ISSN 2289-8506

Global Journal of Business and Social Science Review

journal homepage: www.gjbssr.org
GJBSSR, Vol. 2 (1), April-June 2015: 14-26

A Study of Brand Image, Perceived Service Quality, Patient

Satisfaction and Behavioral Intention among the Medical Tourists

Cham Tat Huei 1*,Lim Yet Mee2, Aik Nai Chiek3

1,2,3
Faculty of Accountancy and Management, Universiti Tunku Abdul Rahman (UTAR), Kajang, Selangor
Darul Ehsan, Malaysia.

ABSTRACT

Objective – This paper aims to examine the importance of brand image, and its impact on hospital
service quality as perceived by the medical tourists. Moreover, this paper also evaluates the
interrelationships among perceived service quality, patient satisfaction, and behavioural intention.
Methodology/Technique – Based on quota sampling method, a questionnaire survey was used to
collect data from 400 medical tourists to test the hypothesized relationships in this study.
Findings – The findings from this study indicate that brand image has a significant positive influence
on perceived service quality; and brand image is significantly and positively related to medical tourists’
behavioural intention (i.e., their revisit intention). The findings also show that level of satisfaction
partially mediates the relationship between service quality and behavioural intention among medical
tourists.
Novelty – This study is one of the very few empirical studies that examine the importance of brand
image in the context of medical tourism. Moreover, this study is also one of the few studies that
addressed patient satisfaction as a mediator in the healthcare context.
Type of Paper: Empirical

Keywords: Brand Image, Service Quality, Patient Satisfaction, Behavioral Intention, Medical Tourism
__________________________________________________________________________________

1. Introduction

In the current tourism landscape, travelling beyond borders for healthcare purpose is no longer
seen as a new phenomenon for the tourists of developing countries. This trend is known as
“medical tourism” where people often travel to other countries to obtain medical and surgical
care and holiday at the same time (Connell, 2006). The demand for healthcare overseas has
become a general pattern of consumption of foreign goods and services, especially in the Asian
countries (Bookman & Bookman, 2007). Rueters (2013) reports that medical tourism is
enjoying a significant growth over the years and that the industry is growing at about 20 percent

*
Paper Info: Revised: April, 2015
Accepted: May, 2015
Corresponding author:
E-mail: jaysoncham@gmail.com
Affiliation: Faculty of Accountancy and Management, Universiti Tunku Abdul Rahman, Malaysia.

ISSN 2289-8506 © 2015 GATR Enterprise. All rights reserved.

 Cham Tat Huei, Lim Yet Mee & Aik Nai Chiek

per year. It has projected that the industry is worth as much as $60 billion in value. There are
various reasons for the stimulated growth of medical tourism. They include deteriorating
standards of care in many developed countries, medical insurance issues, the long waiting list
of the healthcare services of some developed countries, increasing pressure on current health
systems due to aging populations, and the increase in the cost of medical care in the developed
countries (Garcia-Altes, 2005).
The rising costs of medical treatments in developed countries such as the United States
have resulted in a movement where people travel to other developing countries for medical
services. The charges for common procedures in the United States can be five to ten times
higher than that of the developing countries. For example, a knee replacement surgery in the
United States can easily cost up to $40,000 compared to $8,000 in Malaysia, and a heart bypass
surgery can be $130,000 in the United States compared to $11,000 in Thailand (Global Health
and Travel, 2013).
Medical tourism has become a promising industry in the developing countries (Bookman
& Bookman, 2007). Developing countries like India, Thailand, Malaysia, Cuba, and Vietnam
have successfully placed themselves to take advantage and to compete in this new market. The
rapid expansion of the medical tourism in these countries can be attributed by the growth of the
private healthcare sector, a high number of world class specialists who meet the global standard,
state-of-the-art medical facilities, and a strong tradition of care and hospitality. Many of these
hospitals are accredited by the Joint Commission International (JCI), an organization that
provides international healthcare accreditation services to hospitals throughout the world. In
addition, a favorable exchange rate has given these developing countries a competitive
advantage in attracting potential medical tourists especially from the lower- and middle-income
groups (Lautier, 2008; Oberholzer-Gee, KhanNa, & Knoop, 2007).
Among all the countries involved directly with medical tourism in the Southeast Asian
region, Malaysia has become a recognized nation in this industry. It is a preferred destination
for medical tourists of various countries such as China, Indonesia, Japan, Singapore, United
Kingdom, and the United States. It has also been named as the third-best place to go to for
quality yet affordable health care (Businesscircle.com, 2014). The pricing for medical
treatments in Malaysia can be considered as the most competitive among other countries in this
region (see Table 1). Besides the relatively cheaper medical costs, foreign medical tourists and
investors are also attracted by Malaysia’s political and economic stability, a high rate of literacy
of the people, and a very favorable exchange rate (Yanos, 2008). As a competitive player in the
medical tourism industry, Malaysia offers a wide range of services such as general medical
screening, wellness and pain management, dental treatments, cardiothoracic surgeries, fertility
treatments, cosmetic surgeries, cancer treatments, orthopedic surgeries, and rehabilitative
medicine (Bernama, 2010).
Table 1. Comparing Medical Treatment Pricing in Selected Countries (US$)

Procedures Malaysia Thailand Singapore

Coronary artery bypass graft - CABG 20,800 23,000 54,500
Valve replacement with bypass 18,500 22,000 49,000
Hip replacement 12,500 16,500 21,400
Knee replacement 12,500 11,500 19,200
Spinal fusion 17,900 16,000 27,800
IVF cycle, excluding medication 7,200 6,500 9,450
Gastric bypass 8,200 12,000 13,500
Full facelift 5,500 5,300 8,750
Rhinoplasty 3,600 4,300 4,750
Note: The Value of medical treatments across countries. Adopted from
Patientbeyondborders.com (2014).
Despite the increased attention on medical tourism, empirical findings pertaining to
medical tourism are still relatively scant (Heung, Kucukusta, & Song, 2010). Furthermore,
majority of the studies on medical tourism were either conceptual papers or from the service
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providers’ point of view (Lin, 2014; Mohamad, Omar, & Haron, 2012; Taleghani, Largani, &
Mousavian, 2011). Almost all of the prior studies have neglected the perspectives and opinions
from the medical tourists (Hudson & Li, 2012). Since these individuals are the consumers who
directly experience the medical services, it is vital to examine their perceptions to understand
their attitude, intention and behavior. Medical tourism is part of the healthcare and tourism
products and services, studies on medical tourists’ perceptions on such factors as hospital brand
image, service quality, satisfaction, and behavioral intention are much needed.
In the context of marketing, company brand image plays a significant role in representing
a business entity in the marketplace and in attracting new customers. Brand image could create
awareness among the potential first-time customers and provide a significant competitive edge
for the organization (Wu, 2011). However, the examination of brand image has widely been
done on tangible products in the retailing, but not in the service setting (Robert & Patrick, 2009;
Wu, 2011). This represents a major research deficiency from the service marketing and tourism
standpoint. Specifically, the influence of the company brand image on perceived service quality
is still under examined in the healthcare context (Wu, 2011). Extending the concept of company
brand image in medical tourism, an aim of this study is to examine the relationship between
hospital brand image and perceived service quality among the medical tourists.
Furthermore, perceived service quality has been found to have both direct and indirect
effect on behavioral intention, which is an individual’s intention to perform a given behavior
in the future (Ajzen & Fishbein, 1977). Studies that found a direct positive association between
perceived service quality and behavioral intention include Chen (2008); Chen and Chen (2010);
and Sumaedi, Bakti, and Yarmen (2012). Studies that found an indirect relationship between
perceived service quality and behavioral intention are Alrubaiee and Alkaa’ida, (2011) and
Aliman and Mohamad (2013). Perceived service quality was found to have a positive influence
on customer satisfaction, which in turn, is deemed to be a key determinant of behavioral
intention (Akbar & Parvez, 2012; Olorunniwo, Hsu, & Udo, 2006). The review of the relevant
literatures revealed that very few studies address the mediating effect of patient satisfaction on
the relationship between perceived service quality and their behavioral intention in the field of
medical tourism. Hence, another aim of this study is to investigate the mediating role of medical
tourists’ satisfaction on the relationship between their perceived service quality and behavioral
intention.
The objectives of this study were to examine (1) the impact of hospital brand image on
medical tourists’ perception of service quality, (2) the direct relationship between their
perceived service quality and behavioral intention, and (3) the mediating effect of their
satisfaction with the medical experience on the relationship between service quality and
behavioral intention. The remainder of the paper is structured as follows. Firstly, the existing
literature on the concepts and the relationships of hospital brand image, perceived service
quality, patient satisfaction, and behavioral intention was presented. Secondly, the research
methodology and the results of statistical analysis were described. And lastly, the main findings
and the implications of the study were discussed.

2. Literature Review and Hypothesis Development

2.1 Hospital Brand Image

Brand image refers to a set of perceptions in association with a brand and it reflects a
customer’s an overall impression of a brand (Keller, 1993). Brand image has been widely
studied in consumer purchasing behavior as it plays an important role in consumer decision
making (Yagci, Biswas, & Dutta, 2009). The concept of brand image applies not only to
tangible goods but also to business entities. Company brand image refers to the set of
perceptions in relation to an organization’s name and reputation; and it represents the factual
and emotional elements of a firm (Keaveney & Hunt, 1992). In today’s competitive business
environment, the company brand image has become a key success factor in all industries
especially the service industry. A superior company image is the foundation for a service
provider to hold its market position (Kim, Kim, Kim, Kim, & Kang, 2008). It has strategic
implications to attract and retain customers. In medical tourism, brand image plays a strategic

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role in assisting hospitals to outreach and to attract international tourists for medical services.
For the purpose of this study, hospital brand image would be used in place of company brand
image throughout the discussion.

2.2 Perceived Service Quality

Perceived service quality refers to the customer’s assessment of the superiority or inferiority
of the services provided by the organization (Parasuraman, Zeithaml, & Berry, 1988). Service
quality is the heart and soul of any service organization. It is a contributing factor to the success
and survival of the firm (McCain, Jang, & Hu, 2005). In the healthcare industry, receiving good
quality care is a right of all patients and providing good quality healthcare is an ethical
obligation of all healthcare providers (Zineldin, 2006). It is utmost important for the medical
providers to improve their service quality from time to time by taking patients’ perceptions and
expectations into consideration.

2.3 Patient Satisfaction

Patient satisfaction refers to the degree to which the patient’s desired expectations, goals, and
preferences are met by the health care provider and or service (Debono & Travaglia, 2009).
According to Kirsner and Federman (1997), patient satisfaction can be explained as an
interactive process which reflects patients’ quality assessment on the medical services
experienced. It has been found that patient satisfaction is important for the healthcare service
providers in the following three areas: (1) maintaining their relationships with the patients—
satisfied patients are returned customers; (2) identifying areas of strength and weaknesses in
the organization, and (3) association with their financial benefits (Aldaqal, Alghamdi, AlTurki,
Eldeek, & Kensarah, 2012). Consequently, patient satisfaction is another key success indicator
for the healthcare service providers (Pakdil & Harwood, 2005).

2.4 Behavioral Intention

Behavioral intention is an individual’s decision or commitment to perform a given behavior

(Ajzen & Fishbein, 1977). In the field of marketing, behavioral intention is an indicator of
customer loyalty or customer retention; and these three terms have often been used
interchangeably (Chen & Tsai, 2007). For the purpose of this study, behavioral intention was
used due to the phenomenon that purchase of medical services does not occur on a frequent
basis in the medical tourism. In service marketing research, repurchase (or revisit) intention
and willingness to recommend to others is commonly used to measure behavioral intention
(Ramkissoon & Uysal, 2011; Som, Marzuki, Yousefi, & AbuKhalifeh, 2012).

2.5 Linking Hospital Brand Image, Perceived Service Quality, Patient Satisfaction, and
Behavioral Intention

Brand image has been commonly used by consumers to refer to the quality of products or
services. For any product or service with a strong brand image, its quality tends to be perceived
higher by the consumer (Wu, 2011). Since the quality of intangible services is difficult to
evaluate objectively, consumers tend to equate brand image with service quality. A reputable
firm would be seen as a quality service provider; and consumers perceive less risk in using its
services (Brodie, Whittome, & Brush, 2009). A review of past empirical studies indicates that
brand image directly influences perceived service quality (Brodie et al., 2009; Cretu & Brodie,
2007; Suhartanto, 2011; Wu, 2011). For example, the study by Suhartanto (2011) in the hotel
industry argued that brand image has a strong impact on the guests’ perception of service
quality. Moreover, it has also been argued that brand image, especially influences customers’
assessment of service quality in healthcare (Wu, 2011). A favorable hospital brand image not
only has a positive impact on perceived service quality but also helps strengthen its competitive
position in the marketplace (Javalgi, Whipple, McManamon, & Edick, 1992). Thus, it was
postulated that:
H1: Brand image will have a positive direct effect on perceived service quality.
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A number of research studies have found that perceived service quality has a direct positive
relationship with customers’ behavioral intention (Choi, Cho, Lee, Lee, & Kim, 2004; Raza,
Siddiquei, Awan, & Bukhari, 2012; Yap & Kew, 2007). Yap and Kew’s (2007) study found
that the service quality of restaurants has a direct impact on customers’ revisit intention. A
customer is more likely to patron the same restaurant when the service quality served by the
restaurant meets or exceeds his or her expectations. Similarly, the study by Raza et al. (2013)
also found that hotels’ service quality is closely associated with customers’ behavioral
intention. A similar finding has been reported in the healthcare setting, whereby hospital’s
service quality is positively related to patients’ behavioral intention (Aliman & Mohamad,
2013). The findings of these studies indicate that superior quality service would lead to
behavioral intention among the customers via repeat purchase, positive attitude towards the
firm, and positive word of mouth.
However, perceived service quality has also been found to have an indirect relationship
with behavioral intention with customer satisfaction as the mediating factor (Olorunniwo, Hsu,
& Udo, 2006; Qin & Prybutok, 2009). Studies in the healthcare setting have provided some
evidence that hospitals’ service quality has a positive influence on patient satisfaction which in
turn, leads to patients’ intention to return for a particular service provider (Aliman & Mohamad,
2013; Alrubaiee & Alkaa’ida, 2011; Chaniotakis & Lymperopoulos, 2009; Choi et al., 2004;
Murti, Deshpande, & Srivastava, 2013; Vinagre & Neves, 2008; Wu, 2011). In their study of
hospital patients in Malaysia, Aliman and Mohamad (2013) found that satisfaction among the
local patients plays a substantial mediating role in the relationship between their perceived
service quality of the hospital and their revisit intention. Similarly, the study by Murti et al.
(2013) has also found that patient satisfaction partially mediates the relationship between
service quality and patients’ behavioral intention in the private hospitals in India.
Hence, this so-called chain model—“perceived service quality → patient satisfaction →
behavioral intention”—has been recognized in the healthcare context. In this study, it will be
determined whether the same phenomenon applies in the medical tourism industry. Thus, the
following hypotheses were formulated to test both the direct and indirect effects of perceived
service quality on medical tourists’ intention to revisit their respective preferred service
providers:

H2: Perceived service quality will have a positive direct effect on patient satisfaction.

H3: Perceived service quality will have a positive direct effect on behavioral intention.

H4: Patient Satisfaction will have a positive direct on medical tourists’ behavioral intention.

H5: Patient Satisfaction serves as a mediator in the relationship between perceived service
quality and behavioral intention.

H5

Patient
Satisfaction
H4 (+)
H2 (+)

Brand Image Perceived Service Behavioral

Quality Intention
H1 (+) H3 (+)

Figure 1: The Research Model

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3. Methodology

3.1 Sampling Method

The target respondents in this study were the medical tourists from Indonesia seeking medical
services in the top four private hospitals in one of the northern states of Malaysia. This state
has the highest number of medical tourists from the neighboring country of Indonesia, and the
private hospitals included in the study were most visited by them in the state (Borneo Post,
2013). A total of 400 self-administered survey questionnaires were personally distributed to the
Indonesian medical tourists in the four selected hospitals, with 100 respondents each. In order
for the medical tourists to qualify as the respondents for this study, they must have fulfilled two
criteria: (1) they must come to Malaysia for a medical treatment, and (2) they must have a direct
or indirect engagement in any tourism activities during the medical trip. The respondents were
asked to participate on a voluntarily basis. The sample size used in this study is considered
adequate as suggested by Saunders, Lewis, and Thornhill (2007), i.e., a sample size of 400 is
considered large enough for statistical testing.

3.2 Survey Measurements

Existing measurement scales were adapted to measure the variables tested in the research
model. Hospital brand image was measured by Hsieh and Li’s (2008) three-item scale in terms
of personal experience, practicability, and brand symbolic. Perceived service quality was
measured using the scale by Lam (1997) with respect to the five dimensions of assurance,
responsiveness, tangible, empathy, and reliability. Panjakakornsak’s (2008) scale was used to
measure patient satisfaction with regards to their positive affective response to the overall
service experience. The scale used to measure behavioral intention was adapted from Choi et
al. (2004) in terms of positive attitude towards the hospital, making recommendation to others,
and intended repeat purchase. All items were measured using a 6-point Likert scale, from 1 =
Strongly Disagree to 6 = Strongly Agree. The questionnaire employed in this study was made
available in two languages namely English and Bahasa Indonesia.

4. Data Analysis and Result

4.1 Sample Profile

The demographic profile of the respondents was presented in Table 2. The respondents
consisted of 54.40% female and 45.60% male medical tourists. Majority of the respondents
were married (77.80 %) and aged between 36 and 55 years old. For the types of medical
treatments sought, most of the respondents came for orthopedics treatments (23.3%) and
cardiovascular surgery and care (17.9%). About two-third of the medical tourists (68.4%) spent
RM 30,000 or less for medical treatments in Malaysia for the past three years.

Table 2. Sample Characteristics

Variable Classification Frequency Percentage (%)

Gender Female 210 54.4
Male 176 45.6
Marital Single 67 17.4
Married 301 77.8
Divorced 9 2.3
Widowed 8 2.2
Others 1 0.3
Age Group 25 years old and below 17 4.4
26 – 35 years old 71 18.3
36 – 45 years old 104 27.0

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46 – 55 years old 106 27.5

56 – 65 years old 70 18.1
above 65 years old 18 4.7
Medical Service Orthopaedics (e.g. Joint, spine) 90 23.3
Seeking Cardiovascular surgery and care 69 17.9
Comprehensive medical check-ups 63 16.3
Oncology (Cancer treatments) 38 9.8
Sight treatment/ Lasik 37 9.6
Fertility care 22 5.7
Cosmetic/plastic/reconstructive 21 5.5
surgery
Others 46 11.9
Amount spent on Less than RM 10,000 88 22.8
medical treatments RM 10,001 – RM 20,000 106 27.5
in Malaysia for the RM 20,001 – RM 30,000 70 18.1
past three years RM 30,001 – RM 40,000 35 9.1
RM 40,001 – RM 50,000 22 5.7
RM 50,001 – RM 60,000 14 3.6
RM 60,001 – RM 70,000 15 3.9
RM 70,001 – RM 80,000 10 2.6
RM 80,001 – RM 90,000 9 2.3
RM 90,001 – RM 100,000 6 1.6
More than RM 100,001 11 2.8

4.2 Confirmatory Factor Analysis

Confirmatory factor analysis was used to test the convergent and discriminant validity of
the constructs in this study. Based on the suggestions made by Hair, Black, Babin, Anderson,
and Tatham (2006), the selected criteria used to evaluate model fit in this study include the
value of Normed Chi-square (χ²/df), Goodness of Fit (GFI), Root Mean Square Error of
Approximation (RMSEA), Tucker-Lewis index (TLI), Comparative Fit Index (CFI), and
Parsimony Normed Fit Index (PNFI). According to Hair et al. (2006), a research model with a
good fit would have the value for χ²/df less than 3, GFI exceeds 0.90, RMSEA is less than 0.08,
TLI exceeds 0.90, CFI exceeds 0.90, and PNFI is more than 0.50. The results of the CFA
indicated that the model was fit with the value of χ²/df = 1.798, GFI = 0.950, RMSEA = 0.046,
TLI = 0.968, CFI = 0.974, and PNFI = 0.755.
To assess the convergent validity of the data, the following three elements need to be
examined: (1) the construct reliability (should be greater than 0.7), (2) the average variance
extracted (AVE) for each of a construct (should be larger than 0.5), and (3) the standardized
factor loadings (should be significantly linked to the latent construct and have at least a loading
estimate of 0.60) (Hair et al., 2006). As seen in Table 3, the Cronbach’s alpha for each of the
constructs (construct reliability) is well above the recommended value of 0.70, which is
considered satisfactory for basic research (Hair et al. 2006). Moreover, the values of AVE for
all constructs in this study exceed the minimum standard of 0.50; and all value loadings for the
items are greater than 0.60. In view of the above findings, the data of this study have achieved
an acceptable level of convergent validity.
The discriminant validity of the constructs in this study was assessed using the guideline
suggested by Fornell and Larcker (1981). The squared root of AVE for each construct should
be compared with the correlation between the paired constructs. Discriminant validity is
achieved when the squared root of AVE exceeds the correlation between any other two
constructs. Table 3 shows that the constructs tested in this study have achieved acceptable
discriminant validity, as the squared AVE for each construct is greater than the shared variance
between constructs.
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Table 3. Test Results on Convergent Validity and Discriminant Validity

CR FL AVE 1 2 3 4
Brand Image 0.822 0.705-0.837 0.607 0.779
Perceived Service Quality 0.795 0.795-0.902 0.534 0.368 0.731
Patient Satisfaction 0.872 0.781-0.818 0.630 0.375 0.473 0.917
Behavioral Intention 0.832 0.765-0.828 0.623 0.376 0.500 0.608 0.789
Notes:
a) CR= Composite Reliability; FL= Factor Loading; AVE= Average Variance Extracted.
b) The diagonal entries (in Bolds) represent the squared roots average variance, and off diagonals (in
Italics) are the correlations between constructs.

4.3 Structural Model and Hypothesis Testing

Given an adequate measurement model, the hypotheses developed for this study were tested by
examining the proposed structural model. As seen from the AMOS output, the structural model
provides an adequate fit. All the indices of χ2/df = 1.995, GFI = 0.946, RMSEA = 0.051, TLI
= 0.960, CFI = 0.967, and PNFI = 0.767 meet the requirement of good fit. Table 4 presents the
results of the direct relationships depicted in the research model (H1 to H4). The results show
that all of the path coefficients for the hypothesized direct relationships are significant at p <
.001. Hence, H1 to H4 were supported by the data.

Table 4. Results of Hypotheses Testing

Hypothesized Path S.R.W Critical Supported

β Ratio (Yes/No)
H1: Brand Image  Perceived Service Quality 0.470 6.982*** Yes
H2: Perceived Service Quality  Patient Satisfaction 0.586 8.801*** Yes
H3: Perceived Service Quality  Behavioural Intention 0.337 5.109*** Yes
H4: Patient Satisfaction  Behavioural Intention 0.517 7.715*** Yes
Notes: ***p-value < 0.001. S.R.W = Standardized Regression Weight.

Baron and Kenny (1986)’s method was used to examine the mediation effect of patient
satisfaction in the relationship between perceived service quality and behavioral intention.
Baron and Kenny (1986) proposed that three preliminary conditions must be met to determine
the mediating effect. They are: (1) the predictor variable (perceived service quality) is
positively and significantly related to both the mediator variable (patient satisfaction) and the
dependent variable (behavioral intention); (2) the mediator (patient satisfaction) is positively
and significantly related to the dependent variable (behavioral intention); and (3) after
controlling for the mediating variable (patient satisfaction), the impact of the predictor
(perceived service quality) on the dependent variable (behavioral intention), should still be
remained significant but reduced in strength (for partial mediation) or should no longer be
significant (for full mediation). In this study, all the conditions stated by Baron and Kenny
(1986) for the mediating effect of patient satisfaction were examined and the results were shown
in Table 5. The results of Model 1 show that the predictor (perceived service quality) has a
significant positive influence on both the mediator (patient satisfaction) and the dependent
variable (behavioral intention). Condition (1) mentioned above was met. The results of Model
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0 show that the mediator (patient satisfaction) is positively and significantly related to the
dependent variable (behavioral intention). Condition (2) mentioned above was also met. The
standardized regression weight of the predictor (perceived service quality) to the dependent
variable (behavioral intention) was reduced from 0.690 to 0.376 but still remained significant
at p < .001 when patient satisfaction was controlled for in Model 2. This outcome indicated that
patient satisfaction partially mediates the relationship between perceived service quality and
behavioral intention. Therefore, hypothesis 5 for this study is supported.

Table 5. Results of the Mediating Effect of Patient Satisfaction

Path Model 0 Model 1 Model 2
Perceived Service Quality  Patient Satisfaction 0.642***
Perceived Service Quality  Behavioral Intention 0.690*** 0.376***
Patient Satisfaction  Behavioral Intention 0.716 *** 0.606***
Notes: ***p-value < 0.001

4.4 Discussion and Implications of this Study

Based on the results of the statistical analysis of this study, several findings were worth noting.
Firstly, hospital’s brand image was evidently shown to have significant positive influence on
medical tourists’ perception on the quality of the medical services provided by the hospital.
This finding is consistent with those of Brodie et al. (2009); Cretu and Brodie, (2007); and Wu,
(2012). Wu (2011) did argue that brand image is often used as a platform by patients to create
impression and perception of the service quality of the hospital. Given the importance role by
the hospital image, the management must understand what forms a positive brand image among
the medical tourists and allocate a reasonable amount of resources for branding purpose. This
may be achieved by improving their services and refining the current marketing strategies.
Hospitals may actively participate in social media, improve media advertising, enhance public
relations, and engage in any other means which can promote the hospital image in the eyes of
medical tourists.
Secondly, the direct relationship between perceived service quality and medical tourists’
behavioral intention found in this study is in accordance with the existing literature (Choi et
al., 2004; Raza et al., 2012; Yap & Kew, 2007). This implies that a pleasant service experience
would institute a positive attitude and intention among the medical tourists. The superior
medical services experienced by medical tourists would encourage them to recommend the
hospitals which they have visited to their peers, and they would return for the respective
healthcare service providers in the future. In view of this evidence, the management team of
respective hospitals should adopt service-oriented strategies that take consideration of the
various aspects of service delivery namely responsiveness, assurance, reliability, tangibles, and
empathy. For instance, healthcare service providers must upkeep their medical facilities to meet
the needs and requirements of the medical tourists. Moreover, the medical staff should also be
trained to serve the medical tourists in accordance to their respective cultures. Cross-cultural
training and training on both technical and soft skills among the medical staff and/or doctors
may be needed in order to deliver superior quality services to the medical tourists. In addition
to the staff training, financial incentives and other relevant motivational rewards may be
implemented to induce quality in serving the patients.
Thirdly, the results of the study also show that patients’ satisfaction partially mediates the
relationship between perceived service quality and behavioral intention. This result is
consistent with the studies by Aliman and Mohamad (2013), Alrubaiee and Alkaa’ida (2011)
and Choi et al. (2004). This implies that the hospitals in this study should not only depend on
service quality to promote positive behavioral intention among the medical tourists, but they
also need to consider the attainment of medical tourists’ satisfaction. Their satisfaction with
the services provided by the hospitals does play a role in their intention to return for further
medical services. Hence, a special task force or committee may be set up to constantly monitor
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the level of medical tourists’ satisfaction. It is suggested that patients’ suggestion or feedback
programs be implemented to address their issues of concern. Any feedback received from the
medical tourists should be highlighted and entertained to reduce any source of their
dissatisfaction and for improvement purpose. This special care is justifiable given the fact that
medical tourists have different needs and requirements from the local patients.

5. Conclusion

In general, customers’ intention to revisit or repeat purchase is always a major interest for
all business organizations. Customer loyalty or retention is much needed for business survival
and sustainability. This is especially true for service-oriented organizations such as healthcare
providers. The findings of this study indicate that hospitals, just like any other firms, need to
take a strategic marketing approach to attract and retain medical tourists in this global
competitive landscape. They have to apply the concepts of consumer behavior and service
marketing to appeal to the international patients. In order to enhance patients’ intention to
revisit, hospitals need to safeguard their respective “brands” and to achieve quality service and
customer satisfaction.
Despite a promising growth in Malaysia as a medical tourism hub in Southeast Asia,
Malaysia is not the only sole player in the region. There are many other regional countries, such
as the ‘uniquely’ superior-quality Singapore and the ‘amazing’ Thailand, are competing in
attracting potential international patients. Given the intense competition within the industry, it
is important for the medical service providers, the Malaysian government, and other relevant
parties to be more diligent in attracting medical tourists. Medical tourism is a potential growth
industry that will significantly contribute to the economy of the country. Therefore, it is
important to have an in-depth research on the perceptions and behaviors of this international
medical tourism market.
Although the present study has provided theoretical and practical implications, there are
some limitations in this research which need to be highlighted. Firstly, this research study has
only examined a specific group of medical tourists from Indonesia. Future studies should
examine other groups from other countries such as Japan and China as they are the second and
third largest medical tourist groups in Malaysia. Secondly, the absence of qualitative methods,
such as in-depth interviews with individual respondents and focus group, is deemed to be
another limitation of this study. It is recommended the future studies should include samples
from other countries and incorporate qualitative methods of data collection. Furthermore, future
research may also consider a longitudinal approach to examine whether medical tourists’
behavioral intention will result in actual behavior. Such a longitudinal study will greatly add to
the value of research in the field medical tourism.

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