Keywords

1 Introduction

1.1 Importance of Health Tourism

Health tourism including medical tourism is among the topics that have become a trend in the international travel and tourism industry as well as the health sector [1,2,3,4,5]. Having problems while accessing to health services because of reasons such as high costs of health services in people’s own countries, long waiting sequences, etc., or demanding better quality health care, new treatment options with the high technology opportunities in the target market, desire to have a vacation together with treatment, less travel barriers in world of today, increased physical, mental and social well-being, the need to deal with job stress make the health tourism open to improvement. All these factors have led health service providers, tourism enterprises and holiday destinations to develop products and services to meet this demand [6,7,8].

Health tourism is primarily classified as medical tourism, thermal tourism and wellness & spa tourism, and diversified such as elderly tourism and disabled tourism as well in different sources. In this respect, different destinations stand out for each type of tourism. According to the Global Wellness Tourism Economy 2018 report, the top five countries in wellness tourism are the USA, Germany, China, France and Japan. According to the Medical Tourism Index 2016 data, the first five destinations that stand out in the field of medical tourism in the world, respectively; Canada, UK, Israel, Singapore and India. In this study, it is aimed to compare European Union countries in terms of health tourism and evaluate their potential in order to raise an awareness on health tourism issues in these countries.

2 Conceptual Framework

In the conceptual framework of the study, the health tourism and health tourism types, which are medical tourism and wellness tourism concepts, will be mentioned and health tourism potentials of European Union countries will be evaluated from the medical tourism perspective. Concepts such as health tourism, medical tourism and wellness tourism were searched in databases Google Scholar, Ebsco, and web pages of relevant institutions such as WHO, UNWTO. The research is not exhaustive and aims to compare European Union countries in terms of health tourism and evaluate their potential.

2.1 Health Tourism

Health tourism is a huge international trade industry in which continents, countries, regions, destinations and thousands of service providers compete against each other [5]. Many economic, demographic and lifestyle related factors affect the development of this type of tourism [9]. The term of health tourism was first used in 1973 in the mean of a tour visiting a health facility that uses natural water, climate and the environment of a country. Although there is not a single common definition in the literature about health tourism, its scope is quite wide. Helmy [10] stated that health tourism is a broad concept that includes health care, surgery, plastic surgery, spa, cure treatment, rehabilitation, alternative therapies, healing with leisure [11]. Carrera and Bridges [4] describe health tourism as traveling abroad in order to make individuals’ bodies and minds feel better, develop and renew. According to UNWTO [12]; health tourism is a kind of tourism that contributes to physical, mental and/or spiritual health which is its main motivation through medical and healthy life-based activities. Health tourism in general can be defined as traveling to a different location to receive health and treatment. Although there are different classifications for health tourism, in principle it is classified as medical tourism and wellness-spa tourism.

Medical Tourism

Medical tourism is a form of patient mobility in which patients travel abroad or across borders to obtain health care including transplantation, fertility, cosmetic, dental and elective surgery [13]. Another definition of medical tourism is to go to a place other than residence place for medical diagnosis and treatment or therapy, and at the same time, to benefit from the touristic places and facilities. Medical tourism is an important economic activity combining two important sectors which are tourism and medicine [14]. The concept of medical tourism defines planned actions of patients to receive specially purchased and regulated medical assistance. In this context, the aims of health tourists are to utilize advanced technology in the presentation of health services, to get better quality health care, to access health services faster by avoiding long waiting rows and to reach the necessary medical procedures with lower costs [15]. When the current trends of health tourists are checked, medical tourism mobility ranges from developed countries such as America, EU countries, Canada, to other developing cities such as Bangkok, Singapore, New Delhi, and Seoul. The main reasons for this mobility are to benefit from health services with low cost, improved competencies and time efficiency [11]. Major medical tourism practices are cosmetic surgery, orthopedic surgery, heart surgery and dental applications. The price, quality and availability of the services in the destination play an important role in the decisions of the patients and their families. Therefore, successful sustainable health tourism depends on many issues such as health system structure, legislation, patient safety procedures, education standards, insurance framework, travel and visa restrictions, patient experience and treatment outcomes of the country. In Fetscherin and Stephano [16] medical tourism index study, which was performed in 2015, they measured the performance of country-based medical tourism destinations and identified the first 30 countries. In this study, the EU countries among 30 countries are Germany, England, Italy, France, Spain and Poland. Considering that the European Union population is 508 million and it has the third largest population in the world after China and India, it can be seen that the EU cannot benefit sufficiently in itself from this tourism mobility.

Wellness Tourism

Global Wellness tourism is defined as travels one made to protect and maintain goodness state of his/her own. In this context, body treatments made with healthy living methods and natural products such as all kinds of massage, skin care, mud and algae baths, bath care treatments, thalasso therapy can be counted within the scope of wellness [16]. The word Wellness comes as originally from the association of words WELLbeing and fitNESS. Wellness tourists are described as tourists going on vacation to improve their health and well-being. Wellness tourism is carried out by “healthy” people whose main purpose is to protect or promote their health, and medical tourism is the opposite where medical tourists seek treatment for a certain medical condition or disorder [17]. Wellness tourism, which is estimated to be 639.4 billion dollars in 2017, is a rapidly growing tourism segment. Considering that it has grown by 6.5% annually between the years 2015–2017, it is more than twice the growth rate of general tourism industry. Travelers had a tourism mobility of 139 million in 2015 and 830 million in 2017. While Europe continues to be the target for the highest number of wellness trips across the regions, North America is leading the wellness tourism expenditures [18].

2.2 European Union and Health Tourism

There are opportunities that EU provides for EU citizens in every field. The European Directive 2011/24/EU, which is about cross-border health services, is enabling access to health care for European citizens in every country of the Union. When the demographic structure of the EU is analyzed, aging is one of the biggest social and economic challenges facing the EU [18]. The increase in life length expectancy has brought along issues such as elderly care, management of chronic diseases and improving quality of life. In addition, the costs of health care services have increased in EU countries as in all other countries and this situation has brought along problems such as long waiting order in health systems, changing the scope of health insurance and increasing number of insurance policies.

As seen in Table 1, the total number of trips performed to EU in 2014 is 1 billion 361 million, of which 900 million are domestic and 461 million international travels. The total size of the health tourism market is 61.1 million, including 56 million domestic and 5.1 million international. The share of health tourism in all travels to Europe is 4.3. 5.8% of the arrivals to the EU are domestic and 1.1% are international [19]. The proportion of EU citizens receiving treatment in another EU country for the last 12 months is only 5% and 2% of this is planned [20].

Table 1 Distribution of trips performed to European Union in 2014 [1]
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In terms of overnight stays, health tourism in the EU consists of 233.7 million nights for domestic trips and 16.7 million for international travels, and a total of 250.4 million. The average duration of domestic accommodation is 4.1 nights and for international travels this is 8.5 nights. The share of international health tourism arrivals is between 0.3% (UK) and 5.3% (Estonia). While Sweden, Finland and France have very small international health tourism shares (1–3%), Austria accounts for 35% of international tourists for health care, and for small countries such as Luxembourg and Malta, this number rises to approximately 80%.

In terms of the departures from EU countries for health tourism, the total travels for health reasons (international and domestic) range from approximately 1.3% (UK) to 14.3% (Latvia). International output shares are less than 12% in Romania, Spain, Portugal and France, over 60% in Belgium and Malta, and more than 95% in Luxembourg. When the arrivals coming for the purpose of health tourism, the main actors representing health tourism in the EU are Germany, France and Sweden. These three countries constitute 58% of the market share [19].

Table 2 shows data on EU-28 health tourism for 2014 [20]. Accordingly, EU citizens spend most of their nightly travels within their own countries (75%) or within the European Union (19%).

Table 2 Information on EU tourism, 2014 [21]
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Information Related to Patient Mobility Within EU Countries

According to the European Commission [21] leading countries that form the patient mobility demand are France, Denmark, Poland, Norway and Slovakia. The leading countries in the choice of patients are Germany, Spain, Portugal, Belgium, Czech Republic. It is possible to propose that EU citizens tend to go to neighboring countries. When the mobility of the patients in the EU countries in 2017 is examined, 63% of all patients are French. In addition to mobility in France, the other significant flow is from Denmark to Germany, from Poland to the Czech Republic and from Norway to Spain [21]. In another report, published in 2017, it was stated that the number of wellness tours to Europe in 2015–2017 was 291.8 million. Germany, France and the UK are the first three countries to be preferred. In 2015–2017, the expenditure on wellness tourism was 210.8 billion dollars. The roots of wellness tourism in Europe are very old. Europeans are sophisticated health consumers based on long-standing cultural and historical traditions in the region, which in turn affects their tendency for health travel [18].

3 Conclusion

The medical tourism industry is growing day by day. In 2014, a total of 56 million domestic and 5.1 million international travels were recorded in the EU-28. The share of health tourism in these travels is less than 4.3% of all arrivals. Only 5.8% of domestic arrivals and 1.1% of all international entrances are health tourism travels. Health tourism revenues are approximately 34 billion euros, representing 4.6% of all tourism revenues and 0.33% of EU-28 GDP. France, Germany, Italy, Sweden and Poland are economically important health tourism destinations. More than three-quarters of EU health tourism revenues are only among these five countries. In addition, three-quarters and two-thirds of the total market of EU countries in health tourism belong to wellness tourism [19]. As stated above the share of health tourism in all travels to Europe was only 4.3. The proportion of EU citizens receiving treatment in another EU country for the last 12 months was only 5% and 2% of this was planned [20]. It can be argued that health tourism should be developed within the EU countries. Especially the development in the medical tourism sector will have a positive effect in some related sectors like the hospital industry, the medical equipment industry and the pharmaceutical industry. The medical tourism sector leads to increase in the number of doctors, nurses and medical technicians. Medical tourism has a lot of sub-sectors and plays an important role in the world economy.