PROPOSAL

SURVEY OF WELLNESS AND HEALTH TOURISM GROWTH

IN KERALA IN LAST 10 YEARS

SUBMITTED BY:
SUBHAM PANDEY
ENROLMENT NUMBER: 177458081
PROGRAM: BTS

SUBMITTED TO:
PROGRAMME COORDINATOR
(CTS, DTS AND BTS)
SCHOOL OF TOURISM AND HOSPITALITY SERVICES MANAGEMENT
(SOTHSM)
INDISRA GANDHI NATIONAL OPEN UNIVERSITY
MAIDAN GARHI
NEW DELHI 110068

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 INDEX
1. Introduction
2. Tourism Resources of Kerala
3. Health Care Potentials of Kerala
4. Health Tourism Scenario in Kerala
5. Effect of Health Tourism on Other Forms of Tourism
6. Health Tourists Opinion about Kerala’s Health Tourism
7. Potentials of Health Tourism in Kerala: SWOT Analysis

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 INTODUCTION
Kerala is a state on the southwestern, Malabar Coast of India. It was formed on 1
November 1956, following passage of the States Reorganization Act, by
combining Malayalam-speaking regions. Spread over 38,863 km2 (15,005 sq mi),
Kerala is the twenty second largest Indian state by area. It is bordered by
Karnataka to the north and northeast, Tamil Nadu to the east and south, and the
Lakshadweep Sea and Arabian Sea to the west. With 33,387,677 inhabitants as per
the 2011 Census, Kerala is the thirteenth-largest Indian state by population. It is
divided into 14 districts with the capital being Thiruvananthapuram. Malayalam is
the most widely spoken language and is also the official language of the state.
The Chera Dynasty was the first prominent kingdom based in Kerala. The Ay
kingdom in the deep south and the Ezhimala kingdom in the north formed the other
kingdoms in the early years of the Common Era (CE or AD). The region had been
a prominent spice exporter since 3000 BCE. The region's prominence in trade was
noted in the works of Pliny as well as the Periplus around 100 CE. In the 15th
century, the spice trade attracted Portuguese traders to Kerala, and paved the way
for European colonisation of India. At the time of Indian independence movement
in the early 20th century, there were two major princely states in Kerala-
Travancore State and the Kingdom of Cochin. They united to form the state of
Thiru-Kochi in 1949. The Malabar region, in the northern part of Kerala had been
a part of the Madras province of British India, which later became a part of the
Madras State post-independence. After the States Reorganisation Act, 1956, the
modern-day state of Kerala was formed by merging the Malabar district of Madras
State (excluding Gudalur taluk of Nilgiris district, Topslip, the Attappadi Forest
east of Anakatti), the state of Thiru-Kochi (excluding four southern taluks of
Kanyakumari district, Shenkottai and Tenkasi taluks), and the taluk of Kasaragod
(now Kasaragod District) in South Canara (Tulunad) which was a part of Madras
State.

The economy of Kerala is the 12th-largest state economy in India with 7.73 lakh
crore (US$110 billion) in gross domestic product and a per capita GDP of 163,000
(US$2,300). Kerala has the lowest positive population growth rate in India, 3.44%;
the highest Human Development Index (HDI), 0.712 in 2015; the highest literacy
rate, 93.91% in the 2011 census; the highest life expectancy, 77 years; and the
highest sex ratio, 1,084 women per 1,000 men. The state has witnessed significant
emigration, especially to Arab states of the Persian Gulf during the Gulf Boom of
the 1970s and early 1980s, and its economy depends significantly on remittances
from a large Malayali expatriate community.

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Hinduism is practised by more than half of the population, followed by Islam and
Christianity. The culture is a synthesis of Aryan, Dravidian, Arab, and European
cultures, developed over millennia, under influences from other parts of India and
abroad.

The production of pepper and natural rubber contributes significantly to the total
national output. In the agricultural sector, coconut, tea, coffee, cashew and spices
are important. The state's coastline extends for 595 kilometres (370 mi), and
around 1.1 million people in the state are dependent on the fishery industry which
contributes 3% to the state's income. The state has the highest media exposure in
India with newspapers publishing in nine languages, mainly English and
Malayalam. Kerala is one of the prominent tourist destinations of India, with
backwaters, hill stations, beaches, Ayurvedic tourism and tropical greenery as its
major attractions.

The name Kerala has an uncertain etymology. One popular theory derives Kerala
from Kera ("coconut tree" in Malayalam) and alam ("land"); thus "land of
coconuts" which is a nickname for the state, used by locals, due to abundance of
coconut trees. The word Kerala is first recorded as Keralaputra in a 3rd-century
BCE rock inscription left by the Maurya emperor Ashoka (274–237 BCE), one of
his edicts pertaining to welfare The inscription refers to the local ruler as
Keralaputra (Sanskrit for "son of Kerala"); or "son of Chera". This contradicts the
theory that Kera is from "coconut tree". At that time, one of three states in the
region was called Cheralam in Classical Tamil: Chera and Kera are variants of the
same word. The word Cheral refers to the oldest known dynasty of Kerala kings
and is derived from the Proto-Tamil-Malayalam word for "lake".

The earliest Sanskrit text to mention Kerala is the Aitareya Aranyaka of the
Rigveda. Kerala is also mentioned in the Ramayana and the Mahabharata, the two
Hindu epics. The Skanda Purana mentions the ecclesiastical office of the
Thachudaya Kaimal who is referred to as Manikkam Keralar, synonymous with the
deity of the Koodalmanikyam temple. Keralam may stem from the Classical Tamil
cherive-alam ("declivity of a hill or a mountain slope") or chera alam ("Land of the
Cheras"). The Greco-Roman trade map Periplus Maris Erythraei refers to
Keralaputra as Celobotra.According to Tamil classic Purananuru, Chera king
Senkuttuvan conquered the lands between Kanyakumari and the
Himalayas.Lacking worthy enemies, he besieged the sea by throwing his spear into
it. According to the 17th century Malayalam work Keralolpathi, the lands of
Kerala were recovered from the sea by the axe-wielding warrior sage Parasurama,
the sixth avatar of Vishnu (hence, Kerala is also called Parasurama Kshetram

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("The Land of Parasurama"). Parasurama threw his axe across the sea, and the
water receded as far as it reached. According to legend, this new area of land
extended from Gokarna to Kanyakumari. The land which rose from sea was filled
with salt and unsuitable for habitation; so Parasurama invoked the Snake King
Vasuki, who spat holy poison and converted the soil into fertile lush green land.
Out of respect, Vasuki and all snakes were appointed as protectors and guardians
of the land. P. T. Srinivasa Iyengar theorised, that Senkuttuvan may have been
inspired by the Parasurama legend, which was brought by early Aryan settlers.

Another much earlier Puranic character associated with Kerala is Mahabali, an

Asura and a prototypical just king, who ruled the earth from Kerala. He won the
war against the Devas, driving them into exile. The Devas pleaded before Lord
Vishnu, who took his fifth incarnation as Vamana and pushed Mahabali down to
Patala (the netherworld) to placate the Devas. There is a belief that, once a year
during the Onam festival, Mahabali returns to Kerala. The Matsya Purana, among
the oldest of the 18 Puranas, uses the Malaya Mountains of Kerala (and Tamil
Nadu) as the setting for the story of Matsya, the first incarnation of Vishnu, and
Manu, the first man and the king of the region.

 Climate

With around 120–140 rainy days per year, Kerala has a wet and maritime tropical
climate influenced by the seasonal heavy rains of the southwest summer monsoon
and northeast winter monsoon.Around 65% of the rainfall occurs from June to
August corresponding to the Southwest monsoon, and the rest from September to
December corresponding to Northeast monsoon.The moisture-laden winds of the
Southwest monsoon, on reaching the southernmost point of the Indian Peninsula,
because of its topography, divides into two branches; the "Arabian Sea Branch"
and the "Bay of Bengal Branch". The "Arabian Sea Branch" of the Southwest
monsoon first hits the Western Ghats, making Kerala the first state in India to
receive rain from the Southwest monsoon.The distribution of pressure patterns is
reversed in the Northeast monsoon, during this season the cold winds from North
India pick up moisture from the Bay of Bengal and precipitate it on the east coast
of peninsular India. In Kerala, the influence of the Northeast monsoon is seen in
southern districts only. Kerala's rainfall averages 2,923 mm (115 in)
annually.Some of Kerala's drier lowland regions average only 1,250 mm (49 in);
the mountains of the eastern Idukki district receive more than 5,000 mm (197 in) of
orographic precipitation: the highest in the state. In eastern Kerala, a drier tropical
wet and dry climate prevails. During the summer, the state is prone to gale-force

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winds, storm surges, cyclone-related torrential downpours, occasional droughts,
and rises in sea level.The mean daily temperature ranges from 19.8 °C to 36.7 °C.
Mean annual temperatures range from 25.0–27.5 °C in the coastal lowlands to
20.0–22.5 °C in the eastern highlands.

The state's 14 districts are distributed among six regions: North Malabar (far-north
Kerala), South Malabar (northern Kerala), Kochi (central Kerala), Northern
Travancore, Central Travancore (southern Kerala) and Southern Travancore (far-
south Kerala). The districts which serve as administrative regions for taxation
purposes are further subdivided into 75 taluks, which have fiscal and
administrative powers over settlements within their borders, including maintenance
of local land records. Kerala's taluks are further sub-divided into 1,453 revenue
villages.[152] Since the 73rd and 74th amendments to the Constitution of India, the
local government institutions function as the third tier of government, which
constitutes 14 District Panchayats, 152 Block Panchayats, 978 Grama Panchayats,
60 Municipalities, six Corporations and one Township.[153] Mahé, a part of the
Indian union territory of Puducherry,[154] though 647 kilometres (402 mi) away
from it,[155] is a coastal exclave surrounded by Kerala on all of its landward
approaches. The Kannur District surrounds Mahé on three sides with the
Kozhikode District on the fourth.

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  Agriculture
There are six Municipal corporations in Kerala that govern Thiruvananthapuram,
Kollam, Kochi, Thrissur, Kozhikode and Kannur. The Thiruvananthapuram
Municipal Corporation is the largest corporation in Kerala while Kochi
metropolitan area named Kochi UA is the largest urban agglomeration. According
to a survey by economics research firm Indicus Analytics in 2007,
Thiruvananthapuram, Kollam, Kozhikode, Thrissur, Kochi and Kannur are among
the "best cities in India to live"; the survey used parameters such as health,
education, environment, safety, public facilities and entertainment to rank the
cities.

The major change in agriculture in Kerala occurred in the 1970s when production
of rice fell due to increased availability of rice all over India and decreased
availability of labour. Consequently, investment in rice production decreased and a
major portion of the land shifted to the cultivation of perennial tree crops and
seasonal crops.Profitability of crops fell due to a shortage of farm labour, the high
price of land, and the uneconomic size of operational holdings.

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Tourism is not only a growth engine but also an employment generator. According
to the Economic Survey 2011-12, the sector has the capacity to create large scale
employment both direct and indirect, for diverse sections in society, from the most
specialized to unskilled workforce. It provides 6-7 per cent of the world’s total jobs
directly and millions more indirectly through the multiplier effect as per the UN‟s
World Tourism Organization(UNWTO)1. In 2001, the total population of Kerala
was about 32 million, of which 91% was literate. The key crops of Kerala are
coconut, tea, coffee, rubber, cashew, cardamom, pepper and cinnamon. Although
these are still most important for the region’s income, the service sector in Kerala
is booming with financial companies, real estate agencies, mortgage companies,
consultancy services, insurance companies and the tourism industry. Economic
crisis that is underway has been affected by the negative growth effects.
Practically, all sectors of the national economies have been experiencing the
effects, and tourism is no exception. By nature, humans are resilient and in face of
odds and always try to find via media solutions. In the tourism sector against all
the economic odds, dissatisfaction and depression among people has found refuge
in ways of relaxation of soul, body and mind. People, during the last five years,
have increasingly turned towards the ways of health and wellness activities.
Tourism providers have, accordingly, made good on the opportunity and offered
attractive wellness packages in specialized destination. While in the late 1980s and
1990s most of such destinations were primarily located in SE Asia, however, in the
current decade, more and more European destinations are becoming popular. With
Switzerland and France being the cherished destinations of the rich, highly
competitive European destinations like Austria, Greece, Italy, Spain, Croatia,
Turkey and others, have been successfully offering wellness facilities and having
some comparative advantages. Naturally, the already established destinations in the
SE Asia remains strong competitors in the market. However, at least in Europe,
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increased number of people is looking for nearest locations. Although, leading
luxury hotels are among the top providers of such services, modest wellness
service providers have successfully entered this emerging market. Not only more
and more new destinations and service providers are emerging but also new
wellness services are being developed offering the tourists attractive choices.

THE CONCEPTS OF HEALTH AND WELLNESS

The term ‘health tourism’ has not been well defined. Since the 1970s it has
implied ‘the provision of health facilities utilizing the natural resources of the
country, in particular mineral water ad climate’. Goodrich and Goodrich (1987,
217) define it as: The neo-classical economic theory subjectively defines happiness
and has long been the standard of measurement used interchangeably with utility
as well as the general welfare. Modern classical economics no longer attempts to
quantify happiness or satisfaction through measurements in consumption and
profits. Instead, argues that individual’s preference is revealed through choice. The
idea that modern neoclassical economics define happiness on the basis of
consumption is widely disputed. The Happy Planet Index (HPI) is an index of
human well-being and environmental impact that was introduced by the New
Economics Foundation (NEF) in July 2006. The index is designed to challenge
wellestablished indices of countries’ development, such as Gross Domestic
Product (GDP) and the Human Development Index (HDI), which are seen as not
taking sustainability into account. In particular, GDP is seen as inappropriate, as
the usual ultimate aim of most people is not to be rich, but to be happy and healthy.
Furthermore, it is believed that the notion of sustainable development requires a
measure of the environmental costs of pursuing those goals.

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Types of tourism in Kerala
Kerala is far ahead of many other states in India in terms of planning & project
implementation in tourism. The state is also a veritable treasure trove of tourism
assts of diverse nature. There are at least 175 distinct tourist/pilgrim centers of
varying degrees of importance and development potentials across the state.

Heritage and cultural tourism

Heritage and cultural tourism constitutes a dominant component among both
domestic and foreign tourists visiting the state. Among the available assets, it is
imperative to identify and focus upon those that are outstanding enough to attract
and satisfy varied interests. Possible models for tourism development that would
draw strength from the local culture , arts and lifestyle of Kerala include Rural
tourism, development of a heritage village and business tourism packages
incorporating cultural performances, local cuisine etc

. Eco tourism
It is type of tourism that provides the responsible travel to natural areas which
conserves the environment and improves the welfare of the local people".
Ecotourism, also known as ecological tourism, is responsible travel to fragile,
pristine, and usually protected areas that strives to be low impact and small scale. It

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helps educate the traveler; provides funds for conservation; directly benefits the
economic development and political empowerment of local communities; and
fosters respect for different cultures and for human rights. It is a nature - oriented
travel that promotes conservation and resource protection and also adds to the local
economy.

Medical tourism
Medical tourism in Kerala grew without much willful collective efforts. It was
recognized as an opportunity by some sectors, particularly the Ayurveda sector
who took some collective effort to convert Kerala as a source for Ayurveda
treatment. Dentistry and modern medicine also took the role. A combination of
many factors has led to the increase in popularity of medical tourism in Kerala.
 Traditional systems of medicine like Ayurveda and siddha are widely
popular in the state, and draws increasing number of tourists.
 High costs of healthcare in industrialized nations .
 Ease and affordability of international travel.
 Improving technology and standards of care.

Hill station tourism

Kerala is famous for its Hill station tourism. There are many hill station
destinations in Kerala such as Munnar, ponmudi, Wagamon, Ranipuram,
Nelliyampathy, Pythalmala, places in Wayanad District etc. Tourism development
is having a negative impact on the local plantation based economy. One of the
important suggestions put forward is that tourism development may be encouraged
in places where the plantation or other form of local economy is on the downslide
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due to extraneous reasons.

Rural tourism focuses on participating in a rural lifestyle. It can be a variant of

ecotourism. Any village can be a tourist attraction, and many villagers are very
hospitable. Agriculture is becoming highly mechanized and therefore requires less
manual labor. This is causing economic pressure on some villages, leading to an
exodus of young people to urban areas. There is however, a segment of urban
population that is interested to visit the rural areas and understand their
perspective. This segment has been rapidly growing in the past decade and has led
to Rural tourism becoming a good business prospect.

Culture tourism is the subset of tourism concerned with a country or region's

culture, specifically the lifestyle of the people in those geographical areas, the
history of those people, their art, architecture, religion(s), and other elements that
helped shape their way of life. Cultural tourism includes tourism in urban areas,
particularly historic or large cities and their cultural facilities such as museums and
theatres. It can also include tourism in rural areas showcasing the traditions of
indigenous cultural communities (i.e. festivals, rituals), and their values and life
style. It is generally agreed that cultural tourists spend substantially more than
standard tourists do.

Dental tourism is a subset of the sector known as medical tourism. It involves

individuals seeking dental care outside of their local healthcare systems and may
be accompanied by a vacation. Dental tourism is growing worldwide. As the world
becomes ever more interdependent and competitive, technique, material, and
technological advances spread rapidly, enabling providers in "developing
countries" to provide dental care at significant cost savings when compared with
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their peers in the developed world.

Water tourism is traveling by boat while on holiday, with the express purpose of
seeing things meant for the water tourist. This can be traveling from luxury port to
luxury port in a cruise ship, but also joining boat-centered events such as regattas
or landing a small boat for lunch or other day recreation at specially prepared day
boatlandings. Also known as a boating holiday, it is a form of tourism that is
generally more popular in the summertime.

Wildlife tourism can be an eco and animal friendly tourism, usually showing
animals in their natural habitat. Wildlife tourism, in its simplest sense, is watching
wild animals in their natural habitat. Wildlife tourism is an important part of the
tourism industries in many countries including many African and South American
countries, Australia, India, Canada, Indonesia, Bangladesh, Malaysia and Maldives
among many. It has experienced a dramatic and rapid growth in recent years world
wide and is closely aligned to eco-tourism and sustainabletourism.

Religious tourism, also commonly referred to as faith tourism, is a type of tourism,

where people travel individually or in groups for pilgrimage, missionary, or leisure
(fellowship) purposes. The world's largest form of mass religious tourism takes
place at the annual Hajj pilgrimage in Mecca, Saudi Arabia.

Yoga tourism is a new concept for "celebrating your destination with yoga". a
generally accepted idea by the foreigners is, that India is a land of billions of
people, of millions of gods, of great variety of religions, of enormous number of
temples, of philosophers and sadhus or saints, of festivals and fares, of deserts and
hills, of cows and snakes etc.etc.
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Forest tourism Development of tourism in forest areas has often been a subject of
considerable debate. The Tiger Trail (guided trekking programme for tourists) in
the Periyar Tiger Reserve is projected as a model success story in Wildlife
tourism.Thattekakd Bird Sancturay, Parambikkulam, Wayanad (Muthanga) and
Aralam Wildlife sanctuaries; Silent valley National park etc is famous for forest
Tourism.

Ayurveda Tourism There has been a spontaneous growth in Kerala for Ayurveda
which has no competition in the Whole world. By unorganized but collective effort
the name Ayurveda got branded all over the world. With Ayurveda rejuvenation
treatments becoming available widely in different parts of India and abroad, Kerala
would have to strengthen its positioning as the real destination for Ayurveda.
Traditional Ayurveda treatments in Kerala are famous among the tourists

Outdoor tourism The Indian subcontinent is a geographically varied land form that
contains dense jungle, pristine coasts and the highest mountain range in the world,
the Himalayas. These mountains are among the most popular destinations on Earth
for hikers, mountaineers and climbers, and they offer nearly endless possibilities
for trekking adventures. In the lowlands, the forests of India are home to exotic
wildlife, including the rare white tigers of Bandhavgarh National Park, and they
are popular destinations forsafaris and ecological tourism. The varied beaches of
India are popular with surfers,divers, sailors and sun worshipers.

Spiritual tourism Globally people are increasingly mentally disturbed and looking
for solace in spiritual reading, meditation and moments of divine ecstasy. Our
country has been known as the seat of spiritualism and India’s cosmopolitan nature
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is best reflected in its pilgrim with varied attractions but also for many places of
worship; present itself as embodiments of compassion where one get peace of
mind. Kerala is the best place for spiritual tourism. The tradition of Kerala itself
implies a long historical perspective. Temples, mosques and churches in Kerala are
highly inviting the attention of the tourists in to Kerala

Sightseeing tourism Kerala is a popular for historical sightseeing, and it’s

thousands of year’s worth of monuments and architecture are some of the world's
most spectacular

Leisure tourism Kerala is also a global hot spot for those who just want to party or
relax. Luxury resorts that offer all-inclusive holiday’s line for the tourists to enjoy
the scenic beauty of Kerala. Hall (1992, 151) provides an analysis of health
tourism within the context of adventure and sport tourism. Health tourism is
compared to tourism based on its activities particularly Sun and fun activities
 Engaging healthy activities
 Motivation for travel is primarily health
 Travel for sauna, massage, and other health activities
 Medical treatment

Muller and Kaufmann (2000) make a distinction between health and wellness.
They regard wellness tourism as a subset of health tourism. According to Dunn
(1959) wellness is a “sate of health, which comprises an overall sense of well being
and sees a person as consisting body, mind and spirit. Lifestyle and
selfresponsibility for health see paramount in the quest for a better quality of the
life. In some countries like Germany, Austria and Switzerland, there is a
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considerable emphasis on ‘medical well-ness’. Wellness should not be confused by
health. It is supposed to create harmony in mental, physical, spiritual or biological
health in general and has stronger ties with changing lifestyle or doing something
healthy than with curing a specific disease. As stated above, the concept of
wellness is the co-product of the awareness of sound health, well being and
happiness. The three elements differ in understanding. As stated above, the concept
of wellness was developed as a special state of health comprising an overall sense
of well being which sees human being as consisting of body, spirit and mind and
being dependent on their environment. In the western world people have attempted
to define wellness by understanding as the harmony of body, mind and spirit, self-
responsibility, physical fitness, beauty care, healthy nutrition, relaxation,
meditation, mental activity, education, environmental sensitivity, and social
contacts as fundamental elements. Wellness is an active process through which
people become aware of, and make choices towards, a more successful existence.
It advocates positive and optimistic outlook, and a holistic and balanced approach
to life. The concept embraces physical, spiritual, intellectual, emotional, social and
occupational aspects of life. According to the Stanford Encyclopedia (2007) well
being can be defined as ‘what is noninstrumentally or ultimately good for a
person’. It is more than just happiness. As well as ‘feeling satisfied and happy, well
being means developing as a person, being fulfilled, and making a contribution to
the community’ (NEF). Diener and Saligman (2004) consider following constitutes
of high well being:

 living in a democratic and stable society that meets material needs;

 have supportive friends and family;
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  have rewarding and engaging employment with adequate income;
 be reasonably healthy and able to treat physical and mental health problems;
 have one’s own value goals; and
 have a philosophy/religion providing guidance and purpose to one’s life.

Though the term ‘quality of life’ (QOL) is difficult to define, it has come to
understand ‘peoples’ satisfaction with their lives, their physical, mental, social and
emotional health, and the nature of the environment in which they are living. It can
be measured with quantitative indicators which are subjective and objective in
nature. Objective indicators include: life expectancy, employment status, marital
status, education, working hours per week, housing conditions, crime rates, poverty
level, healthcare provisions and legal rights. The subjective indicators relate to
happiness, job satisfaction, sense of community, family relationships, stress level,
use of leisure time, degree of spirituality, sense of safety and number of enjoyed
holidays. QOL is considered to have a balance of most of these mentioned
elements. Researches in the field have shown that travel and tourism and travel
have a positive correlation with QOL. Happiness is a complex and almost an
indefinable term. However, researchers believe that happiest people are those
surrounded by family and friends; engage themselves in relaxing activities; are not
focused on materialism; not obsessed with image, social status, and fame; are
grateful for and satisfied with what they have; are altruistic; trust others and
cooperate; and live in politically stable nations. Travel without doubt creates
happiness on many levels. By visiting friends and relatives, participating in
voluntary activities creates a feeling of belonging and love that forms an important
part of happiness. A wide spectrum of health and wellness tourism has developed
in recent years (see table 2). These range from those which focus on physical or
medical healing to those which have psychological or spiritual dimension. The
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holidays which take place within these environments would in some cases be
radically different from one another. Depending upon motivation, life-stage, and
interests tourists will select the form of wellness required and this could be purely
physical with a focus on sports and fitness; medical with focus on disease
treatment or surgery; mental or psychological with a focus on mind control;
relaxing and pampering; entertaining and recreational or meditation and spiritual.

The concept of health tourism includes two components. That is health care and
tourism attractions. It includes travelling for healthcare (treatment) and enjoying
the tourist attractions of the healthcare destination that is taking treatment in a
relaxed mood. Tourism attractions bring the patients a mood of recreation and
relaxation. Cost effectiveness and taking the advantage of tourism are the keen
factors involved in health tourism. To take the advantage of health tourism niche, a
tourist destination should have high quality healthcare infrastructure and a variety
of tourist attractions that help the patients to rejuvenate his body, mind and soul.
While evaluating the potentials of Kerala in health tourism, its tourism resources
and health care resources should be identified. This chapter describes health
tourism products and providers of Kerala and the strengths, weakness,
opportunities and threats in Kerala’s health tourism.

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Tourism Resources of Kerala

Kerala, God’s Own Country is one of the most sought after tourist destinations in
Asia. It is the only Indian state having all types of tourism products. Secluded
beaches, palm fringed back waters, mist clad hill stations, lush tropical forests,
water falls, exotic wildlife, monuments, art forms and festivals give it a distinctive
charm. Apart from being a tourist destination, Kerala is India’s number one state
with 100 percent literate people, world- class healthcare systems, lowest infant
mortality and highest life expectancy rates, highest physical quality of life and best
law and order conditions. It is India’s most affluent, peaceful and cleanest state
also.

Kerala is located on the south western tip of India with the Arabian Sea in the west
and Western Ghats towering 500- 2700m in the east, covered under an area of

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38863 square kilometer having a population size of 3,18,38,619 (as per 2001
census) people. The state is divided into three regions – the costal low lands, the
fertile midlands and the high lands. The low lands of Kerala are networked by
endless backwaters and the deltas of forty –four rivers. The midlands are rich with
cashew, coconut, tapioca, banana, rice, ginger, pepper, sugar cane and vegetable
plantations. The forested highlands abound in tea, rubber, coffee and spice
plantations and wildlife reserves. Kerala has a moderate climate:
* Summer: February – May
* Monsoon: June – September
* Winter: October – January
For administrative purposes, Kerala is divided into 14 districts and they are the
revenue divisions of the State. The districts are further divided into taluks and
villages. Each district has head quarters where the administrative offices function.
On the basis of geographical, historical and cultural similarities, the districts are
generally grouped into:

o North Kerala: (Kasaragod, Kannur, Wayanad, Kozhikkode,

o Malappuram) Central Kerala: (Palakkad, Thrissur, Eranakulam,

Idukki)

o South kerala:(Thiruvananthapuram, Kollam,Alappuzha,

Pathanamthitta, Kottayam).

Kerala has wide variety of tourism resources which is capable of attracting large
number of tourists. It can become one of the world’s best tourism destinations by
highlighting its natural beauty. Its small area allows a tourist to enjoy back waters,

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beaches, hill stations, wild life, performing arts etc within a short span of time.
Every district in Kerala has much potential to develop in tourism by exploring
unexplored tourism resources. People choosing medical travel will prefer to travel
to Kerala if Kerala’s natural beauty is highlighted.

Kerala can attract tourists of varying interest by adopting niche tourism strategy
that enables optimum utilisation of tourism resources. Different forms of tourism
can also be linked. People who decide to visit Kerala to enjoy beaches may also be
interested in taking Ayurveda and vice versa.

Health Care Potentials of Kerala

Health care resources of Kerala include holistic systems of medicine such as

Ayurveda, Unani, Siddha, Naturopathy, Yoga and Meditation and modern
medicines like Allopathy – surgery, plastic surgery, dental treatment and eye care
treatment.

Ayurveda

Ayurveda is a holistic system of healing that has a tradition of 3000 years old.
Kerala and Ayurveda are synonymous to each other, as it is the only place on earth
where Ayurveda is practised with absolute authenticity and dedication. This
ancient Indian system of medicine has proved to be not only the cure for illness but
also the 100 percent natural way to prefect health. The methods of Ayurveda are
unique and universal. Instead of treating the symptoms of a disease, it treats the

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individual and caring is given for the entire body. Ayurveda medicines are purely
natural and absolutely free of side effects.

Ayurveda treatments can be classified into two types.

1. Rejuvenative: aims at total well – being

2. Therapeutic: ailment – specific.

Following are the rejuvenation treatments:

* Rejuvenation Therapy (Rasayana Chikista): Tones up the skin
and rejuvenates and strengthens all the tissues, so as to achieve ideal
health and longevity. Increases 'Ojas' (primary vitality) and improves
'Sattva' (mental clarity) and thereby increases the resistance of the body.
Includes head and face massage with medicated oils and creams, body
massage with herbal oil or powder, by hand and foot, internal
rejuvenative medicines and medicated steam bath. Herbal baths are also
used.

* Body Immunisation and Longevity Treatment

(Kayakalpa Chikitsa): Prime treatment for retarding the ageing
process, arresting the degeneration of body cells and immunisation of the
system. It includes intake of Rasayana (special Ayurvedic medicines and
diet) and comprehensive body care programmes. It is very effective for
either sex, if undertaken before the age of 50.

* Body Sudation (Sweda Karma): Medicated steam baths

eliminate impurities from the body, improve the tone and complexion of
the skin, reduce fat and are recommended for certain rheumatic diseases,
particularly for pain. Precious herbs and herbal leaves are boiled and the
steam is passed over the entire body for 10 to 20 minutes daily. Hand

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 massage with herbal oils or herbal powder improves blood circulation
and tones up the muscles.

* Body Slimming: Medicated herbal powder and medicated herbal

oil massages and an Ayuvedic diet of herbal juices are part of the
programme.

* Beauty Care: Beauty care programmes include herbal face pack,

intake of herbal tea, herbal oil massage etc for improving the complexion
and beautifies the body.

* Mental And Physical Well Being (Meditation and Yoga) :

Mental and physical exercises meant to isolate the ego from the body
and mind - designed to hone your concentration, improve health and help
attain peace of mind through eight stages of training:
 Disciplined behaviour (yama).
 Self purification (niyama).
 Bodily postures such as the lotus position (padmasana).
 Control of breathing pranayama).
 Control of the senses (pratyahara).
 Fixing of the mind on a chosen object (dharana).
 Meditation (dhyana)

 Samadhi - a state of being, where you experience absolute

tranquillity and well –being.

*Overall Fitness (Panchakarama Treatment): A five fold treatment for

mental and physical well being - tunes the body, organs, mind, breath,
nerves and purifies the blood.

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  Following are the therapeutic treatments:

 Treatment for chronic headaches, insomnia, mental tension and cases of

hysteria, hallucination and insanity (Dhara): Herbal oils, medicated milk
or butter milk and decoctions are poured on the forehead/whole body in a
special manner. Variations include Oordhwanga Dhara (good for diseases of
the eyes, ears and skin), Takra Dhara (for those suffering from memory loss,
severe headache or insanity) and Sarvanga Dhara (for both head and body).

 Treatment to alleviate osteoarthritis, leukemia etc. (Snehapanam):

Medicated ghee is given internally in a gradually increased quantity for
specific periods.

 Treatment of dryness of nostrils, mouth and throat, severe headaches,

facial paralysis and burning sensatin in the head (Sirovasti): Lukewarm
herbal oils are poured into a leather cap fitted on the head for specific
durations as per physician's recommendation.
 Treatment for spondilosis, rheumatic diseases like arthritis, paralysis,
hemiplegia, nervous weaknesses and nervous disorfers (Pizhichil):
Lukewarm herbal oil applied with fresh linen all over the body by trained
masseurs in a rhythmic manner for a period of 1 to1.5 hrs daily for 7 to 21
days.

 Treatment for musculo-skeletal ailments due to trauma or accidents

(Marma Chikitsa): Treatment that works on the extremely sensitive vital
points of the body (the 107 marmas).

 Treatment for nasal ailments (Nasyam): Inhalation of mediated herbal

preparations, decoction oils and ghee to eliminate the morbid factors from
the head and neck area.
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  Treatment for ear ailments (Karnapooranam): Medicated oils are applied
to the ear for 5 to 10 minutes daily to clean as well as treat specific ailments.

 Preventing cataract and strengthening vision (Tharpanam): A treatment

for the eyes, effective in preventing cataract and strengthening the optic
nerve.

 Treatment for wasting of muscles, rheumatism, sports injuries, pain in

the joints, emaciation of the body or parts of the body and certain kinds
of skin diseases (Njavarakizhi): The whole body is made to perspire by the
external application of medicated rice packs in the form of boluses tied bags.

Ayurveda Treatment Providers

Ayurveda treatment centres can be mainly classified into two: Ayurveda hospitals
and hotels and health resorts providing the services of ayurvedic treatment and spa.
Among the Ayurveda hospitals Kottakal Ayurveda Sala is famous for its excellent
treatment services.
Kottakal Ayurveda Sala Kottakal Ayurveda sala is situated in a village called
Kottakal in Malappuram district which was founded by Vaidya Ratnam P.S Varrier
of Kottakkal. Ayurveda owes its present status to him as he made arrangements, to
organise treatment under the Ayurvedic system and prepare and supply medicines
on modern times by strictly following the ancient Ayurveda texts. The Ayurveda
Pata Sala (School for Ayurveda) was set up in 1917 and the Ayurveda chikitsasala
(Hospital) in 1924.

Kottakkal Pooram is the annual festival at the Sree Vishwambara Temple

dedicated to Lord Vishnu in his incarnation as Dhanvanthiri. Dhanvanthiri, in

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Indian mythology, is the patron god of medicine and health. During the festival,
masters of music, art, culture and literature from all over the country participate
in the cultural function organised by the P.S.Warrier Trust. The Trust is run by
the renowned Ayurvedic research, treatment and study centre Kottakkal Arya
Vaidyasala.

Kottakkal Arya Vaidyasala is famous among foreigners. Patients from various

countries are coming here to take treatments even before the concept of health
tourism emerges. This hospital is dedicated to the promotion of Ayurveda and
wanted to propagate the healing effect of Ayurveda. Many travel agents and multi
speciality hospitals have made arrangements for tourists who want to get
rejuvenated their body and mind to take treatments in Kottakkal Arya Vaidyasala.

CLASSIFICATION OF AYURVEDA CENTRES

The ayurvedic system of medication has become an extremely important and

popular attraction for tourism in Kerala. In the state, it is virtually a way of life and
perhaps the only place in the country, where it is practised in its true and authentic
form. A number of centres have come up and they are spread through out the state.
The Government recognised the need to evaluate the safety and service standards
of these ayurvedic centres and classify them properly, to ensure that the efficacy
and the genuineness of this system of medicine does not get affected, which would
have a direct impact on the number of tourists visiting the state. Those centres that
fulfil the essential conditions prescribed by the Department of Tourism would be
classified as the Olive Leaf status.

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Those centres that fulfil the optional conditions also, in addition to the essential
conditions, are accorded the Green Leaf status of classification. Some of the
important features of these are given below:
Personnel:
- Treatment / therapy should be done only under the supervision of a

qualified physician with a recognised degree in Ayurveda.

- Separate Masseurs for male and female patients should be present –

with at least one male and one female masseur.

- The masseurs must have training from recognized Ayurveda

institutions

Quality of medicine:
 Only those programmes approved by the Approval Committee
shall be offered

 Health programmes shall be clearly displayed along with the time

taken for massages and treatments.
 The approved time limit for a massage is 45 minutes.

 Medicines and material shall be clearly labelled, displayed and

acquired from an approved and reputed firm

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 Equipment:
 The massage table shall confirm to a minimum size (7ft x 3 ft),
made of good quality wood or fibreglass.

 A Gas or electric stove shall be operational and medicated hot

water facility for bathing and other purposes shall be provided for.
Sterilization facilities shall be provided.
 All equipment, areas, apparatus shall be clean and hygienic.

Facilities:
 Separate treatment rooms – at least one each, separately for male and
female shall be provided. These should be well ventilated and should be at
least of 100 sq ft of area (width not less than 8 ft). Toilets should have
proper sanitary fittings and floors and the walls should be furnished with
tiles.

 One Consultation room shall be provided for a minimum size of 100ft

(width not less than 8 ft). The rooms should be well equipped with
medical instruments like BP apparatus, stethoscope, examination couch,
weighing machine, etc.

 A separate rest room (minimum size of 100ft with width not less than
8 ft), should be provided, in case the centre is not attached to a
hotel/resort/hospital.

General infrastructure should be good. Locality and ambience, including

accessibility should be suitable. Furnishing should be of good quality. The centre
and surrounding premises should be kept clean and hygienic.

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 Optional conditions for ‘GREEN LEAF’

In addition to the above essential requirements, centres having some additional /

optional features, would be accorded the Green Leaf certification.

High standards of construction of the building, architectural features etc. with

excellent furnishings, curtains etc. in superior quality materials

 Adequate parking facility in the premises.

 Bathrooms facilities for steam bath.

 Separate halls for meditation and yoga.

 Location of the centre in picturesque surroundings with a quiet

ambience.

 Herbal garden attached to the Centre.

Ayurvedic centres that are provided with a licence or classification would be

eligible for claiming a 10% state investment subsidy or electric tariff concession,
offered by the Department of Tourism.
Role of Ayurveda in Health Tourism

Ayurveda is one of the components of health tourism and it is the main

contributor to Kerala’s health tourism. Ayurveda and Kerala are synonymous to
each other. It is the trade mark of Kerala’s health tourism. It is a holistic treatment
that has no side effects and hence it is very popular among health care travelers.
The treatment under Ayurveda helps to rejuvenate body and mind. One can take
holiday and rejuvenate his body and mind undergoing Ayurveda treatment. Not

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only health tourists but also tourists coming with some other specific purposes are
also interested in Ayurveda. Following table shows details regarding the tourists
interested in Ayurveda.

Table No. Health Tourists Taking Ayurveda from Kerala

Ayurveda Treatment Taken No. of Health Percentage

Tourists

Yes 263 71.08

No 107 28.92

Total 370 100

Source: Primary Data

55.89 percent of the respondents are taken Ayurveda treatment from holiday
resorts and 32.32 percent of health tourists are taken Ayurveda treatment from
ayurvedic hospitals and 11.79 percent of the respondents are taken Ayurveda
treatment from multi – speciality hospitals.

Satisfied customers of a service will recommend others also to avail the benefits
of that service. Following table shows the desire of health tourists to recommend
Ayurveda to their friends and relatives.

Majority of health tourists would like to recommend Ayurveda treatment to others

and 9.19 percent of them are not interested in recommending Ayurveda treatment

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to their friends and relatives.1.89 percent of the health tourists have no opinion
about recommending Ayurveda treatment to their friends and relatives.

Health tourists opinion about Ayurveda may vary depending up on the treatment
services provided by various types of Ayurveda treatment providers. Here it
examines the health tourists desire to recommend Ayurveda treatment of Kerala
to their friends and relatives have any relation to the type of Ayurveda provider
from where they had taken treatment. Testing whether the proportion of tourists
who strongly recommend Kerala as a health care center differ with their place of
treatment. The table shows the proportions of tourists who strongly recommend
together with their place of treatment and the value of the Z statistic and
significance level.

Place of treatment and recommending Kerala as a health care

destination of Ayurveda

Z
Place Number proportion significa
value
nce
Holiday Resort 147 0.483
Significant at
-3.83 0.01
85 0.741 level
Ayurvedic Hospital

Holiday Resort 147 0.483

0.99 Not
Multi-speciality significa
nt
Hospital 31 0.581
Ayurvedic Hospital 85 0.741
1.66 Significant at
0.05 level
Multi-speciality 31 0.581
Hospital
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The proportion is significantly greater in the case of tourists treated in Ayurveda
hospitals when compared with other centres. Also there is no significant
difference between the proportions in holiday resorts and multi- speciality
hospitals.

Following table depicts health tourists desire to take Ayurveda from Kerala.

Table No.5.6 Desire to take Ayurveda Treatment from

Kerala
Desire No. of Health Percentage

Tourists
Strongly Agree 152 41.08

Agree 160 43.24

No Opinion 13 3.51

Disagree 39 10.54

Strongly Disagree 6 1.62

Total 370 100

Source Primary Data

Majority of health tourists have strong desire to take Ayurveda from

Kerala.10.54 percent of them are not interested in taking Ayurveda treatment
from Kerala and 1.62 percent of them strongly unwilling to take Ayurveda
treatment from Kerala. 3.51 percent of the health tourists have no opinion
about taking Ayurveda treatment from Kerala in future.

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 Yoga and Meditation

Yoga, the science of man, based on ancient Indian wisdom and culture, is an art of
living a healthy, balanced, peaceful and contented life. Yoga, being a total
integrated system, studies man in his wholeness - body, mind and spirit and is
integrated to certain principles, ideas, values, attitudes and a way of life for
personal and social benefits. Conceived by the great sages in their quest for self-
realization, it has come to be recognized during its long travails from the
hermitages to the cities - as the science of man, a philosophy of old life, a code of
conduct, an attitude and an approach, as well as an art of living which is capable
not only of ensuring physical well-being, mental peace harmony, moral elevation
and spiritual uplift of man but also of transforming man from his gross animal
existence to the sublime heights of divinity.

Yoga had recognized and accepted the importance of the mind and the
subconscious over the total human personality much earlier than modern
psychology did in its present form. Yoga is a stepwise, stage wise eight-fold path
to final liberation from pain and suffering. These steps progressively take us to the
highest state of creativity, of discriminative knowledge and towards attaining the
desired perfection.
The eight steps are:

Yama : Conditional yoga behaviour, personal and

social Niyama : Attitude sublimate to yoga norms

Asana : Discipline of the physical body

Pranayama : Control over bio energy through respiratory

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 action Pratyahara : Withdrawal of the senses inwards
through abstraction Dharna : Concentration
Dhyana : Meditation
Samadhi : Trans consciousness

Of these, the first five, which border on the Psychosomatic Approach, are referred
to as External (Bahiranga) yoga, popularly known as Hatha Yoga, while the latter
three, which directly affect the psyche are known as internal (Antaranga) yoga,
popularly known as Raja Yoga. It is almost impossible to try internal yoga (Raja
Yoga) for the average man before accomplishing the external one (Hatha Yoga).
The respective sequence of the eight steps is the standard methodology of yoga.
Yoga is based on a deep understanding of man and his position in this world and
was the first system evolved in the world to recognize the connection and the
interaction between body and mind. It studies in depth the very structure of the
human personality, through analysis the psychological complexities and the cause
of human pain, sorrow and suffering. It has laid down psychosomatic means
through its various psycho- physiological processes for dealing with the body
mind complex and tries to harmonize and integrate the human personality at all
levels and stages of life.

Yoga is basically a way of Life, which has been evolved as a system to go beyond
the personality - complex and achieving absolute freedom- liberation of the spirit
from the matter.

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Following table gives details about the priority given by health tourists to yoga
and meditation with regard to their purpose of visit to Kerala.
Table No.5.7 Health Tourists Practising Yoga

Order of Priority No. of Health Percentage

Tourists
First 23 6.22
Second 28 7.57
Third 33 8.92
Nil 286 77.30
Total 370 100
Source Primary Data

Among the 370 health tourists 6.22 percent of them have given first priority to
practising yoga and meditation and 7.5 percent and 8.92 percent of them have
given second and third priority to practising yoga and meditation respectively.
77.30 percent of health tourists did not practise yoga and meditation during their
healthcare tour.

Following table shows tourists interest in learning and practicing

yoga and meditation.

Table No.5.8 Interest in Learning Yoga

Interest in learning No. of Health Percentage

Yoga Tourists
Yes 142 38.38
No 228 61.62
Total 370 100
Source Primary Data

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Out of 370 health tourists only 38.38 percent of tourists have interest in learning
yoga and meditation.

Unani and Siddha Unani

Unani, the system of medicine originated in Greece and flourished in Asia,

especially India bears similarities with Ayurveda. Practiced mostly by Muslims,
Unani practitioners are found in all parts of India, and a large number of them in
Kerala. Unani is an Arabic word which means Greek. Unani principles are so close
to that of Ayurveda. According to Unani, the basic elements of nature are earth,
water, air and fire. These four elements are known as ARKAN. Each element has
its own properties and goes into the making of everything in the universe

Siddha

Herbs and minerals found in the nature are used in the production of Siddha
medicine. The medicines are simple, yet effective. All types of diseases have
medicine in Siddha. The materials used in the production of Siddha medicines
include leaves, bark, root and other parts of plants and trees, metals like silver,
gold, iron and mercury. It is to be noted the metals are not used as such, but
prepared through vigorous purification processes that lasts over several days. After
purification, the metal is called bhasma (ash), which the body can use.

The ultimate aim of Siddha medicine is moksha or salvation from the cycle of the
pangs of births and deaths by strengthening the body. The goal is similar to that of
yoga. Siddha medicine tries to reach this stage by giving immortality to body.

Out of 370 health tourists only 7(1.89%) persons of them has given first priority to
Siddha and Unani treatment.

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 Naturopathy

Naturopathy is a system of healing science stimulating the body’s inherent power

to regain health with the help of five great elements of nature Earth, Water, Air,
Fire and Ether. Naturopathy is a call to "Return to Nature" and to resort to simple
way of living in harmony with the self, society and environment. Naturopathy
provides not only a simple practical approach to the management of diseases, but a
firm theoretical basis which is applicable to all the holistic medical care and by
giving attention to the foundations of health; also offers a moreeconomical frame
work for the medicine of future generation.

The methods applied for cure in Naturopathy are the following: -

1. Water Therapy: Water is the most ancient of all the remedial agents. It is
employed in different forms in treatment and produces several types of
physiological effects depending upon temperature and duration.
Hydrotherapy is employed in almost all types of disease conditions.

2. Air Therapy: Fresh air is essential for good health. Air therapy is employed
in different pressures and temperatures in variety of disease conditions.

3. Fire Therapy: Existence of all the creatures and forms depends upon
“Agni” (Fire). In Nature Cure treatment, different temperatures are
employed through different heating techniques to produce different specific
effects.

4. Space Therapy: Congestion causes disease. Fasting is the best therapy to

relieve congestion of body and mind.

5. Mud Therapy: Mud absorbs, dissolves and eliminates the toxins and
rejuvenates the body. It is employed in treatment of various diseases like
constipation, skin diseases etc.

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 6. Food Therapy: Most of the diseases are amenable through food therapy. As
you eat so will you be physically as well as mentally. Your food is your
medicine. These are the main slogans of Nature Cure.

7. Massage Therapy: Massage is generally employed for tonic, stimulant and

sedative effects. It is an effective substitute for exercise.
8. Acupressure: There are different points on hands, feet & body which are
associated with different organs. By applying pressure on these selected
points, related organs can be influenced for getting rid of their ailments.

9. Magneto Therapy: Magnets influence health. South and North poles of

different powers and shapes are employed in treatment, by applying directly
on different parts of the body or through charged up water or oil.

10.Chromo Therapy: Sun rays have seven colours – violet, indigo, blue, green,
yellow, orange and red. These colours are employed through irradiation or
body or by administering charged water, oil and pills for treatment.

Kalari Treatment

Marma chikilsa in Kerala is centuries old. Marma is "Vital spots" and Chikilsa
means "Treatment". It emerged as a treatment system for warriors or soldiers who
fought in wars and conflicts and suffered physical injuries. Several treatment
techniques were used for treating different kinds of injuries like wound, fractures
etc. Siddha system of treatment gives emphasis to marma chikilsa. Marma Chikilsa
is mainly performed by specialists who know well about the vital (marma) spots on
human body. There are total 108 Marma points in the body in which 64 are
considered as deadly points. These points could be used to heel or to harm. If these
points are pierced hard, it could result in trauma or even death. A Kalari masseur

40 | P a g e
uses the Marma points to heal. Kalari marma treatment is as sophisticated as the
uzhichil treatment of Ayurveda.

Kalari massage is a traditional massage, performed by the therapist using his hand
and feet by applying appropriate pressure on vital parts of the human body. It is a
full body massage with medicated. oil to stimulate the Marma points on the body.
Kalari massage helps the body in attaining a healthy constitution with flexibility,
nimbleness and suppleness. It also enables proper blood circulation and easy
maneuverability of the body for twisting and turning. Kalari massage relieves
various aches like back pain, stiffness, dislocations, injuries and also stimulates
various bodily organs and systems7.

Kalarippayattu, evolved as a physical cum material art of Kerala during the early
centuries of the Christian era, had been enlarged in the later years with the
addiction of physiotherapy, bone setting and marma chikitsa systems. Institutions
practising kalarippayattu developed in to treatment centres for marma disorders
and rheumatic ailments. Medicated oils were widely being used for kalari exercise.
Massage or Uzhichil was considered to be one of the essential parts of this exercise
to attain flexibility for different parts of human body. It could be learent that the
kalari masters have been influenced by the knowledge assimilated from the flok
medical systems of Ayurveda. The exercise and therapy attached to kalarippayattu
have paved the foundation for the health of the people of the state through
centuries.

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 Allopathy

The term "allopathy" was coined in 1842 by C.F.S. Hahnemann to designate the
usual practice of medicine (allopathy) as opposed to homeopathy, the system of
therapy that he founded based on the concept that disease can be treated with drugs
(in minute doses) thought capable of producing the same symptoms in healthy
people as the disease itself. This system of medical practice treats disease by the
use of remedies which produce effects different from those produced by the
disease under treatment.
Treatment packages under allopathy system of medicine are:

a. Orthopaedics
Minimally invasive surgery for total knee, hip replacement
Revision of Joint Replacement
Shoulder Replacement
Treatment for all types of sports injuries

b. Spine Surgery

c. Plastic and Cosmetic Surgery

Liposuction
Abdominoplasty
Breast Augmentation
Breast Reduction
Breast lift
Rhinoplasty
Bat ear correction
Eye lid lift
Face lift

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 d. Interventional Cardiology

Coronary Angiography
Minimally Invasive Coronary Artery Bypass Graft
Balloon Valvuloplasty
Biventricular Pacemaker Implantation.

e. Transplant Surgeries

Kidney transplant with keyhole donor Nephroctomy

Liver transplant
Bone marrow transplant

f. Infertility Packages

In Vitro Fertilisation
Intra Cytoplasmic Sperm Injection

Dental treatment includes:

Root Canal Treatment

Dental Implants
Ceramic Crowns
Gum Treatment
Cosmetic Dentistry
Oral Surgery
Orthodontics
Teeth Whitening
Smile Designing

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 Eye care treatment includes:

Eye Lasik Refractive Packages

Lasik Eye Surgery
Eye Care Treatment
Lasik Treatment
Refractive Surgery
Laser Refractive Surgery
Refractive Eye Correction Package
Natural Eye Care Treatment
Vision and Eye Care
Eye Refractive Care Packages

Health Tourism Scenario in Kerala

Kerala is well known as one of the major holistic treatment centres of the world.
Rejuvenation therapy through Ayurveda and Yoga is popular all over the world
and thus Kerala becomes a major centre for revitalizing the body and spirit. Kerala
also offers a range of world quality hospitals and treatments, which is offered
substantially at lower costs than that in developed countries. To know the present
health tourism scenario of Kerala, health tourism providers and their services
should be examined. For that health tourism providers’ inventory should be made.
More over, health tourists’ wants and needs should also be identified.

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 Health Tourism Providers

A health tourism provider or medical tourism provider is an organisation or a

company which seeks to bring together a prospective patient with a service
provider, usually a hospital or a clinic. If the patient is crossing international
borders to obtain medical care, then that individual would usually be known as a
medical tourist. These groups are generally facilitators and developers of medical
tourism, which brings into play a number of issues that do not apply when a patient
stays within their own country of origin. Some such organisations and companies
specialise in certain areas of healthcare, such as cosmetic surgery, dentistry or
transplant surgery, while others are more generalised in their approach, providing
multiple services over a wide range of medical specialities. In addition, there are a
number of non-medical angles which receive varying degrees of attention by
providers. These include:

* Prices and how to pay

* Hotels

* Non-medical risks involved

* Language issues

* Availability of techniques (e.g. new operations, new approaches

to infertility, new imaging techniques)

* Pre-travel health issues, such as anti malarial therapy and

relevant immunisations

* Ethics

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 Medico-legal issues (e.g. are the doctors providing the treatment adequately
indemnified or carrying personal malpractice insurance ? Is the hospital
itself adequately insured? Can a patient sue if things go wrong? Will the
hospital repatriate the body of a patient who dies on the operating table?)

Majority of multi – speciality hospitals of Kerala engaged in health tourism

belongs to private sector. E.M.S Memorial Co – Operative Hospital and Research
Centre, Malappuram is the only one co – operative hospital entered in to the field
of health tourism. Details of multi- speciality hospitals attracting health tourists to
Kerala are given in Appendix .
Currently 19 multi – speciality hospitals of Kerala are engaged in health tourism
by attracting both foreign and domestic health care tourists. Majority of multi –
speciality hospitals is at Ernakulam and Thiruvananthapuram districts that have all
types of tourism resources. Three hospitals have NABH accreditation.
Thiruvananthapuram, Ernakulam and Kozhikode districts have NABH (National
Accreditation Board for Hospitals and Health Care Providers) accredited hospitals.
In Kerala 16 dental clinics and 3 eye care hospitals are engaged in health tourism.
Most of them are situated in Ernakulam district. Details of dental tourism and
ophthalmology tourism providers of Kerala are shown in Appendix

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National Accreditation Board for Hospitals & Healthcare Providers (NABH) is a
constituent board of Quality Council of India, set up to establish and operate
accreditation programme for healthcare organisations. the board is structured to
cater to much desired needs of the consumers and to set benchmarks for progress
of health industry. The board while being supported by all stakeholders including
industry, consumers, government, have full functional autonomy in its operation.

International Linkage
 NABH is an Institutional Member as well as a Board member of the
International Society for Quality in Health Care (lSQua).
 NABH is a member of the Accreditation Council of International Society for
Quality in Health Care (ISQua).
 NABH is on board of Asian Society for Quality in Healthcare (ASQua).

Vision, Mission & Scope

 To be apex national healthcare accreditation and quality improvement
body, functioning at par with global benchmarks.
 To operate accreditation and allied programs in collaboration with

stakeholders focusing on patient safety and quality of healthcare

based upon
national/international standards,through process of self and external
evaluation.

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 Scope of NABH /Objectives
 Accreditation of healthcare facilities
 Quality promotion: initiatives like Safe-I, Nursing Excellence, Laboratory
certification programs (not limited to these)
 IEC activities: public lecture, advertisement, workshops/ seminars
 Education and Training for Quality & Patient Safety
 Recognition: Endorsement of various healthcare quality courses/ workshops

Health Tourists
Health tourists are those persons traveling to health care tourism destinations
seeking health care treatment. Tourists from various countries visited Kerala with
the prime objective of taking the advantage of health tourism. In order to know
more about health tourists visiting Kerala, data from 370 health tourists are
collected. Following table shows demographic distribution and other details of
these respondents.

Age Wise Classification of Health Tourists

Table No.5.9 Age wise classification of Health Tourists

Age No. of health Percentage

tourists

Below 30 86 23.24

30 – 45 108 29.19

46 – 60 109 29.46

Above 60 67 18.11

Total 370 100

Source Primary Data

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Among the 370 health tourists 23.24 percent of them are under the age of 30
years and 29.19 percent of them are in between the age of 30 – 45 years and 29.46
percent of them are in between the age of 46 – 60 and 18.11 percent of them have
more than 60 years of old.
Gender Wise Distribution of Health Tourists

Table No.5.10 Sex Distribution of Health Tourists

Sex No. of health Percentage

tourists

Male 220 59.46

Female 150 40.54

Total 370 100

Source Primary Data

59.46 percent of the respondents are male and 40.54 percent of the
respondents are female health tourists.

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Nation Wise Distribution of Health Tourists

Table No.5.11 Nation wise Distribution of Health Tourists

Nation No. of Health Percentage

Tourists
Europe 185 50

USA and Canada 96 25.95

Arab Countries 70 18.2

Neighbouring Countries* 19 5.14

Total 370 100

Source Primary Data

Neighbouring Countries include Bangladesh, Pakistan, Sri Lanka, Nepal and

Maldives
Half of the health tourists are from European countries and one forth of the health
tourists are from USA and Canada and 18.2 percent of the health tourists are from
Gulf countries and 5.14 percent of the health tourists are from neighbouring
countries of India.

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Mode of Traveling

Table No.5.12 Mode of Traveling

Mode No. of Health Percentage
Tourists
Friends 107 28.92

Family 96 25.95

Community Groups 33 8.92

Tour Operators 47 12.70

Alone 87 23.51

Total 370 100

Source Primary Data

Among 370 health tourists, 28.92 percent of them visited Kerala with their friends
and 25.95 percent of them visited Kerala with their family and 8.92 percent of
them visited Kerala with community groups and 12.70 percent of them visited
Kerala with the help of tour operators and 23.51 percent of them visited Kerala
with out accompanying any one.

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Number of Visits to India

Table No.5.13 Number of Visits to India

No. of No. of Health Percentage

Visit Tourists
1 160 43.24
2 122 32.97
3 48 12.97
4 29 7.84
5 11 2.97
Total 370 100
Source Primary Data

Among the 370 respondents 43.24 percent of them visited India for the
first time and 32.97 percent of them visited India for the second time and
12.97 percent of them visited India for the third time and 7.84 percent of
them visited India for the fourth time and 2.97 percent of them visited
India for the fifth time.

Number of Visits to Kerala

Table No.5.14 Number of Visits to Kerala

No. of No. of Health Percentage

Visit Tourists
1 195 52.70
2 121 32.70
3 43 11.62
4 11 2.97
Total 370 100
Source Primary Data

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Among the 370 respondents 52.70 percent of them visited Kerala for the first time
and 32.70 percent of them visited Kerala for the second time and 11.62 percent of
them visited Kerala for the third time and 2.97 percent of them visited Kerala for
the fourth time.

Classification of Health Tourists in Relation to Prime Purpose of

Visit

Main components of health tourism offered in Kerala can be segregated into nine
components such as allopathy treatment provided by multi – speciality hospitals,
ayurveda treatment in ayurveda hospitals, spa therapy offered by healthcare
resorts, cosmetic surgery, dental care, eye care, yoga and meditation, siddha/
unani treatment and recreation with wellness therapy. Following table gives
classification of health tourists according their main purpose of visit to Kerala.

Table No.5.15 Main Purpose of Present Visit

Primary Purpose No. of Health Percentage
Tourists
Allopathy 58 15.6
Ayurveda Treatment 51 13.8
Cosmetic Surgery 39 10.5
Spa 65 17.6
Dental Care 28 7.6
Eye Care 26 7
Yoga/ Meditation 23 6.2
Siddha/ Unani 7 1.9
Recreation 75 20.3
Total 370 100
Source Primary Data

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Among 370 health tourists, 37.6 percent of them visited Kerala with the prime
objective of taking ayurveda treatment, spa therapy and yoga. 26.1 percent of the
health tourists visited Kerala for availing allopathic treatment and cosmetic
surgery from multi – speciality hospitals and 7.6 percent of health tourists visited
Kerala with the main objective of dental treatment and 7 percent of health tourists
visited Kerala for their eye care treatment and 1.9 percent of health tourists visited
Kerala for taking siddha/ unani treatment.20.3 percent of health tourists visited
Kerala with the prime aim of enjoying holiday but availed spa therapy.

Reasons for Choosing Kerala as a Health Care Destination

The reasons for seeking health care treatment outside their home country may
vary depending up on the nationalities of health tourists.
Following table give details regarding the reasons for selecting Kerala as a
health tourism destination.
Majority of health tourists choose Kerala for their health care treatment for
taking the advantage of tourism with high quality health care treatment at low
cost. Push factors behind healthcare travel are high cost of treatment and long
waiting time in their home country. Most of health tourists favoured Kerala for
their health care treatment because of taking the advantage of Ayurveda, yoga
and meditation

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 Table No.5.16 Reasons for choosing Kerala for Health Care Treatment

Percentage
Reasons for choosing Kerala as a
of Rank
healthcare destination. Agreeme
nt
Long waiting lists in home state 44.0 7

High cost of treatment at home 83.8 3

High quality healthcare at low cost 90.3 2

Ayurvedic treatments 71.3 5

Ayurvedic rejuvenation therapies/Spa 71.4 4

Taking advantage of tourism with healthcare
93.2 1
treatment

Learning/Practicing Yoga, Meditation etc. 48.9 6

Source Primary Data

.

Effect of Health Tourism on Other Forms of Tourism

Countries offering tourism creates different niches of tourism depending on the

tourism resources available in their nation for the optimum use of tourism
resources. Niche tourism aims to attract tourists of varying tastes and interest.
Niche tourism highlights specific tourism attractions like back waters, beaches,
hill stations, farms, cultural and heritage centres,pilgrimage centres, health resorts
etc. By highlighting each forms of tourism a destination can attract prospective
tourists with different preferences.

Kerala is blessed with almost all forms of tourism resources such as back waters,
beaches, hill stations, farms, cultural and heritage centres, pilgrimage centres,

55 | P a g e
 health resorts, water falls, festivals etc. Ayurveda and Kerala are synonymous to
each other. Kerala is suited for every one even if their preferences and tastes in
various forms of tourism vary as they can enjoy different forms of tourism by
traveling a short distance.

Different Forms of Tourism Enjoyed by Health Tourists

The main purpose of visiting a tourism destination may varies to each tourists but
a well developed tourism destination can attract them into other forms of tourism.
Health tourism has a positive impact on other forms of tourism as health tourists
choosing a healthcare tourism destination based on its tourism resources also.
Following table shows the different niche tourism areas of Kerala visited by
health tourists during their healthcare travel.

Sl.No Tourist Spots Percentage of tourists Rank

1 Back Water 76.22 1
2 Beach 62.97 2
3 Farms 62.43 3
4 Eco tourism spots 60.81 4
5 Hill Stations 50.00 5
6 Shopping Malls 39.73 6
7 Cultural Centres 39.19 7
8 Pilgrimage 37.30 8
9 Historical places 36.49 9
Source Primary Data
Table No.5.17 Tourism Areas Visited during the Health care Tour

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Majority of the health tourists had visited back water, beach, farm and eco
tourism areas of Kerala during their healthcare tour to Kerala. Only less than 40
percent of the health tourists had visited shopping malls, cultural tourism areas,
pilgrimage tourism areas and historical places of Kerala during their healthcare
tour.

Desire to Revisit Different Forms of Tourism

Niche tourism is successful as it brings more potential tourists to a tourism

destination. A tourist visiting Kerala with the main purpose of taking Ayurveda
spa therapy can be normally attracted to other forms of tourism. For example if
the health resort is situated near back waters an interest to travel in a cruise to
enjoy the beauty of back waters may be emerged in the minds of tourists.

By knowing and experiencing tourism destination, a tourist evaluates the

destination and decides whether to revisit that destination in the near future. He
also determines different niche tourism areas to be enjoyed at the time of his
revisit. Following table shows details regarding the interest of health tourists
desire to visit different niche tourism areas of Kerala.

Majority of health tourists would like to visit eco tourism areas (95.41%), beach
tourism areas (98.38%), farm tourism areas (99.19%), back water tourism areas
(97.84%), pilgrimage tourism areas (90.54%), health tourism centres (84.05),
historical places (83.79%), cultural centres (75.68%), shopping malls (63.24%)
and adventure tourism areas (62.97%) of Kerala in future

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 Table No.5.18 Desire to Visit Different Forms of Tourism

Desire
Tourism
Area Strongly No Strongly
Agree Disagree Total
Agree Opinion Disagree
Eco 284 69 0 13 4 370
tourism (76.76) (18.65) (0) (3.51) (1.08) (100)
Beach 253 111 0 6 0 370
tourism (68.38) (30) (0) (1.62) (0) (100)
Farm 219 148 0 3 0 370
tourism (59.19) (40) (0) (0.81) (0) (100)
161 174 0 29 6 370
Pilgrimage
(43.51) (47.03) (0) (7.84) (1.62) (100)

119 114 36 101 0 370

Adventure
(32.16) (30.81) (9.73) (27.30) (0) (100)

Health 233 78 0 51 8 370

centres (62.97) (21.08) (0) (13.78) (2.16) (100)

Historic areas 175 135 21 39 0 370

(47.30) (36.49) (5.68) (10.54) (0) (100)
119 161 0 75 15 370
Cultural
(32.17) (43.51) (0) (20.27) (4.05) (100)

136 120 14 100 0 370

Shopping
(30.81) (32.43) (8.38) (28.38) (0) (100)

266 96 0 8 0 370
Back water
(71.89) (25.95) (0) (2.16) (0) (100)

Source Primary Data

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 Health Tourists Opinion about Kerala’s Health Tourism

Satisfied customers are good ambassadors of a product. Therefore, if the health

tourists are satisfied with the services received from health tourism providers of
Kerala they will strongly recommend Kerala as a health tourism destination to
their friends and relatives that will lead to the increased demand of Kerala’s
health tourism. Following table shows health tourists opinion about Kerala as a
health tourism destination.

Table No. 5.19 Health Tourists Opinion about Kerala’s Health Tourism
Desire
Opinion
Strongly No Strongly
Agree Disagree Total
Agree Opinion Disagree

Visit Kerala 320 48 0 2 0 370

Again (86.49) (12.97) (0) (0.54) (0) (100)

Recommend
Kerala as a 222 136 0 12 0 370
Health Tourism (60) (36.76) (0) (3.24) (0) (100)
Destination

Recommend
Kerala as a 307 63 0 0 0 370
Tourism (82.97) (17.03) (0) (0) (0) (100)
Destination

Source Primary Data

Figures in brackets ( ) are percentages

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All respondents (370 health tourists) expect 2 persons would like to revisit
Kerala. Majority of health tourists would like to recommend Kerala as a health
tourism destination to their friends and relatives.

Feel at Home While Taking Treatment

Table No.5.20 Feel at Home While Taking Treatment

Homely Feeling No. of Health Tourists Percentage

Yes 306 82.70

No 64 17.30

Total 370 100

Source Primary Data

Among the 370 health tourists 82.70 percent of them feel at home while they are
taking healthcare treatment from Kerala.

Feeling after Health Care Treatment

Table No. 5.21 Feeling after Health Care Treatment

Feelings No. of Health Tourists Percentage
Very Good 270 72.97
Good 77 20.81
Poor 13 3.51
No Opinion 0 0
Very Poor 10 2.7
Total 370 100
Source Primary Data

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Majority of health tourists (93.78%) felt very good after their healthcare
treatment. 3.51 percent of them opined that they received poor healthcare
treatment and 2.7 percent of them opined that they received very poor healthcare
treatment

Risks Faced by Tourists

Table No.5.22 Risks Faced by Tourists

No. of Health
Sl.No Risks Percentage Rank
Tourists

1 Environment Pollution 249 67.30 1

2 Terrorist Threats 0 0 5

3 Spread of Disease 224 60.54 3

4 Misbehaviour of local people 209 56.49 4

5 Political Parties Strikes 237 64.05 2

Source Primary Data

Among the 370 health tourists 249 tourists felt environment pollution and 224
tourists are feared of the contagious diseases and 209 tourists are the victim of
misbehaviour of local people and 237 tourists felt difficulties because of political
parties’ strikes.

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 Purchase of Handicrafts

Table No. 5.23 Demand for Handicrafts

Purchased Handicrafts No. of Health Tourists Percentage

Yes 246 66.49

No 124 33.51

Total 370 100

Source Primary Data

Among the 370 health tourists 66.49 percent of them purchased handicrafts of
Kerala.

Potentials of Health Tourism in Kerala: SWOT Analysis

Health tourism potentials of Kerala can be evaluated by analyzing the healthcare

and tourism resources and government support given to the

promotion of health tourism. Through a SWOT analysis, the strengths,

weakness, opportunities and threats of health tourism can be identified.

Strengths:

Strengths in health tourism can be classified as healthcare resources, tourism

resources and others.

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 Healthcare potentials:

 Clinical outcomes of hospitals of Kerala are par with the world’s best
centres.
 Highly competent and internationally qualified doctors, nurses and
other paramedical staff.
 International standards in infection control measures
 State of the art equipment and technology
 Accredited hospitals: 4 multi speciality hospitals of Kerala received
NABH accreditation.
 Internationally experienced medical professionals
 World class medical facilities
 Latest technology and procedure
 NRI doctors recognized as amongst best in developed countries
 Kerala nurses are getting international exposure
 Number of software technologists facilitating revolution in healthcare
 Strong Pharma- sector gaining world recognition and fast emerging
as major drug research and development centre.
 Low cost of drug development in India with software support.
 High concentration of expatriate Indian medical staff working abroad
particularly in the US and UK give patients confidence in healthcare
in India.

 Foreigners are already used to the expertise and professionalism of

Kerala medical staff.
 percent of the doctors in America are Indians and 11 percent of the
specialists are Indians.
 Advanced and sophisticated hospitals of international standards

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 located in Kerala
 Renowned doctors specialized in almost all major disciplines
 Trained paramedical staffs and technicians available in Kerala
 Higher hygienic standards
 Multi speciality hospitals are located in major towns of Kerala near
to airport
 Ayurveda and spa is available in all major resorts
 Established and well known medical education system
 Practice of alternative medicines like Ayurveda, naturopathy, unani etc
 Availability of yoga centres and stress releasing programmes
 Ayurveda is synonymous to Kerala
 Computerized hospital information systems

Tourism potentials:

 Kerala is a well-known tourism destination famous with its brand name

‘Gods Own Country’.
 Kerala has wide range of tourism resources such as back waters, beaches,
hill stations, pilgrimage centres, historical places etc.
 Kerala is blessed with good climate, suitable for everyone and moderate
weather through out the year.
 Wide range of cultural programmes
 Kerala has good reputation for hospitality
 Possess good tourism infrastructure: five star hotels, resorts etc
 Good Varity of cuisine.
 Shopping facilities: handicrafts products
 Ideal place for excellent recuperative holiday

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  English speaking tour guides
 Medical tourism packages offered and marketed by tour operators joining
hands with excellent hospitals.
 Air connectivity with all major countries
 Three international airports.
 Tourism awards:

Kerala - The most acclaimed tourist destination in the Country Kerala

has emerged as the most acclaimed tourist destination of the country in the
recent past.

 World Travel and Tourism Council has selected Kerala as a Partner State.

 National Geographic Travel after 2 years of research has chosen Kerala, as

one of the 50 must see destinations of a lifetime. Kerala has been stated as
one of the 10 paradises of the world.

 Antony Weller of National Geographic Traveller impressed by Kerala’s

inquiring sophistication described it as the State of Enlightenment

 The widely read and circulated travel magazine published from UK,
Conde’ Nast Traveller brought out the exotic fragrance of Kerala in its
March 2002 issue.

 The February 2002 issue of Geo Saison, Germany’s largest selling travel
magazine, discovers the magic of Ayurveda in the Mecca of the oldest and
holistic health system – Kerala

 The article by Michael Fathers in the Travel Watch section of ‘Time’

summed up the experience in Kerala as Afoot and afloat, Kerala is worth

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 the journey.

 The Times of India the largest circulated English daily in India, explored
why Kerala is the winning State, in an editorial that appeared on 29th
January 2002

The other acclaims received by Kerala Tourism during the recent past
include;

 One of the 100 great trips for the 21st Century, by ‘Travel and Leisure’
 One of the ten hot spots for the millennium, by ‘Emirates Inflight
Magazine’
 One of the best breakfast in the world, by ‘Travel & Leisure’
 One of the ten love nests in India, by ‘Cosmopolitan’
 One of the six destinations of the millennium, by ‘Khaleej Times’

Awards/Recognitions

 National Award for the Best Performing State in Tourism by

Government of India for 1998-99,1999-2000 & 2000-01
 PATA Grant International award for the Conservation of Heritage
 Best Performing State Award instituted by Outlook Traveller
 PATWA International award for the Best Performing State in
Tourism, 2001

Others

 Zero waiting time combining with exotic experience to the visitors in

various tourist destinations for health and recuperation.
 Cost benefits: high quality treatment at low cost.

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  Holistic medicinal services
 English widely spoken ( Easier communication with majority
English speaking public)
 Favourable currency exchange rates
 Advertisement given by satisfied patients, Non Resident Indians and
Non Resident Keralites
 Well connected by air from major medical tourism markets in the
Middle East, European markets and South Asia.
 Incredibly competitive cost for packages of medical treatment and
surgery compared to other countries.
 Honoring of medical insurance by hospitals in Kerala.
 Marketed efficiently in source markets.
 Government support: (in the form of subsidies, tax exemption etc.)
 The Department of Tourism, Kerala pioneered in promoting Kerala
as a medical tourism destination in the international market.
 The Great India Tour Company (GITC) launched special medical
tourism packages under brand name ‘Heavenly Healing’ in the
international tourism marts in association with Kerala Institute of
Medical Sciences.
 There is an existing demand for treatment, from countries like
Maldives, Bangladesh, Gulf countries and some European countries.
 The Non Resident Keralites are good spokespersons in the
originating countries and prefer their home country for treatment.
 International corporate houses offer medical treatment facilities to
the employees and family are focusing cost effective options.

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 Weaknesses

To attract more health tourists some of the facilities should be improved.

 Poor infrastructure: roads, drainage

 Staffs in attendance need to be better trained to serve.
 Image of Kerala needs to be enhanced.
 Environment pollution.
 Improper waste management system
 In the world community India is not traditionally regarded as a health
conscious country.
 The stagnating drains and open latrines convey a rather dismal message
about healthcare system.
 Spread of diseases like Chikungunya
 Lack of quality hotels
 Dirty roads, contaminated water.
 Internet connectivity not up to the standards
 Unhygienic and unsanitary environment.
 Lack of hospitality services.
 Becoming a terrorism prone area
 Communal unrest
 Heterogeneous pricing of services
 Presence of a large number of unlicensed practitioners or quacks.
 Lack of standardization in medical care and cost of procedures.
 Poor medical insurance coverage.
 Lack of regulatory mechanism.
 Lack of internationally accredited hospitals

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  Weaknesses in public healthcare system
 Lack of co ordination among health tourism providers.

Opportunities
 Increase in NRI investment.
 Link health tourism with other niche tourism and overall development of
the tourism industry.
 Music therapy
 Preventive healthcare
 Health checkup with tourism packages
 Combining leisure tourism with Ayurveda treatment
 Medical outsourcing: Both foreign employers and insurance firms are
expected to outsource large share of medical treatments to India.
 NRI treatment sections
 Health/ Medical City concept
 Stress management centres
 Joint ventures: Health insurance, tour operators, hospitals, resorts
 Corporate employees
 Holistic treatment centres
 Yoga study centres
 Naturopathy
 Creation of employment in all fields
 High tech hospitals
 Business travelers who opt for a through medical checkup, combining it
with business or vacation plans in the region.
 According to an American survey, each year people from Latin America
spend up to US$ 6 billion on medical care in good clinics outside their

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 home countries.

Threats

 Health tourism may damage public healthcare system

o Increase in treatment charges

o Brain drain from public hospitals

o Subsidy to private hospitals creating criticisms

o Medical tourism at the cost of common man

 Affects culture

o Possibility to the development of sex tourism

o Emergence of unlicensed and unqualified physicians

o Unlicensed health centres create bad image to Kerala

 Healthcare becomes commercialized.

 Bad competition among corporate hospitals

Kerala collected Rs 36,528.01 crore as revenues from tourism last year: an increase
of Rs 2,874.33 crore over last year.Over 16.7 million tourists, both domestic and
foreign, visited Kerala in 2018, compared to 15.76 million the previous year,
recording an increase of 5.93 per cent.Of the total footfalls, 1.09 million were
foreign tourists. The share of revenue from foreign visitors touched Rs 8,764.46
crore. There was also a spurt in arrival of domestic tourists to the southern state.

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United Kingdom (UK) accounted for the largest number of foreign
visitors, at 200,000, followed by the United States,
France, Germany and Saudi Arabia. The number of visitors from other European
countries such as Sweden and Italy also rose during the period.

In the first quarter of calender year 2018, tourist arrivals to the state recorded a
12.3 per cent growth of foreign visitors and a 20 per cent rise of domestic
tourists.The Nipah outbreak in May and the floods in August affected arrivals.

“The number of tourists who visited Kerala in 2018 touched almost half the state’s
population. This impressive growth has been achieved against the century’s most
severe deluge,” said Kerala's tourism minister Kadakampally Surendran.

"It was through hard work and determination of the Tourism Department, tourism
trade and the coordinated efforts of other government departments that the state
had been able to achieve this impressive growth,” said Secretary of Kerala
Tourism department Rani George.

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Kerala is a state on the southwestern, Malabar Coast of India. It was formed on 1
November 1956, following passage of the States Reorganisation Act, by
combining Malayalam-speaking regions. Spread over 38,863 km2 (15,005 sq mi),
Kerala is the twenty second largest Indian state by area. It is bordered
by Karnataka to the north and northeast, Tamil Nadu to the east and south, and
72 | P a g e
the Lakshadweep Sea and Arabian Sea to the west. With 33,387,677
inhabitants as per the 2011 Census, Kerala is the thirteenth-largest Indian state by
population.

The Chera Dynasty was the first prominent kingdom based in Kerala. The Ay
kingdom in the deep south and the Ezhimala kingdomin the north formed the other
kingdoms in the early years of the Common Era (CE or AD). The region had been
a prominent spice exporter since 3000 BCE. The region's prominence in trade was
noted in the works of Pliny as well as the Periplus around 100 CE. In the 15th
century, the spice trade attracted Portuguese traders to Kerala, and paved the way
for European colonisation of India. At the time of Indian independence
movement in the early 20th century, there were two major princely states in
Kerala-Travancore State and the Kingdom of Cochin. They united to form the state
of Thiru-Kochi in 1949. The Malabar region, in the northern part of Kerala had
been a part of the Madras province of British India, which later became a part of
the Madras State post-independence.

After the States Reorganisation Act, 1956, the modern-day state of Kerala was
formed by merging the Malabar district of Madras State (excluding Gudalur
taluk of Nilgiris district, Topslip, the Attappadi Forest east of Anakatti), the state
of Thiru-Kochi (excluding four southern taluks of Kanyakumari district,
Shenkottai and Tenkasi taluks), and the taluk of Kasaragod (now Kasaragod
District) in South Canara (Tulunad) which was a part of Madras State.

Tourism is travel for pleasure or business; also the theory and practice of touring,
the business of attracting, accommodating, and entertaining tourists, and the
business of operating tours. Tourism may be international, or within the traveller's
country. The World Tourism Organization defines tourism more generally, in

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terms which go "beyond the common perception of tourism as being
limited to holiday activity only", as people "traveling to and staying in places
outside their usual environment for not more than one consecutive year for leisure
and not less than 24 hours, business and other purposes".

Tourism can be domestic or international, and international tourism has both

incoming and outgoing implications on a country's balance of payments.

Tourism suffered as a result of a strong economic slowdown of the late-2000s

recession, between the second half of 2008 and the end of 2009, and the outbreak
of the H1N1 influenza virus, but slowly recovered. International tourism receipts
(the travel item in the balance of payments) grew to US$1.03 trillion (€740 billion)
in 2011, corresponding to an increase in real terms of 3.8% from
2010. International tourist arrivals surpassed the milestone of 1 billion tourists
globally for the first time in 2012, emerging markets such as China, Russia,
and Brazilhad significantly increased their spending over the previous
decade. The ITB Berlin is the world's leading tourism trade fair Global tourism
accounts for ca. 8% of global greenhouse gas emissions Kerala, a state situated on
the tropical Malabar Coast of southwestern India, is one of the most popular tourist
destinations in the country. Named as one of the ten paradises of the world by
National Geographic Traveler, Kerala is famous especially for its ecotourism
initiatives and beautiful backwaters. Its unique culture and traditions, coupled with
its varied demography, have made Kerala one of the most popular tourist
destinations in the world. Growing at a rate of 13.31%, the tourism industry is a
major contributor to the state's economy.

Until the early 1980s, Kerala was a relatively unknown destination, with most
tourism circuits concentrated around the north of the country. Aggressive

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marketing campaigns launched by the Kerala Tourism Development
Corporation—the government agency that oversees tourism prospects of the
state—laid the foundation for the growth of the tourism industry. In the decades
that followed, Kerala Tourism was able to transform itself into one of the niche
holiday destinations in India. The tag line Kerala – God's Own Country was
adopted in its tourism promotions and became a global superbrand. Kerala is
regarded as one of the destinations with the highest brand recall. In 2010, Kerala
attracted 660,000 foreign tourist arrivals.

Kerala is an established destination for both domestic as well as foreign tourists.

Kerala is well known for its beaches, backwaters in Alappuzha and Kollam,
mountain ranges and wildlife sanctuaries. Other popular attractions in the state
include the beaches at Kovalam, Varkala, Kollam and Kapad; backwater tourism
and lake resorts around Ashtamudi Lake, Kollam; hill stations and resorts at
Munnar, Wayanad, Nelliampathi, Vagamon and Ponmudi; and national parks and
wildlife sanctuaries at Periyar, Parambikulam and Eravikulam National Park. The
"backwaters" region—an extensive network of interlocking rivers, lakes, and
canals that centre on Ashtamudi Lake, Kollam, also see heavy tourist traffic.
Heritage sites, such as the Padmanabhapuram Palace, Hill Palace, and
Mattancherry Palace, are also visited. The city of Kochi ranks first in the total
number of international and domestic tourists in Kerala. To further promote
tourism in Kerala, the Grand Kerala Shopping Festival was started by the
Government of Kerala in 2007. Since then it has been held every year during the
December–January period.

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Backwaters
Backwater tourism is centered mostly around Ashtamudi Lake, Kollam. Boat races
held during festival seasons are also a major tourist attraction in the backwater
regions.

The backwater network includes large lakes such as the Ashtamudi Lake, the
largest among them, linked by 1500 km of canals, both man-made and natural and
fed by several rivers, and extending virtually the entire length of Kerala state. The
backwaters were formed by the action of waves and shore currents creating
low barrier islands across the mouths of the many rivers flowing down from
the Western Ghats range.

Backwaters in Kerala for honeymoon and family holiday are quite popular. You
may short some best Kerala backwaters tour packages after reading about Kerala
backwaters reviews available on various websites.

Eastern Kerala consists of land encroached upon by the Western Ghats; the region
thus includes high mountains, gorges, and deep-cut valleys. The wildest lands are
covered with dense forests, while other regions lie under tea and coffee plantations
(established mainly in the 19th and 20th centuries) or other forms of cultivation.

The Western Ghats rise on average to 1500 m elevation above sea level. Some of
the popular hill stations in the region are Munnar, Vagamon, Paithalmala,
Wayanad, Nelliyampathi, Elapeedika, Peermade, Thekkady and Ponmudi.

Wildlife

The Konni Elephant Training Centre near Pathanamthitta

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Most of Kerala, whose native habitat consists of wet evergreen rainforests at lower
elevations and highland deciduous and semi-evergreen forests in the east, is subject
to a humid tropical climate. However, significant variations in terrain and elevation
have resulted in a land whose biodiversityregisters as among the world’s most
significant. Most of Kerala's significantly biodiverse tracts of wilderness lie in the
evergreen forests of its easternmost districts. Kerala also hosts two of the world’s
Ramsar Convention-listed wetlands: Lake Sasthamkotta and the Vembanad-Kol
wetlands are noted as being wetlands of international importance. There are also
numerous protected conservation areas, including 1455.4 km2 of the vast Nilgiri
Biosphere Reserve. In turn, the forests play host to such major fauna as Asian
elephant (Elephas maximus), Bengal tiger (Panthera tigris tigris), leopard (Panthera
pardus), Nilgiri tahr (Nilgiritragus hylocrius), and grizzled giant squirrel (Ratufa
macroura).[18] More remote preserves, including Silent Valley National Park in
the Kundali Hills, harbour endangered species such as the lion-tailed macaque
(Macaca silenus), Indian sloth bear (Melursus (Ursus) ursinus ursinus), and gaur
(the so-called "Indian bison"—Bos gaurus). More common species include Indian
porcupine (Hystrix indica), chital (Axis axis), sambar (Cervus unicolor), gray
langur, flying squirrel, swamp lynx (Felis chaus kutas), boar (Sus scrofa), a variety
of catarrhine Old World monkey species, gray wolf (Canis lupus), and common
palm civet (Paradoxurus hermaphroditus). Many reptiles, such as king cobra, viper,
python, various turtles and crocodiles are to be found in Kerala—again,
disproportionately in the east. Kerala's avifauna include endemics like the Sri
Lanka frogmouth(Batrachostomus moniliger), Oriental bay owl, large frugivores
like the great hornbill (Buceros bicornis) and Indian grey hornbill, as well as the
more widespread birds such as peafowl, Indian cormorant, jungle and hill myna,
Oriental darter, black-hooded oriole, greater racket-tailed and black drongoes,
bulbul (Pycnonotidae), species of kingfisher and woodpecker, jungle fowl,

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Alexandrine parakeet, and assorted ducks and migratory birds. Additionally,
freshwater fish such as kadu (stinging catfish—Heteropneustes fossilis) and
brackishwater species such as Choottachi (orange chromide—Etroplus maculatus,
valued as an aquarium specimen) also are native to Kerala's lakes and waterways.

Festivals

Thirayattam (kuttychathan ) An Ethnic Ritual Perforning Art Form In Kerala State,

India The major festival in Kerala is Onam. Kerala has a number of religious
festivals. Thrissur Pooram, Attukal Pongala, Beema Palli Uroos, and
Chettikulangara Bharani are the major temple festivals in Kerala. The Thrissur
Pooram is conducted at the Vadakumnathan temple, Thrissur. The Chettikulangara
Bharani is another major attraction. The festival is conducted at the
Chettikulangara temple near Mavelikkara. The Sivarathri is also an important
festival in Kerala. This festival is mainly celebrated in Aluva Temple and
Padanilam Parabrahma Temple. Padanilam Temple is situated in Alappuzha
district of Kerala, about 16 kilometres (9.9 mi) from Mavelikkara town. Parumala
Perunnal, Manarkadu Perunnal are the major festivals of Christians. Muslims also
have many important festivals. Annual festival Thirayattam is conducted Sacred
groves and village shrine of south malabar region (kozhikode and malappuram
districts) in Kerala. "Thirayattam" is a vibrant Ethnic performing art. it is an
admixture of dance,drama, songs,instrumental music,facial and body makeup,
satire, martial art and ritualistic function, composed in a harmonizing manner
Kochi-Muziris Biennale

Kerala is also known for the many events conducted by the Ministry of Tourism
for tourist attractions. Kochi-Muziris Biennale, the first Biennale in India was
conducted in Kochi from 12 December 2012 till 13 March 2013.The government
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contributed about 12-150 million on the event.[22] An International Coir Fest is
conducted annually that is aimed at developing the coir industry of Kerala and
tourism.

Grand Kerala Shopping Festival

To further promote tourism in Kerala, the Government of Kerala started the Grand
Kerala Shopping Festival in the year 2007.[8] Since then it has become an annual
shopping event being conducted in the December–January period. During this
period stores and shops registered under the GKSF offer a wide range of discounts,
VAT refunds, etc. Along with the guaranteed shopping experience, shoppers are
provided with gift coupons for a fixed worth of purchase entering them into weekly
and mega lucky draws. As compared to shopping festivals held in other countries,
this Festival converts the entire state of Kerala into a giant shopping mall,
incorporating not just the big players, but also the small and medium scale
industries. Through this shopping festival, the Kerala Government intends to
transform the State into a hub for international shopping experience and thereby
launch "Shopping Tourism" in the state.

Ayurveda

Medical tourism, promoted by traditional systems of medicine like Ayurveda and

Siddha, is widely popular in the state, and draws increasing numbers of tourists. A
combination of many factors has led to the increase in popularity of medical
tourism: high costs of healthcare in industrialised nations, ease and affordability of
international travel, improving technology and standards of care.

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However, rampant recent growth in this sector has made the government
apprehensive. The government is now considering introduction of a grading system
which would grade hospitals and clinics, thus helping tourists in selecting one for
their treatments

Culture

Main articles: Arts of Kerala and Culture of Kerala

Kerala's culture is mainly Hindu in origin, deriving from a greater Tamil-heritage

region known as Tamilakam. Later, Kerala's culture was elaborated on through
centuries of contact with overseas cultures.[24] Native performing arts include
koodiyattom, kathakali—from katha ("story") and kali("play")—and its offshoot
Kerala Natanam, koothu (akin to stand-up comedy), mohiniaattam("dance of the
enchantress"), thullal, padayani, thirayattam, and theyyam. Other arts are more
religion- and tribal-themed. These include chavittu nadakom, oppana (originally
from Malabar), which combines dance, rhythmic hand clapping, and ishal
vocalisations. However, many of these art forms largely play to tourists or at youth
festivals, and are not as popular among most ordinary Keralites, who look to more
contemporary art and performance styles, including those employing mimicry and
parody. Additionally, a substantial Malayalam film industry effectively competes
against both Bollywood and Hollywood.

Several ancient ritualised arts are Keralite in origin; these include kalaripayattu
(kalari ("place", "threshing floor", or "battlefield") and payattu ("exercise" or

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"practice")). Among the world's oldest martial arts, oral tradition attributes
kalaripayattu's emergence to Parasurama. Other ritual arts includeThirayattam,
theyyam, poorakkali and Kuthiyottam. Thirayattam is a ritual performing folk aet
form of south malabe region in kerala.This vibrant art form blend of dance, music,
theatre, satire, facial & body painting, masking, martial art and ritualistic
function.Thirayattam enacted i courtyards of "Kaavukal"(sacred groves)and village
shrine.

Kuthiyottam is a ritualistic symbolic representation of human bali (homicide).

Folklore exponents see this art form, with enchanting well–structured
choreography and songs, as one among the rare Adi Dravida folklore traditions still
preserved and practised in Central Kerala in accordance with the true tradition and
environment. Typical to the Adi Dravida folk dances and songs, the movements
and formations of dancers (clad in white thorthu and banyan) choreographed in
Kuthiyottam are quick, peaks at a particular point and ends abruptly. The
traditional songs also start in a stylish slow pace, then gain momentum and end
abruptly.

Kuthiyotta Kalaris', run by Kuthiyotta Ashans (Teachers or leaders), train the

group to perform the dances and songs. Normally, the training starts about one to
two months before the season. Young boys between 8 and 14 years are taught
Kuthiyottam, a ritual dance in the house amidst a big social gathering before the
portrait of the deity. Early in the morning on Bharani, after the feast and other
rituals, the boys whose bodies are coiled with silver wires, one end of which is tied
around his neck and an arecanut fixed on the tip of a knife held high over his head,
are taken in procession to the temple with the accompaniment of beating of drums,
music, ornamental umbrellas, and other classical folk art forms, and richly
caparisoned elephants.
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All through the way to the temple tender coconut water will be continually poured
on his body. After the circumambulation the boys stands at a position facing the
Sreekovil (Sanctum Sanctorum) and begins to dance. This ceremony ends with
dragging the coil pierced to the skin whereby a few drops of blood comes out.

A procession of gold-caparisoned Kerala elephants at the Thrissur Pooram

On this day just after midday the residents of the locality bring huge decorated
effigies of Bhima panchalia, Hanuman and extremely beautiful tall chariots in
wheeled platforms, and after having darshan the parties take up their respective
position in the paddy fields lying east of the temple.

During the night, the image of Devi will be carried in procession to the effigies
stationed in the paddy fields. On the next day these structures will be taken back.
A big bazaar is also held at Chetikulangara as part of this festival. Kuthiyottam is
the main vazipadu of the Chettikulangara temple, Mavelikkara.

In respect of Fine Arts, the State has an abounding tradition of both ancient and
contemporary art and artists.The traditional Kerala murals are found in ancient
temples, churches and palaces across the State. These paintings, mostly dating to
between the 9th to 12th centuries AD, display a distinct style, and a colour code
which is predominantly ochre and green.

Like the rest of India, religious diversity is very prominent in Kerala. The
principal religions are Hinduism, Christianity, and Islam; Jainism, Judaism,
Sikhism, and Buddhism have smaller followings. The state's historic ties with the
rest of the world have resulted in the state having many famous temples,
churches, and mosques notably 8 of the world's oldest churches—from the 1st
century CE, founded by Thomas the Apostle when he reached Indian shores, the
first mosque of India, which existed even before the death of the prophet

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Muhammad and the oldest active synagogue in the Commonwealth of Nations.

Recognising the potential of tourism in the diversity of religious faiths, related

festivals and structures, the tourism department launched a "Pilgrimage tourism"
project. Major pilgrim tourism attractions include Guruvayur, Sabarimala,
Malayatoor, Paradesi Synagogue, St. Mary's Forane (Martha Mariam) Church
Kuravilangad built in 105 A.D, AttukalPongala (which has the Guinness record
for being the largest gathering of women in the planet), and Chettikulangara
Bharani.

Advertising campaigns

Kerala Tourism is noted for its innovative and market-focused ad campaigns.

These campaigns have won the tourism department numerous awards, including
the Das Golden Stadttor Award for Best Commercial, 2006, Pacific Asia Travel
Association- Gold Award for Marketing, 2003 and the Government of India's
Best Promotion Literature, 2004, Best Publishing, 2004 and Best Tourism Film,
2001.

Catchy slogans and innovative designs are considered a trademark of brand

Kerala Tourism. Celebrity promotions are also used to attract more tourists to the
state. The Kerala tourism website is widely visited, and has been the recipient of
many awards. Recently, the tourism department has also engaged in advertising
via mobiles, by setting up a WAPportal, and distributing wallpapers and
ringtones related to Kerala through it.

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 Conclusion
Kerala has enormous potential to emerge as one of the world’s best health
tourism destinations. Its splendid flora and fauna, beaches, back waters; festivals
etc. have the ability to lure more and more tourists. It is capable of becoming a
heaven for wellness tourists by highlighting holistic treatments such as
Ayurveda, spa, yoga, meditation, naturopathy etc. Emergence of accredited multi
speciality hospitals gives boost to medical tourism. Health tourism is not a one
time business. Satisfied health tourists will recommend Kerala as a health
tourism destination to their nearby. Hence health tourism providers should try to
maintain service quality. This study also evaluates the service quality of health
tourism providers of Kerala which is depicted in the following chapter.

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 REFERENCES

1. Tourism Brochure. Retrieved. from. Department of Tourism Kerala

2. Therapeutic-programmes. Retrieved May 31, 2008, from http://www.

kerala-tourism-travel.com/therapeutic-programmes/index.html

3. Department of Tourism Kerala

4. Yoga. Retrieved May 31, 2008, from http://www.kerala-tourism-

travel.com/yoga-meditation/index.html

5. Ayurveda. Retrieved May 31, 2008, from http://www.healthtours

kerala.com/ayurveda.html#un

6. Indian Medicine. Retrieved May 31, 2007, from http://indianmedicine

.nic.in/html/nature/nature.htm

7. Marma Treatment. Retrieved July 31, 2007, from

http://www.anjane- yam.com/marma.htm

8. Kurup, k. K. N., and K.Vijaya Kumar. Indigenous Health Tradition

of Kerala. In Aryavaidyan (pp. 165-169).

9. Retrieved June 28, 2006, from http://www.medterms.com/script/

main/art.asp?articlekey=10981

10. Health Tourism Provider. Retrieved June 28, 2006, from

http://en.wikipedia.org/wiki/Health_tourism_provider.

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