**2. Dynamics of the Colombian medical tourism**

In the case of Colombia, the patients come mainly from the United States, Canada, Aruba, the Antilles, and Panama looking for procedures in cardiology, urology, orthopedics, and cosmetic surgery at lower prices than in their countries of origin. The private sector has been the main protagonist of the industry growth limiting the role of the central government to a regulator of medical services that are offered to national and foreign patients. The dynamics of the local industry has followed the model of Porter [1] in which competitiveness is an end in itself and the government has a limited role in the industry's international competitiveness. However, under the current model, the medical industry has not had enough incentives or spaces to position its offer of medical procedures abroad. The shortage of stimuli ranges from the limited tax and nontax incentive's policy for the construction of clinics of high complexity, to limited spaces for dialog between the central government and the health sector operators.

126 Mobilities, Tourism and Travel Behavior - Contexts and Boundaries

This chapter analyzes the role of the central government of Colombia in the promotion and posi‐ tioning of medical tourism based on the Porter model and proposes the application of the sys‐ temic competitiveness model of associative character based on Rugman and Cruz [2] approach as an alternative view for the integral improvement of the industry. This study based on a mixed method begins with the dynamic's description of Colombian medical tourism industry. Next, the main theories of competitiveness are detailed from the traditional view of Porter to the alter‐ native approaches of competitiveness with an associative character. Then, the role of the central government in the promotion and strengthening of the national industry through the efficiency

Also, the potential effects of the implementation of the systemic competitiveness approach in the Colombian medical tourism are analyzed through an experiment that compares the perception of quality of medical services to 200 foreign patients, of whom 100 were attended in clinics with public support of the local governments following the systemic competitive‐ ness approach, and the other 100 were attended in clinics that do not have such support. The purpose of this experiment is to identify if a governmental support for the promotion and positioning of medical services in Colombia improves the perception of quality by foreign patients. This chapter ends by mentioning some recommendations for the national govern‐ ment to improve the Colombian medical tourism from a systemic competitiveness perspective that integrates more agents in the industrial dynamic. The general objective of this research is to analyze the role of the national authority in the promotion and improvement of medical services through the vision of systemic competitiveness as a more efficient form of sectorial

The specific objectives are to study the actions of the central government to develop the sector and determine through a statistical experiment if the application of systemic competitiveness approach improves the perception of quality of foreign patients. The hypothesis that will be verified is that the implementation of the vision of systemic competitiveness improves the industry from a more active role of the national government. The instruments for conduct‐ ing this study were a survey of quality perception to 200 foreign patients who consumed medical procedures in accredited and nonaccredited clinics, executive orders of the central government of Colombia that establish the route map of the industry and consulting reports

describing the international medical tourism market and the Colombian case.

of executive orders under the traditional competitiveness model is studied.

development.

The medical tourism industry is a still incipient sector; at the beginning of the year 2016, achieved around 100,833 patients as presented in **Table 1**. According to the Ministry of Industry and Commerce [3], patients who traveled to Colombia looking for healing proce‐ dures were approximately 10,117, while the ones who traveled for esthetic procedures and preventive medicine were 2351. However, the wellness procedures are the ones that attracted most patients with a total of 88,405 in 2016 [4].

The demand for medical services is based on the search for procedures at lower costs com‐ pared to developed countries such as the United States, which is the first patient's exporter to


**Table 1.** Consumption of medical procedures by foreign patients during 2016.

Colombia. According to the Productive Transformation Program [5] during 2013–2016, there was a decrease in the demand for medical services in 42.3% due to variable causes such as exchange rate volatility and the limited preparation of clinics that receive patients in the follow‐ up of internationally accepted protocols. Medical procedures of greatest demand are orthodon‐ tics, reconstructive surgery of the pelvic floor, cardiovascular surgery, breast augmentation, liposuction, and weight‐loss programs without an invasive procedure [6]. According to the McKinsey and Company [7], noninvasive medical procedures are expected to increase the for‐ eign demand due to multiple factors. The first is that more tourists are looking for alternative experiences and enriching their knowledge about the destination where they go.

The second is that direct investments in this category are lower compared to those of cura‐ tive and preventive medicine, where infrastructure is needed for highly complex procedures with medical and technological equipment. The possibilities for an expansion in this cat‐ egory are much greater, since so much investment is not needed (although more publicity and marketing are needed to promote this category). Medellin, Bogota and Cali are the cit‐ ies with the largest foreign patient´s reception with 75.3% **Figure 1** shows the number of consumption unites in the four categories of Colombian medical tourism during the period 2009‐2014 [8].

In 2015, investments in clinical, hospital, and esthetic infrastructure increased 120% compared to 2013 [9]. The investments have been characterized by providing a high‐quality service, mainly aimed to foreign patients seeking treatment and interventions (invasive or noninva‐ sive), whether for curative, preventive, esthetic, or well‐being purposes. The total investment in infrastructure in private clinics and health centers of high complexity was directed to the acquisition of specialized medical equipment and the training of human resources. Much of this investment in health infrastructure was made under the tax figure of free economic zones, which reduces fixed costs. According to the World Development Indicators [10], incentives for investment in the industry allowed a substantial increase in coverage of healthcare services in the country.

**Figure 1.** Number of consumption unites in the four categories of Colombian Medical Tourism during the period 2009– 2014. *Source*: Ref. [31].

For the National Administrative Department of Statistics of Colombia [11], the total construc‐ tion area of health centers (hospitals of high complexity) of the seven main cities of the coun‐ try (Bogota, Medellin, Cali, Barranquilla, Bucaramanga, Pereira, and Armenia) grew steadily since 2005. In the last quarter of 2005, there were 119,000 m<sup>2</sup> under construction, while in the second quarter of 2014, were 707,000 m<sup>2</sup> under construction resulting in a growth of 494.1% as illustrated in **Figures 2** that shows the thousands of m2 under construction during the period 2004‐2014 and **Figures 3** which illustrates the investment in infrastructure according to the category of medical tourism in 2016. Investments in health infrastructure are expected to grow steadily but at a slower pace by 2020. This is due to the stabilization and consolida‐ tion in the health services focused mainly to patients from the United States and Panama that increasingly seek esthetic medicine and wellness services compared to curative and preven‐ tive medicine of high complexity.

Colombia. According to the Productive Transformation Program [5] during 2013–2016, there was a decrease in the demand for medical services in 42.3% due to variable causes such as exchange rate volatility and the limited preparation of clinics that receive patients in the follow‐ up of internationally accepted protocols. Medical procedures of greatest demand are orthodon‐ tics, reconstructive surgery of the pelvic floor, cardiovascular surgery, breast augmentation, liposuction, and weight‐loss programs without an invasive procedure [6]. According to the McKinsey and Company [7], noninvasive medical procedures are expected to increase the for‐ eign demand due to multiple factors. The first is that more tourists are looking for alternative

The second is that direct investments in this category are lower compared to those of cura‐ tive and preventive medicine, where infrastructure is needed for highly complex procedures with medical and technological equipment. The possibilities for an expansion in this cat‐ egory are much greater, since so much investment is not needed (although more publicity and marketing are needed to promote this category). Medellin, Bogota and Cali are the cit‐ ies with the largest foreign patient´s reception with 75.3% **Figure 1** shows the number of consumption unites in the four categories of Colombian medical tourism during the period

In 2015, investments in clinical, hospital, and esthetic infrastructure increased 120% compared to 2013 [9]. The investments have been characterized by providing a high‐quality service, mainly aimed to foreign patients seeking treatment and interventions (invasive or noninva‐ sive), whether for curative, preventive, esthetic, or well‐being purposes. The total investment in infrastructure in private clinics and health centers of high complexity was directed to the acquisition of specialized medical equipment and the training of human resources. Much of this investment in health infrastructure was made under the tax figure of free economic zones, which reduces fixed costs. According to the World Development Indicators [10], incentives for investment in the industry allowed a substantial increase in coverage of healthcare services in

**Figure 1.** Number of consumption unites in the four categories of Colombian Medical Tourism during the period 2009–

experiences and enriching their knowledge about the destination where they go.

128 Mobilities, Tourism and Travel Behavior - Contexts and Boundaries

2009‐2014 [8].

the country.

2014. *Source*: Ref. [31].

The international positioning strategy of the industry includes patient loyalty (mainly for‐ eigners and Colombians abroad, although national patients with high purchasing power are not discarded), and preference of national medical procedures that include the combination of interventions, esthetic, and wellness treatments with the possibility of knowing the tourist attractions of Colombia. The improvement of the industry goes hand in hand with international accreditations of clinics of the highest quality as a vehicle to attract foreign patients and increase strategic alliances with international medical service providers such as insurance companies, guilds of the international healthcare sector, research and development that could increase Colombian physician's recognition abroad. In that sense, there are four clinics with accredi‐ tation from the Joint Commission International [12] and the Global Healthcare Accreditation Program [13] in medical procedures of high complexity that serves as a reference for foreign patients and insurance companies to send their clients to consume medical procedures.

According to De la Puente [14], under the current model of operation of medical tourism, Colombia would increase its share in the world market from 1.4 to 5% in 2020 being the patients who seek cosmetic operations and weight reduction without intervention, the most demanded. The United States, Canada, Aruba, the Antilles, and Panama are expected to con‐ tinue to be the countries with the largest number of patients. Most of them are Colombians

**Figure 2.** Thousands of M<sup>2</sup> under construction during the period 2004–2014. National Planning Department. Document 3678 of 2010. *Source*: Ref. [21].

**Figure 3.** Investment in infrastructure according to the category of medical tourism in 2016. *Source:* Ref. [11].

living abroad, who decide to consume health services in their country of origin as a result of the high prices of procedures in the country where they live. **Table 2** shows the investment in clinics and private healthcare centers in Colombia according to the National Institute of Technical Standards and Certification in 2016.


**Table 2.** Investment in clinics and private healthcare centers in Colombia according to the National Institute of Technical Standards and Certification in 2016.
