Is there any point of clusters beyond the hype?



Over the past four or five years, several countries seeking to enter medical tourism have hired consultants to build a “medical tourism cluster”. Some of them have gone about contracting for this consulting project as best they could, tackling a complicated task with many moving parts where tourism intersects with healthcare, economic development, institutional strengthening and capacity building, branding, and remaining mindful of public health and the culture and concern for local citizens.

Consulting to national tourism and economic development ministries is pedagogical. The cluster building consultant is called upon and charged with the task to supply technical assistance and "know how" to an entity made up of intelligent individuals established under a Tourism Act, that is responsible for the performance of functions conferred on the Authority by the Tourism Act.

The contracting authority often includes a representative appointed as "Chairperson" by the Minister of Tourism, a representative of the Prime Minister's office, and individuals representing tourism, finance, education, environment, external communication, local governments, and others appointed that have an interest in tourism, travel, trade, tour operating, etc. To this group, others may be added that have background in public health, epidemiology, hospital management, consulting physician key opinion leaders, and so forth. Together they amass tremendous intellect, experience in their professions, influence, and a demonstrated capacity for leadership, communication and organizational skills.

Next the contracting authority generally hires or is provided a project manager and team leaders designated to work with the subject matter experts and technical assistants. Sometimes, these specialists are engaged and appointed by the development bank or donor, and other times it is the contracting authority that hires the consultant. In health tourism there are actually very few such specialists available for hire.

The groundswell of medical tourism over the last six years

Consider for a moment that most of the groundswell in medical tourism, has happened since 2006. Between then and now, the there has been a whirlwind of transformation. The groundswell phenomenon is not a flash in the pan. The technologies and social systems that make it work are evolving at an ever-increasing pace that creates opportunities for those who are ready to play. It's global. It's unstoppable. It affects several industries at once - those that sell to consumers, and those that sell to businesses. This groundswell is a social trend in which people use networking and expensive technologies to get the things they need from each other instead of from companies. A medical tourism cluster organization aligns well, if developed properly and if it functions efficiently. It can be used to create a long-lasting shift in the way medical tourism works in a region or a nation.

Governments, individual hospitals, individual doctors, internet startups, marketing and publicity experts, book authors, “facilitators” and travel agents, even our clients Abercrombie and Kent, a 1962-established luxury travel brand owned by private equity Fortress Investment Group, have thrown a hat into the ring. One could ask “why the groundswell and why now?” But a better question, in my opinion, is to ask “What are the next steps?”  This is our call to action. The groundswell in medical tourism creates the perfect platform for a medical tourism cluster that is responsive, supports communication, supports its internal and external customers, and embraces and facilitates sector sophistication and brand equity development.

Several countries have asked the "what's next" question, and many have developed and implemented a 5-year strategy that includes funding the development and implementation of a “health cluster”. But what is a health tourism cluster really, and what functionality should it provide to its members? What we’ve learned is that when it comes to building a health tourism "cluster", most contracting authorities (and their consultants) simply don't know what they don't know. Therefore, vetting and engaging a consultant for the task in this nascent sector is no easy task.

It is through complete mastery of the subject that a consultant is best equipped to impart “know how” and build in success strategies for a client. The mastery doesn't come from title or association; but instead, comes from understanding the processes and anticipating operational challenges for health tourism that lie ahead. It includes the ability to offer practicable solutions that mitigate risk of failure, inefficiency, and overcoming the obstacles that inhibit people, governments, international organizations and non-governmental organizations from realizing their developmental goals while enhancing the abilities that will allow them to achieve measurable and sustainable results. The ability to plan ahead for success and prevent failure comes from lessons learned, coupled with insight into:

  • clinical operations
  • direct patient care
  • health travel logistics
  • health information systems
  • telehealth
  • medical records transfer
  • population health management
  • controlling introduction of foreign unhealthy pathogens (i.e. tuberculosis, HIV, H1N1, SARS, MRSA, etc.) into a local community
  • hospital management policies and procedures
  • medical practice operations
  • which procedures to safely target
  • healthcare quality and safety, and
  • how the clinical complex intersects with the tourism complex of transportation, accommodation, and destination management

The lessons learned by the consultant before teaching the client must have also included:

  • how to address environmental sustainability and potential medical waste "balloon effect"
  • ideas for taxation or membership fees as they relate to sustainability of the cluster entity
  • cluster leadership training and professional development
  • public and private or PPP funding of the cluster
  • customer satisfaction, dispute resolution activities offered by the cluster
  • marketing, advertising, promotion, and public relations of the health tourism product and the region
  • regulatory compliance of healthcare, privacy, security, internet communications, medical records construction, and practitioner licensure and accreditation
  • international trade and exportation regulation, and the potential to establish free trade zones
  • the establishment of qualifications to participate in health tourism
  • the potential effect of informal economies currently in place
  • educational capacity building
  • cultural sensitivities
  • potential private sector physician brain drain and its effect on local healthcare access of citizens, and
  • inviting and managing relationships of foreign direct investors.

In consulting to this group, the consultant must also have subject matter expertise in knowing what and how to teach the elemental health tourism cluster characteristics:

  • why should it exist (purpose, governance, and economies of scale)
  • who should be involved, why, and what qualifications they should have
  • which roles should be established
  • what should be the function and capacity of the institution
  • how should it work
  • by what methods it will develop brand equity for all members; not just logo
  • how it will apportion equitable strategic benefit to all members
  • where should the cluster and its employees be situated
  • how it will handle dispute resolution between members
  • how it might impartially arbitrate or mediate disputes between the consumer and a member
  • how it might set and monitor quality standards for the cluster members
  • how it might produce training and professional development of cluster member employees
  • how much ongoing funding it will require to sustainably perform its role, and
  • from where will the funding be sourced

Who is accountable for cluster development and project oversight?

Most of the clusters we've examined regrettably fell short of this sort of consideration. One can only assume that this happened, most likely because the consultant didn't know the answers or failed to appreciate these inherent issues themselves, not by nefarious intent. It is my firm belief that the responsibility for scoping and vetting lies with the client, after they've been enlightened. Therein lies the greatest challenge in building such a cluster.

True consulting is an art form, as is teaching. It takes passion to be an effective consultant, and to manage to reduce key aspects of a complex process down to its primary elements. This is not tantamount to "dumbing down". To the contrary, it is to set firm foundation to allow scaffolding of new knowledge to raise the students' understanding and broaden their knowledge. Learning embodies the act of learning. One cannot effectively teach a subject without knowing and mastering that subject. Therefore, the consultants should first have the subject matter expertise themselves before they attempt to sequentially develop a cluster institution that will be functionally supportive of the health tourism players in a given market, region or country. 

Competency in health tourism requires the team leader to have background in integrated health delivery systems operations and management, well-developed tourism industry background, and experience with capacity building and sustainable institutional strengthening and economic development. It requires an ability to orchestrate all the moving parts and develop a totally new sub-sector that addresses all the over-arching considerations that significantly impact the new “tourism product.”  The cluster then serves the sector participants by functioning as a hub or management services organization that can provide overall sector leadership, communications, governance, regulatory compliance oversight, continuous quality measurement, benchmarking and improvement, training and development, development of brand equity, and create efficiencies through economies of scale. These things all have to have processes and procedures to happen. They don’t occur simply because the cluster merely exists.

Without the requisite competency and experience to design and lead such a project, the health tourism cluster is likely doomed to failure or disappointing results. And for many, in hindsight after a few years of attempting to make the cluster perform in a way it was never designed to work, failure it has been. We've seen this time and time again in many countries. Luckily there are ways that these clusters can be rehabilitated remedied or simply scrapped and done again. Expensive and sad, but reality nonetheless.

How to ensure a better cluster project outcome

The best way to ensure a better outcome is by building a better foundation before the cluster development is taken on. This preliminary phase requires well-developed research skills and consulting pedagogy from the chosen consultant. The differentiation can make or break the next steps.

For starters, your consultant must have a few qualities and resources to bring value to your project:

  1. Subject matter expertise
  2. The ability to inspire learning by the task force
  3. Well-developed consulting pedagogical techniques

Knowing the subject

First, the consultant has to know the subject matter and quickly define what the client needs to know to move forward. That learning assessment includes assessing the state of play and then showing the client “how” to learn the subject quickly, while understanding that the client will not be the end user of the information or training to be supplied. Your consultant has to be enthusiastic about the act of learning themselves; and must keep up with the technical aspects of the subject and be excited about doing so, not just selling another consulting gig.

A love of learning

Second, your consultant must convey the love of learning to the influencers of the eventual students in this case, even if the subject beingtaught is not captivating on its own to the contracting authority. Let’s face it, tourism people often have no clue about healthcare, healthcare people know of tourism that which they’ve experienced on vacations. Finance people know neither. Somehow, as if by magic, the consultant must relate to all three and use each one’s individual mental processes such as recognition, recall, analysis, reflection, application, creativity, understanding, and evaluation to scaffold “purposive fast learning.”

Consultants as teachers

Third, the consultant cannot simply “know” things, they have to be teachers, articulate and skilled in the techniques of consulting pedagogy. Consulting pedagogy includes the use of techniques that call upon individual mental processes such as recognition, recall, analysis, reflection, application, creativity, understanding, and evaluation. While each of the committee members of the contracting authority has all these capabilities, they probably don't have the deep understanding about "health care delivery" which is complicated and in most countries, heavily regulated. Therefore without the proper foundation, their own learning cannot be scaffolded. This constraint brings with it the conceivable threat that the client could inadequately scope the measurable objectives for the deliverable from the consultant, contract for inadequate or insufficient accountability, and grossly under-fund or underestimate sufficient time for the cluster development project because of failure to appreciate the complexity of what needs to be built in the first place. If the consultant fails to teach the client “how to learn” about medical tourism operations, it will be very difficult to develop schema and adopt required knowledge or integrate new knowledge. If the consultant doesn't guide the learning connections to occur, the learner cannot associate the lesson with prior knowledge. The ability to supply appropriate and adequate guidance, therefore, is the initial value proposition of the consultant. Without this foundation addressed, the medical tourism cluster development will likely be “hollow.”

If the consultant simply serves up the cheerleading and marketing message for the outcome preferred by the consultant, the learner is at a serious disadvantage.  Since they don't know what they don't know, they are vulnerable to being "sold" by this common approach. The outcome often leads to accusations that the consultant "took the money and ran".  A cunning consultant, however, is very careful not to scope the deliverable (if one is even articulated) into their contract so as to avoid charges of "material breach". As such, the responsibility for scoping the health tourism cluster deliverable and the critical measurable objectives by which it will be evaluated rests with the vulnerable client that doesn't know what they don't know. This is sad but commonplace in a variety of settings, not just medical tourism. It gives rise to what is known in golf circles as a costly "Mulligan" ("Mulligan," in its golf sense, is a relatively new word, but was in common use on golf courses by at least the 1940s, and refers to a "do-over" - hit a bad shot, take a mulligan and try again).

If the consultant has had only limited exposure to the subject matter (“this is how we did [everything] at my last job or project”), the client is vulnerable to copy strategies which produce little differentiation. That brings its own set of problems, including the threat of new competition, the lack of product differentiation which facilitates the threat of substitute products or services, the threat of the market to place the medical tourism cluster participants under pricing pressures with the consultant’s previous client or employer, the bargaining power of suppliers, including trained employees that could switch employers, and the intensity of competitive rivalry.  We've witnessed examples of each of these threats in existing medical tourism clusters. Only one or two have overcome them successfully. One of them is Turkey. Congratulations to Emin Cakmak and his leadership of the Turkish Healthcare Travel Council.

Due diligence is key

Take time for proper due diligence of the groundwork and learning necessary before setting out to build a medical tourism or health and wellness cluster. As you attempt to sequentially develop a cluster institution that will be functionally supportive of the health tourism players in a given market, region or country, keep in mind that for a cluster perform without adequate procedures and processes, failure is likely. We've seen this time and time again in many countries, and many seem to have a trail marked by similar footprints. Luckily, all is not lost unless the money for cluster development and project is exhausted on the wrong guidance, the wrong directions, and misassumptions. There are ways that these clusters can be rehabilitated, remedied, or simply scrapped and done again. This is expensive in time, effort, market opportunity, and cash, and very sad, but reality nonetheless.

I hope that the above lists will provide a high-level outline for task forces charged with the responsibility to engage a consultant to build a health tourism cluster. The lists above, at the very least should guide you in the development of some high level Terms of Reference (ToRs) for your project, and enable better and more thorough vetting of potential consultants to differentiate their actual competency from their marketing claims.

Mercury Advisory Group has been building healthcare management services organizational clusters to manage integrated and aligned health delivery systems since the 1990s. With more than 150 successful vertically and horizontally integrated projects to our credit, and a deep understanding of health delivery service operations, hospital management, surgery management, third-party reimbursement contracting, expatriate health management, we bring know-how, expertise, and practical experience to your project.

We combine healthcare experts with tourism experts to deliver a unique combination of skills knowledge application to the medical tourism nascent market. As a benefit of affiliation with our organization, our consultants are also provided professional development and skills building in teaching pedagogy by some of the brightest minds in organizational development, and adult learning theory. Our clients benefit from these internal training opportunities as much as the consultants themselves.


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