for answers, the deeper into the mire I found myself.

In the business of health and wellness tourism, there are many so-called experts and consultants who sell expensive but uninformative reports, copy-paste strategies that appear on the surface similar to those that other countries have followed, and baseless recommendations made from assumptions and interpretations of raw data. They include in their high-school book report caliber outputs, quotes and cited information from desk research. They have no personal knowledge of the destination, its capabilities, brands, service mix, and observable foot traffic. Some end up so far from reality that the work product is an expensive 50 page PDF that appears to be what the client asked for, but isn't. This is because the client is like the person who enters the hardware store who asks the clerk, "Where are the drills? I want to by a drill."  No the client doesn't want to buy a drill. The client wants to make a hole that meets his needs.  The drill just seemed to be the easiest way to describe his objective and key result: a hole that is the correct diameter to serve as aperture to pass through something.  How would it work if the clerk dutifully took the customer to the drill section handed him the most expensive drill and the most expensive bits they sold, and sent the customer to the cash register to pay? That's exactly how a lot of medical tourism consultants work around the world. You ask for a drill, and by golly, they will hand you the only drill they sell: a platinum-plated 1/4 hp drill and the platinum-plated bits to go with it. To this consultant, it matters not what the material is that the customer needs to remove. What matters to that consultant is that you asked for a drill and they have the only one they sell. After all, to the best of their knowledge, it "worked" for their previous clients, so that is the basis of their assumption that it should work for you. Does that make sense to you?

Lately, one of these $50,000 reports paid for by European Union public funds floated through my inbox courtesy of an industry colleague. The consultants were persuasive enough to sell their ultra-platinum drill. As I read through the document, I can imagine how disappointed their client must have been. But, in all fairness, two things came to mind. The consultants are attorneys. They know how to characterize deliverable in a contract to protect themselves from allegations of breach. I am sure they delivered the ultra-platinum drill and platinum-plated luxury drill bits as described in their contract.  That's a very common trick in consulting. The client has no clue how to specify the aperture they require because they aren't quite sure how to specify it. They are expecting the consultant to know this.

Some consultants will seize the opportunity to sell the ultra-platinum drill and drill bits.  Hand them the drill, escort them to the cashier, and open their wallet for them and place their purchase in the pretty paper bag to carry home and "see if it will work".  As the customer leaves, they wave goodbye, yell "good luck", and gleefully dance all the way to the bank while Pharrell Williams' "Happy" song plays in the background.

Others, me included, will require more information to be able to advise the client. The information we'll request will be information about the objective of the aperture, what needs to go through it, and what the material is that must be removed. That way, as experts, we calculate the feed rate, the tool diameter, the material removal rate in cubic inches per minute, and in turn can advise the client that their objective and key results can best be met or exceeded by a drill that has a specific spindle horsepower and a specific motor horsepower to achieve a specific spindle torque. No more; no less. We then show them all the drills we can offer, or tell them we don't sell the best drill to meet their needs and direct them towards the store that does.

Either way, the clients were handed exactly what the contract specified. A stack of pages with words on them.

What's done is done. The tiny country probably doesn't have money for a do-over. There's also been some talk in the industry that the contract may have had some additional "unpublished agendas". Gossip in medical tourism is a big problem. But in reading the report, I suddenly discovered the a different problem, or at least one of the problems. A big one, in fact.  And it was much bigger than any single consultant attempting to create a medical tourism destination strategy.

When crafting a strategy and the associated action plan to execute on it, there must be some baseline data about the general and health and wellness tourism already happening in the reference country, assuming there is some, and that it is measurable. Without that, we have no starting point. A starting point can be zero, but in my experience having worked in 59% of the countries in the world, that is actually quite rare.

Medical tourism begins in most destinations, right or wrong, good or bad, effective or not, by a few physicians and/or a health facility (hospital, clinic, same-day surgery center) that decide to act on one's own and against expectations to pursue their own interests. This is referred to as "going rogue." Perhaps a colleague physician refers a patient from a distant town or another country for a consultation or medical/dental treatment. The receiving consultant/surgeon thinks, "This was great. I'd like more of these patients. I'll advertise that I am globally-renown because, after all, I am. This patient came from far away to seek my advice and treatment. It's not a lie. I have proof. I'll hire a facilitator to do my marketing, pay them a portion of what I charge the patient for their services, and I will grow my medical/dental tourism business and help people from all over the world."  Five other local physicians and surgeons observe what the first doctor is doing and they say, "Hmm. I can do that. And my cousin has a little B&B where patients can stay." and so it begins.

The physicians have no clue about tourism statistics. They may not even have a clue of their own relevant statistics. They have unclaimed appointment times and excess capacity. They know little about tourism other than they've traveled on vacations and they know it takes a little planning, research, a decision about where to go, booking a hotel, booking travel passage, and researching attractions and activities to do on arrival. In this case, the activities will be the physician's/surgeon's services. Simple as that.

They talk with the hospital owner or administrator, the hoteliers, make a website, and attend some medical tourism conferences. They meet facilitators, match up, and exchange contact details and pricing data and just like that, they are in the business of medical tourism. That's the beginning and ending of their preparation and investment. The facilitator will take on the risk of marketing and advertising costs.  If only it were that simple to plan, launch and grow medical tourism business that way.

Now leap a few steps forward. These rogue physicians and surgeons might gain a little traction. A few cases a month. Patients come from other cities in the same country or other countries. One by one. Nobody in any official capacity asks these patients why they came or measures their arrivals. Medical care is, after all, private and confidential. It's nobody's business why they are there as long as it is for a lawful purpose, there isn't even a place to record the data on a form. The options being recorded on arrival, if recorded, are "leisure, business, MICE." so they declare "leisure".

What I learned after digging through the published data was that sources and collection methods for arrivals differ across countries. In some cases, data are from border crossing statistics, and supplemented by border surveys. In other cases, data are from accommodation establishments. For some countries the number of arrivals is limited to arrivals by air and for others to arrivals staying in hotels. Some countries count arrivals of nationals residing abroad (Diaspora) while others don’t include them in the enumeration.

For as long as the trickle business continues, it remains largely unmeasured. Not reported. Not counted. If we have no way to count up or down and no baseline, how can we improve the flat lines in the graph above? But make no mistake, the medical tourism is "happening". The arrivals are "happening". Whether or not they made it to the World Bank data tables is an entirely different matter. And this was the explanation for the difference between the data available for desk research and my experience in these countries from direct observation and knowledge of the market. The data was not "wrong". It is what it is, as a product of how it was gathered. What one does with the data is another matter entirely. Just like a lab result on a blood test. The interpretation guides the direction and intervention and road map to meet the objective and key results.

The data doesn't infer anything.  It simply exists. The skill and experience and expertise of the data analyst and interpreter transforms the data into information and then forms the strategy and action plan to move forward...and grow the business of health tourism.  But would any professional consultant agree to create a strategy and action plan in the absence of data?  Sadly, the answer is yes.

"What's measured improves." -- Peter F. Drucker

Without analytics, any business strategy is at risk. but the data must be reliable and you must know how it was gathered, why, and by whom. Then, afterward, you must know who did the interpretation of the data. It is possible to simply use World Bank data to compare general or health and wellness tourism arrivals across countries, cite the source of the data and hope for the best. (That takes us back to the ultra-platinum drill sellers who are still dancing to Mr Williams' hit song.)

Words in a strategic plan can be a copy-paste output. Execution cannot.

In medical tourism, there are many novice consultants ... and a few charlatans. That's to be expected. Health tourism is a relatively new category of tourism.  But so far, it is the only business I know where certain conference organizers and people who became ill or injured while on a vacation purport to be expert medical tourism strategists. That's as daft as neurosurgery conference organizers purporting to be subject matter experts on neurosurgical treatment plans.

As such, they take on a big project for big publicly-funded projects, perform inadequate research, and assume the data means one thing when it really represents something quite different. They want to finish the project, assemble the report, collect the check, dance all the way to the bank, and move to the next consulting project.  The client is left standing in place holding a report with an empty bank account and no way to execute. Words in a strategic plan can be a copy-paste output. Execution cannot.

I've determined that, while valuable as a starting point, the research and methodology in the World Bank data on its face is not sufficient to serve as the sole desk research for making strategic assumptions and action plans about targeting medical tourism patients. But often, that is the only data available. The country may not have a tourism board with a budget to do more.  One must really dig to find out what exactly the data represents. It may not be appropriate for use to compare across competing countries in a region, a medical, dental or wellness specialty or even the general tourism receipts.

One step closer to failure

When one makes assumptions and creates recommended action plans in reliance of bad information, it can contribute to fatal errors. The client and the consultant might misinterpret the data and never learn how the research was gathered, enumerated, or defined. The client may attribute more skill and experience to the analyst than deserved. The result could be devastating. I believe the captain (Edward Smith) of the RMS Titanic did exactly that. Under his command, the Titanic collided with an iceberg in the dark of night. We know how that lack of data and experience ended up, don't we?

What's important --and what isn't

What I realize after 30+ years in the business of medical tourism destination development over time but never once articulated in the past is that the research must be studied in a microcosm of that country, its primary data and an understanding of how that data was gathered, and its inclusions and exclusions. That is acceptable if one knows the industry, the ground rules and how the baseline data was collected and interpreted. One can create a strategy, an action (tactical) plan, and establish the metrics to prove the strategy worked or if it didn’t, and measure what the tourism growth or decline was in the city, region, or country. Without valid research and experience to inform the strategy, we have a few options on what to believe as to why someone would proceed to craft a strategy without the data and experience: a) Nefarious intent to produce a "cut and paste" variation on a theme of a previous strategy (also referred to as "cookie cutter") and sell it to vulnerable client prospects eager to win some race to the marketplace; b) pure ignorance and excessive hubris, or c) motivated by fast cash with total disregard to building a reputation and brand as a consultant for the future. In each case, the client suffers.

In my professional opinion, comparison against other locations is really not all that important. Essentially, it’s a number.  But it is remarkable how many clients ask me to do this for them.  Are they simply asking me where the drills are? Is it that they aren't sure which drill they need?  Is the cross comparison what they need? Is it actionable? Will it lead to satisfaction of their objectives and key results? That depends on what the objectives and key results may be.

Some clients (and medical tourism bloggers) use the number to claim bragging rights or for positioning on published ranking lists. While the number in the ranking is merely one of many to be examined and considered, the country-by-country or destination-by-destination comparison list isn’t necessarily essential to the strategy to grow medical, dental or wellness tourism.  In 2010, a so-called consultant published her list of Top 10 Medical Tourism Hospitals in the World.  For years, I had clients tell me they wanted to make "the list." I had to delicately explain, on my best behavior, and point to the public and industry rebuke that followed, and how the list was a gimmick, and that when pushed, how the consultant admitted how the list was compiled. Again, is that a drill or a hole, or something else you need?

Who cares where you are "ranked"? Are you more interested in trophies and accolades or cash? Sadly, some in the business of medical tourism are so focused on awards and accolades that they actually pay to receive them!  They pay "entry fees" to enter their story and then spend USD $20,000 on flying the team to an event to receive their award and have a photo op. That photo op means what exactly? Facebook content? LinkedIn content? So now they have the plaque on the wall, the photo op is over, the posts are on social media, the congratulatory remarks are finished. What did it gain them? Did prospective patients see the photo posts? Possibly, but not likely.  Did it convince the prospect to travel to the award-winning destination? No. Did the recipient of the award generate cash directly attributed to winning the award? No. In fact, the award recipient is out $20K! That needs to be neutralized before any profit taking can begin!  Being listed in a top this or that listing in a consumer magazine gives momentary recognition and mention to a place. Okay, so yes, I've heard that there's no "bad" publicity. Is there low value publicity? I believe so. Does the publicity grow arrivals, curiosity or revenue? Not often.

Articulating objectives and key results

In the book, Measure what Matters, (John Doerr, Penguin Group, 2018) he emphasizes his recommendation to set objectives and key results (OKRs).  Before you hire a consultant for medical tourism, please read this book so you can articulate your objectives and desired key results. You'll be a better consumer of consulting services and may save yourself a ton of money, months of wasted time and opportunity and fatal mistakes in strategy.  The book is an adaptation of Peter Drucker's Management by Objectives. You'll be better prepared to identify and articulate for your consultant exactly what you want to align and focus everyone's efforts on as the most important priorities and connect the work of the team on what truly matters: Quick wins? A pilot to test proof of concept? To start small and test and scale? Or to go big and go loud regardless of what happens 3-5 years downline? Since about 2008, there are actually several countries that share the latter objective in the health and wellness tourism space. They all seem to have a common denominator: The consultants mentioned previously with the $50,000 platinum-plated drills for sale.

What is important, in my professional opinion, is knowing what to message, to whom, where, why, how often, and the revenues from tourism. That revenue translates to jobs at various skill levels, contribution to the national, regional or local economy and tax generation and tax relief per household that is realized from health and wellness tourism receipts. That, to me, is where the rubber meets the road.  I work with clients who want this objective. My clients state to me, “I want to accomplish ‘X’ Objective as Measured by ‘Y’ Key Result.” If they will not or cannot state this, I refuse to work with them. I only have a few openings per year for these projects, so I choose carefully the ones most likely to succeed from among the invitations to consult that I receive each year.  There are other consultants available to help them willing to insist on less specificity to begin working on their project.

After 30+ years earning a living as a consultant, objectives define what my health tourism consulting clients seek to achieve. It goes right into my contract. The key results my clients articulate are those that are the top-priority goals that the client wishes to attain. They expect me to produce a tactical plan that can be executed with specific, measurable actions within a set time frame. If that doesn't happen, there had better be a very good reason why it didn't.

Objectives and key results link objectives across the silos of health tourism economic development listed in the image below.

Just getting all these stakeholders to the table and getting them to agree to agree on the most basic objectives and key results is a huge challenge in many destinations.  These are the public sector stakeholders. Their focus is usually on policy, regulatory legislation and compliance, transparency, and accountability. But not always. Sometimes, elections and getting re-elected or re-appointed by the newly-elected administration is their agenda and all this other stuff is secondary. Then there are the private sector stakeholders to organize. Those that went rogue as first movers will arrive in two groups: The ones that realize something is missing and are open to input and different options, and the ones who have the hubris to believe they know everything and are not open to other ideas. Their objectives in the latter group are to make money, make a reputation and to hell with anything anyone else wants or needs.

Who's right? They both are.  I have developed a coping approach over the past 30+ years. I figure out what will work and if I am the one to help them meet their objectives and key results, identify which group is my client and which is not.

Generally, it turns out that the public sector and the ones in the first group of private sector stakeholders are the clients and the latter group who know it all and are focused on their own self-promotion at all costs... are not. I don't keep trying to poke the latter group and prod them into compliance. I leave them to their programs.  Some come around and join when they watch the success zoom past them. Others never come around and sometimes, they give up and go do something else. No boost in general tourism arrivals will help them, specifically. They are on a different pathway. That's their prerogative. Leave them to it. If they make it and meet their own objectives and key results, congratulate them!  If they decide later to join, and they meet the standards and criteria to be identified with the group I created and helped mobilize, great. Welcome them!

Health and wellness tourism has hit a turning point. No longer are the most exciting conversations about whether to pursue health and wellness tourism; today they’re about how best to go about it. As health and wellness tourism evolve from a novel idea to an export with real growth potential in some areas, health and wellness tourism evolves from an abstract concept to fully developed policies, standards and regulations. But there are complicated questions to answer first.

At most destinations, we’re not starting from scratch as I explained above. Every one of the 160 of the 195 countries (82%) in the world that has announced interest in developing health and wellness tourism export products and services offers important lessons about how seemingly small details can play a big role in shaping the industry, for better or worse. In some cases, where formal organization has been attempted, provisions around taxes or licensing and enumeration systems to measure market growth and progress have made significant impacts on what the market looks like—or even whether that market will be supported by the public sector, to what extent and for how long (in terms of general elections and political platforms and changes in administrative agendas and the pursuits of certain cabinet officials across the 9 pillars above).

In the case of my research, I wanted to know how an increase in arrivals volume for tourism in general correlates to the growth or potential growth of health and wellness tourism income. There’s an old saying ,“”Correlation does not imply causation”. This statement is used to emphasize that a correlation between two variables does not imply that one causes the other.  If we increase the tourism arrivals through general tourism, that does not imply that the health and wellness tourism receipts, production and capacity will also increase. However, if we go the reverse, a boost in health and wellness tourism arrivals will positively impact general tourism arrivals, but only if the country counts their tourism arrivals that way.

First, ask... don't assume why people came to your destination and what they plan to do when they arrive.

If you try to sidestep the data in the World Bank tables without a clear explanation, investors and stakeholders who only see those numbers and have no information about how the numbers came to be, you'll spend a lot of time explaining the methodology. Be transparent. If you built the strategy in a vacuum due to lack of data or lack of reliable data, declare it for the record. Then people have eyes wide open about the risks they are planning to undertake with execution. Progress and growth may start out slower than you like, but like the fable of the Tortoise and the Hare, you'll get to the finish line.. and your objectives and key results... eventually. That's better than not arriving at your objectives and producing no results, right?

Surveys and direct observation are important. Without them, one cannot obtain the data for the baseline metrics.  So many projects to which I am invited have no baseline data. Do they expect me to make something up? Or do they expect me to obtain in from the World Bank reference data? That's not realistic.  But when I pause and suggest that they begin with the data collection, few countries wish to invest in the field research or data collection through surveys. They instead have their mind made up that I should simply tell them what to say to sell surgeries and consultations and which facilitators to meet and engage. I cannot and will not do that because it will do harm.

Three truths about medical tourism revenue growth and success

Allow me to share three truths about medical tourism revenue growth and success I've learned over the past 3 decades:

  1. If the country being studied for a strategic plan and tactical plan does not “ask” about the reason for the visitors’ arrivals in terms of health and wellness tourism, or the respondent isn’t forthcoming about their reason for their arrival, the data won’t exist to be gathered. If the country gathers data from hotel stays and accommodation sources, and the visitor stays with their companion traveler at the health facility which is not included in the counting system, the arrival data will not reflect that stay or head count.
  2. If the patient utilizes a not-for-profit hospital, academic medical center, or other clinic that does not pay tax on its earnings, then jobs are created at various skill levels and education and training are needed, but the tax contribution is lower and the tax relief per household is non-existent. The data is more difficult to gather and progress is harder to measure. And direct and indirect impact - may never be fully measurable or significant. This is one of several reasons why I tend to be reluctant to move towards activating not-for profit or public health outlets that are intended for the locals and crowd them with private medical and dental tourism patients. It is usually a mismatch on mission and service delivery.
  3. If corruption is at play and there is a gray or shadow economy as is a known fact in many countries, then income to private health facilities who are required to pay taxes but do not pay them also affects both the baseline metrics and the resulting metrics once the strategy has been executed. As such, it will be impossible to prove health and wellness tourism was a significant contributor to a destination’s economy, tax generation, and number of jobs inclusive of indirect impact, or how health and wellness tourism was positioned as one of the destination’s export.

Branding is a data-driven exercise; not a logo

As the number of competitor destinations attempting placemaking for health and wellness tourism increases, the reports being published that cite lower utilization of health facilities in that country equals lower arrivals of tourists in that country are also possibly flawed. It could be instead that there were simply more options from more competitors with similar health and wellness tourism offerings.

This, then, is the argument to support a need for professional branding, brand creation, messaging, targeting, psychographics, and integration into the marketing mix by the official tourism board. The official tourism board or agency is designated as the agency with accountability and budget to best select the most appropriate media, best messaging for the destination, and best markets to target to motivate people to visit - for any reason, among them health and wellness tourism activities. Then, only after the tourism board has done its part, can the individual health facilities and suppliers, health resorts and spas align and refine their “subordinate” messages, reputation, brand awareness, source country or region targeting, psychographics, ad placement, and competition within the city, region, or country. Without this integration and alignment, the local hospital who wants to join the health and wellness tourism competitive arena will be wasted much the same as if we had spent money and effort to install screen doors on submarines.

Here's how I view the matter of investing in the pursuit of health and wellness tourism as an export:

  • unless the tourism board is involved and has consented to include health and wellness tourism into its export products and services mix to visitors; and
    until the enumeration system of how visitors will be officially counted and data aggregated, and able to be externally and independently audited and verified; and
    until the official tourism board or agency has researched and determined through rigorous analysis, theme-setting, and a strategy to include and support health and wellness tourism arrivals as an official pursuit; and
  • until there has been consent to create a public-private partnership (PPP) hub, cluster, or management services organization; and
  • until the PPP can support the operational infrastructure to audit and collect tax receipts, study visitor satisfaction, collect clinical and patient satisfaction outcomes data, returning visitor data and customer lifetime value, measure and monitor purchases of specific items and services, measure specialty service line impact, measure indirect tourism revenue, tax relief per household, measure jobs impact, promulgate consumer protection laws, regulations and standards and an overarching theme for marketing, advertising, set standards and regulations and laws for international medical records and telehealth exchange, solid organ transplant for foreigners, and continuously monitor and assess training and professional development needs, skills, and training resources determined; then
  • there should be no legitimate reason to invest in a hub, cluster, or management services organization to create the needed health and wellness tourism growth support and infrastructure; and
  • until reliable data from which to create a rigorous independent marketing or branding strategy or growth strategy for a small clinic, individual hospital, or medical or dental practice in an obscure destination, that the small, unknown, unbranded, unrecognized independent sellers of health and wellness tourism at a destination that does not promote health and wellness tourism as an officially supported leading or burgeoning export will face insurmountable challenges to achieve ROI on any significant investment in marketing, stand rentals at conferences, and purchasing placements in media and advertising and advertorials, or spending money on influencer marketing, pay per click advertisements, or engaging with hundreds of medical tourism facilitators.

The mistake of "jumping to sales" strategies without the required preparation and research

A “jump” to sell without the necessary development in product or strategy or infrastructure is something I’ve encountered from independent consultants to big name international consulting firms. I know about these attempts because the project proposers have invited me to collaborate on their projects and proposals to governments to develop medical tourism at destinations on five continents. I’ve declined each of them because they had already formulated their theme and proposed strategy. They believed they could simply “jump” to selling appointments at individual clinics without the necessary grasp or consideration of the preliminary development work required.  In the earliest stages of health tourism startup at a destination, the rogue stakeholders and first movers may struggle to make revenues with that fast track, easy way strategy. Yes, they'll point to a few wins, but a few wins does not equate to a thriving, sustainable export service or product. It's anecdotal, unofficial, and unsupported. The race will only last so long.  Slower, but steady progress is better while making every step and every dollar and every hour invested count. But we cannot count without the baseline details and a declaration or explanation of how the data came to exist. Then, as Drucker asserts, "What's measured improves." Set the metrics at the same time as the strategy. They are not carved in stone. They do not require perfection. They can be good enough. As Voltaire said, “ Perfection is the enemy of the good.” Get to "good enough" and get started. You'll change goals, objectives, desired results and metrics along the way, and more than once. It is a continual improvement project. That's normal.

The data to build and grow health and wellness tourism as an export is not the same as that which is needed to grow general tourism

Information about general tourism growth is often based on rigorous analysis of data by an expert familiar with tourism arrivals and overnight stays along with balance of payments information. But when it comes to health and wellness tourism, transplant tourism, pharmacy tourism, stem cell tourism, surgery tourism dialysis tourism, executive checkup tourism, cosmetic and aesthetic services tourism, the data does not completely capture the economic phenomenon of tourism. Nor does it provide the information needed to strategize effective public policies, infrastructure, training needs and capacity development, or defend the argument that a hub, cluster, or management services organism is warranted. I need the data about the general tourism statistics and survey responses to help me build the health and wellness tourism strategy. That general tourism data tells me what has been studied without needing to replicate it. But if it is missing or inaccurate or not well analyzed and interpreted, the potential risk of a mistake is great.

In several instances, the consultants who invited me to participate on their project proposals (incidentally, none were ever awarded to them!) merely wanted a recognizable expert's name and brand as “window dressing” for their proposal. In the case of one consulting firm in Northern Africa, they believed they “knew it all” and merely wanted my name on the papers as a rubber-stamp endorsement and access to my list of facilitators to be able to fast track to implementation of the strategy to claim the win. They wanted no input drawn from my expertise because it conflicted with their recommended strategy. They wanted the check and the notch on their belt. I refused to participate. I won't take every offer of a project that isn't right for me or that I know is doomed to fail.

195 countries, 82% want to export health and wellness services

There are 195 countries in the world today. At least 160 have announced intentions to build medical tourism export products. Not all have a chance to succeed as defined by their own goals and objectives. Many will use development bank loans and structural funds to pay these consultants and get a set of documents in their hands. The value of said documents are more often than not, dubious if not downright useless.

Want proof? Just look at the reports and recommended strategies that have been paid for by public funds and development bank-funded projects since 2008, the medical tourism clusters built by some of the consultants claiming success and experience, and the expenditures on failed strategies of event sponsorships, stand and “destination pavilion” rentals, co-publishing agreements for destination directory books featuring hospitals and clinics, pay-per-click medical tourism directory websites, award competitions to win plaques and trophies, international hospital accreditations that nobody recognizes, and other tactical executions. Then trace the results and follow the money. Where are these countries now? Floundering, flailing, struggling, or they’ve abandoned the project altogether. Gone. Vanished.

Exactly how much money was earned from the consultants' outputs to help clients develop jobs and economies in those countries? How much tax relief per local taxpaying household was realized? How much community development was realized? No, that was not medical tourism development that was import balance of trade payments. They imported the consulting services but they really didn’t export health and wellness products and services, did they?  And for many little developing nations, once that money is gone, they are finished. I've seen it again and again in country after country, destination upon destination. 160 starts. How many will meet their objectives and key results and move forward and continue to grow?  Will yours be among the lucky ones?

The available data I encounter when summoned to a destination that desires to enter health and wellness tourism at an international or domestic level often fails to capture the economic phenomenon of tourism or provide the information needed for effective public policies and efficient business operations as a baseline. Without a baseline, how can effectiveness and success over time be measured?  Without a supporting tourism authority stepping up to say, “Yes, we are interested to commit to and support health and wellness tourism and develop it as an export and set in motion the needed infrastructure to jump start the entry into the sector.” the project is more likely doomed to be judged a waste of time and other precious resources.

Success is generally measured by how well clients succeed in meeting their stated objectives. Information on the role of health and wellness tourism in national economies is extremely deficient. Although the World Tourism Organization reports progress in harmonizing definitions and measurement, differences in national practices in enumeration prevent reliable comparability between nations, destinations, individual facilities and practitioners.  There are other technical ways and social sciences methods that are better to measure certain results.

Arrivals data on a country-by-country basis measures the flows of international visitors to the country of reference: each arrival corresponds to one in inbound tourism trip. So when the media or a blogger or some publisher posts raw statistics of the “body count” arriving and declaring intention to seek health and wellness services as the primary purpose of their trip, and conference organizers use that raw data to attract stand rentals and sponsorships, we must first determine if the data is reliable and how it was enumerated. If most medical travelers come as couples, and only one is seeking treatment, then the body count of actual patients would be half that number, right?

In an accounting period, arrivals are not necessarily equal to the number of persons travelling (when a person visits the same country several times a year, each trip by the same person is counted as a separate arrival). If at one destination, an arrival is counted only once per person, per year and that person returns to the clinic for sequential treatments within the same accounting period, and is compared to a competing nearby destination in another country that counts every arrival, is that a fair comparison? Is it reliable? Is it actionable? NO! If an investment will be authorized to count, the count information should be useful. Do you agree? We don't buy drills to buy drills to say we have one. We purchase them for use as intended.

When arrivals data is reported, it should distinguish inbound visitors and indicated both domestic and international tourists and same-day domestic and international visitors. For example, Argentina has decided by national policy to exclude all same-day, non-resident arrivals and purchases from neighbor countries. And yet, Argentina has some absolutely spectacular and attractive medical tourism facilities and practitioners and an array of services that attract day-trippers who pay money for exported health and wellness services, all of which are not enumerated by policy. This revenue most likely far exceeds fly-in source market receipts, but is ignored. Why? Because people in charge of those data chose to set the enumeration that way. As a result, Argentina will never be able to compete on equal footing with other countries and boast its success or popularity in terms of bed days, receipts, tax relief, income from taxes, or indirect impact even though the growth occurs and services are exported. There’s just no way to measure growth because the baseline data is corrupt and incomparable.

In general tourism statistics, the WTO asserts that other types of travelers (such as border, seasonal and other short-term workers, long-term students and others) should be excluded as they do not qualify as visitors. So by WTO recommended statistical counts, Argentina is taking the literal approach in its exclusion of neighbor country receipts. I don’t agree with this literal approach. If someone gets on a plane from a rural area, travels to Buenos Aires to check into a hotel, chooses restaurants to eat empanadas and drink Quilmes, or partake of fine dining and feast on amazing beef and consume Argentinian wines, and pay a private, tax-paying clinic for health and wellness services, but they happen to be domestic travelers from within Argentina or from adjacent countries, why isn’t that revenue and tax relief and indirect impact counted?

Before a consultant can begin working on creation of a health and wellness tourism strategy and tactical plan, the consultant must first review the data and understand how it was gathered and interpreted from all the possible different sources: administrative records (immigration, traffic counts, and other possible types of controls), border surveys or a mix of them. If data are obtained from accommodation surveys, the number of guests is used as estimate of arrival figures; consequently, in this case, breakdowns by regions, main purpose of the trip, modes of transport used or forms of organization of the trip are based on complementary visitor surveys. If that data and its interpretation is unavailable or fails to provide a the basis to create a meaningful baseline from which to lay the foundation for my recommendations and hypothetical rationale for my strategic recommendations and action plans, what’s the point of doing the project?

Tourism, and more specifically health and wellness tourism, are regarded as a directly measurable activity, enabling accurate analysis and effective policy. But if the destination seeking to hire a consultant to help them grow their health and wellness tourism exportation has no data, has not collected the data required, or has chosen to count their baseline statistics in a way that makes little sense, the project takes on risks of flawed assumptions and a basis of unreliable approximations from related areas of measurements (e.g., balance of payments, arrivals data, purchase data, hospital bed days, average daily inpatient revenues, outpatient revenues, etc.)  Health and wellness tourism when private, tax-paying health facilities and practitioners are involved (assuming they pay the taxes), makes health and wellness tourism a key driver of socio-economic progress through export revenues, creation of jobs at all skill levels, creation and investment into small to medium enterprises, infrastructure development and tax relief per tax-paying household. If there is a potential for export product development it is possible that health and wellness tourism can evolve into a major trade category and a source of foreign exchange income at the destination.

Branding, messaging, specialty service line promotion, key producer focus (health facilities, practitioners, resorts, spas, etc.) of independent clinics and hospitals is unlikely to produce measurable destination growth and substantiation of claimed successes as a key competitor in health and wellness tourism. I believe that this is a confusing piece that many public sector officials need help to connect the dots. In reality this is happening sequentially at two different levels: The public side sets the overarching destination brand, message, theme, focus, etc. and the private sector stakeholders sequentially follow once the theme of the destination has been officially set. Together the marching cadence is established and the two move forward collaboratively.  For each parade, the theme, brand message, capabilities, goals, objectives and targeted results could be different and all could be correct. The mass production copy-paste approach to health and wellness tourism destination development can be detrimental because it could cause an otherwise capable destination to pass over its most promising assets and opportunities.

Without the ability to measure growth and market penetration with quantifiable, externally-validated, independently audited data about health and wellness tourism, we may “see” growth but we won’t be able to compare it across nations, or make meaningful claims about trajectory, or take guidance from the statistical data over time to learn where to focus efforts and attention.

And you thought this article was going to contain yet another meaningless and useless list of destinations! Sorry. It just isn’t that simple.

About the Author

Dr. Maria Todd is the founder of the Center for Health Tourism Strategy. She has over 35 years developing health tourism destinations and is a vocal advocate for adding health and wellness tourism services as an export product and the use of standards, regulations, and formal organization of the health tourism sector.  Learn more about her expertise and background on her blogs, on LinkedIn, from her internationally-published trade and professional books, and her Website AskMariaTodd™.

Twitter: @AskMariaTodd