Enhancing Medical Tourism In Bali: A Readiness Analysis of Siloam Hospital Through Actor-Network Theory (ANT)

1. Introduction

Medical tourism involves visiting other countries for healthcare. It also means healthcare providers traveling the world to give world-class care (Kim et al., 2019). Medical travelers want simple and sophisticated surgeries like cardiac, dentistry, knee/hip replacement, and cosmetic surgery. Alternative medicine, psychotherapy, convalescent care, and funerals are also available (Bagga et al., 2020). Travel and tourism, the world’s largest service industry, is growing. It boosts destination countries’ GDP and tax income. Over 10% of global GDP, 7% of international trade, and 30% of service exports come from the USD 7.6 trillion travel and tourism sector (Roman et al., 2022). Asian countries that have medical tourism programs, such as India, South Korea, Thailand, and China, are developing better medical procedures to attract tourists. As an example. Cosmetic surgery is popular in South Korea, orthopedic surgery in India (Sarana & Sari, 2022). Many developing nations are becoming tourist destinations because they are cheaper and faster for foreign visitors. Various factors can support or hinder a nation’s program(Kyrylov et al., 2020).

Indonesia, one of the largest Southeast Asian countries without a worldwide medical tourism destination, is trying to boost its medical tourism potential. Indonesia supplies low, middle, and upper class patients to neighboring countries (Asa et al., 2024). Bali, Province in Indonesia has great medical tourism potential and became a pilot project for medical tourism development in Indonesia(Putra, 2023). Bali is known for health and wellness tourism (Parma et al., 2020), since 2013, Bali has participated in medical tourism and has a lot of potential that can be developed in the future. Four healthcare providers that opened in 2013 report a 10-25% rise in overseas patients visiting Bali. Domestic patients grow 7-10% annually (Purnamawati et al., 2019). Bali, as in Indonesia in general, is optimizing all state-owned and private clinics for medical tourism. Internal constraints include inept health worker and non-human resources, lack of hospital promotion, unfriendly hospital services, lack of patient education, and discipline issues. Foreign promotional initiatives and defective health insurance are external hurdles(Sutanto et al., 2022).

Previous research on the readiness of private hospitals in development, among others, Sudirman stated that several private hospitals in Bali were considered not ready to implement Travel Medicine services (Sudirman, 2019). Okayeni’s research states that medical tourists are not fully satisfied with medical tourism services at one of the private hospitals in Bali (Okayeni, 2018). Adirasari who concluded that medical tourism implemented in the largest government hospital has not shown significant development. (Adirasari, 2014). Public and private hospitals in Bali and Nusa Tenggara Provinces (West and East) have the facilities and people resources to organize medical tourism, according to previous research. Promotion, cross-sectoral collaboration, and Ministry of Health policies are still lacking (Ayuningtyas et al., 2020). Previous researchers besides asserted that in addition to the suboptimal development of medical tourism in Bali and showed that private hospitals in Bali are not ready. Therefore, this study aims to reveal the level of readiness of private hospitals in Bali.

The selected private hospital is Siloam Denpasar Bali hospital located in Badung regency, Bali., were the first hospitals in Bali that passed national hospital accreditation survey with five-stars status (i.e., paripurna)(Wijaya et al., 2020). Siloam Hospitals Bali is part of the Siloam Group Hospital established in Bali Province. This private facility is now ready to support medical tourism. Siloam Hospitals Bali serves both Indonesian and foreign patients. Presumptive studies reveal 1,269, 1,303, and 1,402 visitors hospitalized at Siloam Hospitals Bali from 2017 to 2019 (Dewi et al., 2020). The disclosure of the level of readiness is done to provide an overview of the factors, actors and networks involved in the readiness of Siloam Hospital in the development of medical tourism. Medical tourism is not a simple process. It is a complex decision by an international traveler based on the attributes of the host country, facilities of healthcare professionals, reasonable cost, and the service quality of hospitality and tourism (Olya & Nia, 2021). This study aims to analyse the readiness of private hospitals in Bali, taking into account the case study of Siloam Bali Hospital, in the development of medical tourism using the approach of Actor Network Theory (ANT).

The authors examine a primary actor and other agents’ interactions within Bali’s private hospital preparedness level in medical tourism development using Actor-Network Theory (ANT)(Latour, 1987). As agents interact or collide, the article shows how the network’s linkages converge to enact hospital organizational readiness and third-party connections. This paradigm views non-human “actors” including tourism, government, academics, infrastructure, and policy as unstable. The actors go from compelling and deterministic (policy), internal conflicts, communication to passive (tourist setting). The “actors” join the private hospital readiness networks that pushes medical tourism boundaries. As the “actors” co-constitute, support, question, and reinforce one other, these powerful actors produce affirmations and hurdles that become part of medical tourism development and the networks they service(Tomazos & Murdy, 2023). The resulting network is an evaluative scheme that shows how prepared the hospital is and what factors must be evaluated to maximise the development of medical tourism in Bali, Indonesia and other regions around the world that are developing medical tourism.

2. Literature Review

Previous Studies

Medical tourism, despite its expansion, has hurdles in terms of guaranteeing the quality and safety of medical services, overcoming language obstacles, and upholding consistent healthcare standards. The preparedness of private hospitals to offer medical tourism services is still a relatively unexplored field, especially in rising locations such as Bali. Contemporary research frequently neglects to consider the significance of hospital administration, healthcare staff, and supporting infrastructure in the development of a prosperous medical tourism center. Previous research on the readiness of private hospitals has not been conducted by many researchers in this field. Herpani Sudirman’s research (2019) which analyzed the readiness of hospitals in Bali in implementing travel medicine services, concluded that the input factors in implementing travel medicine services had not been fulfilled, so Sanglah General Hospital, BROS and BaliMed were considered not ready to implement Travel Medicine services. (Sudirman, 2019). Ni Wayan Okayeni’s research analysing the implementation of medical tourism at BROS in Bali states that the implementation procedure of medical tourism at Bali Royal General Hospital (BROS) Denpasar is not in accordance with Permenkes No. 76/2015. Medical tourists have not been fully satisfied with medical tourism services at the Bali Royal General Hospital Denpasar(Okayeni, 2018). (Burhan & Sulistiadi, 2022) who analysed the implementation of medical tourism in several hospitals, which concluded that medical tourism has been well implemented through a natural process. Of the three researchers with a research locus in Denpasar-Bali, it has not been comprehensive and focused on the readiness of the discussion of other private hospitals besides BROS and Balimed. The three researchers also conducted research before the COVID-19 pandemic, where there were differences in the mobilization and orientation of medical tourists in Bali.

The objective of this study is to assess the preparedness of Siloam Hospital Denpasar, Bali, in the development of medical tourism services. Through the application of Actor-Network Theory (ANT), our objective is to discern and comprehend the interactions between different human and non-human entities inside this ecosystem. The project will investigate the collaborative efforts of hospital administration, healthcare professionals, government agencies, and other stakeholders in delivering exceptional medical services to overseas patients. This study presents a new method that combines Actor-Network Theory (ANT) to examine the preparedness of private hospitals for medical tourism. This research will diverge from prior studies by examining a broad network of players, encompassing hospital administration, healthcare professionals, and government organizations, in the aftermath of the COVID-19 pandemic. This study enhances comprehension of the systemic readiness necessary for successful implementation of medical tourism by emphasizing the dynamic interactions and dependencies among the actors involved. Moreover, this study broadens the geographic range by incorporating Siloam Hospital Denpasar, providing valuable insights into the wider effectiveness of medical tourism tactics in other private hospitals in Bali. This paper enhances the existing information by providing a comprehensive examination of the factors that affect the preparedness of private hospitals for medical tourism. This text emphasises the essential functions performed by various individuals in the healthcare system and offers valuable information on how it affects hospital management and policymakers. The results will provide valuable guidance for developing measures to improve the capacities of private hospitals in Bali and other similar areas, ultimately fostering their development as competitive medical tourism destinations.

Readiness Theory and the Role of Private Hospitals in Medical Tourism Development

Medical tourism, the fastest-growing worldwide industry, provides economic and social benefits but also risks. Countries that treat international patients gain from safer foreign cash and fewer healthcare worker migrations. Medical tourists usually pay less and wait less in nations that receive them. (Cioban et al., 2018; Mishra & Sharma, 2021). Competition between countries in the field of medical tourism makes its development requires the right strategy. One of them is to evaluate and map the readiness of private hospitals as one of the main actors. Therefore, it requires in-depth analysis with relevant theories used to understand and analyse various factors as a background for the readiness of private hospitals.

Readiness theory explains the mechanisms of conflict resolution, particularly why participants in conflicts, especially intractable conflicts, engage in communication to resolve the conflict. (Schiff, 2019). Readiness is defined as a key component of the ability to continue services in a resource-constrained environment. Readiness includes complex and interrelated activities designed to prepare staff members to meet the healthcare needs of patients during contingency and crisis operations.(Potter, 2021). The medical tourism discourse is a levelling-up process undertaken by the government, to accelerate the change of designated private hospitals in order to increase the level of medical tourism visits in Bali.

Factors that attract patients to get services at the hospital are high quality services, served by communicative, competent medical personnel and staff with international expertise and reputation, with short service times and affordable prices, clear availability of information, and safe and quality treatment results (Intama & Sulistiadi, 2022). Sutanto with the case of one of the hospitals in Batam stated that there are two causes of obstacles in the readiness of Medical Tourism services, namely (1) Internal obstacles, namely incompetent human resources of health workers and non-human resources, lack of hospital promotion, unfriendly hospital services, lack of education to patients, and discipline problems (2) External obstacles, namely promotional intervention from foreign countries and invalid health insurance (Sutanto et al., 2022).

The main motivations for potential medical tourists to travel abroad for medical treatment are low cost of surgery, shorter or no waiting time, advanced medical technology and facilities, quality of healthcare, highly qualified medical staff, privacy, confidentiality, and also to take a holiday (Medhekar, 2014). Therefore, medical service providers are required to provide quality services, use modern technology, have effective marketing, and provide services at an international level, which has led to the globalisation of hospital services (Raoofi et al., 2024). This requires the readiness and preparation of private hospitals to improve their organisation to meet the standards of international medical tourism service providers.

In the context of medical tourism, readiness theory can be applied to understand how private hospitals prepare themselves to face and fulfil the needs of a growing market. Private hospitals play a key role in providing quality medical services to medical tourists. Private hospitals have greater flexibility in adapting services to market needs compared to government-owned public hospitals (Raoofi et al., 2023). According to research by Chahal et al. (2018) mentioned that private hospitals are able to adapt more quickly to changes in patient demand and expectations, both in terms of technology, facilities, and services provided. This flexibility allows private hospitals to offer medical care that is more personalised and suited to the specific needs of patients (Chahal et al., 2018). Private hospitals must adapt to the shifting medical market to succeed in medical tourism. Private hospitals can quickly adapt new medical technologies and upgrade facilities to attract medical tourists, private hospitals can invest in cosmetic surgery, cardiac care, and reproductive therapy units for medical tourists. Private hospitals compete for international patients, hence the treatment is usually better. Private hospitals often have JCI accreditation to demonstrate worldwide quality standards. This accreditation increases patient confidence and helps hospitals practice quality care. Patient experience is a priority for private hospitals. International patient coordinators, language assistance, and medical tourism packages with transport, lodging, and treatment are routinely offered. This simplifies and organises the patient experience, increasing enjoyment and loyalty. To attract international patients, private hospitals often partner with medical travel companies, insurance companies, and global health groups. This network enhances the hospital’s global reputation(Chahal et al., 2018).

4. Discussion

As shown on Table 3, the Hospital Director, Hospital Staff, Nurses, General Doctor, and Specialized Doctor are highly central, indicating a strong internal structure needed to provide quality service. These players ensure medical tourists receive high-quality care by assuring the hospital’s operational efficiency and service excellence.

Hospital Director: A key node, instrumental in coordinating hospital resources, with a degree centrality of 25.93% and a betweenness centrality of 15.04%. This function is crucial for hospital teamwork and medical tourism service quality.

Nodes for Hospital Staff, Nurses, General Doctors, and Specialized Doctors have 22.22% degree centrality and moderate betweenness centrality. Their patient care and support roles emphasize their network value. They ensure hospital efficiency and medical tourist service quality.

Bali Tourism Board and Local Government: Despite lesser degree centrality (3.70%), their functions are vital due to their significant betweenness centrality. They promote and support Bali medical tourism with required infrastructure. Their help is crucial to hospital external support.

Related to Readiness Theory

Readiness Theory stresses preparedness in complicated situations like healthcare(Khirekar et al., 2023). This theory states that preparedness requires preparing and coordinating all human and non-human resources to fulfil goals(Pruitt, 2015; Weiner, 2009). The strong centrality measures of important internal players at Siloam Hospital imply a well-coordinated and prepared internal organization, supporting Readiness Theory. These players’ close affiliations and collaborative roles show their preparedness to meet medical tourism expectations. Found Weaknesses and Readiness Gaps Despite strengths, the investigation revealed many issues that must be addressed to improve readiness:

Heavy reliance on Medical Tourism Package & Service node, with 100% centrality across metrics, suggests potential vulnerability. This key node’s failure could cripple the network. Siloam Hospital must create alternative paths and backup systems to ensure operations even if major nodes fail. This method supports Readiness Theory’s resilience and contingency planning.

Peripheral Nodes: Cultural Identity, Interior Design, and Embassy have low centrality scores (3.70%), indicating underutilization. Better integration could boost these nodes’ network contributions. Enhancing their roles could complement and diversify the network’s capabilities, which is crucial for holistic readiness.

Educational and Health Institutions: Nurse Schools and Universities have moderate centrality but low betweenness, indicating ineffective network connectivity. Increasing their training and knowledge interchange is essential for creating a professional staff that can satisfy international patient needs. Closer partnership with these institutions assures a steady supply of well-trained medical experts, supporting Readiness Theory’s focus on capacity creation and ongoing improvement.

External vulnerabilities: Low integration of nodes like International Insurance Officer and Immigration Office exposes them to external forces. These connections are essential for international patient influx and administrative efficiency.

To reduce external change vulnerabilities, international policies and regulations must be more aligned and integrated. This alignment streamlines administrative processes for international patients, which Readiness Theory requires for total preparation. Advice for Improvement. The following suggestions address these deficiencies and prepare Siloam Hospital Bali for medical tourism:

Enhancing Integration and Collaboration: Collaborating with peripheral nodes like Cultural Identity, Interior Design, and government agencies can enhance the network. Incorporating cultural and artistic elements into hospitals can improve patient experiences.

Developing Redundancy: Alternative paths and backup solutions help mitigate network interruptions in critical nodes. This redundancy will let the hospital continue operations if central nodes fail, supporting Readiness Theory’s resilience and contingency planning.

Enhancing Educational Involvement: Educational institutions’ involvement in training and knowledge sharing can boost network expansion and innovation. Readiness Theory emphasizes capacity building, and Siloam Hospital can maintain a steady supply of trained medical personnel by working more closely with Nurse School, University, and other educational institutions.

Aligned with International Policies: Enhancing network resilience and aligning with foreign insurance officers and immigration offices helps reduce the impact of external policy changes. This alignment will streamline administrative processes for international patients, which Readiness Theory recommends for comprehensive readiness.

Siloam Hospital can increase its medical tourism preparation and competitiveness by following these suggestions. This complete analysis of the network’s strengths and weaknesses helps drive improvements and keep Siloam Hospital Bali a top medical tourism destination. The hospital must adapt and improve its network to remain Bali’s top medical tourism provider, following Readiness Theory.

5. Conclusions

Actor-Network Theory (ANT) was used to assess Siloam Hospital Bali’s medical tourism preparation, revealing its strengths and weaknesses. The Medical Tourism Package & Service node was found to be the network’s central hub, linking diverse participants. The Hospital Director, Hospital Staff, Nurses, General Doctor, and Specialized Doctor are very central, indicating a robust internal structure necessary for optimal service delivery, consistent with Readiness Theory. However, the network’s dependence on the central node may make it vulnerable. The low redundancy and underutilization of peripheral nodes like Cultural Identity and Interior Design recommend integration improvements. The moderate centrality but low betweenness of educational and health institutions suggests greater training and knowledge sharing. Critical external nodes like the International Insurance Officer and Immigration Office are under integrated, making them vulnerable.

The report suggests boosting integration and coordination with outlying nodes, network redundancy, educational institutions, and international policy alignment to prepare Siloam Hospital for medical tourism. These suggestions can improve the hospital’s resilience, operational stability, and medical tourism competitiveness. This complete analysis of the network’s strengths and weaknesses helps drive improvements and keep Siloam Hospital Bali a top medical tourism destination. Siloam Hospital can meet Readiness Theory standards by resolving its deficiencies and maximizing its strengths. The facility will be better prepared to handle medical tourism demands and help Bali become a premier medical tourism destination.

This study has some drawbacks despite its observations. First, qualitative data collection via interviews and document analysis may bring subjectivity and biases. Siloam Hospital Bali’s findings may not apply to other hospitals or locations without similar settings. Centrality measures may also misrepresent the network’s dynamic nature by taking a snapshot in time. The ANT and Readiness Theory analysis does not account for all external elements that could affect the hospital’s readiness, such as rapid foreign policy changes or pandemics. Integrating peripheral nodes and educational institutions based on present data may not reflect future changes in these linkages.

A larger, more diversified dataset with quantitative measures to supplement qualitative findings should overcome these shortcomings in future study. Longitudinal investigations could illuminate network dynamics. Comparative studies of many hospitals in different regions would help generalize findings and identify best practices. International health legislation and economic volatility may affect the hospital’s readiness. More research is needed. Investigating how technology and digital health tools improve network integration and resilience may help modernize medical tourism infrastructure. The hospital’s readiness may be better assessed by include patient viewpoints and experiences. Understanding patient expectations and satisfaction can assist medical tourism providers better serve overseas patients. Finally, partnering with global health organizations and insurance firms may reveal ways to boost the hospital’s medical tourism readiness. Future research can expand on this study’s findings to better understand hospital readiness in medical tourism.