Category: Writing

To What Extent Does the Doctrine of Parliamentary Supremacy Explain why the UK Continues to Have an Uncodified Constitution? It is well known among the legal and political communities across the world that the UK possesses quite a unique constitution. Our constitution is different to most others, with the possible exception of Israel and New Zealand, because it is not codified, or contained within one written document. The most recognisable codified constitution is that of the USA, which is contained in one old, formal looking document that is freely available for their public to see.
Having an uncodified constitution has been a somewhat contentious issue for the British over time; however the real question that must be asked is why we continue to proceed with an uncodified document and what reason(s) we have for not having codified it some time ago, in accordance with most of the rest of the world. One such potential reason is that it may infringe on the doctrine of Parliamentary supremacy and that a codified constitution would become the de facto supreme control on British laws, as opposed to Parliament, which has been sovereign since the Bill of Rights was passed in 1689. Of course, there are those that would argue that the doctrine of Parliamentary supremacy has little or no effect on our continued use of an uncodified constitution.
The first argument for our continued use of an uncodified constitution being down to the doctrine of Parliamentary supremacy could be formulated from Dicey’s analysis of the constitution, which sets out the fact that Parliament is indeed sovereign and must remain so, regardless of the constitution or monarch in place at the current time. From this, it could be taken that the constitution has not been codified and made the highest form of legal authority so that the judiciary would not be able to override and refuse to observe Parliamentary statutes on the basis of them being ‘unconstitutional’, as could be done in America. Dicey’s appropriation of the doctrine of Parliamentary supremacy as the core value of British politics and law forms the basis of any argument that our continued use of an uncodified constitution is so as not to undermine the doctrine or even to reinforce the doctrine itself. There have been a series of proposed reforms to the constitution and the desire to codify, entrench and give it a higher place in British law have been expressed time and again.
Of the three main proposals for constitutional reform, Tony Benn’s proposal in 1992 was the first to propose a complete procedural overhaul of the British political system, turning it into a Commonwealth with no monarch, replacing the House of Lords with a publically elected Senate of sorts and the instating of a president and for the constitution only to be amended through referenda, all in order to uphold and follow the new, more rigid constitution. Though the new, reformed House of Lords would not strictly be a constitutional court, this reform would clearly undermine, if not destroy the Doctrine of Parliamentary supremacy and instead, place that power into the constitution and give the Judiciary the ability to challenge any Bill that Parliament should put forward. It can be argued that is mainly, if not only because our system seeks to protect the sovereignty of Parliament; that this proposal never came into effect, because were the Doctrine of Parliamentary supremacy not so important, or even vital to our political system, there would have been no reason to turn this idea into a fully functioning system.
Another, more contemporary argument asserting that Parliamentary Supremacy is what prevents the UK from adopting a codified constitution can be taken from Robert Hazell’s publication ‘Towards a New Constitutional Settlement: An Agenda for Gordon Brown’s First 100 Days and Beyond’, which details a list of political difficulties that would arise, should Britain attempt to adopt a written constitution. One of the reasons is that it would even out the power balance between Parliament and the Judiciary and that should such a motion be voted through, “MPs who are asked to vote for a written constitution will be aware they are reducing their own power”. Another difficulty noted by Hazell is that the codification of the constitution would lead to its entrenchment and writes that “A fully entrenched constitution would become the fundamental source of legal authority… Superseding the traditional doctrine of the sovereignty of Parliament”, therefore it would be somewhat presumptuous and unrealistic to assume that Parliament would vote in such change.
Furthermore, looking once more at Dicey’s Laws of the Constitution, it is taken as a formal constitutional convention that no Parliament can bind its successors, nor can it be bound by its predecessors by means of any law passed. Therefore, there is a somewhat paradoxical problem, in that if Parliament were to pass a law that places the constitution above itself in terms of legal authority, it would be counteracting the constitutional convention on binding future Parliaments and it should be asked whether future Parliaments would be forced to follow the reforms at all, because they would no longer be restricted by the doctrine of Parliamentary sovereignty, but rather, a constitution that was initially not followed in order to give it authority. On the other side of the debate lies the argument that the doctrine of Parliamentary sovereignty has little or nothing to do with the fact that the UK continues to use an uncodified constitution.
Looking once more at the proposed constitutional reforms put forward by Tony Benn in 1992, as analysed by D. Oliver, it must be noted that the changes made to the House of Lords would require the new incarnation to be elected through the ‘Proportional Representation’ system, as opposed to the ‘First Past the Post’ system which was the status quo for elections at the time. Tony Benn’s proposal was made some years before the devolution of Wales, Northern Ireland and Scotland, which incorporated a system of proportional representation. It could be surmised that if his proposal were put forward while the country was under a Liberal Democrat government that supported proportional representation, the outcome would have been vastly different. It can also be noted that the Institute for Public Policy Research (IPPR) proposal would have kept Parliament sovereign, if not strengthened it further and yet, the constitutional reforms in question were not fully carried out.
There are even more reasons why the constitution has not been codified, irrespective of the doctrine of parliamentary supremacy. Looking once more at Hazell’s publication on Gordon Brown’s potential future position on constitutional reforms, it should be noted that the political and procedural difficulties that have nothing in regard to parliamentary sovereignty far outnumber those that do. The lack of public pressure, opinion or priority placed on the topic bring to mind the saying “If it isn’t broken, don’t fix it”, but certainly the most logistically and procedurally problematic factor is the need for a consensus on just what rules and conventions would be considered ‘constitutional’ enough to become law and would form what would then become the highest form of legal authority in the country as well as reaching a consensus on the length and scope of the document. Another reason for our continued use of an uncodified constitution could be explained historically.
In Bogdanor’s ‘The British Constitution’, it is noted that “the constitution has thus remained uncodified precisely because there has never appeared to be a genuine ‘constitutional moment’ and … there is a sense in which England… never began”. In other words, it is possible to trace France’s codified constitution, for example, to the French Revolution of 1789 and the events that followed afterwards. The same can be said for the United States of America and the War of Independence in 1775.
After the death of Oliver Cromwell, the British political system was restored to a monarchy, with the main exception to the systems of the past being further constitutional control over the monarchy. In addition to this historical point, it can also be argued that the reason the UK has not codified its constitution is due to cultural individuality Britain has while it retains its current constitution and the fact that the abolition of a monarchy as according to Benn’s reforms or huge changes in the House of Lords would simply be too expansive a cultural step to undertake at once.
In conclusion, it seems that the doctrine of Parliamentary supremacy goes a considerable distance in explaining why the UK continues to use an uncodified constitution; however, it is not solely the most prominent reason. It can be seen that the doctrine of Parliamentary supremacy or sovereignty is part of a plethora of reasons why our constitution retains its uncodified state, however, that is not to say that there will never be an uncodified constitution, irrespective of Parliamentary supremacy and the logistical and procedural hurdles our system would currently have to undertake to make such changes in one fell swoop; the Human Rights Act 1998, Constitutional Reform Act 2005 and the various other changes made to the British constitution have presented great leaps forward.
Since the British constitution was formulated in a piecemeal manner with components being added, interchanged and amended over time, it is difficult to say what form the constitution will finally take, however, changes will be made. It is quite possible that all of the difficulties our political system faces with constitutional reform now may in fact no longer be the case in the future and the same may even be said for the doctrine of Parliamentary supremacy.
Annotated Bibliography:
Books:
* Bogdanor, V., ‘The New British Constitution’ (2009 Hart Publishing, Oxford). Chapter 1 was the basic source given to me to start pointing me in the right direction. It was particularly chapter 1 that was useful in highlighting the history of the constitution and turning that into an argument for why the constitution remains uncodified. It also provided some background knowledge that helped me to understand the topic better, the knowledge without which I wouldn’t know where to start gathering information.
* Dicey, A.V., (1885), ‘Introduction to the Study of the Law of the Constitution’, All Souls College Oxford, Oxford, found at http://www.constitution.org/cmt/avd/law_con.htm , Accessed 10/12/2010. This book was a necessity in understanding the main functions of the British constitution and historical views on it, especially since Dicey’s rules are such an authoritative source that they are used in nearly every entry on the British constitution that I have come across. Through analysing the fundamental principles of the constitution and how they relate to parliamentary sovereignty, I could build arguments showing that the two are still inexorably linked, therefore the doctrine being the primary reason why we still use an ‘unwritten’ constitution.
* Webley, L. & Samuels, H., ‘Public Law: Text, Cases, and Materials’ (2009 Oxford University Press, Oxford). In specific, the extract from Oliver, D., ‘Written Constitutions: Principles and Problems’ (1992) which helped my understanding of previous proposals to reform the constitution. The three proposals being the MacDonald Constitution, Tony Benn’s Constitution and the IPPR Constitution, respectively. In looking at these proposals, I could see where potential difficulties arose in bringing the changes forward and had to relate them to the question. In looking at the different proposals, I had to ask myself why they weren’t passed and what possible arguments pertaining to the doctrine of parliamentary sovereignty could be formulated. Articles:
* Hazell, R. with contributions from Glover, M., Paun, A., and Russell, M., ‘Towards a New Constitutional Settlement: An Agenda for Gordon Brown’s
First 100 Days and Beyond’ (London: The Constitution Unit, UCL, 2007). This was a particularly useful document for finding arguments for both sides. While there was possibly an overabundance of arguments against the premise that parliamentary sovereignty is the cause for current constitution remaining uncodified, I felt that the arguments for the premise were fairly heavily weighted and consistent enough to form an argument in their own right.
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[ 1 ]. See Dicey, A.V., (1885), ‘Introduction to the Study of the Law of the Constitution’, All Souls College Oxford, Oxford, found at http://www.constitution.org/cmt/avd/law_con.htm , Accessed 10/12/2010. The passage underneath the heading ‘The Sovereignty of Parliament’ in the introduction specifically highlights that parliamentary sovereignty is the most important part of our politics and law. If one was to take that into account as a constant rule, then the constitution has remained as it is so as not to upset this principle, therefore forming the basis of the argument that the Doctrine of Parliamentary Supremacy is the reason for our continued use of an uncodified constitution. [ 2 ]. Oliver, D., ‘Written Constitutions: Principles and Problems’ (1992), Cited in Webley, L. & Samuels, H., ‘Public Law: Text, Cases, and Materials’ (2009) at 72-73, Oxford University Press, Oxford – This passage highlights the most radical and important changes to the British political system that Benn would have introduced, all of which would have a profoundly damaging effect on Parliament’s sovereignty. [ 3 ]. Hazell, R. with contributions from Glover, M., Paun, A., and Russell, M., ‘Towards a New Constitutional Settlement: An Agenda for Gordon Brown’s First 100 Days and Beyond’ (London: The Constitution Unit, UCL, 2007) at 13 – While not all of this list refers to Parliamentary Sovereignty as being the reason for the difficulty in passing constitutional reform, it is definitely possible to argue that the weakening of power in Parliament and the appropriation of the constitution as the primary source of legal power over Parliament are the most noteworthy political blocks to constitutional codification, not least considering the fact that it would have to be voted in by Parliament, thus limiting itself. [ 4 ]. Id.
[ 5 ]. Ibid at 14.
[ 6 ]. See Dicey, A.V., (1885), ‘Introduction to the Study of the Law of the Constitution’, All Souls College Oxford, Oxford, found at http://www.constitution.org/cmt/avd/law_con.htm , Accessed 10/12/2010 – Once again, Dicey’s writings can help these arguments by strengthening the position of Parliament as legal sovereign in Britain. However, if one was to take Dicey’s writings as a set of unbreakable rules or main unalterable pillars for their argument, strange paradoxical problems are encountered when theoretically imagining a Parliament that would actually vote through constitutional entrenchment and codification. [ 7 ]. Oliver, D., ‘Written Constitutions: Principles and Problems’ (1992), Cited in Webley, L. & Samuels, H., ‘Public Law: Text, Cases, and Materials’ (2009 Oxford University Press, Oxford) at 72,– This time around, I have chosen to focus on the new formation of the House of Lords, as opposed to the impact the entire proposal would have on Parliamentary sovereignty. I did so because I believe that it is possible to extract two separate stances from this text, rather than just being able to construct one linear argument. [ 8 ]. Ibid at 73
[ 9 ]. Hazell, R. with contributions from Glover, M., Paun, A., and Russell, M., ‘Towards a New Constitutional Settlement: An Agenda for Gordon Brown’s First 100 Days and Beyond’ (London: The Constitution Unit, UCL, 2007) at 13-14 – It can be seen that the arguments against the premise that the doctrine of Parliamentary sovereignty being the main reason for a lack of a codified constitution do far outweigh those that do, in number, however, the strength of those arguments in comparison is debatable. [ 10 ]. Bogdanor, V., ‘The New British Constitution’, ‘Chapter One: A Peculiar Constitution’ (2009 Hart Publishing, Oxford) [ 11 ]. Ibid at 11. Bogdanor goes on to explain that it is hard to assess when or if at all England had become a modern state, because it is difficult to find breaks in its historical continuity.

Few people would defend the Victorian attitude to children, but if you were a parent in those days, at least you know where you stood: children were to be seen and not heard. Freud and company did away with all that and parents have been bewildered ever seen. The child’s happiness is all important, the psychologists say, but what about the parent’s happiness? Parents suffer constantly from fear and guilt while their children gaily romp about pulling the place part. A good old-rearing manual would permit such barbarity. The trouble is you are not allowed even to shout.
Who knows what deep psychological wounds you might inflict? The poor child may never recover from the dreadful traumatic experience. So too is that parents bend over backwards to avoid giving their children, complexes which a hundred years ago hadn’t even heard of. Certainly a child needs love, and a lot of it. But the excessive permissiveness of modern parents is surely doing more harm than good. Psychologists have succeeded in undermining parent’s confidence in their own authority. And it hasn’t taken children long to get wind of the fact.
In addition to the great modern classics on children care, there are countless articles in magazines and newspapers. With so much unsolicited advice flying about, mum and dad just don’t know that to do anymore. In the end, they do nothing at all. So, from early childhood, the kids are in changes and parents lives are regulated according to the needs of their offspring. When the little dears develop into teenagers, they take complete control. Lax authority over the years makes adolescent rebellion against parents the entire move violent. If the young people are going to have a party for instance, parents are asked to leave the house.
Their presence merely spoils the fun. What else can the poor parents do but obey? Children are hardly creatures (far harder than the psychologists would have us believe) and most of them survive the harmful in influence of extreme permissiveness which is the normal condition in the modern household. Bit a great many do not. The spread of juvenile delinquency in our own age is largely due to parental laxity. Mother, believing that little Johnny can look after himself, is not at home when he returns from school, so little Johnny roams the streets.
The diving ‘line between permissiveness and sheer negligence is very fine indeed. The psychologists have much to answer for. They should keep their mouths shut and let parents get on with the job. And if children are knocked about a little bit in the process, it may not really matter too much. At least this will help them to develop vigorous views of their own and give them something positive to react against. Perhaps there’s some truth in the idea that children who’re had a surfeit of happiness in their childhood emerge like stodgy puddings and fail to make a success of life.

Abstract
Thailand has emerged as a leading medical tourism destination in recent years. The increase in the number of international patients shows that Thailand has great potential for medical tourism and the improvement of its marketing strategies will further increase the image of Thailand as a medical tourism destination. In order to face off the challenges of growing competition form India, Singapore, Malaysia and other destinations, Thailand needs among other things to improve its marketing as a favourite medical tourism destination in the region. Therefore, this exploratory research was set to evaluate the current marketing strategies of healthcare providers and intermediaries through interviews with stakeholders and observation, and to propose effective marketing strategies for preserving and enhancing Thailand’s position as a leading medical tourism destination.
This qualitative research employed semi-structured interviews to examine the current marketing strategies of Thailand’s healthcare service providers. Interviews took place with healthcare service providers (public hospitals, private hospitals, and clinics), medical travel agents and related parties, at several popular tourism destinations of Thailand: Bangkok, Phuket, and Pattaya. Respondents were selected through purposive sampling. In addition, observation of stakeholders’ websites and online marketing of service providers of competitors (Singapore, India, and Malaysia) took place.
The paper identifies the strengths of Thailand’s healthcare service providers and points at a number of problems that may reduce the growth opportunity of this industry. These include lack of practical government policies with regard to medical tourism and of other supporting regulations, lack of organization as a cooperation centre aimed at promoting the medical tourism industry as a whole, remaining low awareness of the opportunities presented by the industry among potential foreign patients, and shortage of doctors and qualified medical staff. Measures for improvement are suggested.
Keywords: medical travel, medical tourism, Thailand, marketing strategies
1. Introduction
Medical tourism is a new form of a niche tourism market which has been rapidly growing in the recent years. The term “Medical tourism” describes tourists who travel to oversea countries to obtain healthcare services and facilities such as medical, dental and surgical care whilst having the opportunity to combine it with visiting the tourist attractions of that country. The main groups of Medical tourists come from the industrialized countries of the world especially Europe, the UK, Middle East, Japan, U.S. and Canada where the cost of medical treatment is very expensive and there are often long waiting times for treatments [1]. Other than Thailand, countries that are currently promoting medical tourism are Bolivia, Brazil, Belgium, Cuba, Costa Rica, Hungary, India, Israel, Jordan, Lithuania, Malaysia, Poland, Singapore and South Korea. The main reasons for the growing popularity in medical tourism are: 1.) The long waiting lists in the developed countries, 2.) The low cost of medical treatments in developing countries, 3.) The affordable international air fares and favorable exchange rates,
4.) The Internet; with the development of communications, new companies have emerged who acts as middlemen between international patients and hospital networks, giving patients easy access to information, prices and option, 5.) The state-of-art technology that has been adopted by the new healthcare services [2]. Thailand has emerged in recent years as one of the leaders in the industry. Data collected from 30 private hospitals by Department of Export Promotion of Ministry of Commerce shows the increasing number of international patients who came to obtain the medical treatments in private hospitals in Thailand. In 1997 only 120,000 patients came for medical treatment; since then, the number has drastically increased to 975,532 in 2003 and 1,356,000 in 2006 (see Figure 1).
Source: Data collected from 30 private hospitals by Department of Export Promotion, Ministry of Commerce (cited in http://mrd-hss.moph.go.th/ac/download.asp) Thailand has a number of competitive advantages: it is already a well-known tourist destination; it is one of the first countries which entered the medical tourism market; it is known for its unique culture of service – the renown Thai hospitality; and also provides high quality services by qualified staff at a reasonable price. Under the guidance and regulation of the Ministry of Public Health, some Thai hospitals have been recognized and approved for the standards set by the Hospital Accreditation of both Thailand and International (Joint Commission International or JCI), and also other international standards such as ISO and Hazards and Critical Control Points Principle (HACCP).
Thailand’s main Asian competitors in the industry of medical tourism are India, Singapore, Malaysia and Hong Kong [3]. India, with its lower cost of health services, has recently emerged as an important competitor to Thailand. It had approximately 150,000 patients in 2004 and the Indian government predicted that this industry could grow by 13% per year in the near future [4]. Despite this, India still lacks the quality of standards and infrastructure, and suffers from a negative image due to the low hygiene and sanitation perception of travelers. Singapore has high living standards, a strong government support for the medical tourism industry, excellent English speaking communication and high quality medical services. Their services are offered at somewhat higher prices than in Thailand but are still much cheaper than in developed countries. In 2006, 410,000 patients traveled to Singapore specifically for healthcare and the country hopes to attract 1 million medical travelers annually by 2012 (www.singaporemedicine.com).
Malaysia also offers low prices for healthcare services, and as a predominantly Muslim country has a competitive advantage in attracting patients from the Middle East [5]. According to the Association of Private Hospitals Malaysia [6], the number of international patients seeking medical services in Malaysia has grown from 75,210 patients in 2001 to 296,687 patients in 2006 and generated 59 million USD in revenue. In order to face off the challenges of growing competition, Thailand needs among other things to improve its marketing of healthcare services.
Therefore, this research was set with the objectives to study and observe the current marketing strategies of service providers in medical tourism in Thailand (public hospitals, private hospitals, clinics, and medical travel agents) and related parties such as the Ministry of Public Health, the Tourism Authority of Thailand (TAT) and to analyze and evaluate the marketing strategies of Thailand and its main competitors in the region (Singapore, India, and Malaysia) in order to come up with a proposal of effective marketing strategies to develop and promote medical tourism in the country. This is the first such study carried out in Thailand, and is expected to enhance knowledge as well as to contribute to the development effective planning in the future and to enhancing the co-operation between stakeholders.
current marketing strategies of Thailand’s medical tourism service providers. Interviews took place with healthcare service providers (public hospitals, private hospitals, and clinics), medical travel agents and related parties, at several popular tourism destinations of Thailand: Bangkok, Phuket, and Pattaya. Respondents were selected through purposive sampling, based on information from secondary data and the researchers’ experience in the area, as well as observation of healthcare providers’ websites.
Criteria for inclusion in the interview list included: membership in Thailand Private Hospital Association, high number of international patients who received medical treatments, active marketing on the Internet, and non-medical care serviced provided to the patients. The interview topics included questions related to current and future target markets and marketing strategies, channel distribution, positioning, main competitors, threats to medical tourism in Thailand, industry collaboration, involvement of new stakeholders, medical travel packaging, and other relevant topics. In addition, observation of stakeholders’ websites and online marketing of service providers of competitors (Singapore, India, and Malaysia) was used to accomplish the objectives of the study.
3. Results and Discussions
The findings from the interviews with the healthcare service providers and observation of stakeholders’ websites about the current marketing strategies used by Thailand’s healthcare service providers are described based on the 7 Ps of marketing mix: Product, Price, Place, Promotion, People, Process, and Physical Evidence [7], [8]. Product: Thailand’s healthcare service providers offer a wide range of tertiary and elective medical treatments such as Cardiology, Orthopedic, Cosmetic and
2. Methodology
This qualitative research employed semi-structured interviews to examine the Plastic surgery, Dental care, Eye treatment, and etc. to attract the international patients. Well-trained medical staff with international board certification (US, UK, Australia, Germany, Japan) are considered as a valuable asset of the companies and used as an important tool to promote healthcare services. The patients of Bumrungrad Hospital and Bangkok Hospital Medical Center (the major player of Thailand’s medical tourism business) can select their required doctors through their websites by name, gender, photo, medical qualification, their specialty, language spoken, and even the working day. Moreover, the cutting-edge technology and equipment available made by each service provider was also used as one of the major products in this industry.
Quality of treatment in a less-developed and developing countries is the major concern raised by the medical travelers from industrialized countries. Most of respondents commented that Thailand is still considered as developing country among Westerners, especially those who have never been in the country before, so the availability of high quality medical care services is not easily recognized – unlike Singapore, with its positive image of high living standards country.
However, the results of previous research [2] about satisfaction with health service in Thailand indicated that most of the patients who have been treated were very satisfied with facility of hospitals, medical staffs’ professionalism, and quality of medical treatments and willing to recommend to their friends/relatives which spread word of mouth information to more potential patients Another marketing strategy used by service providers is to create more value through services. Superior value-added services have been created to differentiate themselves from their increasing competitors, increasing its efficiency, creating convenience for the patients, and developing and strengthening the customer relationships. These non-medical care services are services such as, on-line service for medical arrangement, travel arrangement, interpreter services in many languages (Arabic, Burmese, Bengali, Bhutanese, English, French, Japanese, Korean, German, Spanish, Mandarin, Vietnamese, and etc), luxury service apartments for patients’ relatives adjacent to the hospital, hotel selection and reservation, sightseeing tour services, medical transportation both on land and air, one-to-one nursing care service, and etc.
Major healthcare service providers in Thailand have started expanding their business to other countries by investing in and/or operating hospitals or medical center overseas. These hospitals function as a diagnostic center for screening cases and also for follow-ups in medical treatments. Bumrungrad Hospital invested in the newest private medical center in Manila, Philippines and is investing about US$ 10 million into a new hospital in Dubai, as well as having plans to manage other two new regional hospitals in Yangon, Myanmar and Dhaka, Bangladesh to expand its operations in other potential countries. Moreover, Bangkok Dusit Medical Services Group (a listed holding company operates 17 hospitals in Bangkok, Pattaya, Phuket, and Koh Samui which also includes Samitivaj Hospital, Bangkok Hospital Center, and BNH Hospital) already operates the Royal Angkor International Hospital in Siem Reap, Cambodia and also has future plans of setting up diagnostic centers in Abu Dhabi, and the United Arab Emirates which will be a joint venture hospital network to the UAE and the Middle-East.
It also plans to open a boutique hospital in Phnom Penh, Cambodia which will offer health check-up programs, investigating diseases and primary treatments as well as making referrals of patients to Bangkok Hospital Medical Center in Bangkok for further secondary treatments if needed in the near future. Price: Thailand’s healthcare service providers have a competitive advantage among their competitor due to its high standard of medical treatments and services offered to the patients at a very competitive price. Singapore offer medical treatments at a higher price than Thailand because of its positioning as a high-end complex quality acute care [9]. India offers lower price than Thailand but still has the negative image of poor hygiene and sanitation. India complicated medical procedures are being done only at one tenth of the cost in industrialized countries but in terms of infrastructure facilities such as roads, sanitation, power backups, accommodations, and public utility services much more is needed for the country to become a medical tourism destination [4].
Malaysia offers prices lower than Thailand, partly due to the favorable exchange rate but its focus is mainly on the Muslim patients from Indonesia, Brunei and the Middle East. Place: Internet is the main means for disseminating information related to medical and non-medical care services offered by each of healthcare service providers (both hospitals, and clinics). It is the most effective and inexpensive way to reach the product to its target customers directly, and at the same time helping patients acquire correct and valuable information allowing them to make an informed decision. Informative online marketing of each service provider creates awareness of the medical treatments available and reassures potential patients.
Interactive communication, treatments description, description of services and facilities, quality assurance other concierge services were also presented on the websites to attract the patient who are on medical traveling program. At the moment Thailand does not have a central organization to publicize valuable information on the health care services to the medical travelers. Singapore established the outstanding websitewww.singaporemedicine.com as the center of the country’s healthcare services. It aims at promoting Singapore as a world class medical tourism destination, and has proved very successful in this respect. All the healthcare service providers mentioned that there is the increasing use of agents in the target countries to be representative for them. These agents provide information and recommend the patients regarding their treatments to the hospitals. They work as a center cooperating between patients and hospitals for screening cases, sending all the necessary medical reports of the patients to the hospitals.
And at the same time agents have the responsibility of advertising and doing marketing in those countries for healthcare service providers, spreading word of mouth advertising of service assurance and reliability. Some respondents expressed concerns about the services of the medical travel agents, with regard to low accuracy in the medical correspondence and overpromising to the patients which both lead to overall patient’s subsequent dissatisfaction and create negative image of the medical service provider. Promotion: Most healthcare service providers particularly hospitals participate in travel marts, travel fairs, trade fair, exhibitions, seminars, conferences, and advertise in travel magazines in countries with the supporting from the government. With the cooperation from the Ministry of Public Health, Tourism Authority of Thailand (TAT), Ministry of Foreign Affairs, and Department of Export Promotion (DEP) organized these activities for promoting healthcare services to international markets.
In addition, other informative materials such as brochures, booklets, video-cds, paper bags and t-shirt with logos were also used to create awareness of the available healthcare services as well. Moreover, some healthcare service providers build up cooperation with the local institutes, universities, medical schools in other countries to establish collaboration in education, exchange of knowledge and training as well as to promote their alternative healthcare services. Advertising about medical and nonmedical services in both local and international media are used by healthcare service providers. The advertisement has to be based on Thai laws and regulations about how to advertise healthcare services. Media such as magazines, newspaper (both in Thai and English), television etc. are used to target local people and expatriates who work in Thailand. For the international market, most of respondents stated that they let medical travel agents do the marketing in each target country which is based on their professional background and knowledge about those people’s behavior.
Articles, video, news related to their high quality and standard of medical treatments and services, health issues, latest medical technology equipment, quality assurance/awards/accreditation available on their own websites and also to the international media. These help to create awareness of the available alternative medical treatments as well as to build up a positive image of the high quality and international standard of medical care in Thailand. People: Another strategy that healthcare service providers use to attract the international patients for their treatments in Thailand is to emphasize its well-trained medical specialists, over with degrees from well-known overseas institutes.
It was acknowledged by all the health care service providers that having specialized and qualified doctors and staffs proved a competitive advantage for the hospitals. This has been observed for example on the websites of Bumrungrad hospital and Bangkok hospital, where the qualifications of doctors and hospitality of nurses and the medical staff were intensively promoted to attract and capture the potential patients. However, shortage of doctors and trained medical staff was the major concern currently commented by the respondents. Moreover, language communication skills – sometimes of doctors, but more often of nurses, receptionists, and other relevant staffs – and misunderstanding of the patients’ culture were still considered as problem and challenges for the medical tourism business for both hospitals and clinics.
Process: Patients who seek medical treatments abroad are mostly concerned with the quality of treatments and have to make sure the hospital they select is licensed and preferably accredited by a recognized international organization that audits medical quality. Therefore, acquiring the international accreditation with Joint Commission International (JCI) which recognizes that the standard of the hospital meets or exceeds the standard of medical facilities in the US was used as one of the marketing strategy tools by healthcare service providers. Currently, in Thailand Bumrungrad Hospital, Samitivej Hospital, and Bangkok Hospital Medical Center attained this JCI accreditation, compared to 11 hospitals in Singapore (accounting for one-third of all JCIaccredited facilities in Asia), and 8 hospitals in India [9].
There are other hospital assurance schemes and awards which are also important to guarantee the quality of medical care services, such as Thailand Hospital Accreditation Program (HA) conducted by the Institute of Hospital Quality Improvement & Accreditation, and ISO. Moreover, the result from observation indicated that the websites of the major hospitals display not only JCI accreditation but also other awards and Thai government’s accreditation treatments such as ISO, HACCP, HA (Thailand Hospital Accreditation Program), and so on to reassure the standard and their high quality of medical treatments.
Physical Evidence: Because the healthcare system has developed relatively recently in Thailand, it has been observed that the major healthcare service providers have developed significantly in both infrastructures and facilities. Most hospitals have a good ambience in their buildings with spacious, luxury rooms and excellent amenities same as that of a five star hotel for patients and relatives, and also come equipped with cutting-edge technology. This is a competitive advantage of Thailand in order to gain the confidence and build up the trust of international patients, making a decision to choose Thailand as their preferred choice.
References
[1] Connell, J. (2006). Medical tourism: Sea, Sun, Sand and … Surgery. Tourism Management , 27 (6), 1093-1100. [2] Suthin, K., Assenov, I., and Tirasatayapitak, A. (2007). Medical Tourism: Can supply keep up with the demand. Proceedings, APac-CHRIE & Asia Pacific Tourism Association Joint Conference 2007, May 23-27 May, 2007, Beijing, China. [3] Bangkok Bank. (2005). Health Products and Health Services: Another Industry in which Thailand is Competitive. Retrieved August 25, 2007, from http://www.bangkokbank.com/download/Hea lth_Products_and_Health_Services.pdf. [4] Kaur, J., Sundar. G H., Vaidya D., and Bhargava S. (2007). Health Tourism in India Growth and Opportunities. Proceedings, International Marketing Conference on Marketing & Society, 415-422. Retrieved September 2, 2007, from http://dspace.iimk.ac.in/bitstream/2259/345/1 /415-422.pdf [5] Tirasatayapitak, A., Suthin, K., and Assenov, I. (2007). Medical Tourism in Thailand: Meeting Better the Needs of Japanese Tourists and Patients. Thailand: Prince of Songkla University. [6] Advertising and Publicity Division, Tourism Malaysia. (2007). Media Info Health Tourism in Malaysia, Retrieved April 4, 2008, from http://www.tourism.gov.my/tourismbiz/medi acentre/articles/travelideas/PR%20Health%2 0Tourism%206%20Nov%2007.pdf [7] Kotler, P., Armstrong, G. (2008). Principles of Marketing. New Jersey: Pearson Education, Inc. [8] Chartered Institute of Marketing. (2005). Marketing and the 7Ps A brief summary of
4. Conclusion
The medical tourism industry in Thailand is still growing and expanding in spite of the high competition. Both online and offline promotion tools were used to create awareness of the availability of high quality medical care and non-medical care services, reassure patients about the standards and quality of medical treatments, and offer alternative healthcare services for selection by potential target customers. This research had recommended marketing strategies for further promoting medical tourism in Thailand. These include building and promoting the image of Thailand as “High quality medical tourism destination”, creating and promoting new combination of medical tourism products, promoting as health and wellness destination, exporting healthcare business to other countries, keeping up the high standard of quality treatments at a reasonable price, providing informative online and offline materials and make them available to the potential customers, emphasize on patients’ testimonials (word of mouth), attaining the accreditation/standard to reassure the quality of treatments as well as emphasizing on the needs and demands of the existing target markets and also the potential target markets. This research also identified some issues related to the development and expanding of medical tourism in Thailand which may slow down the growth of this business. The researcher hopes that these issues will be given immediate attention and addressed responsibly and appropriately by the government, healthcare services providers and the other related stakeholders in the nearest future.
marketing and how it works. Retrieved March 1, 2008 from www.cim.co.uk/MediaStore/FactFiles/Factifi le7ps.pdf [9] Boston Consulting Group. (2008). Overview of Medical Tourism – Give back deck. BCG.

Nutritional Care Plan
For this project, you will identify a case study and then develop a nutritional care plan for the client associated with that case. You should begin working on your project in advance of Week 5 as you construct the details of your case. The completed nutritional care plan for your client is due in Week 10.
Please read this entire document to gain understanding of the project scope and those tasks you will complete. This project will take you several weeks to complete. Do not delay beginning the work on this project.
Task 1:
Choose from one of the following stages: pregnancy, infancy and childhood, adolescence, adulthood, and old age.
List the specific nutrition issues affecting individuals in your selected stage.
Task 2:
Choose a disease or medical condition that could possibly, or commonly, affect your individual. This could be anything ranging from diabetes to cirrhosis.
Using the ABCDs of nutritional assessment, create a case study based on an actual client or patient. You can also make one up. Include the following in your case study:
Anthropometrics, relevant biochemical tests, clinical assessment, and dietary intake analysis.
Be sure to include a list of common medications that may be used to treat your patient’s condition and identify potential herb/nutrient/drug interactions that may be relevant.
Identify your client’s cultural background and give clues as to their socioeconomic status and psychosocial variables. For example, your patient may be a senior living alone on a fixed income or might be living in a nursing facility with reputed staff.

Scenario
Acting as the president of a local hospital in an economical and socially deprived county in the US, you have just received a phone call from the state’s CDC office advising the hospital of an outbreak of Whooping Cough. As of now, a majority of the state is being affected by the outbreak and resources are becoming scarce. Your hospital is the only medical center that serves the county. Based on trends and tracking, the CDC believes that your county in which can expect a major increase in patients in the next 48-72 hours with the disease. As the president of the 300-bed hospital which serves a diverse population of 50,000 citizens, it is the president’s responsibility to create a plan of action to help address and treat patients of the county who might become ill in the next 48-72 hours.
The first task you will undertake is to research the disease, its course of treatments, and cures to help effectively treat the potential outbreak. Once you have done so, you will create a presentation that you can give to the county board and e, treat patients, and develop strategies to prevent the spread of the outbreak.
As the president, you will need to work with internal and external vendors on ensuring that the hospital has enough resources and that more resources can be ordered and delivered as quickly as possible. You will need to reach out to and gain assistance from other healthcare organizations in the area to help you track, treat, and control the spread of the disease.  As the leader of the hospital, you will have to make decisions on how to properly manage the shortage of beds, doctors and nurses, and resources that may occur due to the outbreak.
Instructions
Create an executive summary addressing how best to successfully manage the problem outlined in the scenario. This plan has two parts. First is the executive summary followed by a PowerPoint presentation with audio.
Step 1
– Write an Executive Summary covering the following:
Develop an action plan to share with the hospital staff and CDC local office to address and contain the outbreak in an effective and efficient manner at the hospital.
Outline the process of developing alliances and partnerships to help treat and contain the outbreak through the use of efficient and effective approaches to the healthcare delivery systems.
Analyze the organizational decisions needed to be undertaken as a leader; that would play a part in addressing and containing the outbreak along with the use of limited resources.
Determine the best leadership style to use to effectively bring together multiple departments and agencies to work together as one team in containing and treating the outbreak.
Summarize innovative processes needed to address the outbreak given the shortage of resources and time to implement a strategy.
Outline any ethical considerations that should be addressed as part of the strategy in treating and containing the outbreak due to the shortage of resources such as money, manpower, and medicine.
Write a conclusion on the process changes needed to help improve reaction time and containment from the standpoint of the hospital.
Step 2
– Create a PowerPoint presentation with audio
As president of the hospital, you will need to create and record a 5-minute presentation using PowerPoint made up of at least 12 slides covering your findings and suggestions in dealing with the outbreak and containment of the disease. The presentation will be presented to local health officials including the officials from the counties identified by the CDC. Therefore, the style of the presentation needs to be formal. Use the Screencast-O-Matic to record your presentation. (Please send audio link seperately along with the link).

Abstract
The goal of this study was to find out if teachers were teaching nonverbal communication in their classroom, and also if it was important to teach nonverbal communication in the classroom. Teachers have a variety of teaching styles, and techniques. Some teachers using nonverbals and some do not. However, sometimes class size, classification levels, and gender can cause teachers to either use nonverbal communication or not. The participants of this study were asked whether or not their teacher use different types of nonverbal communication in the classroom setting. The study found that students said most teachers in their classes use nonverbal communication to teach. This study also provides support of the importance nonverbal communication has when teaching.
Nonverbal communication in the classroom:
A research about the importance of teaching nonverbal communication
Communication in general is the process of sending and receiving messages that enables humans to share knowledge, attitudes, and skills. Although we usually identify communication with speech, communication is composed of two dimensions, which are verbal and nonverbal. Nonverbal communication has been defined as communication, but just without any words. Communicating is not something we can just do without, nonverbal communication especially considering it can never be shut off, unlike verbal communication we are always communicating nonverbally. One cannot not communicate. Nonverbal communication is always around you and impossible to ignore.
Research, in many studies, has indicated that nonverbal communication can serve a wide range of functions in human interaction. Nonverbal communication is an essential part of every day life. No matter if at work, school, or even at home, nonverbal communication plays a huge role in life. As Blatner (2002) says, “Often people cannot understand the impact of nonverbal communications involved in a situation unless it is replayed and figured out” (pg.3). Teachers need to be practicing and teaching nonverbal communication in the classroom everyday, and that by doing so students will become much better communicators. Nonverbal communication strategies are important to the development of an effective educational system. Nonverbal communication should be practiced in more classes than just communication classes, because no matter what major of study you are in communication is always going to be an essential thing to know.
Many social scientists have conducted research in the field of nonverbal communication as it affects students and educators. Ritchie (1977) found that seven percent of communication is nonverbal. Voice inflection accounts for 38% of the message, and facial expression, including “body language,” communicates 55% of the message. Speer (1972) states that because 90% of the total impact of a message can come from nonverbal elements, sharpening nonverbal communication skills cannot help but make a person a better communicator. So why are not all teachers using this method of teaching in the classroom setting? That is one of the questions I would like to answer in my research. This paper will work to determine if nonverbal communication is essential to be taught in the classroom and the importance of the teaching of nonverbal communication.
Literature Review
Research has been investigated, by many different scholarly researchers, about nonverbal communication and the importance of why it should be taught to students in their learning career. Nonverbal communication can be defined as signing, symbols, colors, gestures, rhythms, and much more. Those are just a few examples that will be discussed (Ritchie 1977). Speer (1972) believes that it is important to know all the different ways to communicate nonverbally and explains all of those ways in the book. Speer (1972) also emphasizes on the fact that in order to communicate, you must first know what nonverbal communication actually is. Pilner, Alloway, & Krames (1974) however compare how humans and animals communicate differently nonverbally and the importance of knowing the different ways, and they also point out how humans and animals can communicate very similarly nonverbally as well. Ethology is the way of studying behavior amongst people. Weitz (1974) refers to ethology as a way to conduct research, knowing how to study different peoples behavior is essential to know before observing how people act.
Visual interactions are also ways of studying nonverbal communication in the classroom, according to Weitz (1974). According to Molcho (1985), nonverbal communication is critical in the classroom setting, especially in interpersonal communication. The most credible messages teachers generate are said to be nonverbal. Duggan (2012) discusses all of the different nonverbal cues and why they are important. For example, he states the importance of facial expressions, gestures, and appearance. Along the same lines Carli (1995), Mayo &Henley (1981) and Thompson (2012) have different articles about differences between men and women and the different thoughts they have on nonverbal communication. He also discusses different research scenarios in which research has been conducted to prove the importance of nonverbal communication, and why men and women communicate differently sometimes.
Area of Study
Nonverbal communication plays a huge role in the classroom, and how teachers should be using nonverbal communication. (Pliner 1974) This paper is a research intended to help understand why nonverbal communication is so important in teaching, and what those importance’s are. Teachers should be using nonverbal communication everyday, in every course no matter what the major of study is. I want to research to see if teachers are using nonverbal communication skills in the classroom environment, and if so how they are using them. My hypothesis is that yes I believe teachers are using nonverbal communication as a way of teaching in their classroom.
If the answer is no however, I will research why teachers are not using nonverbal communication in their every day teaching techniques, and if there are reasons behind why they are not using it. I will conduct surveys in class to see if students believe teachers are teaching enough about nonverbal communication, and if they believe it is important to be learning about. I would ask, does nonverbal communication play a role in the classroom? For instance, is nonverbal communication important in the classroom setting, whether it be how the teacher dresses, lectures, stands, etc. I also want to find out if teachers are teaching enough about nonverbal communication to their students. Are students gaining enough knowledge about nonverbal communication while in the classroom setting? Also, I would like to find out, what is the importance of nonverbal communication. Why should we study this and why do we need to learn this study for our whole careers.
Finally, what would a classroom setting be like with zero nonverbal communication? This consists of no eye contact, appearance codes, gesture, or any other kind of nonverbal communication behavior. The following research questions and hypotheses guide the current study: H1: Students believe teachers are using nonverbal communication to communicate with them on a daily basis. H2: There is no difference between what males believe teachers use in the classroom and what females believe. H3: All ages believe the same thing when it comes to how often their teachers communicate nonverbally and how they are communicating this way. RQ1: Does nonverbal communication play a role in the classroom? RQ2: Are teachers teaching enough about nonverbal communication to their students?
Methodology
Instrument
I used the convenience type sampling method. (see appendix A) This is a nonrandom type sampling; in which I used volunteers in my class to take my survey. The survey contained nine questions. Participants were asked nine questions about how their teachers use different nonverbal communication skills to communicate with them. The students were asked to mark yes or no depending on if the teacher used those certain styles of nonverbals while teaching, Students were also asked some demographic questions: sex, classification, and age. I used evidence by Wilmont (1995), about research of nonverbal communication to come up with my research questions. I developed my questions very carefully before choosing what the right questions were to ask. I thought about questions that could be useful to my research and that would help me develop the results I needed in order to prove or disprove my topic. I choose questions that wouldn’t be offensive to anyone, so that everyone could participate. I was trying to find out the significance of nonverbal communication being used and taught in the classroom setting.
Participants
I had twenty-five students in my research communication class participate in my survey. There were fourteen males and eleven females who participated, however gender doesn’t have much of an affect on my research. The ages for my survey ranged from nineteen to twenty-three years old. All of the students who took my survey were in some kind of communication field. I conducted my survey and distributed it during our class hour, along with everyone else. I distributed my surveys on Thursday October 18th, 2012.
I distributed my survey to each member in the class in a row order. I simply passed my survey out row by row to each class member, and when everyone received my survey they began taking it. When the class was done taking my survey they proceeded to the front of the classroom and put my surveys in a pile for me to pick up. I then took a look at all of my results later that night. I made an excel document and went through each individual paper and recorded my results in to excel. I recorded the number of females and males, class rank, and also the answers to my yes and no questions.
Results
The first hypothesis was concerned with if students believed teachers were using nonverbal communication with them to teach on a daily basis. The hypothesis inferred that students did believe teachers were using nonverbal communication on a daily basis to communicate with them. . This hypothesis was supported. All students answered yes to at least some type of nonverbal communication. The second hypothesis looked at the sex of the students. This hypothesis inferred that the sex of the student was not significant for this survey. This hypothesis was supported. Sex was not significant in the research. Males and females answered mostly the same for every question in the survey.
The third hypothesis looked at age of the students. This hypothesis stated that age was not significant in the survey. This hypothesis was supported. After recording all the results, age was not a factor. All of the students came up with mostly the same answers no matter their age.
Research question one asked if nonverbal communication played a role in the classroom setting. From my survey, students believed that yes, nonverbal communication does in fact play a role in the classroom, and the survey also showed that numerous amounts of different types of nonverbal communication are being used every day in the classroom setting. Research question number two asked, are teachers teaching enough about nonverbal communication to their students? The question was answered yes by every single student. Students believe that yes there is enough nonverbal communication being taught in the classroom.
Discussion
The goal of this study was to see if nonverbal communication was being taught in the classroom and if it was important to be taught. Teachers have many different ways of teaching, and many different techniques but the overall outcome was that yes, nonverbal communication is very important in the classroom and that many teachers do use nonverbal communication on a daily basis to teach. Class size, gender, and classification did not really matter in this study. Previous research has also found that nonverbal communication is a very important factor in teaching as well. My study supported previous research, and agreed that nonverbal communication is being taught in the classrooms, and it is important for teachers to teach and use nonverbal communication.
Another interesting find was that gender did not play a big part in the overall outcomes. I figured since females tend to notice things more, like proximity, gestures, posture, etc., that females would answer a lot differently than males but that was not true in this case. All students believed pretty much the same things.
I was not surprised that students believed nonverbal communication was important because I agree, it is. After conducting my survey I learned a lot of things from classmates. Some of the things I discovered were, body posture is a very important nonverbal in the classroom. Body posture can tell when students understand the content presented or when they have trouble grasping the major concepts. A student who is slouching in his seat sends a very different message than the student who learns forward or sits erect.
I also learned that eye contact plays a very important role in teaching. Teachers often use eye contact in the classroom to decide who is prepared to answer a question, or who has completed a homework assignment. If a student does not want to be called on they will try and have no eye contact with the teacher, and that indicates to the teacher they do not know the answer or wish to not speak. Students also responded that distance is used on a daily basis in the classroom. The teachers are supposed to stand in the front, and the students sit in desks in the middle and back. I also discovered that students would interact more comfortably with a teacher when they are in same vertical plane. Dress being a form of nonverbal communication, I discovered plays a role in every classroom. Teachers dress appropriately for class everyday, as in dress pants, dresses, nice shirts, etc.
Effective teaching depends on successful communication. By definition of non-verbal communication without uttering a single word, teachers and students constantly send messages to each other (Thompson, 2012).
Limits and Future Study
Although my study found a lot of reliable information, there were some limitations. When conducting my survey, although it turned out very helpful, I would have changed the questions and been a little more descriptive with them. For example, I would have not only asked if the certain nonverbals were used in the classroom, I would have also asked when and how these forms of communication were used.
Another limitation was class classification. There were a wide variety of grade levels that took my survey, and all teachers in every grade level have a different way of teaching, so I would have tried to get maybe all Juniors or all Seniors to take my survey. I would have tried to have all people who take the same classes with the same teachers to take the survey.
Future researchers could look more in to how students use nonverbal [communication to communicate rather than just teachers. I think students use just as much nonverbal communication as teachers do and that would be an interesting research to conduct also.
This research was conducted to show the importance of nonverbal communication while teaching in the classroom. Nonverbal communication plays an essential role in the classroom so I believe more studies should be done concerning nonverbal communication.
References
Carli, L. (1995). Nonverbal behavior, gender, and influence. Journal Of Personality And Social Psychology, 68(6), 1030-1041.
Duggan, T. (2012). Nonverbal cues between men and women in the workplace. Hearst Newspapers. Retrieved from
http://smallbusiness.chron.com/nonverbal-cues-men-women-workplace-
11424.html.
Key, Mary Ritchie. (1977) Nonverbal communication: a research guide & bibliography. Metuchen, N.J.: Scarecrow Press
Mayo, C., & Henley, N. (1981). Gender and nonverbal behavior. New York : Springer-Verlag.
Molcho, S. (1985). Body speech. New York, NY: St. Martin’s Press.
Pliner, P., Alloway, T.,Krames, L. (1974). Nonverbal communication: Advances in the study of communication and affect. New York: Plenum Press. Speer, D. C. (1972). NonVerbal Communication. Beverly Hills, Sage Publications.
Thompson, J. (2012). The science and fun of nonverbal communication [Electronic Version]. Are man and woman equals in nonverbal communication?
Weitz, S. (1974) Nonverbal communication: Readings with commentary. New York: Oxford University Press.
Wilmont, W. (1995). Relational Communication. New York: McGraw-Hill.