The Development and Behavioral Intention in Choosing Malaysia as Destination for Medical Tourism

Medical tourism has gained huge popularity because it has become a major source of income for most nations. There are a lot of literatures available about the tourism industry and the competitiveness of the destination. Problem statement: It is important especially those in emerging countries like Malaysia to look into and put efforts to strategize their capabilities and facilities to respond to the global competition and business opportunities in enhancing their performance. Malaysia has been recognized as the Health and Medical Tourism Development for three consecutive years from 2015 to 2017 by the International Medical Travel Journal. Referring to the National Transformation Programme 2017 Annual Report, Malaysia was targeting to increase the hospital revenue by RM2.8 million by 2020 and the target markets is from Indonesia, Myanmar, China and Vietnam. The industry has shown excellent growth potential ranging between 16-17% every year. As for the year 2016, the healthcare travel industry grew by 23% from 2015, compared to the average growth rate of 15% from 2011 – 2015. Research objective: Therefore, this research attempts to examine the behavioral intention of the medical tourist in choosing Malaysia as medical tourism destination. While considering all four variables chosen as having significant impact on behavioral intention of the medical tourists. Findings: The result demonstrated that there is a positive relationship between perceived destination image, perceived quality, perceived value and patient satisfaction. Keyword: Medical Tourism, Behavioral Intention, Perceived Destination Image, Perceived Quality, Perceived Value and Patient Satisfaction. Introduction Medical tourism is the act of travelling abroad to obtain medical care. It is about a vacation that involves travelling abroad across international borders in order to obtain a broad range of medical services. Moreover, medical tourism which sometimes termed as medical travel, health tourism or global health care initially combined with travel agencies and the mass media to explain the speedy growing practice of travelling across international borders to obtain health care (Connell, 2013). International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2341 The effort to gain better healthcare while at the same time enjoying the sea, sun and sand through relaxation, exercise or visiting spas has risen to a new level with the increase of developing countries becoming destinations for medical tourism (Connel, 2006). The term ‘medical tourism’ is normally used to describe the phenomenon whereby people travel to the other parts of the world across international borders, spending a vacation to obtain a broad range of medical services in a foreign countbookmry in which medical technology is advanced as well as affordable. Medical tourists may gain the benefits of having the treatment or medical surgery while enjoying a stay in one of the most popular destinations. The benefits not only include leisure, fun and relaxation but also comprise of wellness and health care services. The programs for medical tourism comprise products that are supported with excellent medical services, together with tourism services for the foreign visitors, which are earning foreign revenues and developing related industries in addition to those normally developed leisure tourism packages (Bookman & Bookman, 2007; Lunt & Carrera, 2010; Smith & Puczkó, 2008). The main reasons why people travel to seek health care are because health care services that are lower in cost, less expensive than those at home and to get quicker, affordable and comfortable medical treatments (Gan & Frederick, 2015). The new phenomenon of people moving away from their home country to get the treatment has forced the destination to look for alternative marketing strategies that can identify and adventure new opportunities that are attractive, economically rewarding and sustainable (Buhalis, 2000). Such alternatives of marketing strategies depend on identifying how customers perceive the destination’s tourism products and how these products are designed to satisfy the needs of the targeted market. Medical tourists normally stay longer than other tourists, most of them need to come back for follow-up procedures and most of them travel at least with one person to accompany them (Whittaker, 2008). In fact, Malaysia is also one of the top five destinations in the medical tourism sectors and its targeted patients are from developed and less developed countries. Malaysia provides good facilities and competitive rates compared to other parts of the world. Malaysia has carried out several strategies to ensure that it is the leading choice for medical tourism destinations. Therefore, this research attempts to examine the behavioral intention of the medical tourist in choosing Malaysia as medical tourism destination. While considering all four variables chosen as having significant impact on behavioral intention of the medical tourists. The result demonstrated that there is a positive relationship between perceived destination image, perceived quality, perceived value and patient satisfaction. Literature Review Overall, the globalization of health care has given the opportunity for the new form of tourism, commonly known as health tourism. Health tourism is a combination between both illness-oriented medical tourists and well-being achieving wellness tourists: nevertheless, definitions and estimations for each varies (Bushell & Sheldon, 2009; Lunt & Carrera, 2010). Surrounded by the health tourism arena, medical tourism is one of the most fastest growing sectors and this had led many countries making legal and practical plans to venture in this sector (Heung et al., 2011). International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2342 Medical tourism can be defined as patients travel from the other part of the world, cross the border care arrangements to seek for the medical treatment, dental, surgical care just because the destination enables better access to care, providing a higher quality care or offers the same treatment at a more affordable price which are usually paid for out of pocket (Crooks et al., 2010). Hong et al (2007) describe that medical tourism is about people who choose to seek treatment or disease treatment or maybe to enhance physical and psychological well-being at the other parts of the world other than their own country. Traditionally, people travel to other parts of the world to seek medical, surgical care and dental treatment while at the same time enjoying the holiday (Taleghani et al., 2011). In addition, medical tourism is about the relative time spent on medical service and tourism on the trip. Researchers claimed that medical tourism not only involved medical services but it involved more than that such as engaging in tourists activities like recovering in resorts or recuperation (rest seekers) and not forgetting those who wanted to receive essential medical services (essential seekers)(Smith & Puczkó, 2008;) that include organ transplant which is not immediately available in theirown country. Other than that, there are also people who seek “affordable health care seekers” because of the high cost of the service in their home country. Not forgetting those who seek “quality health care seekers” because they are after safer and securer medical services in overseas hospitals with international recognition or certification. This is because their home country’s medical services are behind in terms of quality. Finally, they are after the “premium health care seekers” who actually prefer themselves of luxurious medical services. A steady development in technology together with huge amount of information in the recent years has transformed the nature of exchange, specialization and communication among countries. With the new style of globalization, people style has changed rapidly because they are exposed to the new ways of getting treatment. One of the advantages that can be found in medical tourism is that it involved globalization of both health care and tourism, which already constituted major arenas of transnational economic activity (Bookman & Bookman, 2007). Medical tourism is a niche and has been one of the new emerging industries because it has the potential of increasing the economic which involves trade in services while simultaneously being holidaymakers, in a more conventional sense. Medical tourism is not new. It has emerged from the 18th century where people visited spas because they wanted to get treatment to heal diseases for example bronchitis and gout by using mineral waters (Connel, 2011). The original phenomenon is the extraordinary expansion at the world level. In the beginning the medical tourists were the ancient pilgrims who travel from Mediterranean to Epidauria in the Saunic Gulf for treatment (De & Dasgpta, 2012) . Patients from the third world countries with the essential resources began mobile to most important medical centres in Europe and United States for the sake of getting the treatment that is unavailable in their country. Meanwhile, in Asia, Thailand has been one of the three top medical tourism destinations, in part because of the quality of treatment and the range of services available to medical seeking tourists. Thailand has been the leader in Asian medical tourism market, which manages to attract approximately 1.2 million medical tourists especially from UAE, Qatar, Oman and Japan. It was found that Thailand was one of the preferred destination for International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2343 the American medical tourists (Lunt & Carrera, 2010). One of the reasons why Thailand is famous among the medical tourists is the lower cost expenditure that they provided. Their cost was 50% lower than Singapore, three times lower than Hong Kong and five to ten times lower compared to Europe of USA (Heung et al., 2011). Furthermore, Thailand is a well-known specialty destination for gender reassignment surgery (Connel, 2006). Literature reported that there were many countries preferred medical tourism as countrywide income, (Suess et al., 2018). Recently, the growing numbers of medical tourism has increased rapidly. The World Health Organisation predicts that by 2022, tourism will account for 11%of global GDP, and the highest scale of health will account for 12 % (Lin & Zhang, 2018). Among the popular and hot spot countries were India, Thailand, Singapore, Malaysia, Tunisia, Lithuania, Columbia, Hungry, Poland and Jordan. It was forecasted by The World Medical Tourism Association that the growing number of medical tourists would keep on increasing dramatically around 15% to 25% annually. Even though many experts questioned the exact percentage of medical tourist, it was agreed that medical tourism would continue to grow and transform the healthcare landscape globally. The Development of Medical Tourism in Asia Medical tourism provides the opportunity to fuel the growth of hospitals by tapping the international patient markets. The supporting system such as the advancement in medical technologies, patient mobility and quality of healthcare has aroused the medical providers globally. Medical tourism in Asia could be considered as new in the market. It arises due to Asian Financial Crisis in the year 1997 which had led the private hospitals to find other alternatives for revenue. Malaysia, Singapore, India and Thailand have deliberately linked medical care to tourism and indirectly boost the attractions of nearby sandy beaches and other interesting places as well. At the same time, medical tourism has also developed in South Africa and in countries not hitherto associated with significant levels of western tourism, for example Belarus, Latvia, Lithuania and Costa Rica. Hungary had declared 2003 as the Year of Health Tourism. South Africa has been known as a popular place for cosmetic surgery due to its lesser costs and it was less than half compared to United States, from where most of the patients came from. The Caribbean had found it difficult to embark in the medical tourism bazaar even though it was close to United States because of cheaper prices that could not beat with those in Latin America (Huff-Rousselle et al., 1995). Asia has been the main popular medical tourism destination since 1970 because it focused in sex change operations but after that it focused on cosmetic surgery. According to the development process as shown in Table 1, medical tourism has become a highly competitive business in the Asian countries. International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2344 Table 1: The Development of Medical Tourism (Wang, 2012) Country Development situation Source India Medical tourism is one of the fastest growing subsectors of its industries. Surgical procedures that can cost hundreds of thousands of dollars in the USA can be only at a fraction of the cost in India. News from India Tourism Report (2010) The total healthcare market in India is expected to increase its contribution to GDP from 5.2 percent at present to 8.5 percent over the next ten years Connell (2006) India advertises itself as the global center of medical tourism by offering everything from alternative Ayurvedic therapy to coronary bypasses andcosmetic surgery. Travel companies in India are also cooperating with hospitals to facilitate travel by arranging phone consultations with doctors to help foreign patients save time and money once they get to India Lal (2010) Thailand Thailand has the longest history; it became notable as a destination for medical tourism as early as the 1970s when the medical tourism profession began to specialize in sex change operations; later they moved to cosmetic surgery Bookman and Bookman (2007), Connell (2006) Medical tourism in Thailand is now a prosperous industry. In 2007, as many as 1.4 million visitors arrived in Thailand seeking medical care; the Health Ministry expects the number of medical tourists to surpass two million by 2012 Report from Airline & Travel News (2009) To build brands in the healthcare industry, leading hospitals in Thailand have spent the last decade striving to be the biggest and best in the world. They have recruited not only experienced doctors but also embraced foreign management expertise de Arellanolee (2007) Singapore Singapore, whose global reputation as a medical tourism center has sought to compete with Thailand. Most of the private hospitals in Singapore are participating in the medical tourism program; some of these hospitals have gained international health accreditation from the Joint Commission International (JCI) of the USA Lee (2010) Malaysia The government has made various efforts to promote healthcare services for the benefit of the medical tourism industry. Malaysia is getting a reputation as one of the preferred locations for medical tourists on account of its excellent and efficient medical staff, as well as advanced healthcare and wellness facilities (Musa, Thirumoorthi, & Doshi, 2012) International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2345 Dubai Dubai has just built Healthcare City in an attempt to capture the Middle Eastern market and divert it from Asia; the country also plans to include a branch of Harvard Medical School within the Healthcare City, which will make it one of the most prestigious foreign healthcare facilities outside of the west. The main medical treatments offered by Dubai include cochlear implants, diabetes treatments, orthopedics, cardiology, cosmetic surgery and lung treatments Report from medicaltourism.com (2012) New Zealand New Zealand is trumpeting its expertise in hip and knee replacements Pickert (2008) South Korea South Korea is enticing medical tourists with highend non-medical amenities like golf Pickert (2008) The countries in Central and South America Several countries in Central and South America also developed strong reputations for cosmetic and plastic surgery, bariatric procedures and dental care Horowitz and Rosensweig (2007) Medical Tourism in Malaysia The Malaysia Healthcare Travel Council (MHTC) was established to help the development of Malaysia’s healthcare travel industry. At the same time, it was established the country’s profile as a well-known preferred destination for world class healthcare services. Malaysia has been recognised as the Health and Medical Tourism Development for three consecutive years from 2015 to 2017 by the International Medical Travel Journal (IMTJ). Referring to the National Transformation Programme (NTP) 2017 Annual Report, Malaysia was targeting to increase the hospital revenue by RM2.8 million by 2020 and the target markets is from Indonesia, Myanmar, China and Vietnam. The industry has shown excellent growth potential ranging between 16-17% every year. As for the year 2016, the healthcare travel industry grew by 23% from 2015, compared to the average growth rate of 15% from 2011 2015(webway.nisha, 2017). Furthermore, the government was going all out in making a tremendous effort to change the country into the medical tourist hub. In addition, Association of Private Hospital of Malaysia (APHM), president Dr Jacob Thomas stated that the private healthcare industry in Malaysia had all the necessary communications and tools to have a further development especially the ones brought about the expanding of healthcare tourism. The private hospitals in the country had enough facilities and infrastructure for patients both local and foreign. Malaysia has been documented as one of the best medical expertises in the world and mostly all the private hospitals in the country have worldwide recognized of its quality and standards. The standard included MS ISO9002 or accreditation by the Malaysian Medical Society for Quality of Health (MSQH). According to the Ministry of Health, they had instructed that every private hospital should be approved and licensed(Economic Planning Unit (EPU), Eleventh Malaysia Plan 2011-2015, 2016). People from all over the world seeking varieties of International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2346 medical needs had chosen Malaysia as their preferred health and medical destination due to the growing reputation. The increasing of the reputation included both critical health services as well as cosmetic and remedial care (Bahari, 2017) In addition, Malaysian government had been focusing to sustain the health tourism industry to increase the escalation of Malaysia’s market share from 0.29% to 2% in 2012, as quoted by the Minister in the Prime Minister’s Department Tan Sri Nor Mohamed Yakcop (Foong, 2009). Competitive medical fees and modern medical facilities were two vital factors that make Malaysia a popular destination among health tourists. Patients could undergo treatment and recuperated in any parts of the country for much less than what it would cost them for a treatment in other countries. For example, a normal cardiac bypass surgery (CABG) in Malaysia would cost around US$9,000. Most private medical centres in Malaysia offer comfortable accommodation ranging from private rooms to suites for single occupancy or more. Room charges, inclusive of meals, vary at medical centres but were attractively priced. Some medical centres even provided highly qualified and trained private nurses with foreign qualifications and personal butlers at a reasonable cost. In summary, factors that contributed in making Malaysia a centre of medical excellence in the region are Malaysia offers safe and politically stable country. Furthermore, there are wide choice of world class infrastructure facilities such as The National Heart Institute and Tun Hussein Onn National Eye Hospital.For example, these private hospitals are well equipped with technology such as MRI, 64 slice CT Scan, PET Scanner for early detection of cancer and other diseases, cyberknife which is able to radiate tumours without damaging adjacent vital structures. Not forgetting, competitive plus affordable and favourable pricing together with favourable exchange rate e.g. a normal cardiac bypass surgery would only cost around US$9,000. Since Malaysia is a multi-cultural and multi religions country, it is easy to accommodate all patients of different cultures and religions from all over the world. Lastly, Malaysia is offering appealing and affordable packages during recuperation period. Listed below is the statistics of medical tourism in Malaysia: Table 2: HealthCare Patients Visiting Malaysia according to the Association of Private Hospitals of Malaysia (APHM) ("Medical Tourism to Malaysia," 2015). 2011 2012 2013 2014 2015 641,000 728,800 881,000 882,000 859,000 Listed below is the percentage of foreign patients visiting Malaysia: Table 3: Malaysia Medical Tourism Patients by Country of Origin ("Medical Tourism to Malaysia," 2015) Indonesia Middle East India China Japan Aust& UK 62% 7.4% 3% 2.6% 2.6% 2.5% According to Medical Tourism to Malaysia (2015), Malaysia manage to generate RM588.6 in the healthcare revenue between January and September 2015 with the target for the full year was set at RM854 million. As for the year 2015, the travel numbers manage to achieve above 90% of full year targets, and the targets were higher than the year 2014(2015). Based from Table 1.3 above, it was found that the highest contributor for medical tourism in International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2347 Malaysia was from Indonesia 62%, second from Middle East 7.4%, third from India 3%, followed by China 2.6%, Japan 2.6%, whereas Australia and United Kingdom 2.5%. Based from the report by IMTJ 2015/2016, it indicates that Malaysian private hospital is excellence in Cardiology, orthopaedics, oncology, neurology and dentistry. Moreover, there are growing demand for infertility, cosmetic surgery and rehab services ("Medical Tourism to Malaysia," 2015). Methodology According to (Cooper & Schindler, 2003), research design is the blueprint which included experiments, interviews, observation, record analysis and also the aids for the researcher to find the answer when implementing their research. It specifies the details of the procedures necessary for obtaining the information needed to structure and or solve marketing research problems. This study is a quantitative research study. Creswell (1994) defined a quantitative study as an inquiry into a social or human problem, based on testing a theory composed of variables, measured with number and analysed with statistical procedures, in order to determine whether the predictive generalizations of the theory hold true. This research is a descriptive study. The descriptive method is purposely design to investigate or gather all the information regarding the existing condition and it is also the “blueprint” of a research (Malhotra, 2009). The reasons of doing this method are to describe the characteristics of the international medical tourists by collecting the data through distributing the questionnaire given to them. The design of this study will offer an understanding of the relationship that exists among variables that is involves. Furthermore, it is understood that a research design is important because it is needed to achieve the research objectives as accurately as possible. First, this study was designed to find out which independent variables gives the highest impact, secondly to examine the relationships, then finding the relationship between trust as mediating and finally repeat visits as moderating variables. Primarily, the dependent and the independent variables were identified. Then, the measurement scales of the identified variables were sought and determined. Before the measurement scales were used, reliability of the scales was assessed then followed by validity. Validity is the ability of a scale to measure what it is supposed to measure (Zikmund et al., 2012). Secondly, a representative sample was selected to represent the population of the study so that the results of the study could be generalized to the population at large. The medical tourists answered the survey questions concerning perceived destination image, perceived quality, perceived value, patient satisfaction, and trust as mediating factor and also repeat visit as moderating factor. Next, the data was collected from the sample using the validated and reliable research instrument. After the data was collected, and in most cases before any actual analysis can be performed, it is advisable to run preliminary data analysis (PDA). PDA is mostly recommended to make sure that all the data is cleaned and cleansed of any substantial noise that will attract biases in the final result of actual analysis. Further clarification of data collection and data analysis procedures were presented in the later part of this chapter. International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2348 Based on the preceding chapters, a research model was developed. This model was used to assist in determining research instruments, formulating relationships between variables as well as to enable research questions to be tested. The model was also used for validation and model testing and in this study, it served as a heuristic character for exploring relationships between variables. Behavioural intention as the dependent variable was conceptualized in this model. Included in the model was a list of carefully selected independent variables that were investigated together with future intention. Based on empirical studies, it was reported that these variables: perceived destination image, perceived quality, perceived value, overall patient satisfaction was associated with behavioural intention. Hence, this study was conceptualized to determine the nature and degree of the relationship between these independent variables with behavioural intention. Below is a figure of conceptual framework of international medical tourists:Figure 1: Research Framework of Travel Behavioral Intention of Choosing Malaysia as Destination for Medical Tourism Results Based from the above results, it was advisable for the researcher not to use SEM for data analysis. Instead, to use PLS-SEM because it did not emphasize on normality of data distribution (Ringle et al., 2012). As indicated in Table 1, the finding of this study revealed the respondent’s profile by country. Most of the respondents were from Indonesia which reached more than 50% that is 68%. Next was from England 7.5%, Bangladesh 6%, both USA and Vietnam were 4.0% and 3.5%, Myanmar 4.0%, followed by Saudi Arabia 1%, Australia 3% and finally 0.5% from Canada, Holland, India, China, Singapore and Sweden respectively. International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2349 Table 4: Respondents profile by country Country Frequency Percent Indonesia Australia Bangladesh Canada England Holland India Myammar China Saudi Arabia Singapore Sweden United States of America Vietnam 136 6 12 1 15 1 1 8 1 2 1 1 8 7 68.0 3.0 6.0 0.5 7.5 0.5 0.5 4.0 0.5 1.0 0.5 0.5 4.0 3.5 Model Validation Stage 1: Assessing the Measurement Model Before the measurement of the model assessment could be done, measurement of the full research model was checked for reliability and validity. The criteria were shown in Chapter Three and the results are described in this following section. The next step was to assess their reliability and validity (Anderson & Gerbing, 1988; J.F Hair et al., 2006; Wulf, Odekerken-Schröder, & Iacobucci, 2001). For reliability, it would be assessed by using Cronbach’s alpha, composite reliability (CR) and average variance extracted (AVE), whilst for validity would use construct, convergent and discriminant. The results showed that sufficient item reliability with the individual item loading was above 0.5; composite reliability of more than 0.70, and average variance extracted (AVE) as shown in Table 4.10. The square root of AVE for each latent also exceeded as shown in Table 4.9. Reliability of the variables was further supported by Cronbach’s alpha of more than 0.70 and a variance inflation factor (VIF) of less than 5. Table 4.10 represents the Cronbach’s alpha for all the constructs that met the benchmark of 0.7 (Nunnally, 1979). Using confirmatory factor analysis, construct reliability (CR) and average variance extracted (AVE) were calculated by using formulas by Fornell and Larcker (1981) to further confirm the reliability of the constructs. As for the constructs in this research, have CR above 0.70 and AVE of at least 0.50 as recommended by Bagozzi and Yi (1988), suggesting further support of the reliability of the constructs. Confirmatory factor analysis was being used to assess the validity of the constructs and it was vital for theory testing (Bagozzi & Yi, 1988). Furthermore, the constructs validity could be confirmed based on goodness of fit indices (Hsieh & Hiang, 2004). It was found that there was evidence of convergent validity showing the results that was high factor loadings (greater than 0.50) of all factors (Anderson & Gerbing, 1988). Besides, the results of AVE provide further supported composite reliability. The square root of AVE for each latent also exceeded the inter construct correlations as shown in Table 4.10. International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2350 Coltman et al.’s (2008) reflective construct assessment was used to confirm sufficient indicator loadings (more than .50) on their respective factor, construct reliability (Cronbach’ alpha > .70), average variance extracted (AVE) (Table 4.10) for each construct which was higher than the construct correlation with other construct and showed positive weightloading sign (WLS). Model Validation Stage 2: Assessment of The Structural Model Based on the results in section 4.5 above, the measurement model showed beneficial individual item reliability, convergent reliability and discriminant reliability. The next step was to examine the structural model to determine its explanatory power and after that to test the hypotheses of the study. The effects of the constructs defined in the proposal model were assessed through coefficient of determination (R2), path coefficient (β), effect size (ƒ2) and predictive relevance (Q2). Figure 4.2 depicts the results and shows all the hypotheses which were supported. Based on the results, it showed 70% variations in behavioural intention (INTENT), represented by the combined effect of exogenous variables (R2 = 0.70). R2 of this magnitude showed that the model has substantial predictive accuracy according to the standards suggested by (Chin, 1998b; Hair Jr, et al., 2014). Hair Jr, et al (2014) suggested R2 of 0.75, 0.50 and 0.25 as substantial, moderate and weak. On the other hand, Chin (1998b) considered 0.67, 0.33, and 0.19 at a similar level. Regardless of which standard was being used, R2 in this model had substantial predictive accuracy. Table 5: Structural Model Parameters Path Β P-VALUE ƒ2 Hypotheses IMAGE FBI 0.15 = 0.02 0.10 H1 :Supported QLTY FBI 0.22 < 0.01 0.17 H2 :Supported VALUE FBI 0.32 < 0.01 0.25 H3 :Supported SATISFY FBI 0.24 < 0.01 0.18 H4 :Supported H1: Perceived destination image has positive relationship with behavioural intention. Hypotheses 1 proposed a positive relationship between perceived destination image and behavioural intention. As shown in Table 5, the standardized path coefficient was significant at β = 0.15. Furthermore, p-value was (p = 0.02). This suggested that image of the country had attracted the medical tourists to choose Malaysia as their destination. Since the result was significant, therefore hypotheses 1 were supported. H2: Perceived quality has positive relationship with behavioural intention. Hypotheses 2 proposed a positive relationship between perceived quality and behavioural intention. As shown in Table 5, the standardized path coefficient was significant at β = 0.22. Furthermore, p-value was (p < 0.01). This suggested that quality provided by the private hospital had attracted the medical tourists to choose Malaysia as their health treatment. Since the result was significant, therefore hypotheses 2 were supported. International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2351 H3: Perceived value has positive relationship with behavioural intention. Hypotheses 3 predicted that there is a positive relationship between perceived value and behavioural intention. As shown in Table 5, the standardized path coefficient was significant at β = 0.32. Furthermore, p-value was (p < 0.01). This suggested that the medical tourists value Malaysia’s private hospital treatments and this would allure the medical tourists to choose Malaysia as their destination. Since the result was significant, therefore hypotheses 3 were supported. H4: Patient satisfaction has positive relationship with behavioural intention. These hypotheses posit that there is a positive relationship between patient satisfaction and behavioural intention. As shown in Table 5, the standardized path coefficient was significant at β = 0.25. Furthermore, p-value was (p < 0.01). This suggested that the medical tourists were satisfied with the Malaysia’s private hospital treatments and this would attract the medical tourists to choose Malaysia as their destination. Since the result was significant, therefore hypotheses 4 were supported. Conclusion and Recommendation In the current competitive globalized environment, medical tourism presents a great business opportunity for the Malaysian healthcare and tourism industries. It is very important for Malaysian players to grasp this opportunity and understand the needs of the medical tourists in hope to remain competitive and sustainable in this promising market. It is a fact because there is intense competition in the region because there are many players involve such as Thailand, Singapore and India. These countries have been in the business for a substantial amount of time and currently they are the leading countries for medical tourism. In the competitive market, it is vital for Malaysia, as medical service providers to be more aggressive in attracting as many potential international patients as possible. Moreover, it is relevant for the healthcare providers to have appropriate strategies in attracting international patients. Findings from this study clearly indicated that motivations for treatment by medical tourists are complex and multiple. Mostly, behavioural intention is often used to access customer potential’s for revisiting because it is considered as a relatively accurate predictor for future behavior (Alexandris et al., 2002; Ishaq, 2012). It was noted that from the result of the study, it was found that all dimensions that was chosen were found to have a significant relationship that drive the medical tourists to travel (Caber & Albayrak, 2016; Chan & Baum, 2007; Crompton, 1979; Dann, 1981). It demonstrates that the dimensions chosen to have a direct impact in motivating the medical tourists to visit Malaysia. Moreover, understanding what motivates the medical tourist to travel is an important factors for the players because they come from different background and culture(Mee et al., 2018). Since the number of medical tourists has been increasing from year to year the Malaysian Tourism Board (MTOB) should focus, support and enhance the motivational factors to attract more medical tourists in the future. The greater demand of medical treatment justifies the need for more marketing tourism approaches. Furthermore, investigating the variables that will influence travel motivations is very important for marketers and decision International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2352 makers so that better tourism products can be offered for the medical tourists. Knowing the importance of motivational factors, perceived from medical tourist’s opinions will help the destinations provide their needs in future. In term of marketing and promotion, mass media, at the same time, should play a critical role in forming a distinctive destination image for Malaysia, to distinguish itself from competitors within the region. The strategic challenge for destination is not only on how to perform positive images that induce travel to the country, but also on how to develop sustainable differential images from other competing locations. A successful matching of all the dimensions chosen is essential for a marketing strategy in destination areas, and the examination of the motives are useful for the destination, designing promotional programs, and decision-making about destination development. Thus, the tourism authorities in Malaysia can develop a variety of different marketing strategies based on specific motivations of the medical tourist in order to satisfy their underlying needs. The result of the study has provided important contributions to define the medical tourist’s motivations. In addition, in order to achieve a competitive advantage against other competitors, the private hospitals in Malaysia must keep on improving their services from time to time to make sure that the level of quality of their products and services are at the maximum level with other well-known private hospitals especially of that in Thailand, Singapore and India. This is important because it is one of the ways to gain patient satisfaction because this would have a direct impact on patient’s behavioural intention especially in the future. As a service provider, the private hospitals would like the medical tourist to think that Malaysia will be their first choice in the near future. Therefore, the hospital service quality can be used as a benchmark for the hospitals to keep on improving their services compared to others. The private hospitals should pay more attention towards the service quality aspects (Aagja & Garg, 2010; Arasli et al., 2008; Padma et al., 2010). In order to achieve this, private hospitals must have adequate information regarding the level of patient satisfaction. Furthermore, one of the most important aspects that would influence patient satisfaction’s in terms of tangible facilities, for example equipment and facilities. Updating the products and services provided and at the same time educating patients about the tangible and intangible elements in hospital are important so as to contribute towards service quality improvement. In addition, hospital providers must make sure they learn how to balance requirements from employees to patients to maintain a good relationship between patients and employees (Gaur et al., 2011). For the private hospitals to enhance their staffs’ skills in communication and to motivate the staff to provide a good service to their respective patients, effective training and courses are needed for all staff that includes doctors, administrators and not forgetting nurses. One of the strategies to enhance the employee’s performance is by sending them for training (Chahal & Kumari, 2010; Gaur et al., 2011). As for this reason, there should be a better understanding of patient satisfaction formation so that the marketing managers’ knowledge could be enhance (Herrmann et al., 2007). 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Medical tourism: assessing the evidence on treatment abroad. Maturitas, 66(1), 27-32. Medical Tourism to Malaysia. (2015). http://www.health-tourism.com Musa, G., Thirumoorthi, T., & Doshi, D. (2012). Travel behaviour among inbound medical tourists in Kuala Lumpur. Current Issues in Tourism, 15(6), 525-543. Suess, C., Baloglu, S., & Busser, J. A. (2018). Perceived impacts of medical tourism development on community wellbeing. Tourism Management, 69, 232-245. International Journal of Academic Research in Business and Social Sciences Vol. 1 1 , No. 11, 2021, E-ISSN: 2222-6990 © 2021 HRMARS 2354 webway.nisha. (2017). Malaysia Healthcare Travel Council (MHTC) Receives Well the 2018 Budget Allocation Announcement. from https://www.mhtc.org.my Wulf, K. D., Odekerken-Schröder, G., & Lacobucci, D. (2001). Investments in consumer relationships: a cross-country and cross-industry exploration. Journal of Marketing, 65(4), 33-50. Zikmund, W., Babin, B., Carr, J., & Griffin, M. (2012). Business research methods: Cengage Learning.


Introduction
Medical tourism is the act of travelling abroad to obtain medical care. It is about a vacation that involves travelling abroad across international borders in order to obtain a broad range of medical services. Moreover, medical tourism which sometimes termed as medical travel, health tourism or global health care initially combined with travel agencies and the mass media to explain the speedy growing practice of travelling across international borders to obtain health care (Connell, 2013).
The effort to gain better healthcare while at the same time enjoying the sea, sun and sand through relaxation, exercise or visiting spas has risen to a new level with the increase of developing countries becoming destinations for medical tourism (Connel, 2006). The term 'medical tourism' is normally used to describe the phenomenon whereby people travel to the other parts of the world across international borders, spending a vacation to obtain a broad range of medical services in a foreign countbookmry in which medical technology is advanced as well as affordable. Medical tourists may gain the benefits of having the treatment or medical surgery while enjoying a stay in one of the most popular destinations. The benefits not only include leisure, fun and relaxation but also comprise of wellness and health care services. The programs for medical tourism comprise products that are supported with excellent medical services, together with tourism services for the foreign visitors, which are earning foreign revenues and developing related industries in addition to those normally developed leisure tourism packages (Bookman & Bookman, 2007;Lunt & Carrera, 2010;Smith & Puczkó, 2008).
The main reasons why people travel to seek health care are because health care services that are lower in cost, less expensive than those at home and to get quicker, affordable and comfortable medical treatments (Gan & Frederick, 2015). The new phenomenon of people moving away from their home country to get the treatment has forced the destination to look for alternative marketing strategies that can identify and adventure new opportunities that are attractive, economically rewarding and sustainable (Buhalis, 2000). Such alternatives of marketing strategies depend on identifying how customers perceive the destination's tourism products and how these products are designed to satisfy the needs of the targeted market. Medical tourists normally stay longer than other tourists, most of them need to come back for follow-up procedures and most of them travel at least with one person to accompany them (Whittaker, 2008).
In fact, Malaysia is also one of the top five destinations in the medical tourism sectors and its targeted patients are from developed and less developed countries. Malaysia provides good facilities and competitive rates compared to other parts of the world. Malaysia has carried out several strategies to ensure that it is the leading choice for medical tourism destinations. Therefore, this research attempts to examine the behavioral intention of the medical tourist in choosing Malaysia as medical tourism destination. While considering all four variables chosen as having significant impact on behavioral intention of the medical tourists. The result demonstrated that there is a positive relationship between perceived destination image, perceived quality, perceived value and patient satisfaction.

Literature Review
Overall, the globalization of health care has given the opportunity for the new form of tourism, commonly known as health tourism. Health tourism is a combination between both illness-oriented medical tourists and well-being achieving wellness tourists: nevertheless, definitions and estimations for each varies (Bushell & Sheldon, 2009;Lunt & Carrera, 2010). Surrounded by the health tourism arena, medical tourism is one of the most fastest growing sectors and this had led many countries making legal and practical plans to venture in this sector (Heung et al., 2011).
Medical tourism can be defined as patients travel from the other part of the world, cross the border care arrangements to seek for the medical treatment, dental, surgical care just because the destination enables better access to care, providing a higher quality care or offers the same treatment at a more affordable price which are usually paid for out of pocket (Crooks et al., 2010). Hong et al (2007) describe that medical tourism is about people who choose to seek treatment or disease treatment or maybe to enhance physical and psychological well-being at the other parts of the world other than their own country. Traditionally, people travel to other parts of the world to seek medical, surgical care and dental treatment while at the same time enjoying the holiday (Taleghani et al., 2011).
In addition, medical tourism is about the relative time spent on medical service and tourism on the trip. Researchers claimed that medical tourism not only involved medical services but it involved more than that such as engaging in tourists activities like recovering in resorts or recuperation (rest seekers) and not forgetting those who wanted to receive essential medical services (essential seekers) (Smith & Puczkó, 2008;) that include organ transplant which is not immediately available in theirown country. Other than that, there are also people who seek "affordable health care seekers" because of the high cost of the service in their home country. Not forgetting those who seek "quality health care seekers" because they are after safer and securer medical services in overseas hospitals with international recognition or certification. This is because their home country's medical services are behind in terms of quality. Finally, they are after the "premium health care seekers" who actually prefer themselves of luxurious medical services.
A steady development in technology together with huge amount of information in the recent years has transformed the nature of exchange, specialization and communication among countries. With the new style of globalization, people style has changed rapidly because they are exposed to the new ways of getting treatment. One of the advantages that can be found in medical tourism is that it involved globalization of both health care and tourism, which already constituted major arenas of transnational economic activity (Bookman & Bookman, 2007). Medical tourism is a niche and has been one of the new emerging industries because it has the potential of increasing the economic which involves trade in services while simultaneously being holidaymakers, in a more conventional sense.
Medical tourism is not new. It has emerged from the 18 th century where people visited spas because they wanted to get treatment to heal diseases for example bronchitis and gout by using mineral waters (Connel, 2011). The original phenomenon is the extraordinary expansion at the world level. In the beginning the medical tourists were the ancient pilgrims who travel from Mediterranean to Epidauria in the Saunic Gulf for treatment (De & Dasgpta, 2012) . Patients from the third world countries with the essential resources began mobile to most important medical centres in Europe and United States for the sake of getting the treatment that is unavailable in their country.
Meanwhile, in Asia, Thailand has been one of the three top medical tourism destinations, in part because of the quality of treatment and the range of services available to medical seeking tourists. Thailand has been the leader in Asian medical tourism market, which manages to attract approximately 1.2 million medical tourists especially from UAE, Qatar, Oman and Japan. It was found that Thailand was one of the preferred destination for the American medical tourists (Lunt & Carrera, 2010). One of the reasons why Thailand is famous among the medical tourists is the lower cost expenditure that they provided. Their cost was 50% lower than Singapore, three times lower than Hong Kong and five to ten times lower compared to Europe of USA (Heung et al., 2011). Furthermore, Thailand is a well-known specialty destination for gender reassignment surgery (Connel, 2006).
Literature reported that there were many countries preferred medical tourism as countrywide income, (Suess et al., 2018). Recently, the growing numbers of medical tourism has increased rapidly. The World Health Organisation predicts that by 2022, tourism will account for 11%of global GDP, and the highest scale of health will account for 12 % (Lin & Zhang, 2018). Among the popular and hot spot countries were India, Thailand, Singapore, Malaysia, Tunisia, Lithuania, Columbia, Hungry, Poland and Jordan. It was forecasted by The World Medical Tourism Association that the growing number of medical tourists would keep on increasing dramatically around 15% to 25% annually. Even though many experts questioned the exact percentage of medical tourist, it was agreed that medical tourism would continue to grow and transform the healthcare landscape globally.

The Development of Medical Tourism in Asia
Medical tourism provides the opportunity to fuel the growth of hospitals by tapping the international patient markets. The supporting system such as the advancement in medical technologies, patient mobility and quality of healthcare has aroused the medical providers globally. Medical tourism in Asia could be considered as new in the market. It arises due to Asian Financial Crisis in the year 1997 which had led the private hospitals to find other alternatives for revenue. Malaysia, Singapore, India and Thailand have deliberately linked medical care to tourism and indirectly boost the attractions of nearby sandy beaches and other interesting places as well.
At the same time, medical tourism has also developed in South Africa and in countries not hitherto associated with significant levels of western tourism, for example Belarus, Latvia, Lithuania and Costa Rica. Hungary had declared 2003 as the Year of Health Tourism. South Africa has been known as a popular place for cosmetic surgery due to its lesser costs and it was less than half compared to United States, from where most of the patients came from. The Caribbean had found it difficult to embark in the medical tourism bazaar even though it was close to United States because of cheaper prices that could not beat with those in Latin America (Huff-Rousselle et al., 1995).
Asia has been the main popular medical tourism destination since 1970 because it focused in sex change operations but after that it focused on cosmetic surgery. According to the development process as shown in Table 1, medical tourism has become a highly competitive business in the Asian countries. Medical tourism is one of the fastest growing subsectors of its industries. Surgical procedures that can cost hundreds of thousands of dollars in the USA can be only at a fraction of the cost in India.
News from India Tourism Report (2010) The total healthcare market in India is expected to increase its contribution to GDP from 5.2 percent at present to 8.5 percent over the next ten years Connell (2006) India advertises itself as the global center of medical tourism by offering everything from alternative Ayurvedic therapy to coronary bypasses andcosmetic surgery. Travel companies in India are also cooperating with hospitals to facilitate travel by arranging phone consultations with doctors to help foreign patients save time and money once they get to India

Thailand
Thailand has the longest history; it became notable as a destination for medical tourism as early as the 1970s when the medical tourism profession began to specialize in sex change operations; later they moved to cosmetic surgery Bookman and Bookman (2007), Connell (2006) Medical tourism in Thailand is now a prosperous industry. In 2007, as many as 1.4 million visitors arrived in Thailand seeking medical care; the Health Ministry expects the number of medical tourists to surpass two million by 2012 Report from Airline & Travel News (2009) To build brands in the healthcare industry, leading hospitals in Thailand have spent the last decade striving to be the biggest and best in the world. They have recruited not only experienced doctors but also embraced foreign management expertise de Arellanolee (2007)

Singapore
Singapore, whose global reputation as a medical tourism center has sought to compete with Thailand. Most of the private hospitals in Singapore are participating in the medical tourism program; some of these hospitals have gained international health accreditation from the Joint Commission International (JCI) of the USA Lee (2010)

Malaysia
The government has made various efforts to promote healthcare services for the benefit of the medical tourism industry. Malaysia is getting a reputation as one of the preferred locations for medical tourists on account of its excellent and efficient medical staff, as well as advanced healthcare and wellness facilities (Musa, Thirumoorthi, & Doshi, 2012)

Dubai
Dubai has just built Healthcare City in an attempt to capture the Middle Eastern market and divert it from Asia; the country also plans to include a branch of Harvard Medical School within the Healthcare City, which will make it one of the most prestigious foreign healthcare facilities outside of the west.

Medical Tourism in Malaysia
The Malaysia Healthcare Travel Council (MHTC) was established to help the development of Malaysia's healthcare travel industry. At the same time, it was established the country's profile as a well-known preferred destination for world class healthcare services. Malaysia has been recognised as the Health and Medical Tourism Development for three consecutive years from 2015 to 2017 by the International Medical Travel Journal (IMTJ). Referring to the National Transformation Programme (NTP) 2017 Annual Report, Malaysia was targeting to increase the hospital revenue by RM2.8 million by 2020 and the target markets is from Indonesia, Myanmar, China and Vietnam. The industry has shown excellent growth potential ranging between 16-17% every year. As for the year 2016, the healthcare travel industry grew by 23% from 2015, compared to the average growth rate of 15% from 2011 -2015(webway.nisha, 2017).
Furthermore, the government was going all out in making a tremendous effort to change the country into the medical tourist hub. In addition, Association of Private Hospital of Malaysia (APHM), president Dr Jacob Thomas stated that the private healthcare industry in Malaysia had all the necessary communications and tools to have a further development especially the ones brought about the expanding of healthcare tourism. The private hospitals in the country had enough facilities and infrastructure for patients both local and foreign.
Malaysia has been documented as one of the best medical expertises in the world and mostly all the private hospitals in the country have worldwide recognized of its quality and standards. The standard included MS ISO9002 or accreditation by the Malaysian Medical Society for Quality of Health (MSQH). According to the Ministry of Health, they had instructed that every private hospital should be approved and licensed (Economic Planning Unit (EPU), Eleventh Malaysia Plan 2011, 2016. People from all over the world seeking varieties of medical needs had chosen Malaysia as their preferred health and medical destination due to the growing reputation. The increasing of the reputation included both critical health services as well as cosmetic and remedial care (Bahari, 2017) In addition, Malaysian government had been focusing to sustain the health tourism industry to increase the escalation of Malaysia's market share from 0.29% to 2% in 2012, as quoted by the Minister in the Prime Minister's Department Tan Sri Nor Mohamed Yakcop (Foong, 2009). Competitive medical fees and modern medical facilities were two vital factors that make Malaysia a popular destination among health tourists. Patients could undergo treatment and recuperated in any parts of the country for much less than what it would cost them for a treatment in other countries. For example, a normal cardiac bypass surgery (CABG) in Malaysia would cost around US$9,000.
Most private medical centres in Malaysia offer comfortable accommodation ranging from private rooms to suites for single occupancy or more. Room charges, inclusive of meals, vary at medical centres but were attractively priced. Some medical centres even provided highly qualified and trained private nurses with foreign qualifications and personal butlers at a reasonable cost. In summary, factors that contributed in making Malaysia a centre of medical excellence in the region are Malaysia offers safe and politically stable country. Furthermore, there are wide choice of world class infrastructure facilities such as The National Heart Institute and Tun Hussein Onn National Eye Hospital.For example, these private hospitals are well equipped with technology such as MRI, 64 slice CT Scan, PET Scanner for early detection of cancer and other diseases, cyberknife which is able to radiate tumours without damaging adjacent vital structures. Not forgetting, competitive plus affordable and favourable pricing together with favourable exchange rate e.g. a normal cardiac bypass surgery would only cost around US$9,000. Since Malaysia is a multi-cultural and multi religions country, it is easy to accommodate all patients of different cultures and religions from all over the world. Lastly, Malaysia is offering appealing and affordable packages during recuperation period.
Listed below is the statistics of medical tourism in Malaysia:  (2015), Malaysia manage to generate RM588.6 in the healthcare revenue between January and September 2015 with the target for the full year was set at RM854 million. As for the year 2015, the travel numbers manage to achieve above 90% of full year targets, and the targets were higher than the year 2014(2015). Based from Table 1.3 above, it was found that the highest contributor for medical tourism in Malaysia was from Indonesia 62%, second from Middle East 7.4%, third from India 3%, followed by China 2.6%, Japan 2.6%, whereas Australia and United Kingdom 2.5%. Based from the report by IMTJ 2015/2016, it indicates that Malaysian private hospital is excellence in Cardiology, orthopaedics, oncology, neurology and dentistry. Moreover, there are growing demand for infertility, cosmetic surgery and rehab services ("Medical Tourism to Malaysia," 2015).

Methodology
According to (Cooper & Schindler, 2003), research design is the blueprint which included experiments, interviews, observation, record analysis and also the aids for the researcher to find the answer when implementing their research. It specifies the details of the procedures necessary for obtaining the information needed to structure and or solve marketing research problems. This study is a quantitative research study. Creswell (1994) defined a quantitative study as an inquiry into a social or human problem, based on testing a theory composed of variables, measured with number and analysed with statistical procedures, in order to determine whether the predictive generalizations of the theory hold true.
This research is a descriptive study. The descriptive method is purposely design to investigate or gather all the information regarding the existing condition and it is also the "blueprint" of a research (Malhotra, 2009). The reasons of doing this method are to describe the characteristics of the international medical tourists by collecting the data through distributing the questionnaire given to them. The design of this study will offer an understanding of the relationship that exists among variables that is involves. Furthermore, it is understood that a research design is important because it is needed to achieve the research objectives as accurately as possible. First, this study was designed to find out which independent variables gives the highest impact, secondly to examine the relationships, then finding the relationship between trust as mediating and finally repeat visits as moderating variables.
Primarily, the dependent and the independent variables were identified. Then, the measurement scales of the identified variables were sought and determined. Before the measurement scales were used, reliability of the scales was assessed then followed by validity. Validity is the ability of a scale to measure what it is supposed to measure (Zikmund et al., 2012). Secondly, a representative sample was selected to represent the population of the study so that the results of the study could be generalized to the population at large. The medical tourists answered the survey questions concerning perceived destination image, perceived quality, perceived value, patient satisfaction, and trust as mediating factor and also repeat visit as moderating factor.
Next, the data was collected from the sample using the validated and reliable research instrument. After the data was collected, and in most cases before any actual analysis can be performed, it is advisable to run preliminary data analysis (PDA). PDA is mostly recommended to make sure that all the data is cleaned and cleansed of any substantial noise that will attract biases in the final result of actual analysis. Further clarification of data collection and data analysis procedures were presented in the later part of this chapter.
Based on the preceding chapters, a research model was developed. This model was used to assist in determining research instruments, formulating relationships between variables as well as to enable research questions to be tested. The model was also used for validation and model testing and in this study, it served as a heuristic character for exploring relationships between variables.
Behavioural intention as the dependent variable was conceptualized in this model. Included in the model was a list of carefully selected independent variables that were investigated together with future intention. Based on empirical studies, it was reported that these variables: perceived destination image, perceived quality, perceived value, overall patient satisfaction was associated with behavioural intention. Hence, this study was conceptualized to determine the nature and degree of the relationship between these independent variables with behavioural intention. Below is a figure of conceptual framework of international medical tourists:-

Results
Based from the above results, it was advisable for the researcher not to use SEM for data analysis. Instead, to use PLS-SEM because it did not emphasize on normality of data distribution (Ringle et al., 2012). As indicated in Table 1, the finding of this study revealed the respondent's profile by country. Most of the respondents were from Indonesia which reached more than 50% that is 68%. Next was from England 7.5%, Bangladesh 6%, both USA and Vietnam were 4.0% and 3.5%, Myanmar 4.0%, followed by Saudi Arabia 1%, Australia 3% and finally 0.5% from Canada, Holland, India, China, Singapore and Sweden respectively. 68.0 3.0 6.0 0.5 7.5 0.5 0.5 4.0 0.5 1.0 0.5 0.5 4.0 3.5

Model Validation Stage 1: Assessing the Measurement Model
Before the measurement of the model assessment could be done, measurement of the full research model was checked for reliability and validity. The criteria were shown in Chapter Three and the results are described in this following section. The next step was to assess their reliability and validity (Anderson & Gerbing, 1988;J.F Hair et al., 2006;Wulf, Odekerken-Schröder, & Iacobucci, 2001). For reliability, it would be assessed by using Cronbach's alpha, composite reliability (CR) and average variance extracted (AVE), whilst for validity would use construct, convergent and discriminant. The results showed that sufficient item reliability with the individual item loading was above 0.5; composite reliability of more than 0.70, and average variance extracted (AVE) as shown in Table 4.10. The square root of AVE for each latent also exceeded as shown in Table 4.9. Reliability of the variables was further supported by Cronbach's alpha of more than 0.70 and a variance inflation factor (VIF) of less than 5. Table 4.10 represents the Cronbach's alpha for all the constructs that met the benchmark of 0.7 (Nunnally, 1979). Using confirmatory factor analysis, construct reliability (CR) and average variance extracted (AVE) were calculated by using formulas by Fornell and Larcker (1981) to further confirm the reliability of the constructs. As for the constructs in this research, have CR above 0.70 and AVE of at least 0.50 as recommended by Bagozzi and Yi (1988), suggesting further support of the reliability of the constructs.
Confirmatory factor analysis was being used to assess the validity of the constructs and it was vital for theory testing (Bagozzi & Yi, 1988). Furthermore, the constructs validity could be confirmed based on goodness of fit indices (Hsieh & Hiang, 2004). It was found that there was evidence of convergent validity showing the results that was high factor loadings (greater than 0.50) of all factors (Anderson & Gerbing, 1988). Besides, the results of AVE provide further supported composite reliability. The square root of AVE for each latent also exceeded the inter construct correlations as shown in Table 4.10.
Coltman et al.'s (2008) reflective construct assessment was used to confirm sufficient indicator loadings (more than .50) on their respective factor, construct reliability (Cronbach' alpha > .70), average variance extracted (AVE) ( Table 4.10) for each construct which was higher than the construct correlation with other construct and showed positive weightloading sign (WLS).

Model Validation Stage 2: Assessment of The Structural Model
Based on the results in section 4.5 above, the measurement model showed beneficial individual item reliability, convergent reliability and discriminant reliability. The next step was to examine the structural model to determine its explanatory power and after that to test the hypotheses of the study. The effects of the constructs defined in the proposal model were assessed through coefficient of determination (R 2 ), path coefficient (β), effect size (ƒ 2 ) and predictive relevance (Q 2 ). Figure 4.2 depicts the results and shows all the hypotheses which were supported.
Based on the results, it showed 70% variations in behavioural intention (INTENT), represented by the combined effect of exogenous variables (R 2 = 0.70). R 2 of this magnitude showed that the model has substantial predictive accuracy according to the standards suggested by (Chin, 1998b;Hair Jr, et al., 2014). Hair Jr, et al (2014 suggested R 2 of 0.75, 0.50 and 0.25 as substantial, moderate and weak. On the other hand, Chin (1998b) considered 0.67, 0.33, and 0.19 at a similar level. Regardless of which standard was being used, R 2 in this model had substantial predictive accuracy. Hypotheses 1 proposed a positive relationship between perceived destination image and behavioural intention. As shown in Table 5, the standardized path coefficient was significant at β = 0.15. Furthermore, p-value was (p = 0.02). This suggested that image of the country had attracted the medical tourists to choose Malaysia as their destination. Since the result was significant, therefore hypotheses 1 were supported.
H2: Perceived quality has positive relationship with behavioural intention.
Hypotheses 2 proposed a positive relationship between perceived quality and behavioural intention. As shown in Table 5, the standardized path coefficient was significant at β = 0.22. Furthermore, p-value was (p < 0.01). This suggested that quality provided by the private hospital had attracted the medical tourists to choose Malaysia as their health treatment. Since the result was significant, therefore hypotheses 2 were supported.
H3: Perceived value has positive relationship with behavioural intention.
Hypotheses 3 predicted that there is a positive relationship between perceived value and behavioural intention. As shown in Table 5, the standardized path coefficient was significant at β = 0.32. Furthermore, p-value was (p < 0.01). This suggested that the medical tourists value Malaysia's private hospital treatments and this would allure the medical tourists to choose Malaysia as their destination. Since the result was significant, therefore hypotheses 3 were supported.
H4: Patient satisfaction has positive relationship with behavioural intention.
These hypotheses posit that there is a positive relationship between patient satisfaction and behavioural intention. As shown in Table 5, the standardized path coefficient was significant at β = 0.25. Furthermore, p-value was (p < 0.01). This suggested that the medical tourists were satisfied with the Malaysia's private hospital treatments and this would attract the medical tourists to choose Malaysia as their destination. Since the result was significant, therefore hypotheses 4 were supported.

Conclusion and Recommendation
In the current competitive globalized environment, medical tourism presents a great business opportunity for the Malaysian healthcare and tourism industries. It is very important for Malaysian players to grasp this opportunity and understand the needs of the medical tourists in hope to remain competitive and sustainable in this promising market. It is a fact because there is intense competition in the region because there are many players involve such as Thailand, Singapore and India. These countries have been in the business for a substantial amount of time and currently they are the leading countries for medical tourism. In the competitive market, it is vital for Malaysia, as medical service providers to be more aggressive in attracting as many potential international patients as possible. Moreover, it is relevant for the healthcare providers to have appropriate strategies in attracting international patients.
Findings from this study clearly indicated that motivations for treatment by medical tourists are complex and multiple. Mostly, behavioural intention is often used to access customer potential's for revisiting because it is considered as a relatively accurate predictor for future behavior (Alexandris et al., 2002;Ishaq, 2012). It was noted that from the result of the study, it was found that all dimensions that was chosen were found to have a significant relationship that drive the medical tourists to travel (Caber & Albayrak, 2016;Chan & Baum, 2007;Crompton, 1979;Dann, 1981). It demonstrates that the dimensions chosen to have a direct impact in motivating the medical tourists to visit Malaysia. Moreover, understanding what motivates the medical tourist to travel is an important factors for the players because they come from different background and culture (Mee et al., 2018).
Since the number of medical tourists has been increasing from year to year the Malaysian Tourism Board (MTOB) should focus, support and enhance the motivational factors to attract more medical tourists in the future. The greater demand of medical treatment justifies the need for more marketing tourism approaches. Furthermore, investigating the variables that will influence travel motivations is very important for marketers and decision makers so that better tourism products can be offered for the medical tourists. Knowing the importance of motivational factors, perceived from medical tourist's opinions will help the destinations provide their needs in future.
In term of marketing and promotion, mass media, at the same time, should play a critical role in forming a distinctive destination image for Malaysia, to distinguish itself from competitors within the region. The strategic challenge for destination is not only on how to perform positive images that induce travel to the country, but also on how to develop sustainable differential images from other competing locations. A successful matching of all the dimensions chosen is essential for a marketing strategy in destination areas, and the examination of the motives are useful for the destination, designing promotional programs, and decision-making about destination development. Thus, the tourism authorities in Malaysia can develop a variety of different marketing strategies based on specific motivations of the medical tourist in order to satisfy their underlying needs. The result of the study has provided important contributions to define the medical tourist's motivations.
In addition, in order to achieve a competitive advantage against other competitors, the private hospitals in Malaysia must keep on improving their services from time to time to make sure that the level of quality of their products and services are at the maximum level with other well-known private hospitals especially of that in Thailand, Singapore and India. This is important because it is one of the ways to gain patient satisfaction because this would have a direct impact on patient's behavioural intention especially in the future. As a service provider, the private hospitals would like the medical tourist to think that Malaysia will be their first choice in the near future. Therefore, the hospital service quality can be used as a benchmark for the hospitals to keep on improving their services compared to others. The private hospitals should pay more attention towards the service quality aspects (Aagja & Garg, 2010;Arasli et al., 2008;Padma et al., 2010). In order to achieve this, private hospitals must have adequate information regarding the level of patient satisfaction. Furthermore, one of the most important aspects that would influence patient satisfaction's in terms of tangible facilities, for example equipment and facilities. Updating the products and services provided and at the same time educating patients about the tangible and intangible elements in hospital are important so as to contribute towards service quality improvement. In addition, hospital providers must make sure they learn how to balance requirements from employees to patients to maintain a good relationship between patients and employees (Gaur et al., 2011).
For the private hospitals to enhance their staffs' skills in communication and to motivate the staff to provide a good service to their respective patients, effective training and courses are needed for all staff that includes doctors, administrators and not forgetting nurses. One of the strategies to enhance the employee's performance is by sending them for training (Chahal & Kumari, 2010;Gaur et al., 2011). As for this reason, there should be a better understanding of patient satisfaction formation so that the marketing managers' knowledge could be enhance (Herrmann et al., 2007).