The Politics of International Health

PROSPECTS AND PROBLEMS OF MEDICAL

TOURISM IN BANGLADESH
Muhammad Z. Mamun and Syed Saad Andaleeb

The growing trend of Bangladeshi patients travelling abroad for medical

services has led to some soul-searching in policy circles. While other
countries of the Southeast Asia region are profiting from medical tourism,
Bangladesh not only lags behind, it also loses patients to these countries in
a continuous stream. This exodus for medical treatment is seemingly driven
by the higher perceived quality of treatment abroad, despite the fact that
similar treatment is available more cost-effectively within the country. Certainly the Bangladesh health care system is not without its problems, which
have diminished the perception of quality in the sector. Thus, this study
focuses on key factors for Bangladeshi health service providers to address.
By doing so, they will be better able to develop the local health care sector
and retain Bangladeshi patients within the country. Subsequently, by identifying strategic niches, Bangladesh could focus on delivering higher quality
health care services to develop medical tourism and attract patients from
abroad in specific categories of health care.

Medical tourism is a rapidly growing global industry. More than 50 countries

have identified it as a national industry (1). It is estimated that gross medical
tourism revenues in 2004 were more than US$40 billion worldwide and
projected to increase to US$100 billion by 2012 (2). The rapid globalization of
health services is driven by many factors. These include the rise in privatesector participation in health care in many countries, the liberalization of sectors
such as insurance, and increased mobility of patients as a result of greater ease
of travel and technological advances (3). In addition, differences in costs, availability, and quality of health care across countries and the general increase in
International Journal of Health Services, Volume 43, Number 1, Pages 123141, 2013
2013, Baywood Publishing Co., Inc.
doi: http://dx.doi.org/10.2190/HS.43.1.i
http://baywood.com

123

124

/ Mamun and Andaleeb

demand for better health services, given rising income levels, have also contributed to the globalization of health services (4).
Bangladesh has a population of 160 million people in an area of 147,570
square kilometers (5). Rich in cultural legacy and home to simple and friendly
people, this agrarian country is gradually transforming itself into a good location
for business. In fact, it has been categorized as one of the next 11 countries
that will achieve the economic success of the BRIC countries (Brazil, Russia,
India, and China) in the long run (6).
Although various opportunities are opening up in Bangladesh, it also has
its share of problems in governance, political stability, infrastructure, energy,
corruption, and regulation, among other areas (7). Despite all this, Bangladesh
continues to achieve steady and sustainable growth and has made good progress
on several Millennium Development Goals (MDGs), such as reducing population growth, improving per capita income growth, decreasing child mortality,
expanding primary and secondary education, and enhancing capacity for disaster
management (8). It has already attained goals related to gender parity in schooling
and universal primary education. However, it faces many challenges in providing quality health services, including reducing child malnutrition and maternal
mortality. Hence, one area that prevents Bangladesh from achieving sustainable
growth is health care.
Proper medical care is, in fact, markedly deficient in Bangladesh. To serve
its burgeoning population, there are only 1,683 hospitals, 44,632 registered physicians, and 20,129 registered nurses/midwives. This means there is one doctor
for every 3,125 people (5). However, these data may be erroneous. Many of the
registered doctors may no longer be serving, since registration is not regularly
updated. In addition, an average of 200 doctors from the government sector
alone migrate abroad every year (9). Thus, the number of doctors may actually
be much lower. This inadequacy of health workers is alarming because it has
been estimated that by the year 2015, 57,752 doctors and 144,365 nurses/
midwives will be required to meet the health care needs of patients (8). Unfortunately, 65 percent of newly graduating doctors attempt to get a job abroad,
which worsens the situation (9).
The Bangladesh public health care system has four levels of delivery:
(1) community outreach, (2) health and family welfare centers, (3) upazila
health complexes, and (4) district hospitals (10). While the first three levels
are used for initial diagnosis (the first referral system), district hospitals and
specialized centers, especially in Dhaka City, are used as second referrals.
The private medical facilities in the country include clinics, medical centers,
nursing homes, and hospitals. These tend to be relatively small, usually with a
limited number of beds, and do not provide a full range of services. Recently,
however, a number of private hospitals have been set up in the capital, purportedly
providing high-class services. Hospitals like Labaid Cardiac Hospital, Square
Hospital, United Hospital, and Apollo Hospitals not only have modern facilities,

Medical Tourism in Bangladesh / 125

but are also very expensive. The vast majority of such facilities are located in
the capital for two reasons: first, the services are targeted toward the upper-middle
class and, second, because of the countrys small size geographically, patients
can easily travel to the capital in a matter of hours (11).
In addition, there is a fairly extensive network of health care facilities
run by non-government organizations (NGOs). For example, BRAC provides
door-to-door health care services that reach an estimated 31 million rural poor
through 70,000 community health volunteers and 18,000 health workers (12).
Similarly, RTIs NGO Service Delivery Project, funded by USAID, is helping
32 NGOs and 320 clinics deliver care to Bangladeshs most needy citizens (13).
The level of care provided by the NGOs, however, is very basic and not amenable
to the specialized needs of those availing themselves of medical tourism.
Of the available hospitals, 678 are government hospitals and 1,005 are
private hospitals (5). Most of the government-run hospitals are dilapidated and
in a state of general disrepair, while the better-equipped private hospitals are
mostly in the cities and towns. Thus, the majority of the population, especially
in the rural and semi-urban areas, has to depend on poor quality of service from
the government hospitals. Certain public hospitals do provide advanced services
such as heart surgery, organ transplants, radiation therapy, cosmetic surgery,
and neurosurgery at competitively priced packages. Nonetheless, the overall
utilization rate for public health care services is low, at 30 percent (14).
As the utilization of public health care services has been declining, the
rate of utilization of private health facilities has been on the rise (15). Private
hospitals have been able to attract more patients because of their superior
services, which are then justified in terms of higher prices. Though only a niche
segment of the population can afford private medical care, more patients are
turning to it. Despite providing better services than most state-run hospitals,
these health care facilities have their own set of problems. For example, the
private health care sector has been accused of not living up to its quality claims.
Despite the high cost that patients have to bear, the pursuit of profit has led
to compromising quality. Some of the primary complaints include disregard
of standard treatment protocols, lack of qualified nurses, and unnecessary diagnostic tests (7).
The diagnostic services offered range from routine tests such as blood, urine,
and stool examination, microbiological cultures, routine biochemical tests, and
X rays to more sophisticated services such as imaging, ultrasonography, and
immunological tests. While there is a great demand for these services, there
has also been a great deal of abuse: physicians and hospitals often prescribe
unnecessary and often contradictory tests. This, added to the general apathy of
the diagnostic centers, leads to a large number of misdiagnoses (15). The unsatisfactory services provided by hospitals, uncaring behavior of medical professionals, and inaccurate diagnostic tests have resulted in a general distrust among
Bangladeshi people concerning the health care system. As a result, more and

126

/ Mamun and Andaleeb

more patients are opting to go abroad for diagnosis and treatment (16) when
they can afford it. In many cases, treatments that could have been successfully
performed within the country are now being done in countries like India,
Singapore, Malaysia, and Thailand. Hence, Bangladesh is promoting medical
tourism of other countries within the region while the prospects within the country
remain unexplored.
CONCERNS REGARDING HEALTH CARE
IN BANGLADESH
The trend of Bangladeshi patients travelling abroad for medical services seems
to be growing because of a number of pressing concerns.
Perceived Quality
Several countries of the Southeast Asia region are profiting handsomely from
medical tourism. Bangladesh not only lags behind in this area, it actually loses
patients to these countries who go abroad for medical treatment because of
the higher perceived quality of the treatment, despite the fact that the same
treatment can be achieved more cost-effectively within the country. As a result
of the increased medical expenditures abroad, the financial resources of the
country are being regularly diverted out of the economy. It is important
to note, however, that Bangladesh should be willing to outsource services in
areas where it lacks comparative advantage. At the same time, it should identify and build strategic areas of health care services to deliver better care to
both local and overseas patients, thereby contributing to developing a medical
tourism sector.
Marketing and Promotion
Health care facilities are being set up in Bangladesh in greater numbers, while
the established facilities are increasing their capacities and capabilities. These
facilities extend the possibilities of starting a nascent medical tourism industry.
Despite this, the rate of patients depending on foreign health care is increasing.
Unfortunately, marketing of these high-quality local hospitals is very weak,
whereas foreign hospitals are establishing their reputation and building a
commanding presence in Bangladesh every day. Ironically, while Bangladeshi
patients are seeking treatment in Apollo Hospitals in India and Sri Lanka,
the Apollo Hospital in Dhaka is being underutilized and the hospital has
had to lay off staff. This calls for strengthening the marketing programs of
the newer and more specialized hospitals if medical tourism is to be effectively promoted.

Medical Tourism in Bangladesh / 127

Information Dissemination
Another significant problem is the lack of information about services provided
by the local hospitals. Many patients are simply not aware of the competitively
priced service packages available to them. For instance, procedures such as
coronary bypass surgeries have been very successful in a number of facilities,
like the National Heart Foundation and the Ibrahim Cardiac Hospital & Research
Center. A range of more complex procedures, such as liver transplants, are also
available within the country. However, general ignorance caused by the lack
of information dissemination has led patients to seek such services in other
countries. If such information is more widely disseminated, it could help nurture
a medical tourism industry in Bangladesh.
Quality Evaluation
When dealing with the health care system, the question of quality arises instinctively. Proper policy for evaluation of the quality of physician and nursing care
in Bangladesh is absent. Not only is physician registration rarely updated, there
is no system that would allow patients to scrutinize a physicians past record.
Furthermore, the licenses of physicians are rarely revoked for gross misconduct and malpractice. The dormant state of national medical bodies such as
the Bangladesh Medical Association (BMA) and lack of interest by the Ministry
of Health allow hospitals and private practitioners to take advantage of patients,
largely because ethical malpractices go unchecked. To develop a medical tourism
industry, patient confidence must be garnered through established evaluation
procedures within the industry. Only then can such an industry, fully sustainable,
be envisaged.
Trade and Supply of Health Services
Health services are traded in various ways. The dominant modes of exchange
include cross-border delivery, consumption abroad, commercial presence, and
movement of health personnel (17). There are mixed implications for such trade.
On the bright side, it may trigger upgrading the health care exporters infrastructure, technological capacities, and health care standards. For countries that
import health services, medical tourism can be an important means of overcoming shortages of resources, particularly for specialized health services.
However, trade in health services may also result in a dual market structure
or aggravate such tendencies within the health care system (18). Thus, it can
result in the creation of higher quality and expensive health care facilities that
cater to a few wealthy locals, as reflected by the recent number of designer
hospitals that are being established in Dhaka, while lower quality facilities serve
the large majority.

128

/ Mamun and Andaleeb

There are, however, numerous constraints to trade in health services. The

three broad categories of constraints include: (a) restrictions on entry and terms
of practice by foreign health service providers; (b) restrictions on foreign
direct investment in the health sector and in related sectors; and (c) domestic
infrastructural, regulatory, and capacity constraints (3). In each case, it is
necessary to evaluate whether these barriers are justified, whether they can
be overcome, and whether alternative measures can be considered that would
facilitate trade in health services to serve unserved needs across the region
while bolstering trade.
Other Issues
Health care service providers and planners in Bangladesh are often more concerned about the cost of health care than its quality. The majority of complaints
of patients, however, are the behavior, conduct, and attitude of health care
workers; yet nothing has been done to incorporate this into the training of
doctors and nurses at the national level. Factors influencing patients dissatisfaction in Bangladesh, derived from popular media, include:

Doctors recommending unnecessary medical tests for diagnosis of diseases

Irregular supply of drugs at the hospital premises
Irregular supervision of patients by care providers
Unavailability of specialists
Doctors not providing correct treatment the first time
Long waiting time
Negative word-of-mouth that dissuades others from pursuing health care
within the country
Not addressing the queries of patients
Lack of assurance of recovery
Low accessibility to the hospitals
Scarcity of doctors and nurses
Presence of extra payments (bribes) in every tier of the service
Low-capacity and overpriced services of quality hospitals

These issues have to be vigorously addressed before local, as well as foreign,

patients can be persuaded to consider utilizing medical services in Bangladesh.
This research explores the reasons why Bangladeshi patients prefer to be
treated abroad. Insights from the findings can lay the foundations for developing
medical tourism to serve patients from neighboring countries. The development
of such a sector in the country can help earn foreign currency and further
strengthen the tourism sector by developing joint programs. With a decrease
in the number of patients travelling abroad, foreign currency losses from the
economy can be better utilized in other sectors.

Medical Tourism in Bangladesh / 129

OBJECTIVES
This study attempted to determine the problems in the health care sector in
Bangladesh and, thus, the prospects of developing medical tourism in the country.
Specifically, the study looks into:
1.
2.
3.
4.

The popular medical tourism destinations for Bangladeshi patients;

The factors attracting patients to these destinations;
The major shortcomings of the local health care system; and
Comparative advantages of Bangladesh in terms of health care facilities.
METHODOLOGY

This research gathered both primary and secondary data. A survey was conducted
with people seeking medical treatment at home and/or abroad. Secondary information was derived from books, journal articles, and reports relevant to this sector.
In addition, in-depth interviews were conducted with doctors and specialists.
A questionnaire was developed for this study that included checklists, dichotomous questions, Dockert ranking, Likert scales, and open-ended questions. The
Likert scale consisted of 16 service rating variables in two identical sets: one
for Bangladeshi hospitals and the other for foreign medical service providers.
The questionnaire was self-administered. A total of 99 respondents were surveyed
for this purpose using a non-probability sampling technique. The respondents
were chosen on the basis of accessibility and judgment because of a lack of
reliable lists of potential respondents.
The scope of this research includes only the respondents who sought
medical treatment in Dhaka and/or abroad. The following private hospitals of
Bangladesh were considered: Apollo Hospital, United Hospital, Square Hospital,
and LabAid Hospitals. The public-sector medical service providers considered
in this research were limited to BIRDEM Hospital, BSMMU, National Heart
Foundation, and National Cancer Institute. It may be noted here that Dhaka,
the capital of Bangladesh, is the hub of all socioeconomic activities. As all the
reputable hospitals and experts are available in Dhaka, the research was primarily
confined to Dhaka City.
ANALYSIS AND FINDINGS
Respondents Profile
Of the 99 respondents, 66 percent were males while 34 percent were females.
The majority (70.7%) earned above Tk. 50,000 per month. The age of the
respondents going abroad for medical treatment was between 20 and 29 and
between 50 and 59.

130

/ Mamun and Andaleeb

Purpose of Visit
As illustrated in Table 1, treatment is the major reason for going abroad
(65.65%). However, we also note that a sizable portion of the respondents
(26.26%) went to accompany a patient, and some went for tourism (8.08%),
which shows the potential of these countries not only as a destination for
medical services but also as a tourist destination.
Types of Foreign Health Care Services
Medical services include a wide variety of treatments and not all patients seek
the same services (Table 2). Treatment of a medical condition reflects the most
common reason for going abroad (64.65%), followed by diagnostic purposes
(31.31%), and general checkup (24.24%). The high numbers seeking treatment
are probably because medical treatment requires a high degree of trust in the
competency and quality of medical service, which needs to be bolstered in

Table 1
Purpose of visit
Frequencya (%)

Purpose of visit
Treatment
Tourism
Accompanying a patient
Business

65 (65.65)
8 (8.08)
26 (26.26)
9 (9.09)

aIncludes multiple responses.

Table 2
Types of health care services sought
Type of service

Frequencya (%)

Treatment
Diagnosis
General checkup
Follow-up

64 (64.65)
31 (31.31)
24 (24.24)
9 (10.1)

aIncludes multiple responses.

Medical Tourism in Bangladesh / 131

Bangladesh. After all, the rise in patients going abroad can be attributed to the
differences in availability and quality of health care across countries (4).
The study also noted that the range of illnesses treated in foreign hospitals
is quite wide. Primarily, however, people seek foreign medical services for
heart-related illness (25.25%). Other treatments sought abroad are general
checkups and treatments for age-related diseases (12.12%), cancer (10%), and
neurological disorders and brain tumor (8.1%). In addition, ear, nose, and
throat, pain and inflammation, vision, respiratory problems, gynecological and
pregnancy-related, abdominal surgery, bone, kidney, cystic disease, liver, and
pathology matters are also consulted and treated.
Popular Medical Tourism Destinations for Bangladeshi Patients
The respondents were asked to name their medical destination of choice. Table 3
summarizes the result. The greatest number of respondents went to India, which
is likely because of cost factors since various expenses, especially travel, are
the lowest for India among the three countries. In addition, the nearness of
India makes travelling convenient. Singapore, despite being relatively the most
expensive destination among the three, enjoys a little higher response than
Thailand. This is probably because Singapore has established itself as providing
premier quality in medical services with additional opportunities for tourism.
The study also revealed that accommodation is easily available in all three
countries. Again, when the respondents were asked whether accommodation
was priced reasonably, most indicated in the affirmative for India and Thailand;
Singapore was seen as expensive.
Role Played by Other Countries
India and Thailand are now promoting their high-tech facilities for more serious
medical cases, including hip and knee replacements and cardiac surgery (19). This

Table 3
Destination choice
Destination

Frequency

India
Singapore
Thailand
Others
Total

67
16
12
4
99

132

/ Mamun and Andaleeb

is reflected in the survey findings where most people sought heart-related,

cancer, neurological, and other major treatments in foreign hospitals. There are
also those people who go abroad for a general checkup in addition to taking a
tour of the country. Interestingly, Bangladesh offers a full range of treatments
ranging from heart bypasses and brain tumor removal to complex hip and knee
surgery. However, services such as heart transplants, bone marrow transplants,
and complex cancer treatments are not yet widely available in Bangladesh.
Research shows that India is one of the most prominent of the developing
countries engaged in exporting health services (20). This is supported by the
survey, showing that the highest number of respondents from Bangladesh went
to India to seek specialized treatment because of the latters competitive prices,
geographic proximity, and expertise (4). An estimated 50,000 patients from
Bangladesh seek treatment in Calcutta and other Indian cities each year (20).
Singapore, despite being relatively the most expensive destination among
the three, enjoys higher visitation than Thailand. This is probably because
Singapore has modern, high-quality hospitals and is home to three hospitals
accredited by the Journal of Clinical Investigation (3). Thus, when developing a
destination for medical tourism, instead of focusing only on cost-effectiveness,
the quality of medical service should be highlighted whenever possible and
disseminated through word-of-mouth and other promotional campaigns.
Among the destinations, Apollo Hospital in India, Mount Elizabeth in
Singapore, and Bumrungrad in Thailand take the top three positions, respectively, as the most popular health care providers. This is no surprise since Apollo
is Indias first corporate hospital and plans to invest Rs. 2,000 crores to build
15 new hospitals (21), while Bumrungrad treats about 430,000 medical tourists
a year from 190 different countries (3).
Since more than half of the respondents (56.56%) have gone abroad only
once, it may be inferred that going abroad for medical services is still reserved
for very special situations; it is not a routine decision. For Bangladeshi medical
service providers, this might indicate that there is still room for domestic medical
service providers to improve their quality and performance, thereby retaining
patients who are inclined to go to neighboring countries.
Factors Influencing Destination Choice
Among the factors behind choosing a certain destination abroad, the institutions reputation and references proved to be crucial (Table 4). This once again
illustrates that trust in the perceived quality of medical service provided is one
of the most important factors in choosing a destination abroad.
Regarding the reputation of the medical institutions, 71 percent of the respondents ranked the factor from I to III; only 12 percent ranked it between VI and VIII.
This shows that reputation is the primary reason for choosing a destination for
medical service. Reputation of a medical institution spreads primarily through

Medical Tourism in Bangladesh / 133

Table 4
Factors affecting decision to choose foreign destination

Factors influencing decision to go to a foreign hospital

Reputation
Familys and friends reference
Doctors reference
Cost
Ease of access (visa, tickets, etc.)
Past experience
Tourist facilities
Presence of family and friends at the destination

Index (Rank)
Scale of 1 (most important)
8 (least important)
2.8 (I)
3.0 (II)
3.5 (III)
4.2 (IV)
4.7 (V)
5.5 (VI)
5.8 (VII)
6.5 (VIII)

word-of-mouth in Bangladesh. Thus, it is no surprise that referrals from family

and friends ranked as a close second in the mean ranking with nearly 25 percent
of the respondents ranking it at number I.
Doctors reference comes third, with a marked difference in mean ranking. This
shows that although doctors opinion is supposed to be more knowledge-based
and accurate, the opinions of family and friends are held in higher regard. This
could be because of the doctors own lack of awareness about foreign medical
services, compared to the first-hand experience of the patients friends and family.
An important survey finding is the ranking of cost at fourth place and tourism
facilities at seventh. This shows that cost as a determining factor is relatively
weak since medical services are usually pursued for treatment purposes, and trust
in the quality of the medical institution is more important. The low ranking of
tourism facilities reveals that tourism is yet to be an important determinant for
Bangladeshis when choosing a destination for medical service: very few people
(7.42%) went abroad for health care with tourism in mind.
Information Source
Choosing a medical treatment provider takes time and thought. According to the
survey (Table 5), a majority of respondents (70.7%) found information about the
hospital from friends and family. This once again illustrates that word-of-mouth
plays an important role in creating awareness of foreign medical service. It also
illustrates that doctors reference plays an important role (18.2%) in choosing a
foreign medical facility. It is also seen that a few respondents (9.1%) obtained
the information on their own (e.g., from the Internet, articles, etc.).

134

/ Mamun and Andaleeb

Table 5
Primary information sorce
Information source
Friends/family
Doctors reference
Searched on my own
Seminars
Advertisements

Frequency (%)
70 (70.7)
18 (18.2)
9 (9.1)
1 (1.0)
1 (1.0)

Complaints against Local and Foreign Health Care Services

When asked about complaints concerning the services of the hospitals visited,
differences were found in the pattern of results between foreign and Bangladeshi
hospitals. In the case of foreign medical services, very few complaints were
noted in comparison to overall services of Bangladeshi hospitals (see Table 6).
Regarding foreign hospitals, inaccuracy of treatment and time-consuming
procedures were rarely mentioned. Though there is a perception that people
seeking treatment abroad complain mostly about the high cost of treatment,
there was only one such complaint. The low frequency of overall complaints also
suggests that complaint minimization is a trait of reputable health care providers,
an insight that similar providers in Bangladesh ought to be cognizant of.
On the other hand, health care services in Bangladesh reflect a very different
picture, where most of the complaints are about unavailability of service, misdiagnosis, improper treatment, poor service, and discourteous staff. These
complaints, unfortunately, represent factors that are commonly known to form
the basis of medical service. The failures in these factors can result in losing a
hospitals credibility among the patients, thus forcing them to consider foreign
medical services.
A number of the respondents made use of emergency health care facilities
abroad (23.23%), while 38 percent did so in Bangladesh. While more than half
of the foreign emergency users were served immediately, the domestic service
providers could not match such responsiveness. Half of the respondents of local
emergency unit users were served in a reasonable time and almost 40 percent of the
respondents were dissatisfied with the responsiveness of the service providers.
Country-Wise Quality Comparison
A five-point Likert scale (5: excellent, 1: very poor) was used to measure the
quality of the tourism destinations as perceived by the respondents. The purpose

Medical Tourism in Bangladesh / 135

Table 6
Frequency of complaints
Foreign hospitals
Reason for complaint

Bangladeshi hospitals
Frequencya Reason for complaint

Inaccuracy of treatment
Time-consuming
Commercial
Crowded
Did not provide all the documents
Substandard doctors and nurses
Expensive

2
2
1
1
1
2
1

Unavailable service
Misdiagnosis
Improper treatment
Could not diagnose
Poor service
Discourteous staff
Commercial
Poor communication
Unreliable
Inadequate knowledge
Wrong test report

Frequencya
10
9
9
8
8
8
4
4
3
3
2

aMultiple responses (total respondents: 99)

was to compare the ratings of the different countries visited by the participants.
Table 7 summarizes the results.
In terms of food price and food availability, India is considered better than
the other two destinations. Not surprisingly, Singapore rates the poorest in terms
of food prices. On the other hand, Thailand rates the highest on hospitality,
recreational facilities, and shopping. This is also supported by Vajirakachorn
(22), where the strengths of Thailand were considered its hospitality, the ease
of access from Europe, Australia, Americas, and Asia, and the high quality of
tourist facilities and amenities, along with its rich culture and renowned hospitality. Of the three destinations, Singapore was rated highly in terms of food
quality, hospitality, recreational facilities, shopping, sightseeing, and transportation. Thus, of the three destinations, overall, Singapore was perceived to be the
best tourist destination.
Country-Wise Comparison of Medical Service Parameters
A comparison was made among Bangladesh, India, Thailand, and Singapore
regarding the quality parameters of hospital services (Table 8 and Figure 1).
The ratings of the service parameters follow a relatively parallel path for India
and Singapore, where Singapore is always rated higher than India. However,
for Thailand, the parameters demonstrate some variability, falling behind India
in the area of nurse-patient communication and exceeding Singapore when it

136

/ Mamun and Andaleeb

Table 7
Quality parameters of tourism
India

Thailand

Singapore

Parameters

Mean

St. Dev.

Mean

St. Dev.

Mean

St. Dev.

Food quality
Food price
Food availability
Hospitality
Recreational facilities
Shopping facilities
Sightseeing
Transportation facilities

3.89
3.89
4.24
3.68
3.82
4.23
4.10
4.03

0.86
0.94
0.81
0.90
0.83
0.76
0.83
0.84

3.83
3.42
3.92
4.25
4.45
4.67
4.17
4.25

0.58
0.90
0.90
0.97
0.52
0.65
0.58
0.45

4.56
3.13
4.13
4.25
4.44
4.56
4.44
4.38

0.63
1.31
0.81
0.78
0.73
0.63
0.73
0.72

Note: Highest ratings shown in bold figures.

comes to the timely and orderly processing of reports, documents, and hospital
formalities. This is perhaps because while the respondents have been to a varied
number of hospitals in Singapore and India, most respondents who have been
to Thailand went to Bumrungrad. Thus, the chart is essentially a comparison of
one Thai hospital (Bumrungrad) against the general perceived quality of the
medical service industry in India and Singapore. This comparison could have
been better if more respondents could be found who went to other hospitals in
Thailand. Overall, the perceived quality is highest for Singapore, followed by
Thailand and India, respectively.
The chart reveals the comparative strengths and weaknesses of Bangladeshi
medical service providers and those of India, Thailand, and Singapore. By comparing the mean rankings, we note that there is no single service parameter on
which Bangladesh enjoys a comparative advantage at present.
Looking at the mean scores, it is clear where the weaknesses lie and where the
strengths must be further developed. What needs most urgent attention is proper
training of nurses, both those new to employment and those presently employed.
Attention is also needed to improve the aesthetics and cleanliness of hospitals. In
the area of nurse training, not only must their knowledge and skills be improved,
their overall numbers must also be increased. Since nurses are the most frequent
caregivers and contact points for patients, they can greatly influence patients
perception of the quality of medical service provided.
It may be noted that aesthetics and cleanliness of a hospitals premises are
the first quality indicators of medical services that a patient encounters and
experiences; hence, it is important to create a positive first impression. For
Bangladesh to be even considered as an alternate destination for medical tourism,

India
4.42
4.43
4.42
4.57
4.19
4.40
4.09
4.42
4.22
4.48
4.45
4.25
4.23
4.21
4.28
4.24

Original variables

1. Completeness of services
2. Accuracy of diagnosis and treatment
3. Responsiveness of doctors
4. Knowledge and skill of doctors
5. Knowledge and skill of nurses and other staff
6. Communication between doctor and patient
7. Communication between nurse and patient
8. Doctor courtesy and empathy
9. Nurse courtesy and empathy
10. Timely and orderly processing of reports, documents, and hospital formalities
11. Timeliness of laboratory tests
12. Availability of doctors
13. Availability of nurses and other staff (e.g., ward boys)
14. Physical appearance of hospital staff
15. Physical appearance and cleanliness of hospital premises (aesthetics)
16. Proper performance of hospital equipment

Country comparison of medical service parameters

Table 8

4.58
4.50
4.58
4.58
4.27
4.17
3.93
4.33
4.25
4.83
4.73
4.50
4.67
4.60
4.82
4.78

Thailand

4.69
4.75
4.69
4.81
4.50
4.50
4.31
4.73
4.67
4.69
4.75
4.75
4.69
4.50
4.69
4.67

Singapore

2.61
2.61
2.76
3.06
2.26
2.78
2.29
2.87
2.35
2.79
2.89
2.67
2.84
2.45
2.41
2.83

Bangladesh

Medical Tourism in Bangladesh

/ 137

138

/ Mamun and Andaleeb

Figure 1. Country comparison of medical service parameters. Refer to Table 8 for

variables.

this parameter must be given singular attention. It must be noted that some
hospitals, such as Apollo Hospital, United Hospital, and a few others, are beginning to develop these parameters and may serve as a benchmark for others.
CONCLUSIONS
Medical tourism is fast-growing globally as a lucrative industry. Can Bangladesh
partake in this growth industry, given its extensive network of health care
facilities and the experience it has garnered over the years in dealing with a
burgeoning population? The answer is a cautious but resolute yes.
This would require strategic thinking on the part of health policy experts
in the country. The first order of business is to determine why so many Bangladeshis are leaving for other countries to seek health care. By most indications, the

Medical Tourism in Bangladesh / 139

quality of services must improve significantly as the findings suggest in
Tables 6 and 8. Clearly, services provided must be more comprehensive, with
significant decreases in misdiagnoses and improper treatment. In addition, service
quality must also improve, requiring greater responsiveness of doctors, who
must demonstrate greater knowledge and skills, communicate better with
patients, and display higher levels of empathy and courtesy. Processing of patients
and lab reports must also be conducted in a timely and orderly fashion. Also,
the aesthetic appeal of hospitalsespecially their hygiene and cleanlinessand
the quality and availability of nurses and other staff are areas of weakness facing
hospitals in Bangladesh. On the other hand, the doctors proved to be relatively
better, as some degree of trust still resides in their competency, as well as their
availability and courtesy. To achieve these goals, structural shortages of key staff
in the health care system must be alleviated. If needed, impediments to bringing
staff from abroad must be lifted until the demand can be filled internally.
Several hospitals, particularly from the private sector, may also be encouraged
to develop areas of comparative advantage that would make them stand out in
the region. At the same time, greater effort at marketing these advantages must
also be pursued to establish distinctiveness. Since Bangladesh has a cost
advantage and doctors are perceived as adequately skilled compared to foreign
doctors, they could take advantage of these two factors to create Bangladesh
as a destination for medical services for neighboring countries, but especially
for Bangladeshis themselves.
Unfortunately, looking at the countries where the patients are going for medical
servicesIndia, Thailand, and Singaporethe difference in perceived quality
was significant and in no area did Bangladesh have a comparative advantage.
Yet, roughly 10 to 15 years ago, the quality of health care offered in these countries was comparable to that in Bangladesh. For lack of a vision and sustained
attention to this sector, it lost its comparative advantage while other countries
in the region made advances that Bangladesh did not. This loss of opportunity
is partly attributable to the lack of a research culture in the country that fails
to monitor both internal deficiencies and regional progress.
Full-blown medical tourism will thus take time to become a reality for
Bangladesh, as structural impediments and process elements are gradually
brought to global standards. For example, the government, with the help of
medical bodies, must find ways to attract more people into the nursing profession
and to train existing nurses to improve their services. At the same time, the medical
industry can work together with the Department of Tourism to create a more
positive image of Bangladeshi doctors that is communicated both domestically
and internationally. Whether progress is being made will be indicated when
the outflow of patients begin to slow down and a reverse steady trickle begins
to be evident. For that to happen, however, small steps may be taken by private
hospitals to create the right conditions for the medical tourism industry to emerge.
To build the trust of patients, the health care industry must begin to align with the

140

/ Mamun and Andaleeb

phrase, Say as you do, do as you say. That is when the foundation will have
begun to be set for a sustainable medical tourism industry to emerge.
The will and ability to excel in health care provision exists in good measure
in the country, which has continued to deliver services despite the adversities.
It is time for national leadership to pay better attention to this sector and facilitate
its steady development within a decade.
REFERENCES
1. McKinsey & Company and the Confederation of Indian Industry. Press Trust of
India. Delhi, 2005.
2. Herrick, D. M. Medical Tourism: Global Competition in Health Care. NCPA Policy
Report No. 304. National Center for Policy Analysis, Dallas, 2007.
3. MacKain, S. A. Review of Health-Seeking Behavior: Problems and Prospects. Health
Systems Development Programme, University of Manchester, 2003.
4. Bangladesh Bureau of Statistics. Statistical Pocket Book of Bangladesh, 28th Issue.
Dhaka, 2007.
5. Goldman Sachs. How solid are the BRICs? Global Economics Paper No. 134. New
York, 2005.
6. World Bank. Improving the Investment Climate in Bangladesh. Pilot Investment
Climate Assessment, Dhaka, 2003.
7. Millennium Project. Millennium Development Goals Needs Assessments: Country
Case Studies of Bangladesh, Cambodia, Ghana, Tanzania and Uganda. United
Nations, 2004.
8. Adkoli, B. V. Migration of health workers: Perspectives from Bangladesh, India,
Nepal, Pakistan and Sri Lanka. Reg. Health Forum 10(1):4959, 2006.
9. Islam, A. M. Health and health sciences. In Banglapedia: National Encyclopedia
of Bangladesh. Asiatic Society of Bangladesh, Dhaka, 2004.
10. Ahmed, Z. U. Private hospitals and clinics. In Banglapedia: National Encyclopedia
of Bangladesh. Asiatic Society of Bangladesh, Dhaka, 2006.
11. Wikipedia. BRAC. http://en.wikipedia.org/wiki/BRAC (NGO) (accessed July 3,
2011).
12. RTI International. Improving Health Care Delivery in Bangladesh. http://www.rti.org/
brochures/rti_Bangladesh_health_brochure.pdf (accessed July 3, 2011).
13. Ricardo, B., et al. Comparative Advantages of Public and Private Providers in
Health Care Service in Terms of Cost, Pricing, Quality, and Accessibility. Government
of Bangladesh, Health Economics Unit, Ministry of Health and Family Welfare,
Dhaka, 2004.
14. Andaleeb, S. S., Siddiky, N., and Khandakar, S. Patient satisfaction with health
services in Bangladesh. Health Policy Plann. 22(4):263273, 2007.
15. Zarilli, S., and Kinnon, C. International Trade in Health Services: A Development
Perspective. UNCTAD/World Health Organization, Geneva, 1998.
16. Dacanay, J., and Rodolfo, M. Challenges in Health Services Trade: Philippine
Case. Discussion Paper Series No. 2005-30. Philippine Institute for Development
Studies, 2005.

Medical Tourism in Bangladesh / 141

17. Chanda, R. Trade in Health Services. CMH Working Paper Series: 5. Commissions
on Macroeconomics and Health, 2007.
18. Ernst, D. Medical tourism: Why Americans take medical vacations abroad. Health
Policy Prescriptions 4(9), 2006.
19. Chanda, R. India and services outsourcing in Asia. Singapore Econ. Rev. 53(3):
419447, 2008.
20. Leon, F., et al. Modernization and Foreign Trade in Health Services: Case of the
Chilean Health System, 19832000. Santiago, 2000.
21. Vajirakachorn, T. Implementation of an Effective Health Tourism Development Plan
for Thailand. University of Wisconsin Stout, Menomonie, 2004.

Direct reprint requests to:

Syed Saad Andaleeb, Ph.D.
Sam & Irene Black School of Business
Pennsylvania State University
5101 Jordan Road
Erie, PA 16563
saadandaleeb@gmail.com