Motivational factors affecting outbound medical tourism: the case of Nepal, a developing nation

With globalization and the increasing interconnectedness of healthcare systems, the demand for medical care beyond one’s home country has surged significantly. Medical tourism, a rapidly expanding sector, has seen remarkable growth in recent decades, with more people traveling abroad for advanced medical treatments, impacting the health systems of both sending and receiving nations (Whittaker, 2008; Sharma & Meena, 2025). By 2022, the global medical tourism market reached a valuation of USD 97.31 billion, with projections estimating it will grow to USD 273.72 billion by 2032, at a compound annual growth rate (CAGR) of 11.8% from 2023 to 2032. The medical tourism market has reached approximately $272.70 billion, particularly post-pandemic, with patients from developed countries seeking affordable and high-quality healthcare abroad (Covalenco, 2023). More people than ever before are traveling abroad to receive high-quality medical care (Connell, 2006; Kim et al., 2016).

These figures underscore the rapid evolution and promising future of the medical tourism industry, particularly in Asia, which has emerged as the fastest-growing region. Countries such as Singapore, Thailand, South Korea, and India dominate the market as popular destinations for international medical travelers (Hwang, Lee, & Kang, 2018).

Medical tourism involves traveling outside one’s domestic healthcare system to receive medical treatment, including advanced and specialized procedures. As Carrera and Bridges (2006) noted, disparities in access to quality healthcare, high costs, and bioethical considerations often motivate medical travel (Mogaka, Thompson, Mupara, & Tsoka-Gwegweni, 2017). For developing nations, improving healthcare infrastructure is critical to providing equitable access to medical services (Ali & Medhekar, 2018). Many individuals from low-to middle-income countries seek better healthcare options abroad due to the lack of advanced medical facilities or cost-effective solutions in their home countries (Kumar, Bagchi, & Ray, 2021; Snyder et al., 2015).

Unlike many other nations, Nepal, however, faces unique challenges in developing a competitive medical tourism industry. The country’s healthcare infrastructure struggles to meet the demands of its population, with public healthcare systems being overcrowded and under resourced and private healthcare options being limited and expensive. Nepal also lacks the advanced facilities needed for specialized treatments, such as joint replacements, cardiac surgeries, and cosmetic procedures (New Business Age, 2022). Despite a skilled medical workforce, inadequate infrastructure and medical supplies prevent Nepal from becoming a medical tourism destination (Republica, 2023). Consequently, a growing number of Nepalese residents are seeking healthcare abroad, contributing to a rise in outbound medical tourism.

Globally, countries such as Thailand, India, and Brazil are popular destinations for patients from developing nations due to their affordable and advanced medical facilities (Béland & Zarzeczny, 2018). The UK, the US, Germany, India, and Thailand are the top destinations for such travel (Alnakhi, Segal, Frick, Ahmed, & Morlock, 2019). India, for instance, attracts a significant portion of Bangladeshi patients seeking self-funded treatments, as highlighted by Zakaria et al. (2023). Despite the increasing demand for international medical services, the motivations driving outbound medical tourism remain complex and multifaceted, encompassing healthcare quality, costs, safety, and tourism-related factors (Roy, Mukherjee, & Bhattacharya, 2018).

Whittaker (2008), Gill and Singh (2011), Han and Hyun (2015), Chia and Liao (2020), and AbdelAziz and Kewina (2022), examine medical tourism demand, national healthcare system-influenced motivations, and effects. International hospital service quality improves with outbound medical tourism (Whittaker, 2008). Before traveling abroad, Gill and Singh (2011) rank high-quality medical care among the top three factors. Han and Hyun (2015) found that service quality and staff confidence strongly influenced patients' medical destination returns. According to AbdelAziz and Kewina (2022), both healthcare provider- and destination-specific pull factors increase medical tourism intentions. Destination-specific elements include the environment, safety, cultural and historical attractions, and tourism amenities. However, healthcare provider service quality, waiting times, and medical costs influence patient decisions (AbdelAziz & Kewina, 2022). Though researchers from developed countries and different disciplines have carried out empirical studies on medical tourism, little is known about this phenomenon in developing countries (Chia & Liao, 2020). Despite high-profile media interest and coverage, there is a lack of hard research evidence on the role and impact of medical tourism (Lunt et al., 2011).

In Nepal, research on medical tourism remains limited despite its growing relevance. Outbound medical tourism offers speedy, economical, and advanced care. No in-depth research has examined medical tourism to or within Asia (Whittaker, 2008). Likewise, Khanal (2017) highlighted the lack of scholarly attention on this subject, which leaves a critical gap in understanding the drivers of outbound medical tourism among Nepalese patients. Nepal's healthcare system’s shortcomings, coupled with complex regulatory frameworks, often push residents to seek faster, more affordable, and advanced medical care abroad. This trend raises important questions about the motivations behind Nepalese individuals' decisions to pursue foreign medical treatment.

This study seeks to bridge the research gap by exploring the factors influencing outbound medical tourism among Nepalese patients. By examining patient motivations and decision-making processes, it aims to enhance both theoretical and practical understandings of medical tourism in Nepal. Additionally, the study provides valuable insights into how healthcare infrastructure, service quality, and cost considerations shape outbound medical tourism trends. Through this analysis, it contributes to the existing literature while offering actionable recommendations for stakeholders in Nepal’s healthcare and tourism sectors.

Several theories may be relevant to outbound medical tourism. There isn't a single, widely recognized theory that can fully explain outbound medical tourism. However, we can use two theories to understand outbound medical tourism. Two related theories are the push-pull theory, which is commonly associated with migration theories, and the theory of planned behavior, which considers psychological factors influencing individuals' decisions to seek medical treatment abroad.

Push-Pull theory: It states that push-or-pull variables affect migrations. Push factors cause people to leave, whereas pull factors lead them to their destination. Research indicates that these factors influence individuals who travel for medical purposes. Pull factors predominate over push factors (Segal, Borgia, & Schoenfeld, 2005; Shinnar & Young, 2008). Both force people to leave their home country for medical treatment (Hanefeld, Smith, Horsfall, & Lunt, 2014). The push-pull theory explains the reasons behind outbound medical tourism. The push and pull theory explains why people seek medical treatment abroad. It examines the “push” and “pull” elements from Nepal and other countries that cause this occurrence.

Internal push factors include a lack of quality healthcare in the home nation. Pull influences can be external, like new medical technology or decreased expenses. Hanefeld et al. (2014) examined the push and pull factors that drive medical tourism. They discussed push factors such as extended wait times or the inability to acquire specific procedures in the home country, as well as pull variables such as reduced costs or the reputation of the destination country.

Theory of Planned Behavior (TPB): Psychology links outbound medical tourism to the Theory of Planned Behavior. Fishbein and Ajzen (1975) developed the Theory of Planned Behavior, which expanded attitudes' predictive power. According to this hypothesis, attitudes, subjective norms, and perceived behavioral control all have an impact on behavior. This can influence an individual's decision to travel abroad for medical reasons. While intentions are a good predictor of behavior, environmental factors such as resources and opportunities can have a significant impact on medical tourism. Wang and Pfister (2008) examined Chinese patients' medical tourism intentions using the TPB framework. With the Theory of Planned Behavior, we may explore how attitudes, subjective norms, and perceived behavioral control affect outbound medical tourism in Nepal. The TPB helps explain how psychological factors influence medical care decisions abroad, giving reasons and options. Positive attitudes toward the quality, cost, and availability of foreign medical procedures can have an impact on treatment travel. Friends, family, and healthcare professionals' advice and experiences can substantially impact medical tourism decisions. Financial feasibility, information accessibility, language obstacles, and logistical ease of overseas medical tourism affect perceived behavioral control.

The literature presents the concept using various jargon, such as “Medical Tourism', “Medical Travel', “Healthcare Tourism', “Holistic Tourism', “Health Tourism', and “Wellbeing Tourism', which often describe different concepts (Voigt, Brown, & Howat, 2011). Medical tourism, often encompassing overseas travel for health improvements through invasive procedures or medical check-ups, differs from the more passive nature of health and wellness tourism; it is now primarily characterized by short-distance, cross-border, and diasporic movements (Connell, 2013). DeMicco (2017) explores the intersection of hospitality and healthcare, emphasizing the role of medical tourism and wellness in this dynamic. Medical tourism involves traveling abroad for medical treatment, while wellness tourism focuses on enhancing physical, psychological, and spiritual well-being (DeMicco, 2017).

Medical tourism can be understood conceptually as the practice of foreign nationals traveling across international borders to receive specific medical procedures (Banerjee, Robinson, Dev, & Singh, 2024); as well it occurs when individuals travel abroad for access medical, reproductive, cosmetic, dental, transplant, and elective surgery (Adam, Ghasemi, & Nejad, 2024). Similarly, Sharma, Alam, and Priya (2024) mentioned medical tourism refers to the increasing trend of cross-border patient migration in the global healthcare industry, involving individuals traveling to receive cost-effective and efficient medical treatment. It is characterized by the movement of patients from one country to another, often from developed to developing nations, where healthcare costs are lower (Sharma et al., 2024). In this Banerjee et al. (2024) refers medical tourism to traveling across borders for medical treatment, primarily motivated by cost-effectiveness and quality of care (Banerjee et al., 2024). Similarly, medical travel has a broader scope, encompassing both domestic and international healthcare journeys, reflecting the growing trend of patient mobility (Sharma et al., 2024).

Similarly, Connell (2006) mentioned that a vacation that involves traveling across international borders to obtain a broad range of medical services is medical tourism. Similarly, Hwang et al. (2018), mentioned that medical tourism is the tourism activities that involve medical treatments or activities aimed at improving the well-being of tourists. Similarly, Carrera and Bridges (2006) mentioned that health tourism is organized travel outside the local environment for maintaining, enhancing, or restoring well-being in mind and body. Medical tourism is the sum of all the relationships and phenomena resulting from a journey by people whose primary motive is to treat or cure a medical condition (Voigt, 2010; Kunwar, 2019). Pocock and Phua (2011) define medical tourism as a part of health tourism, which generally refers to traveling outside one's usual area to improve one's physical or mental well-being. Gill and Singh (2011) state that medical tourism is one of the newest trends in the tourism sector, and it has the potential to continue increasing tremendously every year.

Voigt (2010) identified four forms of medical tourism: illness-related check-ups, surgery, and dental treatment; wellness-related beauty care, spa treatments, yoga, and herbal therapy; enhancement-related cosmetic surgery; reproduction: fertility treatment; and birth tourism. Patients' international medical travels, referred to as “medical tourism,” (Ormond & Lunt, 2020). Medical tourism and medical travel are interchangeable terms referring to patients seeking treatment abroad due to limitations in their home countries, highlighting global healthcare disparities and patient mobility (Ormond & Lunt, 2020). Therefore, in this study “medical tourism” was considered, assuming the broader definition of medical tourism.

According to the literature, the majority of patients base their decisions on their personal experience, information technology, and feedback from previous patients because it is difficult to establish clear standards for hospital selection, the most important aspect of medical tourism. Studies like Lee, Han, and Lockyer (2012), Wong, Velasamy, and Arshad (2014), Wongkit and McKercher (2016), and Connell (2006) mentioned factors like insurance coverage, medical procedures, and quality of care service. Canadians, for example, dislike standing in long lines. Patients in the United Kingdom cannot afford to see a doctor in private practice and must wait for care through the National Health Service (Alleman et al., 2010). Common medical tourism destinations include Thailand, India, Malaysia, Singapore, and Thailand, South Africa, South and Central America (especially Brazil, Costa Rica, Cuba, and Mexico), the Middle East (Dubai), and Western, Scandinavian, Central, and Southern Europe (Lunt et al., 2011). However, industry sources may be biased and imprecise in their estimations. Some destinations promote themselves as biomedical cities or healthcare hubs. Since 2001 (Cyranoski, 2001), Singapore has positioned itself as a biomedical and biotechnological hub. For instance, medical tourists from Indonesia have been visiting neighboring nations with superior healthcare for years (Asa, Fauk, McLean, & Ward, 2024). Similarly, there is a significance number of outbound medical tourism from African countries (Eze, Inyang, & Orji, 2020; Mogaka, Tsoka-Gwegweni, Mupara, & Mashamba-Thompson, 2017) such as Nigeria (Joseph, Ntombana, & Sibanda, 2022), South Africa (Orekoya & Oduyoye, 2018) to Asian countries, prominently India.

Insurance coverage affects people's medical tourism decisions; it provides financial security and reduces the risks of expensive medical procedures and healthcare. Lunt and Carrera (2010) mentioned insurance-related issues in their study, which emphasized the need for specialized insurance products that cater specifically to the needs of medical tourists. Bányai et al. (2017) focused on the structures of medical tourism risk management, including insurance contemplations. According to Zolfagharian, Rajamma, Naderi, and Torkzadeh (2018), medical cost is an important factor to consider when choosing medical treatment abroad. There is a strong connection between outbound medical tourism and insurance policies that provide compensation for expenses such as travel and health care (Mattoo & Rathindran, 2006). According to Singh (2019), one of the driving reasons for medical tourism is a lack of insurance policies. Likewise, Tseng's (2013) research revealed that issues such as a lack of insurance and a lack of complete coverage at home have all increased the number of people seeking medical care abroad over the past 20 years. With this note the null Hypothesis 1 is formulated.

According to Musa, Doshi, Wong, and Thirumoorthy (2012), cultural similarity drives medical tourists to visit Kuala Lumpur for medical treatment. Language is an important factor in selecting a medical destination. According to Singh (2013), social and cultural considerations are one of the main driving forces behind medical tourists. Olya and Nia (2021) also highlighted the cultural and linguistic aspects of medical tourism. The language barrier is one of the most common barriers in medical tourism (Horsfall, 2020). Chen, Lai, Rebecca, Petrick, and Lin (2016) provided insights into how medical care adjusted to the local culture. Likewise, Chen and Rahman (2018) stressed language compatibility in medical tourism. Squires et al. (2019) examined how language barriers affected Chinese medical tourists' satisfaction and value. As India's closest neighbor, Bangladesh shares a similar culture, and transportation and other costs are comparable between the two countries (Mahmud, Rahman, Lima, & Annie, 2021).With this note the null Hypothesis 2 is formulated.

A variety of risks frequently accompany medical tourism (Crooks et al., 2013). Expertise in medical support is an essential factor for cross-border medical tourism (Kumar et al., 2021). Ampaw, Chai, Liang, Tsai, and Frempong (2020) results reveal that inadequate hospital safety led to patient dissatisfaction. According to Lunt and Carrera (2010), procedural safety plays a vital role when deciding on outbound medical tourism for treatment. Xu, Wang, and Du (2020) mentioned that low cost, short waiting list, quality, and available procedures were the motivators for treatment abroad. Similarly, Çapar and Aslan (2020) mentioned security and safety, quality of health care service, and low cost, and Medhekar and Wong (2020) also mentioned factors like hospital facilities and services, patient safety, travel risk, and surgical costs. In DeMicco and Poorani (2022) mentioned on-site care, discharge, and follow-up care for critical phases of the medical tourism. With this note the null Hypothesis 3 is formulated.

Customers were more likely to travel if they thought the health care provider was excellent (Lajevardi, 2016). Service quality improvement in international hospitals is directly linked to outbound medical tourism (Whittaker, 2008). According to Gill and Singh (2011), high-quality medical treatment is one of the top three considerations before traveling abroad. Han and Hyun (2015) findings showed that service quality, as well as confidence in it and its staff, greatly influenced patients' inclinations to return to the medical destination. Parasuraman, Zeithaml, and Berry (1994) identified healthcare tourists as placing paramount importance on the quality dimension. Zakaria et al. (2023) mentioned the availability of well-experienced doctors, hospital or medical facilities with high standards, well-trained doctors, reputable doctors, and quality treatments and medical materials. Facility and service are among the strongest predictors in the Zakaria et al. (2023) study. Similarly, AbdelAziz and Kewina (2022), Shikha and Vallabh (2022) mentioned that the success of medical tourism relies on quality services. With this note the null Hypothesis 4 is formulated.

The cost of treatment influences outbound medical tourism, leading people to seek healthcare elsewhere. The cost of medical tourism improved hospital relationships, recommendations, and feedback. As a result, treatment costs have a significant association with outbound medical tourism (Kumar et al., 2021) and are critical to its success (Hwang et al., 2018). Hanefeld, Lunt, Smith, and Horsfall (2015) say cost savings drive medical tourism. Heung, Kucukusta, and Song (2010) study highlighted cost as a major determining factor for medical tourism. Cost has a significant relationship with medical tourists from China, Japan, and Korea (Yu & Ko, 2012). Drinkert and Singh (2016) demonstrates that cost motivates the desire for medical tourism. Shikha and Vallabh (2022) mentioned that the success of medical tourism relies on cost-effectiveness, while AbdelAziz and Kewina (2022), Crooks and Jin (2022) emphasized that medical tourism focuses on both costs and care quality. With this note the null Hypothesis 5 is formulated.

Word of mouth plays an important role in the selection of outbound medical tourism (Connell, 2006). Johnston, Crooks, Snyder, and Whitmore (2015) mentioned that word-of-mouth communication has more influence on patients’s intentions than doctors’ advice. Hanefeld, Smith, and Noree (2016) mentioned how WOM affects medical tourism destination selection. Lu, Wu, and Chen (2016) found that personal factors, such as risk attitude and self-esteem, along with an external factor, word-of-mouth, positively moderate the relationship between hospital elements and the perceived value of medical travel. The relatives were the key source of information regarding medical tourism for more than one-fourth of the respondents (Zakaria et al., 2023). Likewise, the findings of Hyder, Rydback, Borg, and Osarenkhoe (2019) showed that word-of-mouth marketing is crucial for bringing in new clients and spreading knowledge about medical tourism services. With this note the null Hypothesis 6 is formulated.

Multiple factors drive outbound medical tourism from developing countries, often across geographies. Higher-quality care, improved medical technologies, specialized therapies, reduced wait times, and local healthcare provider recommendations are common themes. Cultural links, language competence, and destination country diaspora communities also impact developing country medical tourists' decisions (see Figure 1).

The study takes on a quantitative approach to analyze the motivational factors affecting outbound medical tourism. The study purposefully contacted individuals who had undergone medical treatment abroad to form the sample for this study. A total of 400 questionnaires were distributed and received a response from 388 individual patients from major cities in Nepal, including Kathmandu, Bhaktapur, Lalitpur, Makawanpur, Nepalgunj, Biratnagar, and others. A sample of 382 individual patients’ responses were significant and utilized them for further analysis. The minimum estimated sample size was 146, using Gpower 3.1 with an effect size of 0.15 (medium) and six predictors with a 95% CI and a 0.05 estimated error. SEM is considered a large sample method that usually demands a minimum sample size of 200 (Dash & Paul, 2021). We conducted data analysis using PLS-structural equation modeling (SmartPLS 4.0) for both the measurement and structural model analyses. We also performed a descriptive analysis using SPSS v24. Table 1 presents the respondent profile. Tables 2 and 3 present the area for treatment sought and the main reason for seeking the treatment abroad, respectively. The ethical consideration was followed in this research study, along with the approval of research and review committee of School of Management, Tribhuvan University.

A structured questionnaire comprising 35 items was developed to represent six exogenous variables and one endogenous variable. Each variable was measured using five items adapted from validated instruments in previous studies, including Helble (2010), Loureiro (2015), Suzana, Walls, Smith, and Hanefeld (2018), Collins, Medhekar, Wong, and Cobanoglu (2019), Alnakhi et al. (2019), and Lianto, Suprapto, and Mel (2020). A 7-point Likert scale was employed for responses, ranging from “strongly disagree” (1) to “strongly agree” (7), allowing respondents to indicate the extent of their agreement with each statement.

The survey instrument underwent pre-testing with a sample of 25 respondents, representative of the target population. This pilot test provided valuable feedback, leading to refinements in question clarity and overall relevance. Following these adjustments, the questionnaire demonstrated a high level of internal consistency, with a Cronbach’s alpha coefficient of 0.950 for the 35 quantitative items. Additionally, the questionnaire included items to gather demographic information and insights specific to medical tourism.

To test the univariate and multivariate of the data, the Mardia’s univariate and multivariate test was done. The data failed to achieve univariate and multivariate normality. Mardia's multivariate skewness and kurtosis shows Skewness = 376.462 (p = 0.001) and Kurtosis 1886.197 (p = 0.001), which is above the threshold of + -3 skewness and +-2 Kurtosis (Kline, 2012) is not normal data. The Mardia’s coefficient is significant, (i.e. the critical ratio is greater than 1.96 in magnitude) the data may not be normally distributed.

As this study adopts a cross-sectional approach, it might be susceptible to common method bias. Following Kock (2015) recommendation, a comprehensive collinearity test was conducted. All latent variables were regressed against a shared dummy variable (marital status). The results, in line with Hair et al. (2021), indicated VIF values below 5. Consequently, the study concludes that there is no discernible threat of common method bias.

The study proceeded with a sequential analysis approach, commencing with the evaluation of the measurement model before conducting path analysis to test the hypotheses and present the model estimates. The measurement model assessment involved scrutinizing reliability, convergent validity, and discriminant validity. Following this, the structural model was analyzed for path analysis. The data analysis for this study was conducted using SmartPLS 4.0.

The measurement model was assessed with reliability, convergent validity, and discriminant validity. The convergent validity has achieved a value of more than 0.70 (Hair et al., 2021) and the reliability was achieved as per thresholds of above 0.7. Subsequently, discriminant validity was tested with F&L criteria, HTMT, and cross-loading. The Fornell-Larcker criterion (Fornell & Larcker, 1981) was achieved. However, to achieve the HTMT_0.9 (Gold, Malhotra, & Segars, 2001), few items were considered dropped (SQ1, SQ5, PS4, PS5, PS1) as there was a cross load of items. The HTMT inference has been tested using bootstrapping at 10,000 sub-sample, percentile method (Hair et al., 2021) to test whether HTMT is significant. The HTMT values are significant in the upper limit and lower limit in 95% CI. Tables 4–6 presents the reliability, convergent validity, and discriminant validity indices. Cross loading table is presented in (Table A1)  Annexure 1. Additionally, the measurement model output is placed in  Annexure 2.

On average, respondents exhibited moderate agreement with the concept of need-based outbound medical tourism, highlighting a growing willingness to seek treatment abroad and a positive attitude toward international medical tourism. This suggests that factors such as the quality of medical care, competence of healthcare professionals, and personalized attention provided overseas are key drivers influencing the decision to pursue medical care abroad. These preferences underline the importance of quality and personalized experiences in shaping medical tourism trends.

Respondents also expressed moderate to strong agreement regarding the safety of medical tourism abroad. They conveyed trust in the procedures, standards, and expertise of internationally accredited hospitals, including confidence in diagnostic tests, medication quality, and experienced doctors. This indicates that perceptions of safety and trust in international healthcare systems are significant factors in encouraging outbound medical tourism.

The findings further reveal that treatment costs play a critical role in shaping respondents’ decisions to seek medical care abroad. Respondents showed a noticeable interest in countries that offer reasonably affordable treatment and living expenses, indicating that affordability is a crucial factor in determining medical tourism. This inference emphasizes the need for destination countries to position themselves as cost-effective options to attract medical tourists.

Insurance policies related to outbound medical tourism emerged as another influential factor. Respondents agreed that the availability and terms of such policies significantly motivate individuals to seek medical care abroad. This highlights the importance of supportive insurance frameworks in facilitating outbound medical tourism, suggesting that well-structured insurance offerings can play a pivotal role in decision-making.

Similarly, language and cultural considerations showed a moderate level of agreement among respondents. This implies that while these factors are not the primary drivers, they still hold importance in shaping the overall experience and decision to engage in medical tourism. Respondents’ shared perspectives on these factors underline the need for medical tourism providers to consider language support and cultural sensitivity as part of their service offerings.

Finally, we identified word-of-mouth communication as an influential element in shaping respondents' decisions about medical tourism abroad. Respondents generally believed in the reliability of information shared through such channels, indicating the critical role of informal communication networks in building trust and credibility for international healthcare services. This insight suggests that leveraging patient testimonials and positive experiences can be an effective strategy for promoting medical tourism destinations.

Further, there were moderate to strong correlation between Outbound Medical Tourism and Insurance Policy (r = 0.698, p < 0.001), Language and Culture (r = 0.679, p < 0.001), Procedural Safety (r = 0.666, p < 0.001), Service Quality (r = 0.804, p < 0.001), Treatment Cost (r = 0.672, p < 0.001), and Word-of-Mouth Communication (r = 0.710, p < 0.001). All factors were statistically significant at the 1% level of significance. The Table 7 presents the descriptive and correlations analysis.

These findings suggest that outbound medical tourism is most strongly associated with service quality and word-of-mouth communication. This implies that the perceived quality of services provided abroad, combined with positive recommendations and testimonials, plays a crucial role in shaping individuals’ decisions to seek medical care internationally. The substantial correlations with insurance policy and procedural safety indicate that trust in the financial and procedural aspects of international healthcare significantly influences the decision-making process. This highlights the importance of transparent and supportive insurance policies, as well as confidence in the safety and reliability of medical procedures.

The notable correlation with language and culture underscores the value of cultural alignment and language accessibility in enhancing the comfort and ease of patients traveling for medical care. Similarly, the relationship with treatment cost reflects the financial considerations that heavily influence medical tourists, underscoring the need for affordable yet high-quality healthcare options in destination countries. Overall, these insights emphasize the multifaceted factors driving outbound medical tourism, with service quality, word-of-mouth communication, and insurance policies emerging as particularly critical dimensions.

Table 8 summarizes the final structural model that assesses the relationships between exogenous and endogenous variables. The hypotheses were tested using path analysis with 10,000 sub-samples and percentile bootstrapping, employing a one-tailed test with a 95% confidence interval (Hair et al., 2021).

The analysis revealed that only Service Quality (β = 0.575; t = 9.798, p < 0.01) and Word-of-Mouth Communication (β = 0.215; t = 2.57, p < 0.05) had a statistically significant effect on Outbound Medical Tourism. Service Quality demonstrated a strong and highly significant positive influence at the 1% level of significance, indicating that perceptions of high-quality healthcare services are a primary driver of individuals seeking medical treatment abroad. Similarly, Word-of-Mouth Communication exhibited a positive and moderately significant influence at the 5% level, highlighting the role of personal recommendations and shared experiences in shaping medical tourists' decisions.

Conversely, other factors, including Insurance Policy (β = −0.005; t = 0.068, p > 0.05), Language and Culture (β = 0.043; t = 0.659, p > 0.05), Procedural Safety (β = 0.003; t = 0.052, p > 0.05), and Treatment Cost (β = 0.068; t = 1.063, p > 0.05), were not statistically significant in explaining Outbound Medical Tourism. This suggests that, while these variables may play a role in influencing medical tourism preferences, their direct impact is limited when compared to Service Quality and Word-of-Mouth Communication. The findings underscore the critical importance of Service Quality as the strongest determinant of Outbound Medical Tourism, emphasizing that potential patients prioritize healthcare excellence and reliability when choosing to travel abroad for medical purposes. Additionally, the significant role of Word-of-Mouth Communication highlights the trust placed in personal recommendations and testimonials, suggesting that marketing efforts in the medical tourism sector should leverage patient experiences and success stories to attract more international patients. The lack of significance for other variables such as Insurance Policy and Treatment Cost indicates that these factors might act as secondary considerations rather than primary motivators in the decision-making process.

In summary, the results indicate that Service Quality and Word-of-Mouth Communication significantly and positively influence Outbound Medical Tourism, leading to the rejection of H04 and H06. However, Insurance Policy, Language and Culture, Procedural Safety, and Treatment Cost were found to have no significant impact, supporting H01, H02, H03, and H05. These findings underscore the critical importance of Service Quality and Word-of-Mouth Communication as key determinants of Outbound Medical Tourism.

Likewise, the coefficient of determination (R²) value is 0.688, which shows a considerable substantial (Hair et al, 2021) effect of the factors on Outbound Medical Tourism. That means the factors explain a variance of 68.8% in Outbound Medical Tourism. Additionally, the structural model output is placed in  Annexure 3.

Similarly, ƒ² values of Service Quality (0.344) show a large effect, and Word-of-mouth-communication (0.035) show a small effect and other variables have negligible ƒ² value. The f² summary table is placed in Table 9. The goodness of fit criterion, the result shows SRMR value of 0.055, within the threshold value of 0.08, and signifies the study’s explanatory power (Henseler et al., 2014; Hu & Bentler, 1998), the result is place in Table 10.

The study's goal was to investigate the motivational factors that influence Nepalese patients' decisions to seek outbound medical tourism in Nepal. This study integrated service quality, procedural safety, treatment cost, insurance policy, language and culture, word-of-mouth communication, and outbound medical tourism for treatment into a single framework and examined the relationship using a sample of Nepalese context. The study purposefully included 382 respondents who had received medical treatment abroad.

According to the study's findings, people were in favor of outbound medical tourism when it was necessary. This is evidence that people are willing to receive medical care and travel overseas for medical tourism. As stated by Kim, Arcodia, and Kim (2019), medical tourism is one of the most recent trends in the tourism industry, and it has the potential to continue expanding at an amazing rate each year. Quality, trained staff, and customized attention were the three most important factors that respondents considered while selecting medical treatment abroad. When seeking treatment in a foreign country, an individual prioritizes safety, confidence, and the quality of diagnostic tests, medication, and facilities with worldwide accreditation and experienced medical professionals. People have faith in the healthcare facility's protocols, standards, and professionals. The study's findings also showed that the cost of treatment influences respondents' decisions to seek medical care overseas. They have a moderate preference for countries with low living and medical costs. Affordable treatment costs have an effect on the destinations they choose for their medical vacations. Outbound medical tourism insurance compels individuals to seek medical attention in a foreign country. There is a strong indication that individuals place priority on language and culture when it comes to medical tourism. Individuals also relied on word-of-mouth information when making judgments about medical tourism overseas.

The study revealed a strong correlation between outbound medical tourism, service quality, word-of-mouth communication, insurance policy, language and culture, treatment cost, and procedural safety. Previous studies such as Lee et al. (2012), Wong et al. (2014), Wongkit and McKercher (2016), Connell (2006), Çapar and Aslan (2020), and Medhekar and Wong (2020) have consistently cited factors such as insurance coverage, medical procedures, and quality of care service for outbound medical tourism. It would appear that geographical proximity is an important, but not a decisive, factor in shaping individual decisions to travel to specific destinations for treatment (Exworthy & Peckham, 2015).

In addition, the research found that the quality of service and word-of-mouth communication have a substantial influence on outbound medical tourism, with the quality of service showing a considerable influence. The findings about the quality of service are consistent with previous research by Whittaker (2008), Gill and Singh (2011), Han and Hyun (2015), Parasuraman et al. (1994), AbdelAziz and Kewina (2022), Shikha and Vallabh (2022), and Zakaria et al. (2023). According to the findings of this research, patients are more likely to return to a medical institution located in a different country if they had a positive experience there. Furthermore, Zakaria et al. (2023) found that the quality of service ranks among the top three factors that influence travelers to seek medical treatment overseas. Zakaria et al. (2023) found that facilities and services serve as exceptional predictors. In addition, the findings in terms of word-of-mouth communication lend support to earlier research such as those conducted by Connell (2006), Johnston et al. (2015), Lu et al. (2016), Hanefeld et al. (2016), Zakaria et al. (2023), and Hyder et al. (2019).

This study found that word-of-mouth influences outbound medical tourism. Most respondents got medical tourism information from friends and family, demonstrating the power of word-of-mouth marketing to attract new clients and promote services. Service quality and word-of-mouth communication strongly affect outbound medical tourism from Nepal, according to this study. Service quality matters because Nepali medical tourists believe international hospitals provide better care than domestic ones. Modern medical technology, skilled healthcare experts, and improved patient care are all compelling reasons for people to seek treatment abroad. Word-of-mouth also shapes medical tourism opinions. Because individuals trust personal recommendations more than other information, positive reviews from friends, family, and the internet can influence their selections.

On the other hand, factors such as insurance policy, language and culture, procedure safety, and treatment cost do not play a significant role in explaining Nepal's outbound medical tourism. These findings do not support the prior research by Crooks et al. (2013), Kumar et al. (2021), and Xu et al. (2020) that discussed the procedural safety associated with medical tourism. Several researchers, including Shikha and Vallabh (2022), AbdelAziz and Kewina (2022), Crooks and Jin (2022), Kumar et al. (2021), Hwang et al. (2018), Yu and Ko (2012), and Drinkert and Singh (2016), cited cost as the key factor in medical tourism. Possible explanations include the fact that Nepal's healthcare system does not have sufficient facilities or services. While private hospitals are in short supply, public healthcare facilities are congested and lacking in both knowledge and technology. As a result, an increasing number of individuals are seeking treatment in other countries. Although there is a sufficient number of skilled medical professionals accessible, the nation does not possess contemporary infrastructure or supplies (Republica, 2023). Furthermore, even if a few hospitals do offer the services, they may be prohibitively expensive.

The results of our study contradict several previous research findings. Notably, studies such as those by Lunt and Carrera (2010), Bányai et al. (2017), Singh (2019), Tseng (2013), Zolfagharian et al. (2018), and Mattoo and Rathindran (2006) have identified a strong connection between outbound medical tourism and insurance policies. Singh (2019) emphasizes that the absence of insurance coverage serves as a significant motivator for individuals to seek medical treatment abroad. However, in Nepal, our findings indicate no significant correlation between insurance policies and outbound medical tourism. The general lack of medical insurance in Nepal could explain this discrepancy, suggesting that other factors influence the decision to travel for medical purposes.

Moreover, prior studies by Mahmud et al. (2021), Musa et al. (2012), Singh (2013), and Olya and Nia (2021) have posited that cultural similarity plays a crucial role in motivating medical tourists to seek treatment in specific destinations. Contrary to these findings, our study reveals that in the Nepali context, language and cultural factors do not significantly impact outbound medical tourism. While Heung et al. (2010) and Pan and Moreira (2018) have highlighted the influence of language on medical tourism destinations, our research indicates that these elements are less critical for Nepali medical tourists.

The lack of universal access to comprehensive health insurance may prevent people in Nepal from prioritizing insurance coverage when deciding whether to seek medical care elsewhere. Alternatively, people may be relying more on personal resources and out-of-pocket expenses, which increases the importance of word-of-mouth recommendations and service quality. While linguistic and cultural affinities are significant in some contexts, medical tourists from Nepal may find that these factors are less significant and instead be more treatment-focused. Many Nepalese patients may place greater importance on the perceived quality of medical care than on linguistic and cultural factors. Furthermore, many highly appreciated medical tourism locations feature a large English-speaking population, which can assist Nepali patients with language challenges.

Nepalese medical tourists already trust that foreign hospitals have superior safety standards than local hospitals; therefore, the perceived safety of medical operations overseas may not be a unique factor. Thus, the belief in greater safety laws in other nations may lessen the importance of this issue in their decision-making. Medical tourists worldwide consider cost, but Nepalese seeking better care abroad may prioritize other criteria. Wealthy patients abroad experience less impact from cost disparities due to their focus on therapeutic quality and efficacy. Additionally, the cost difference between domestic and international treatments may not be large enough to justify choosing better service. The results show that Nepali medical tourists prioritize top-notch medical care and positive reviews. Understanding these factors would help healthcare practitioners and lawmakers in Nepal and potential destination nations better serve this group. We should further study these dynamics to develop more sophisticated methods for facilitating and overseeing external medical tourism from Nepal.

The divergence in our findings suggests that factors influencing outbound medical tourism in Nepal may differ from those in other regions. In Nepal, the primary reasons for seeking medical treatment abroad may be more related to the availability and quality of healthcare services than to insurance coverage or cultural and linguistic similarities. This insight is crucial for policymakers and healthcare providers aiming to understand and address the specific needs and motivations of Nepali medical tourists. Further research is required to investigate these distinct factors and develop targeted strategies that can better meet the healthcare needs of the Nepali population.

The findings of this study shed light on the various dynamics of the elements that influence the decisions that Nepalese people make regarding outbound medical tourism. This study supports previous research on pleasant experiences and trustworthy recommendations, emphasizing the significance of word-of-mouth communication and service quality in various decision-making processes. On the other hand, insurance rules, procedural safety, treatment prices, and cultural considerations are all different in Nepal, which highlights the particular complexities that are involved in making judgments regarding outbound medical tourism.

This study comprehensively presents the complex factors influencing people's decisions for outbound medical tourism in Nepal. Service quality and word-of-mouth Communication plays a pivotal role in the decisions of individuals regarding outbound medical tourism. Notable factors such as insurance policies, procedural safety, treatment costs, language, and culture are associated with outbound medical tourism; however, these factors do not necessarily play a significant role, illustrating Nepal's healthcare choices' unique complexities. These insights can help policymakers, healthcare providers, and stakeholders comprehend and deal with Nepal's outbound medical tourism dynamics. According to Republica (2023), Nepal can increase healthcare confidence and reduce the trend of seeking treatment abroad by investing in emergency services, essential personnel, and suitable facilities. For adequate medical care and services, any developing nation with a large population should invest more as a percentage of GDP in healthcare (Ali & Medhekar, 2018).

This study holds significant implications for policymakers and healthcare providers in Nepal, as it sheds light on the influential factors driving outbound medical tourism. The study revealed that service quality and word-of-mouth communication significantly influence outbound medical tourism. With a deeper understanding of the motivations behind individuals seeking medical treatment abroad, policymakers can design targeted policies and strategies to enhance the domestic healthcare system. According to medical specialists, Nepal can also draw a sizable number of foreigners if it can advertise Nepali hospitals overseas, which offer high-quality services at reasonable prices (Singh, 2004). Effective resource allocation in the healthcare sector is crucial, and understanding the motivations behind outbound medical tourism can assist healthcare providers in making informed decisions. By identifying specific areas for improvement, such as service quality enhancements, ensuring stringent procedural safety measures, and optimizing treatment costs, providers can allocate resources effectively to meet the needs and expectations of patients.

This study offers policymakers various insights to improve Nepal's medical tourism landscape. To address Nepalese patients' particular motives and barriers to outbound medical tourism, policy implications could include investing in renovating healthcare facilities and equipping them with innovative technology and medical supplies. Training and incentivizing healthcare workers to stay in the country ensures constant and high-quality care. Developing patient satisfaction initiatives has the potential to improve word-of-mouth and attract more patients to Nepal. The government should also lower medical costs and make healthcare more affordable by offering financial support or subsidies for people who need pricey treatments, making domestic options more enticing. The government should advocate for comprehensive medical insurance policies that encompass a wide range of treatments and procedures. It can also partner with reputable global hospitals to share information and offer joint treatment programs. Policymakers can make Nepal's healthcare environment more appealing and competitive, reducing outbound medical tourism and potentially attracting inward medical tourism. This strategic allocation of resources can contribute to the overall improvement of the healthcare system, reducing the dependence on medical tourism and promoting the delivery of quality healthcare services within Nepal.

Furthermore, addressing cultural and language considerations is essential to catering to the diverse needs of patients. By investing in language services, providing cultural sensitivity training for healthcare staff, and creating an inclusive environment that respects and embraces different cultures, healthcare providers can enhance the patient experience and satisfaction. This, in turn, encourages individuals to choose domestic healthcare options, reducing their inclination toward outbound medical tourism.

Collaborations and partnerships with international insurance providers can also play a vital role in improving insurance coverage for medical treatments. By establishing alliances and working closely with insurance companies, policymakers can expand coverage options, ensure financial support for patients, and reduce the need for individuals to seek medical treatment abroad due to insufficient insurance coverage. Such collaborations can enhance the affordability and accessibility of healthcare services in Nepal.

Additionally, this study highlights the need for further research in the field of outbound medical tourism in Nepal. Future studies can go deeper into the identified factors, explore additional variables, conduct more comprehensive analyses, and investigate the long-term impacts of outbound medical tourism on the local healthcare system, economy, and patient outcomes. The continuous exploration of these research areas can provide ongoing insights for policymakers and healthcare professionals to refine strategies, adapt to evolving trends, and continuously improve Nepal's healthcare landscape. From a managerial perspective, it is essential for Nepali medical service providers to understand the factors that influence the decisions of Nepali medical tourists when they consider seeking medical treatment abroad. This knowledge becomes crucial as it allows Nepali health institutions to utilize these factors strategically to influence medical tourists' choices positively and encourage them to opt for treatment within Nepal. Therefore, medical service providers should formulate targeted strategies that prioritize these factors to attract potential customers. Particularly important will be placing a significant emphasis on the quality of medical services and ensuring procedural safety.

Furthermore, the goal of this study was to advance knowledge of the factors that motivate Nepali medical tourists to travel overseas for treatment. This study has a small sample size, with the majority of respondents being patients who traveled abroad for medical treatment. Because of time limitations and data quality issues, the researcher limited the inclusion of diagnostic tests in the conceptual model. Future studies can aim to create a more complex model for investigating medical tourism.

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