Research articles

By Ms. Sindhu Joseph
Corresponding Author Ms. Sindhu Joseph
GPM Government College, Manjeswar, Kerala, India, - India 671323
Submitting Author Ms. Sindhu Joseph

Medical tourism, Realm, Bootstrap, IFC, Sustainability, Healthcare

Joseph S. A Bootstrapped Realm- Ayurveda: The Strategy for Sustainability and Development for Medical Tourism in Kerala. WebmedCentral INDIAN MEDICINE 2012;3(2):WMC003080
doi: 10.9754/journal.wmc.2012.003080

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Submitted on: 23 Feb 2012 01:46:05 PM GMT
Published on: 24 Feb 2012 07:01:03 AM GMT


The concept of medical tourism is almost as old as medicine itself. Kerala has emerged as hub for state-of-the-art Ayurvedic healing. Ayurveda, the Indian system of medicine, is deep- rooted in Kerala from time immemorial. This is an outcome of a study under which the investigator gathered data by visiting Ayurvedic hospitals, patients, healthcare professionals, etc. This study presents the ground realities of medical tourism in Kerala apart from the perceived aspect. This study envisages evaluating the facilities and services provided by the hospitals for medical tourism in Kerala thus trying to foresee the future scenario of medical tourism in Kerala. In this paper, the expectations of  medical tourists and the experience they had is analyzed for giving a clear picture about the success level of  medical tourism in Kerala as of now and that will give the pitfalls in the areas concerned as well.
Key words: Medical tourism, Realm, Bootstrap, IFC,  Sustainability, Healthcare.


Medical Tourism
Medical tourism or medical travel is the act of traveling to other countries to obtain medical, dental, and surgical care. The International Union of Travel Officials first designated medical tourism as a commercial activity only in 1973 (Milica Bookman: 2007). India is contemporary global center for medical tourism, and it offers everything from alternative Ayurvedic therapy to coronary bypasses and cosmetic surgery. Kerala’s strengths in Ayurveda and modern medical technology combined with strong marketing skills have helped the medical tourism industry grow in leaps and bounds. Now the slogan can be:
Medical Treatment in USA = A tour to Kerala + Medical Treatment + Savings.
Many tourists have now realized that Kerala has a pool of trained doctors and nurses and an excellent network of hospitals that offer international standard treatments at very affordable prices. Previously residents of Kerala working abroad, especially in the Persian Gulf countries, would return to India for medical treatment make recommendations as well. Now International patients too have realized the advantages of traveling to Kerala and the medical tourism industry is picking up momentum. Faced with exorbitant fees for procedures such as cardiac surgery, dentistry and cosmetic surgery in their home countries, patients from the West and the Middle East have begun looking at Kerala. Kerala doctors and nurses have established themselves as highly skilled and conscientious caregivers worldwide. Their reputation has led to the growth of the medical tourism industry in Kerala. The excellent hospital facilities, pre and post-treatment care and pleasant climate make medical treatment and recovery in Kerala a positive experience. A holiday coupled with treatment is something, which we would not have thought of in our wildest of dreams before, but today it has become a reality as the total cost, including airfare, hospital expenses, hotel accommodation and the added tourism experience, works out very economic in comparison with the surgery cost in the developed nations.
There has been a trend of healthcare practitioners from other countries such as Japan and South Korea visit Kerala to attend trainings in Ayurveda healthcare practices. Such practitioners set up their hospitals in their home countries after completion of their training. In addition, many entrepreneurial Indians have set-up their Ayurveda hospitals in various countries such as the US, the UK, Canada, and Sweden, Switzerland etc. The trend is expected to continue in the near future and it is estimated that the global Ayurveda healthcare industry would be about USD 5,000 billion in 2050[2]. According to recent estimates, the market size for Ayurveda healthcare in India is about USD 1.4 billion. This includes exports of herbal raw material and medicines worth more than USD 700 million per year. Further, the Ayurveda healthcare market in India is expected to grow at about 20 % per year during the next five years [2]. According to the CII-McKinsy report, medical tourism industry in Kerala is expected to be worth $4 billion by 2017. This sector will bring in as much as $2 billion by 2012 as compared to an estimated $333 million in 2006-07.

Health Care and Kerala

Kerala possesses the finest health indices in the country. Kerala achieved its health status at par with that of USA spending roughly $ 10 per capita per year while USA spends $ 3500 per capita per year on healthcare (Health and wellness-stark world). Kerala is on par with U.S in longevity and standard of living aspects. With high literacy rates, public distribution system of food, easily available public medical system (three tier system-the primary health and the community centers, taluk and district hospitals, medical colleges) as per in 1995 Government decentralization of healthcare sector, medical pluralism consisting of both formal and informal traditional medical systems, with several unique characteristics, Kerala bags this credit [3].
Kerala is known as a land of medicines alternative medical therapies such as Ayurveda for many centuries and has a long history of a well-nurtured health system. The state of Kerala is   the main generating region of ‘medical –paramedical staff of the world. The Confederation of Indian Industry (CII) has declared 2006-2007 as Medical Tourism Year in Kerala. Kerala is being promoted for its cheap health care and medical tourism packages are especially desirable because of the scenic surroundings, including the famous backwaters and houseboats. The Department of Tourism in Kerala in partnership with CII organizes a show and international conference on medical tourism, which is attended by prominent medical tourism hospitals, medical insurance companies, and travel operators. "Kerala has an immense potential to develop the scope of health tourism in the country. It can become the hub and one of the most preferred destinations in the world for potential health tourists," Sri Lankan Minister for minor export crop promotion, Reginald Cooray, opined on an international conference and exhibition on health tourism, Kerala Health Tourism 2011. Low cost is the norm today without compromising on the quality and it is this ‘cost -effectiveness and competency’ bundled and packaged well with amazing tourism products of Kerala.
Ayurveda, the Indian system of medicine, is deep- rooted in Kerala from time immemorial. Though Ayurveda is practiced all over India, Kerala is perhaps the only State where this science of medicine still follows age-old traditional laws. Because of Kerala’s unique location, its natural wealth, and rich culture, the system of Ayurveda- practiced here has developed certain characteristics different from those observed elsewhere. Kerala has an unparalleled wealth of herbs and natural vegetation. However, similar herbs and plants may be found in the Himalayas, those found in the State have a special potency due to Kerala’s unique geographical position and tropical climate. Even for classical Ayurvedic preparations. The practitioners of Kerala have evolved their own formulations that are superior in effect. Various forms of treatments are offered to patients in Kerala, which are varied in duration. Some of the treatments like massages and rejuvenation therapies are done during monsoon when the atmosphere remains dust free and cool, opening the pores of the body to the maximum, making it most receptive to Ayurveda herbal oils and therapy. The climate in Kerala is tropical and the temperature varies from 180C to 370C. Rejuvenation is the major purpose of Ayurvedic tourist arrivals (78.9%) followed by curative purposes and 89.5% of the visitors like to revisit the Ayurvedic centers again [4].

Ayurveda - A Bootstrapped Realm

Kerala medical tourism based on Ayurveda is receiving customers from Middle East, Europe and developing countries (low GDP countries) and are motivated by the comparatively cost effectiveness, personal and quality care (Refer Graphs 1and 3). Many tourists are coming from the neighboring countries as the cultural assimilation is easier and easy accessibility. NRIs and other Keralites are there at the forefront for promoting Kerala by giving attractive packages to them. However, the perception-reality analysis indicates that there is a slight difference in these two variables, which calls for conscious and coordinated efforts from the service providers and the competent authorities (Refer Table 1). Leisure component contributes comparatively little to the industry as it is slowly picking up momentum. Now the phenomenon is merely ‘medical travel.' There is an increase in supply of medical tourism products especially in Ayurveda treatments; leading to greater competition and commerialization.There is a chance for Ayurveda and its products to become ‘pseudo products’.

The research shows the absence of an effective follow up care, which makes the potential and actual customers in a dilemma. There should be assured after care system through proper legislation. Quality rather than quantity should be ensured for managing and developing the medical tourism product. They should reconsider their pricing strategies keeping in mind the fact that not all the foreigners are price in elastic. English linguist capabilities of the medical and paramedical staff may be considered as a serious bottleneck of the industry.

The main source of promotion is word of mouth and that should be sustained through the provision of quality of services. The NRIs and Keralites also act as ambassadors of promotion. Medical tourism destinations’ “creative” marketing strategies predominantly use the Internet as an electronic marketing tool to transcend national borders. There should be concentrated and objective oriented promotional efforts, which can make use of other tools of marketing as well. Both the service providers and the governments should actively promote the destination as a medical tourism hub.

Need for Joined Effort
The health and tourism industries should link up to provide medical tourism packages through their websites and brochures, a strategy actively employed by regional competitors like Thailand, Philippines, and Malaysia. There is a lack of co-ordination felt between the key players of medical tourism – airline operators, hotels, hospitals and between Government and private sectors. Transform of Institutes for Collaboration (IFCs) into centers of innovation and competitiveness. The cluster should develop distinctive products, a market niche based on its strengths, e.g. resort- or spa-based cosmetic surgeries and tourism packages incorporating alternative healthcare such as Ayurvedic therapies, and massage. The health industry and the tourism industry should work together and make a concentrated and aggressive effort to market Ayurvedic tourism. Participation in forums and conferences on medical tourism will benefit the state. Develop a market niche and unique value proposition to distinguish itself in the face of strong regional competitors. The cluster should collaborate with major players in the global medical tourism industry to push for global health insurance portability. Both the government and the cluster should proactively and vigorously train skilled workers in medical tourism, insurance staff, and translators, which are vital for sustainability and growth of the cluster. The establishment of an efficient recourse system to deal with complaints would become the Kerala’s comparative advantage competing with countries such as Thailand and Malaysia. Provide readily available package medical services, for example, the Lakeshore Hospital, Cochin provides packages for general medical check-ups and a range of cosmetic surgery procedures, without the long waiting times. Government and hospitals should undertake capacity building programmes to train medical and non-medical staffs to handle the international patients. There should be focused language training for catering to the needs of outbound patients from countries of Middle East which is the major market, particularly Arabic.

Infrastructure Development
The viability and sustained growth of the medical travel industry is dependent upon well-developed transport system (i.e., air, land, and water transport) and well-developed infrastructure (i.e., airports, roads, power, telecommunications, etc.). The study reveals that the patients are much disturbed by the poor infrastructure of Kerala and the inhibiting social activities like hartals and strikes (Refer Graph 2). There should be an effective system to make sure that these disturbances are frustrating them anymore with developmental measures and corrective mechanism.
Role of the Government
There is very little / no government intervention/support in medical tourism industry. Government should make special effort to ensure on-time implementation of current and planned infrastructure projects, especially solid waste disposal system, new airports and roads linking to major tourist sites currently under construction. Attract foreign investment and partnership for medical tourism facilities, incentives, and rules encouraging cluster-based R&D and innovations, initiatives such as tax incentives etc. There are examples of Singapore, Malaysia, and Dubai where government has direct interest in medical tourism. Government can play a role of facilitator and regulator and should determine about the market and product.
Government may initiate efforts to have corporate/ institutional arrangements/tie-ups with an objective to tap the potential of countries /governments who are responsible for medical care of their citizens. Government should also take part in the medical tourism industry with competitive advantages along with the private sector, which would open up the competition and can break up their monopoly, which would automatically result in quality care. The government should bring out a medical tourism policy emphasizing the quality, cost effectiveness, and care.
The government can act as a facilitator for getting hospital accreditations and regulator for hospitals- both public and private and other stakeholders. Public -private partnerships (PPP) in healthcare should be encouraged. Government should institute a uniform grading and accreditation system for hospitals to build consumers’ trust. Primary, secondary, and tertiary medical facilities and services have to be offered to the patients and regulated by a proper mechanism.
The result of the study reveals that there is a positive perception among the medical tourist that Kerala is a medical tourism destination (Refer Table 2).


The author acknowledges the University Grants Commission, New Delhi for the financial assistance in the form of a Minor Research Project No. MRP (H)- 795/09-10/KLKA024/UGC-SWRO dated 30-Mar-2010.


1. Milica Z. Bookman and Karla R. Bookman, Medical Tourism in Developing Countries,  2007, Palgrave Macmillan,  New York      
2. T. Agarwal, January 13, 2011, Ayurveda – As It Is Today, Ayurveda and Sustainable Healthcare development magazine, 41.
3. Unnikrishnan Payyappallimana, Health System Development and Medical Pluralism in Kerala State in India, (Thesis), 2010.
4. Robinet Jacob, 2008, Health tourism  and Ayurveda, Abhijeet Publishers, New Delhi.

Source(s) of Funding

UGC Minor Research Project No. MRP (H)- 795/09-10/KLKA024/UGC-SWRO dated 30-Mar-2010.

Competing Interests



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