CHAPTER - 1

INTRODUCTION

1.0 Introduction

1.1 Tourism Product and Service

1.2 Current Scenario of Tourism Industry

1.3 Background of Indian Tourism

1.4 Prospects of Health Tourism

1.5 Health tourism in India

1.6 Advantage of India in Medical Tourism

1.7 Kerala Travel History

1.8 Prospects of Kerala Tourism

1.9 Health Tourism in Kerala

1.10 Ayurveda

1.11 Statement of Problem

1.12 Rationale of the Study

1.13 Major Objectives

1.14 Major Hypothesis

1.15 Organization of Chapters

1.16 Conclusion
 “A customer is the most important visitor on our premises, he is not
dependent on us. We are dependent on him. He is not an interruption in our work.
He is the purpose of it. He is not an outsider in our business. He is part of it. We
are not doing him a favour by serving him. He is doing us a favour by giving us an
opportunity to do so”.

- Mahatma Gandhi

A customer is the king of any business as the growth of business is a function of

customer delight and retention. The success in business ultimately depends on what

customers finally choose to buy. Thus, it is vitally important to understand the

psychology of customers as to why they choose to buy one product when compared to

another and why they purchase a particular product (Rust et al., 1999). Since a

customer‟s decisions are the direct functions of the customer‟s cognition, customer

preference, and perception. Each one is important to identify the pre and post-purchase

behaviour to determine customer satisfaction. Needless to say, it is a complex process

to find the behaviour of a customer in the service industry as it involves several steps to

send a tourist delighted from the host destination region.

1.1 TOURISM PRODUCT AND SERVICE

Tourism is a service industry with typical features. The service qualities of the

tourism industry are determined by the integration of service providers at both the

forward and backward link points. The salient inherent challenges of tourism marketing

is how the information of tourism product is communicated to the customers. The

challenges before the service provider are to understand the need, preference, and
demand in order to deliver the products that suit the customer needs. Thus, it is an

uphill task of the tourism intermediaries to ensure service quality as it is controlled by

peculiar characters such as heterogeneity, intangibility, inseparability, seasonality,

perishability, and lack of ownership. Given the peculiar features, marketing can be used

as a tool to sensitise actual and potential customers with regard to the merits of

products and services, as the industry is highly competitive in the present global

scenario.

Tourism products are the sum total of physical and psychological perceptions

that are associated with travel motivation which satisfy the tourist needs. Tourism also

provides a platform for both the customer as well as the service provider to directly

interact at the time of delivery of services. Various travel motivators give shape to

different tourism products. They include fairs, festivals, beaches, wildlife, adventure

sports, yoga, spas, conventions, conferences, and shopping. Accessibility, amenities,

and facilities for tourists, and climate, natural, and cultural resources also influence a

customer‟s purchasing decision (Jacob et al., 2007). Nevertheless, all the efforts of

service providers aim at catering to the customer needs as a customer is regarded as

God. Moreover the true symbolism of “Athithi Devo Bhavo” or “A guest is a God” is deep

rooted in India‟s value and ethos. More importantly, a customer is renamed as a tourist

who is greeted and treated as a God in the true sense in India. Thus, customer is the

key player in this service industry.

In the past few decades, tourism has experienced sustained growth around the

world. It is one of the largest and fastest growing economic change agents, thereby

contributing enormously to the International trade and commerce. Generation of

revenue from the International tourism is so huge that it holds the fourth place after

petroleum products, chemicals, and automobile products. For developing and third

world countries, it is one of the primary income and employment resource sectors, since

tourism is acknowledged as a major driver of economic development for its multiplier

effect.

Tourism is an extrinsic social phenomenon and an intrinsic mental phenomenon.

It is about the transitory movement of people across geographic and cultural landscapes

for an experience and the mental transformation. Thus, the nature of tourism is complex

and its scope is very wide (B.P.George and S.K.Swain, 2005).

1.2 CURRENT SCENARIO OF TOURISM INDUSTRY

According to the United Nations World Tourism Organisations (UNWTO),

International tourist arrivals grew from 25 million to 903 million between 1950 to 2007. In

1950, the top 15 locations received 98 per cent of international tourist arrivals. Whereas

the proportion was 75 per cent in 1970 and it declined to 57 per cent in 2007. It reflects

the emergence of new destinations with a lot of appeal in developing countries.

The current development and forecasts in the UNWTO Tourism Highlights show

that, international tourist arrivals reached 903 million in 2007, an increase of 6.6 per

cent over 2006. Between 1995 and 2007, the growth averaged over four per cent a

year, in spite of the stagnation between 2001 and 2003 due to terrorism, SARS, and the

economic downturn. International tourism receipts rose to US$ 856 billion (625 billion

euros) in 2007, corresponding to an increase in real terms of 5.6 per cent over 2006.

Consequently, outbound tourism, in recent years, has been increasingly driven by rising
middle-class families with huge disposable incomes. According to the UNWTO World

Tourism Barometer of June 2008, tourism business witnessed growing demand in the

first four months of 2008. Overall, international tourist arrivals grew at around 5 per cent

between January and April 2008 compared to the same period of 2007. For the whole of

2008, a sluggish growth was anticipated, due to the global economic meltdown that

affected the consumer confidence thereby constraining disposable income.

In 2007, international tourist arrivals grew by 6.6 per cent to reach the record

figure of over 900 million. This represented 56 million greater arrivals than in 2006. That

was the fourth consecutive year of growth in 2007 above the long-term forecast of 4.1

per cent and surprisingly, it even exceeded the 5.5 per cent from 2005 to 2006.

Similarly, the international tourism receipts grew to US $ 856 billion in 2007

corresponding to an increase of 5.6 per cent over 2006. Receipts from international

passengers transport are estimated at US $ 165 billion (World Tourism Barometer).

1.3 BACK GROUND OF INDIAN TOURISM

India is a country known for its friendly treatment to all visitors, regardless of their

origin. India‟s traditions, varied life styles, cultural heritage, and colourful fairs and

festivals offer an unforgettable experience.

India being a vast and diverse country is endowed with credible attractions to

entice tourists with a wide range of interests. Moreover, visiting India gives an

enthralling and memorable experience. The country is a tourist paradise and it has all

the unique features of modernity and traditional hospitality. Tradition and modernity

have blended here resulting in it becoming a tourist paradise (Jacob, 2008).

 Travel and tourism is an integral part of Indian tradition and culture. In the olden

days, travel was primarily for the purpose of pilgrimage – as the holy places dotting the

countryside attracted people from different parts of the vast sub-continent. People also

traveled to participate in fairs and festivals in different parts of the country. With such a

background, there developed a cultural tradition wherein “Athithi Devo Bhave” (The

Guest is God) and “Vasudhaiva Kutumbakam” (The World is One Family) become

unwritten laws by which the Indian social behaviour is recognised. From ancient times,

the rulers in different parts of India built luxurious palaces, enchanting gardens

marvelous temples, grand forts, tombs, and memorials as a symbol of expression of the

depth of one‟s feeling and sentiments. These remain as testimony to the rich cultural

heritage of this land as examples of exquisite craftsmanship. The other splendid

architectural marvels of India include Taj Mahal, Jama Masjid, Qutub Minar and caves

of Ajanta, Ellora and Elephanta, the Sanchi Stupa, and the Sun temple of Konark. India

is also a shopper‟s delight with its marble statues, wood and ivory carving, block printed

fabrics, jewellery, and handicrafts and handlooms. It is the home of classical Indian

music and dance (R.Pruthi, 2005).

The Indian handicrafts particularly jewellery, carpets, leather goods, ivory and

brass works are the main shopping items of foreign tourists. The estimates indicate that

nearly forty percent of the tourist expenditure is on such shopping (R.L.Parekh, 2009).

Globalization has caused many countries to revamp their economic strengths

and weaknesses as well as reassess products or services in which the nation can get

benefitted. One such product or service that has emerged through the quest of novelty

is „Health Tourism‟.
 Travel and health are complimentary to each other. The basic theories of travel

motivation is based on leisure, recreation, spiritual, and rest and recuperation. All these

motivations revolve around the theory of health. Leisure, recreation, and rest and

recuperation directly contribute to the well-being of body and mind. Spiritual tourism

also compliments the well-being of mind and soul. The differentiation between other

tourism and health tourism is, in health tourism, tourists voluntarily spend on wellness

whereas in the other categories of tourism it involuntarily rejuvenates the mind and body

of tourists.

1.4 PROSPECTS OF HEALTH TOURISM

Medical travel is often undertaken in combination with tourism services.

However, it is estimated that the business of health tourism is very huge as US $ 40

billion worldwide (2004) with an expected annual growth rate of 20 per cent. Health care

is an area in which the tourism industry can take advantage as it is a thriving sector in

the new globalization and liberalization. International travel for health purposes

becomes a way of life for new age Western and Asian tourists. India is on the threshold

of a health care revolution and the country is emerging as a global destination for

medical tourists. Health tourism is an emerging concept and is still at the nascent stage.

Governments are increasingly concerned about their readiness to meet their social

obligations in the health sector. Complimenting health care with tourism is the new

mantra that has seen foreigners flocking to India for treatment (R.Pruthi, 2006). Health

industry data (CII-Mckinsey, 2003) show that the total health care market in India is

expected to rise from the current Rs.1,030 billion (5.2 per cent of GDP) to Rs.2,320

billion to Rs.3,200 billion. As a result, India would spend 6.2 – 8.5 per cent of its Gross
Domestic Product (GDP) on health care by 2012, thereby contributing 7 – 8 per cent of

the GDP. It accounts for 3 – 5 per cent of the healthcare delivery market (CII-Mckinsey,

2003). Medical tourism in India is growing by an estimated rate of 30 per cent per

annum (J.Rao and F.Zaheer, 2010). Health care is estimated to be $ 3 trillion industry

worldwide, where India is in position to attract the high-end segment tourists by

highlighting its facilities and services and exploiting the brand equity of leading Indian

health care professionals across the globe.

1.5 HEALTH TOURISM IN INDIA

The present trend of health tourism as set by the health conscious consumers

can enhance the well-being of tourists through travel experience (S. Kulkarni, 2008).

This type of customer seeks to look and feel better to lose weight, to slow the effects of

aging, to relieve pain or discomfort, and to alleviate stress or to partake in the use of

natural supplements like vitamins and minerals to improve their health. Most health

tourism focus on two areas such as pampering and wellness. Pampering involves

offering people an experience that makes them feel good. Services such as massages,

herbal wraps and exfoliating scrubs where wellness involves helping healthy people

prevent problems so they stay well, both physically and mentally (R. Pruthi, 2006).

Health Tourism triggers travel to improve one‟s health, for the primary reasons of

visit to a health resort or weight-loss camp whereas wellness tourism is one of the most

ancient form of tourism that Romans and Greeks used to pay much attention to, for the

well being of the people. The quests for spiritual enlightenment of medieaval pilgrims or

the medical seaside and spa tourism of the 18 th and 19th century European elite aim at
providing the people good health. Arguably, there has been an unprecedented

intensification in the pursuit of wellness in the history of tourism. The consumer survey

conducted in 1997 by Health Fitness Dynamics, Inc., that is a Florida spa consulting

firm, revealed that 81 per cent of consumers who went to resort based spas expected a

property to offer health care services. These consumers actively seek out resorts that

offer those services (R. Pruthi, 2006).

Among the factors that make India an attractive proposition for medical treatment

is cost efficiency. The estimated cost for a heart surgery in the US is $ 30,000, however

the same could be performed in India for about $ 6,000. Similarly, a bone marrow

transplant could cost about $ 2,50,000 in the USA while it could be done in India for

about $ 26,000 (P. Begde, 2008).

Foreigners have already started trickling into India for medical treatment, thus,

various initiatives are taken to increase the influx in the next three to four years. The

Government has also introduced various policy measures such as the National Health

Policy (NHP) that recognises the treatment of international patients as an export. It

allows private hospitals treating such patients to enjoy benefits such as lower import

duties, increase in the rate of depreciation (from 25 per cent to 40 per cent) for life-

saving medical equipments, and several other tax sops in order to encourage medical

tourism in India (P.K. Singh, 2008).

Another factor is America‟s fascination with fitness and alternative therapies for

health maintenance and healing. In 1997, 42 per cent of Americans spent $ 21 billion on

non-traditional medical therapies and products. In the past three years, nearly 25 million
U.S. travelers fought the battle of bulge by using a fitness centre or gym while on the

road (S. Kulkarni, 2008).

The third element spurring health tourism is the fact that today‟s consumers are

already well traveled. As a result, they seek something new and different in a holiday

experience. They often want something educational or experimental and various

aspects of health tourism fulfill those requirements. In Canada and Britain, long waiting

lists at home are prompting some to go abroad to seek medical care.

There are two clear advantages for India in the field of medical and health

tourism. The first and foremost is the cost advantage. The next unique advantage of

India is that it offers holistic medicinal services with yoga, meditation, ayurveda,

allopathy, and natural herbal treatments.

Health and medical tourism are perceived as one of the fastest growing

segments in India. With yoga, meditation, ayurveda, allopathy, and other systems of

medicines, India now offers a unique basket of services to an individual. It is difficult to

match by other countries. According to the Ministry of External Affairs (MEA) India‟s

healthcare industry is worth US $ 23 billion roughly 4 per cent of GDP. The industry is

expected to grow by around 13 per cent per year for the next four years. . According to

the Insurance Regulatory and Development Authority (IRDA), India‟s health care

industry could grow exponentially as software and pharmaceutical sector have grown

over the past decade. Medical tourism focuses on treatment of acute illness and

elective surgeries such as cardiology, cancer, organ transplantations etc.

1.6 ADVANTAGE OF INDIA IN MEDICAL TOURISM

India is fast emerging as a cost-effective destination for healthcare as compared

to neighbouring countries, and West Asia. Healthcare and tourism can go hand in hand,

but it is not an entirely new concept. People have been coming for rejuvenation

packages to Kerala or Goa. The effort now is to institutionalise and en-route patients

from foreign markets to Indian hospitals.

Packages have been designed to include value added services to suit all clients

while patients recuperate in the hospital and their relatives enjoy the sights and shops.

Hospitals like Apollo Group have opened information centers in key foreign countries to

attract medical tourists. Most hospitals have put up detailed information on Internet. The

expertise of Indian doctors in modern medicine from heart surgery to photonic cataract

removal has put India on the world healthcare map. The country attracts about one lakh

medical tourists from abroad every year (Pruthi, 2006).

Healthcare organisations have recognised that every point along the patient care

continuum is interrelated. To truly maximize re-engineering efforts, there is a need to

integrate and make the entire process and information flow within or across the

enterprise. The inflow of health tourists from the West, especially the UK, US, and some

of the European countries has been on the rise for the last couple of years. Price

difference or affordability of the treatment, coupled with quality of doctors are the main

reasons for the growing Western traffic. These are the following advantages that India

possesses to position health tourism across the world.

India gets around 70,000 visitors annually from Gulf region. After the September

11 WTC attacks, Arab nationals have almost stopped going to the US and

Europe. This factor also helped in increasing the number of tourists from the

Middle East to India. Tourist from abroad also visit India for alternative treatments

like Ayurveda, Yoga, Kairali etc.

World class Hospitals : India has a number of hospitals offering super speciality

quality treatments in nearly every medical sector such as cardiology, joint

replacement, gastroenterology, ophthalmology, transplants, and urology to name

a few for their quality of service and available infrastructure. India is attracting a

vast pool of tourists from the Middle East, the USA, the UK, and Africa. Indian

corporate hospitals like Apollo, Max Health Care, AIIMS, Fortis etc., are on par

with the best hospitals in Thailand, Malaysia, and Singapore. There is scope for

improvement and it has become the most sought after destination for medical

tourists.

Manpower : India has a large pool of highly qualified doctors with adequate

experience from abroad and a good number of nurses and physicians with the

required specialisation and expertise along with English speaking skills which

have become the strength of the health care industry.

The Price Advantage : For long, India was promoted for its cultural and scenic

beauty. India is now being put up on the international map as a heaven for those

seeking quality and affordable healthcare. In India, complicated surgical

procedures are being done at 1/10th the cost as compared with the procedure in
 the developed countries. Besides which the hospitals are well-equipped to

handle the data and information through computerised Hospital Information

System (Kaur et al., 2007).

No Waiting : In addition to the increasingly top class medical care, a big draw for

foreign patients is also the very minimal or hardly any waiting list for treatment as

it is common in European or American Hospitals.

Alternative Therapy : India offers not just treatment but spiritual and mental

healing as well. The alternative therapy namely AYUSH-Ayurveda, Yoga and

Naturopathy, Unani, Siddha and Homeopathy etc. are the USP of the health

tourism. These unique health care services have aroused interest in patients

from first world countries remarkably as these treatments can be done at a third

world price.

As the link between health care and tourism becomes increasingly common, it is

important to mention that the expression of medical tourism is based on a contradiction

which combines the notions of leisure and pleasure with those of diseases, suffering,

and treatment. The union of these words suggests that healthcare is now associated

with ubiquitous consumerism.

1.7 KERALA TRAVEL HISTORY

Kerala is known as the land of spices. The need for spices brought people of

various nationalities to Kerala. The early traders were the Babylonians, Greeks,

Romans, Chinese, and Phoenicians (Menon, 1996). The Arabs and Jews travelled to
Kerala. Meanwhile the discovery of Vasco de gama at Kappad near Kozhikode

established trade and political relationship of Kerala with Portugal. Subsequently the

Dutch, French, and British landed in Kerala for the specific purpose of trade and

commerce. Evidence indicates that Kerala‟s foreign contacts increased after the

discovery of monsoon winds (Jacob, 2008).

1.8 PROSPECTS OF KERALA TOURISM

Popularly known as “God‟s own country” across the countries in the world, Kerala

provides a wide-range of tourism products. It is blessed with unmatched natural

diversity that provides immense scope for tourism. The state‟s social culture, 100 per

cent literacy, and above all the hospitality of people have drawn the attention of visitors

from all over the world. (Sarangadharan and Sunandha, 2009). They have pointed out

that Kerala stands unique in terms of providing rich tourism experience, by virtue of the

customs and traditions of the state. Salubrious climate, lush green vegetation, natural

tourist spots, colourful festivals, martial arts, wild life sanctuaries, and rich ayurvedic

heritage of Kerala have added immense scope for growth of tourism in the state

(www.keralatourism, 2005).

As early as 1986, Kerala had identified tourism as a potential market and

subsequently, all appropriate support was granted to tourism just like other industries in

Kerala. These included subsidies, technical guidance, and marketing assistance

(P.Ravikanth, 2010).
1.9 HEALTH TOURISM IN KERALA

Kerala is a pioneer in health and medical tourism in India. It has made a

concerted effort to promote health tourism along with its unique Ayurveda treatment.

Ayurveda is a significant money earner for Kerala tourism as it has been a key to a

substantial increase in the number of visitor arrivals into the state. Next to beaches,

tourists visited Kerala for Ayurveda, as it has become an integral part of Kerala tourism

since mid 1990s. Kerala‟s USP was the ABC acronym, for Ayurveda, Backwaters, and

Culture and Cuisine. There was a demand for stress busting vacations as people

preferred to take vacations where their health was also looked after and where they

could rejuvenate. Kerala identified this need to tap this area and established ayurvedic

resorts and spas near the beaches and backwaters so that the combination of a

wellness holiday in a location which is naturally endowed would attract numerous

people.

An ayurvedic resort combines relaxing resort holidays with ayurvedic treatments

and massages. Kerala has been promoting Panchakarma and other ayurveda

treatments for centuries. The picturesque landscape of Kerala, its verdant forests, and

hilly tracts nurture an abundance of herbs and trees as valuable ingredients in several

ayurvedic medicines. The ancient tradition of ayruvedic vaidyas belong to just eight

families and are named as the ashta vaidyas on account of their expertise.

The Department of Tourism has declared ayurveda to be one of its major thrust

areas. Tourism is a major revenue earner for the state. Kerala attracted 1.9 lakh and 2.6

lakh international tourists in 2007 and 2008 respectively. The flow of tourists is bound to
pick up greatly in the coming years, owing to its a pivotal attractive feature - Ayurveda.

Tourists who go to beaches and sanctuaries for leisure and fun in Kerala now spend a

major part of their holidays in ayurvedic resorts for “rejuvenation and recharging”

(R.L. Parekh, 2008).

1.10 AYURVEDA

In ancient India, every branch of science was developed by abiding by natures‟

rules. Ayurveda is the ancient Indian health science developed through centuries by

long intensive research work of great Sages. The term „Ayurveda‟ denotes that it is the

knowledge of life, and not only a system to cure diseases, but also a system to teach

how to achieve „perfect health‟ from diseased or abnormal conditions and how to lead a

good life both physically and mentally so as to attain the bliss of real life (Sumathi

Kuttiamma, 2003).

Ayurveda has a concrete basis in Indian philosophy and wide reaching

applicability in life of all sorts. Since, it is holistic, it approaches a human being as a

whole and cares for a human being‟s physical, mental, and spiritual health. It is almost

as old as mankind and at the same time as new as the modern man such that no

disease is there which is incurable or uncontrollable unless missed too much.

Ayurveda dictates the social norms for an individual. This helps in maintaining

spiritual health and also elaborates on the daily routine. These changes in routine life as

per the change in habitat, age, food, and lifestyle have made compulsion to search for

wellness activities. This can give preventive as well as curative treatment for a healthy

and long life. Ayurveda believes that man is influenced to a great extent by his
environment which affects health status too. This routine includes diets, habits, and a

general attitude towards life. These are to be changed according to the age and sex of

an individual, living condition, and the environment. This helps the body to maintain its

natural resistance to diseases (Sumathi Kuttiamma, 2003).

1.11 STATEMENT OF PROBLEM

The growth in the tourism sector has been impressive in India and the World. It is

a known fact that India has tremendous potential for development of tourism. The

diversity of India‟s natural and cultural richness provides the basis of a wide-range of

tourist products and experiences which embrace business, leisure, culture, adventure,

spirituality, ecotourism, health tourism, and many other pursuits. Apart from

acknowledging the traditionally recognised advantages of developing tourism for the

promotion of national integration, international understanding, earning of foreign

exchange, and vast employment generation, it plays a major role in strengthening the

socio-economic objectives of nation. Even then, India‟s share in total global tourism

arrivals and earnings is quite insignificant.

As we closely study the nature and cause for the tourism Industry, it is an

amalgam of multi-stakeholders with different purposes and agendas. This has profound

influence on the overall quality in offering tourism services. Tourism and Travel

promotes experiences and memories that tourists cherish for a life time. However there

is an inherent difficulty largely in promoting some intangible aspect of tourism. Finding

out what the customer exactly expects is essential to ensure service quality. Thus,

marketing research is a key vehicle for understanding customer preference and

perception of service. Marketing research on customer preference is needed to explore

the changing customer requirements (Zeithaml and Bitner, 2000). In this background,

the researcher has chosen to identify new customer relation techniques in the health

tourism of India with special references to Kerala.

1.12 RATIONALE OF THE STUDY

According to L. William (2006), Tourism and Hospitality have become global

economic activities, as expectations with regard to the use of leisure time have

increased significantly. Attributing greater meaning to free time, marketing the

importance of tourism more than in any other industry the potential of tourism is not

always harnessed (Morgan et al., 1994). L. William (2006) argued that a major reason

for such unfulfilled potential lies in most tourism marketing focusing on the destination

outlet (in other words, the products being offered) and lacking focus on the customer.

Therefore, Tourism Boards use a number of planned and controlled marketing activities

to experiment the core strength of tourism product. This study purports that they could

also exploit the destination image enhancement opportunities that exist through

developing an insight about the customer or tourist preferences and satisfaction in the

desired service package.

The study is based on the fact that the growth in the health tourism may definitely

provide several benefits to the Kerala tourism market. Hardly any systematic study has

been conducted on customer preference and satisfaction in health tourism. With regard

to health tourism, most of the studies focused on historical evolution and operations of

ayurvedic resorts, from the perspective of the western countries. However, some
contemporary studies highlighted Kerala as a health tourism destination. This made the

researcher to conduct an exclusive study on the Health Tourism from the perspective of

customer preference and satisfaction. The current study on customer preference and

customer satisfaction discusses issues about health tourists pre-purchase expectations

and post-purchase evaluation respectively. This can help the tourism planners to focus

on niche tourism market which can contribute in developing the destination manifolds.

After ascertaining the core elements of customer preference variable for health and

wellness services, typical health resorts can formulate the appropriate marketing

strategies to increase customer satisfaction, loyalty, and retention, thereby

strengthening their competitive position. However, it is absolutely impossible in the

contemporary world to remain cost competitive and offer every feature desired by

customers (Pollman et al., 2002).

Thus, this study with reference to customer preferences and satisfaction in health

tourism can guide the tourism planners to target segmented tourism market, thereby

achieving significant development in tourism in Kerala. The study can help to identify

the health tourism attributes to satisfy health tourists seeking for unique health services

at destinations like Kerala. With this backdrop, the health tourism planners and

operators can develop better customer relationship strategies to increase whereas

increasing the number of repeat visits besides attracting new visitors.

1.13 MAJOR OBJECTIVES

The main objectives of the present study.

1 : To understand the major preferences of health tourists.

2 : To identify the socio-economic factors influencing the perception of health

tourists.

3 : To investigate the major factors influencing the perception of tourists on

ayurvedic health tourism in Kerala.

4 : To Investigate the association of socio-economic factors of health tourists with

level of perception and satisfaction.

5 : To find out the level of satisfaction of tourists on the services and facilities of

health tourism.

6 : To identify the factor influencing overall perception and overall satisfaction.

7 : To identify the most effective retention technique in a health resort.

8 : To formulate suitable customer retention strategies for the health resorts.

1.14 MAJOR HYPOTHESES

H0(1) : There is no significant difference of perception between major socio economic

determinants and overall perception on health tourism services.

H0(2) : There is no significant difference between the travel profile of the respondents

and overall satisfaction on booking, awareness creation, environment and

facilities.

H0(3) : There is no significant association between socio economic indicators and

satisfaction on booking, awareness creation environment and facilities.

H0(4) : There is no significant association between socio economic indicators and

overall satisfaction.

H0(5) : Socio economic indicators are not associated with various service attributes for

obtaining overall perception and satisfaction.

H0(6) : Overall satisfaction is not positively influenced by the elements of health care

packages and destination image.

H0(7) : There is no association with overall satisfaction of health tourists with the

retention technique used in the health resort.

H0(8) : There is no relationship between overall perception and overall satisfaction and

customer retention techniques in the ayurvedic resorts.

1.15 ORGANIZATION OF CHAPTERS

The study is structured with six major chapters as follows :

Chapter I : Introduction

This introductory chapter gives a panoramic view of tourism in general and the

background of Indian tourism and health tourism. It also highlights the significance of

the study, lists out the major objectives and limitations of the study.

Chapter II : Review of Related Literature

An attempt has been made to relate the current work into the related theoretical

background to build a solid foundation of theory with a specific purpose of ascertaining

the relationship of conceptual variables affecting the growth of health tourism in Kerala.

Chapter III : Research Methodology

It discusses the research procedures adapted for this study, a detail account of

data analysis and various statistical tools adapted for the study and its implications is

also explained in this chapter.

Chapter IV : An Overview on Kerala and Ayurveda

This chapter gives a detail account of Kerala tourism statistics. Importance of

ayurveda and the principle behind ayurveda. It also describes about the ayurvedic

resorts under the study.

Chapter V : Analysis and Interpretation

The data analysis and the test of various hypothesis and interpretation of results

are covered in this chapter.

Chapter VI : Findings, Suggestions and Conclusion

Apart from presenting major findings and suggestions, the chapter presents the

conclusion and the implications of the present study both for the advancement of theory

and for the managerial implications of tourism. It also opens some avenues for the

conduct of future research in health tourism area in India or elsewhere in the world.

1.16 LIMITATIONS OF THE STUDY

Despite best efforts, there were several limitations which the researcher faced

during the course of the study :

The researcher collected primary information mostly through field visits. Due to

the time and cost constraints, it was not possible to visit all places, thereby

produced an exhaustive work.

The statistical tools used in this study have their own limitations.

The size of the sample is another limitation. This is due to the fact that the

research is purely an exploratory one and the data is mainly primary. Limited

generalizability of the study exists because of the use of convenient sample.

During the collection of the primary data, the researcher had to thoroughly

convince the respondents and the health tourism operators about the purpose of
 the study. Furthermore, their reliability of the questionnaire survey method

always leaves rooms for questioning and doubts.

Many organisers were reluctant in permitting their customers to participate in the

study. And many respondents were found to be conservative while providing

some information.

Hence, findings of the present study should be used judiciously and carefully by

taking into account of the above limitations.

1.17 CONCLUSION

Health tourism is the new thrust area of the tourism industry and it has come to

be recognised as a significant factor in the economy of Kerala (Sarangadharan and

Sunanda, 2009). Medical tourism and health tourism are the terms being used

interchangeably. Medical tourism is a developing concept people from all over the world

travel for treatments of acute illness, surgeries and replacement surgeries mainly on

account of cost effective quality treatments available in India. Health tourism mainly

includes ayurvedic treatments, yoga therapy herbal treatments and indigenous systems.

Ayurvedic tourism is a craze for the tourists visiting Kerala and it has become the major

element of tourism in the state. The present study revolves around the pre-consumption

and post-consumption dimensions of health tourists.