**4. Actions of the central government in medical tourism under the current model of competitiveness**

The documents of the National Council for Economic and Social Policy (NCESP) which belong to the National Planning Department of Colombia seek to establish roadmaps that promote the improvement of the medical tourism industry following the traditional con‐ cept of competitiveness in which the central government is an outsider that does not involve indirectly in the improvement of the industry. One of the documents of the NCESP, which promotes greater dynamism in the Colombian medical tourism is the number 3678 of 2010 [21] called *National Policy Productive Transformation and Promotion of Micro, Small, and Medium Enterprises: A Public and Private Effort* that seeks a higher level of productivity of micro, small, and medium‐sized enterprises through the facilitation of both financial instruments such as capital, and access to markets that allows greater participation of its productive activity and in the generation of human resources of high quality. Another document number is the 3582 of 2009 [22] called *National Policy of Science Technology and Innovation,* which secures financial resources for the training of physicians and nurses in 1.2 million dollars for exchange pro‐ grams for the learning of a second language and availability of resources for medical research in the United States or European research centers.

The specific objectives of document 3582 are as follows: (1) to foster innovation in produc‐ tive systems; (2) to consolidate the institutional framework of the national system of science, technology and innovation; (3) to strengthen human resource for research and innovation; (4) to promote the social appropriation of knowledge; and (5) to focus public action in strategic areas. Another objective is to consolidate the intellectual property system by developing the guidelines formulated by the document 3533 of 2008 [23] called *Bases of a plan of action for the adaptation of the intellectual property system to competitiveness and national productivity 2010–2020*, so entrepreneurs find reward for their innovation efforts and take advantage of intellectual property to empower technology transfer processes.

However, De la Puente [14] mentions that although there are three independent strategies to improve the Colombian medical tourism through the administrative documents presented, each one is being implemented in an isolated way without each being complemented with the other two in order to generate a comprehensive strategy. This is because according to the current competitiveness model, clinics, health personnel, national insurers, and intermediar‐ ies are the only agents that must act actively to specialize the provision of medical services in order to attract foreign patients.

enhance competitive advantages. For the *macro* level to have an effect on the overall strat‐ egy of systemic competitiveness, it must ensure stable macroeconomic conditions, as well

To achieve the goal level, it is necessary to coordinate the objectives of the previous levels, tak‐ ing into account the scope of a long‐term welfare state (understood as the change in the concept of information sharing between competitors, state agents, civil society, consumer responsibility to determine the positive and negative impacts in business organizations, the ability to formu‐ late sectorial strategies, policies that imply an improvement of civil society, and social cohesion through incentives, not imposition through coercion). On the other hand, it is at this level that the social structure that complements the economic structure takes shape, so that networking,

as achieving the objectives of economic growth and competitiveness.

horizontal coordination, and social integration must be strengthened [20].

**current model of competitiveness**

134 Mobilities, Tourism and Travel Behavior - Contexts and Boundaries

in the United States or European research centers.

property to empower technology transfer processes.

**4. Actions of the central government in medical tourism under the** 

The documents of the National Council for Economic and Social Policy (NCESP) which belong to the National Planning Department of Colombia seek to establish roadmaps that promote the improvement of the medical tourism industry following the traditional con‐ cept of competitiveness in which the central government is an outsider that does not involve indirectly in the improvement of the industry. One of the documents of the NCESP, which promotes greater dynamism in the Colombian medical tourism is the number 3678 of 2010 [21] called *National Policy Productive Transformation and Promotion of Micro, Small, and Medium Enterprises: A Public and Private Effort* that seeks a higher level of productivity of micro, small, and medium‐sized enterprises through the facilitation of both financial instruments such as capital, and access to markets that allows greater participation of its productive activity and in the generation of human resources of high quality. Another document number is the 3582 of 2009 [22] called *National Policy of Science Technology and Innovation,* which secures financial resources for the training of physicians and nurses in 1.2 million dollars for exchange pro‐ grams for the learning of a second language and availability of resources for medical research

The specific objectives of document 3582 are as follows: (1) to foster innovation in produc‐ tive systems; (2) to consolidate the institutional framework of the national system of science, technology and innovation; (3) to strengthen human resource for research and innovation; (4) to promote the social appropriation of knowledge; and (5) to focus public action in strategic areas. Another objective is to consolidate the intellectual property system by developing the guidelines formulated by the document 3533 of 2008 [23] called *Bases of a plan of action for the adaptation of the intellectual property system to competitiveness and national productivity 2010–2020*, so entrepreneurs find reward for their innovation efforts and take advantage of intellectual

However, De la Puente [14] mentions that although there are three independent strategies to improve the Colombian medical tourism through the administrative documents presented, According to Arias and Matos [24], the current model of industrial development limits the cooperation between central government agencies for the promotion of the Colombian medi‐ cal tourism due to the bureaucratic limitation that prevents an efficient location of monetary and nonmonetary resources. This affects the international presence of national clinics that have international accreditation in high‐quality medical care in several procedures, despite the efforts of Colombia's trade and investment promotion agency [4]. Also, under the current competitiveness, the strategies for positioning the industry abroad are implemented in an isolated way in which the public promotion and regulating agencies do not share the same view. According to Arias et al. [25], a proof of this is the inconsistency between the strategies focused on the administrative documents presented above and the Colombian commercial policy according to the Ministry of commerce in which it is expected that oil exports increase its participation in the trade balance while other entities such as Procolombia are looking for a more diversified international commerce.

On the other hand, the measures for positioning industry do not include factors for the improvement of social cohesion, which means that other agents who are indirectly affected by the implementation of these strategies are not taken into account. According to Conell [26], medical tourism is perceived as a source of inequity in health services in which only those with monetary resources can consume high‐cost medical procedures while health sys‐ tems in developing countries spend more time in adapting and training to attend foreign patients.

This position is in line with Vijaya [27] in which medical tourism has proliferated the trans‐ fer of health problems, such as greater number of physicians and nurses looking for higher salaries that prefer to work in private clinics than in public systems, as well as nonaccred‐ ited medical procedures offered in developed countries increasing the international patient's risks. Both statements are happening in the Colombian industry due to the isolated way the strategies are executed. According to the Productive Transformation Program [5], the perception of the population in general about medical tourism is that it is an industry far from the interests of the citizens, which makes it less taken into account for the planning and implementation of industrial policies by the central government.

The immediate effect is the domain of private agents in the structuring of international medi‐ cal offer prioritizing the application of measures that attract patients with greater monetary capacity. According to De la Hoz and Leiva [28], the negative externalities of the Colombian medical tourism coupled with a strategy application that does not include agents who are indirectly affected create a distortion of the perceived benefit of the industry with negative consequences for its national positioning. However, local governments who implemented the model of systemic competitiveness have generated spaces of promotion of the sector in local and foreign scenarios so it is not perceived as far from the general population's interests. One example is in the city of Medellin that through joint commissions that integrate the local gov‐ ernment representatives and medical operators, have established a roadmap for the industry to grow in accordance with the global vision of the local authorities.

The establishment of direct communication vehicles between the medical tourism operators and the local government increased the tax and nontax benefits, and the adaptation of the public space for the attention of foreign patients increased the police force in areas bordering medical centers and created clusters of health that integrates the services and products most demanded by patients.
