Keywords

1 Introduction

Health tourism is the new challenge of the twenty-first century and represents the most dynamic sector of global medical travel. Health tourism become a future business from the moment that generates profit for all involved actors. The potential of the market is large and emerging. A powerful health tourism is supported by a modern infrastructure and has the capacity to promote intense natural and cultural resources, but also depends on how the health system is seen in terms of safety and hospitality. Health tourism turns into a real business when those interested in this field understand and exploit all the opportunities offered. Over the years, health tourism has grown in importance and has evolved in the same time with the economic and social changes. There are a lot of specialists who combine the analysis of health tourism with medical tourism, noting that this domain depends one to each other.

Tourism represents the ensemble of measures applied for organizing a travel for many reasons and involves leisure trips and specialized companies (Scorţe et al. 2013). Sometimes medical tourism means medical travel and the medical tourists are people from industrialized and developed nations as USA, Australia, Europe (Purandare 2014). The changes of society had generated new consumer needs or new forms of tourism: medical tourism, cultural tourism, city-break, adventure tourism. Using best marketing strategies, Romania can compete with the most famous medical tourism destinations like India, Hungary and Turkey, with particular emphasis on dental health tourism (Enache et al. 2013). Overall, it begins to be more obvious the competition inside health care industry and patients are following services at a cost as low as possible (Devon 2007). In Europe of the last 20 years there has been an unprecedented comeback of spa tourism. EU countries with a tradition in promoting natural therapeutic factors, such as Germany, Italy, France, Spain, have paid a special attention to this area and have supported the investors in everything they did around these sources of health. The integration of the balneoclimateric resorts in the healthcare system is the concept of Doctor Pratzel, The President of the International Society of Balneology and Climatology. This concept means rehabilitation of the chronically ill with treatment in balneoclimateric resorts (Soare et al. 2011). Health tourism is one of the most dynamic areas in which natural recreation resources can be harnessed, especially for medical purpose (Aluculesei et al. 2013). Medical tourism means the movement of patients for the purpose of medical care and combined with other tourist facilities, with the mention that it has several connotations. The global market for medical tourism is estimated to 100 billion dollars (Iordache and Ciochina 2014). The demand for medical tourism is increasing continuously and patients communicate globally on healthcare issues and medical treatment in other countries than the homeland (Ricafort 2011). In Romania, even if the medical tourism is still at the beginning, there is interest, curiosity and demand for this type of tourism development. Health tourism can generate a mix of accelerated economic growth and technological progress. The global medical tourism market is estimated at 12 million tourists. Medical tourism is the most dynamic sector of the global travel with an annual growth rate estimated at 30 % (Enea and Pupazan 2013). Spa and health tourism include aspects as: the combination between holiday and the recovery of body capabilities, prevent and combat aging, maintaining vitality and beauty (Condrea et al. 2014). Spa tourism is the most expressive form of medical tourism, valuing natural factors with therapeutic role. Regarding spas, they have become a real business and have an annual profit of over 20 million euros at the European level (Munteanu et al. 2013).

2 Literature in Review

Medical tourism must be analyzed in relation to trends in health, global vision, the consumers profile, the medical technology and future trends (Siddharth 2014). A qualitative medical tourism it is based on a high level of patient satisfaction. Qualitative health services means competence, accessibility, efficiency, effectiveness, continuity, physical infrastructure and comfort (Cepoi 2014). Patients travel in foreign countries for medical treatment thanks to: 100 % medical quality, 100 % non-clinical services, relatives, friends, cost/benefits, waiting lists or because they analyzed some challenges as: legal aspects, safety, ethical considerations, economic aspects, language skills or staff qualification. Consumers may travel with the purpose of receiving health care services or combine the travel with an enjoyable vacation (Purandare 2014). Medical and health tourism can mean: cosmetic surgery, spa therapies, fertility or treatment of illnesses. The basic factors, which include ideal climatic conditions, natural resources and geographic location, are the advantages for medical tourism especially for visitors from colder climates (Lee and Spisto 2007). Balneary resort is the most expressive form of health tourism and means the presence of natural therapeutic factors. For medical tourism, the importance of the research of therapeutic properties of the natural factors it is essential for promoting spas. The attention given to health tourism at the international level is point out by the declaration of the 2000 year as “The International Year of Balneology” and the scientific manifestations organized: The International Congress of Balneology from Rome, 2000, with the theme “Balneology for the Third Millennium”, where specialists from different countries presented points of view and valuable solutions for the future of European balneology. Sometimes, especially in the European countries, modern spa cure and balneotherapy form a complex medical treatment. Medical tourism which is practiced in countries such Hungary, Thailand, Tunisia, can be practiced in Romania with the help of the treatments by Dr. Aslan and refers to surgical procedures performed in specialized institution at a lower prices than in other countries (Munteanu et al. 2013).

There are various interpretations and different significations of the two concepts analyzed, namely medical tourism and health tourism and there are levels at which there are interconnected. The conceptual framework it is complex, as we can observe also from the analysis performed by Kelly (2013) (Fig. 1) and the delimitation of these two concepts is difficult and complicated. The economic and social aspects as privatization or global competition are influenced by the institutional and technological structures and in the same time this aspects may influence the health outcomes. The technological aspects and the whole health system, have a high impact for medical tourism. All of this coexist in globalization context and depend one to each other. We cannot confirm which are the limits of the two concepts, noting that there are some specialists who sustain the interdependence of this two concepts, medical tourism being completed by health tourism.

Fig. 1
figure 1

Conceptual framework of globalization and medical tourism. Source: Kelly (2013)

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Romania is an international force through the richness and variety of spa products, with over 200 locations with potential spa natural factors that can solve over 14 types of health problems and 29 spa resorts with national importance (Stancioiu et al. 2013). Romania has a great balneary heritage and own a third of spas resources and mineral resources of the European continent, being placed in the Southeast Europe (Munteanu and Munteanu 2011). Romania has a valuable ground with lakes with therapeutic potential, therapeutic mud and a lot of climatic zones with effect for health. Romania has a huge potential for health tourism, particularly by exploiting the spa resources, especially the therapeutic mud resources located in resorts as: Amara (therapeutic mud for gynecological and endocrinological diseases) Balta Alba (therapeutic mud for dermatologic diseases), Fundata si Nuntasi (therapeutic mud for musculoskeletal problems) Techirghiol (for all mentioned diseases). Romania also has a huge potential for therapeutic cures made with mineral mud which is located in Sibiu, Sovata, Mures, Telega Turda and Salt Lake (Munteanu 2012). In Romania, we can observe littoral resorts, mountain resorts and balneal resorts. One of the classifications of spa resorts in Romania is based on the treated affections. The specialized institutions in this field, divided them into some categories, namely: spas for rheumatic affections at Lacul Sărat, Amara, Băile Felix, Băile Herculane and Eforie Nord; spas for procedures and naturistic treatments at Băile Herculane and Eforie Nord; spas for medical cosmetic treatments in locations as Băile Felix, Băile Herculane and Eforie Nord; spas for respiratory affections at Govora and Slănic Prahova; spas for digestive affections and internal diseases at Olăneşti and Călimăneşti. Localities as 1 Mai or Băile Felix, may be considered international spa resorts, through the high qualitative standards of the medical structures and through the of the international demands that are fulfilled. Other national spa resorts, such as Vatra Dornei, Slănic Moldova or Băile Herculane, aspire to this statute, trying to attract new tourists. Covasna and especially Sovata already attract international tourists that are interested for medical tourism, but need significant investments in the infrastructure in order to raise their standards and to diversify their offer (Erdeli et al. 2011). Romania can develop a qualitative spa tourism and has approximately 8500 mineral and thermal springs. The employers of Spa Tourism field, argue that Romania is the richest country in Europe in terms of spa resource, but only 10 % of resources are exploited (Munteanu and Cinteza 2011).

Romania must intensively promote the extraordinary effects on health offered by therapeutic mineral water springs for internal treatment. Romania has to promote the external effects of the cure with salt water, sulfur water, carbonated waters, alkalinous waters but also litinifere waters. This types of cures with water springs, may be found in resorts such as: Sovata, Amara, Ocna Sibiului, Techirghiol, Slanic Prahova, Govora, Olanesti, Baltatesti, Govara, Olanesti, Borsec, Tusnad, Vatra Dornei, Covasna, Sangeorz-Bai, Slanic Moldova. External cure with salt water it is recommended for a lot of diseases such as: musculoskeletal disorders, degenerative spondylosis or inflammatory spondylosis. External cure can be done in resorts such as: Amara, Sovata, Ocna Sibiu, Balta Alba, Lacul Sarat, Ocna Mures, Ocna Sugatag, Slanic Prahova, Turda, Singeroz-Bai, Calimanesti-Olanesti, Baile Herculane, Tusnad, Buziaş, Covasna and a lot of other resorts (Munteanu 2013). In addition to the potential offered (spas, therapeutic water springs, resorts with salt water), Romania must take the advantage of the existing climatic factors that have therapeutic action. Climatic factors are of several types and may solve various diseases such as: rheumatic diseases, cardiovascular diseases, bronchitis, osteoporosis, intellectual overexertion, neurovegetative disorders. This types of factors may be found in resorts such as: Slănic Moldova, Slănic Prahova, Govora, Băile Olăneşti, Băile Herculane, Sovata, Ocna Şugatag, Amara, Lacul Sarat, Băile Felix, Buziaş, Tuşnad, Borsec, Sinaia, Vatra Dornei, Lacul Rosu, Cheia, Buşteni, Predeal, Păltinis (Munteanu and Cinteza 2011).

3 Objectives of the Research

The first objective of the research is to know the Romanian health tourism and medical tourism potential, related to its current level of development and promotion. The second research objective is to identify the advantages and the vulnerabilities of the Romanian health tourism in order to formulate a several recommendations useful both for interested specialists in this field and both for involved competent authorities.

4 Research Methodology

Research methodology is based on the literature in review. Research methodology includes the identifying and the investigation of the literature but also the analyzing and the synthesizing of the most important information. I investigated the contents of the most recent studies in the domain of heath tourism and medical tourism and extracted the most relevant and important information for this field. Research methods are focused on understanding the health tourism phenomenon but also are focused on the meaning and the importance of medical tourism. I read books and articles specialized on medical tourism theme. I extracted and analyzed relevant information that were contained in some presentations of the scientific conferences. I analyzed the market of health tourism at the intern level and international level and I focused on current trends and on the offered opportunities. I decided to choose this research methodology in order to generate a conceptual framework useful for all interested persons such as: researchers from this field, tourist operators, business persons, economists, medical staff or policy makers.

5 Macro Environment Analysis

5.1 Positive Actions Undertaken for Practicing a Qualitative Medical Tourism and a Qualitative Health Tourism

The Medical Cluster “Health Romania” is the first step made for progress and also to align this field with European Directives and to the EU market requirements. This Cluster brings together top healthcare institutions, health care providers and medical tourism facilitators (Borsan 2014).

Romanian Association of Balneology supports ARB strategy and try to develop health tourism in 2014 by promoting scientific research in the spa field and also by promoting an opened system for a knowledge-based economy that could generate the prerequisites for growth and competitiveness (Romanian Association of Balneology 2014). The Tourism Master Plan led to a hierarchy of the balneoclimateric resorts in accordance with their attractiveness, the existing potential and the competitors in the field (Stancioiu et al. 2013).

In the context of International Forum for Health Tourism, the 5th-Edition, there have been discussed major issues for medical tourism development and the importance of the partnerships in promoting medical tourism destinations (Siddharth 2014). Regarding the medical tourism, Romanian Medical Tourism Association (RMTA) is the first nonprofit association which promotes this concept both nationally and internationally, trying to include Romania among the countries with tradition in medical tourism. This association will promote a small guide that will include the best hospitals and clinics for various treatments (dentistry, cosmetic surgery, rehabilitation, spa) but also the specific attractions and activities in this area (Romanian Medical Tourism Association 2011).

Seytour is the first company in Romania specialized in medical tourism that improves the quality of life through the intermediation of health services, dental surgery and plastic surgery. Seytour intermediates medical services from countries such as Romania, Hungary, Austria, Germany, Switzerland, Spain, France, Italy, Turkey, Greece, USA and more (Seytour 2011). Romanian national strategy for tourism includes the spa treatment resorts for preventing aging, repositioning of traditional spas, implementing new technologies and retraining of medical staff to work in spa treatment centers. In 2015, it is estimated according to data provided by the National Tourism Authority, that medical tourism revenues will be double compared to 2010 and will be over 500 million euros (Enea and Pupazan 2013). We have significant potential to develop dental tourism (Table 1) with low prices and well-trained doctors and we need to intensively promote these positive aspects (Enache et al. 2013).

Table 1 Comparative prices of dental services in three countries of Europe
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5.2 Negative Trends that Are Evident for Nationwide

At a general level we could mention that it does not exist a clear strategy for marketing, are missing the promotional activities, there is not a unique base of tourism information, there is not a system of evaluations and criteria of performance that should be obtained. We have not a good representation of tourism and the presentations of sites is out-of-date (Ministry of Regional Development and Tourism 2010).

At the nationwide we can observe a high level of bureaucracy and the lack of transparency of Government decisions for foreign investment but also the lack of sustainable development of tourism and the early stage of health reforms (Moraru 2011). The volume of the workforce in tourism and the number of specialized employees in medical tourism is gradually reduced (Erdeli et al. 2011) and the level of financing medical tourism research it is at a low level. We do not have relevant information about certain qualitative indicators such as the tourist typology, there are not tourist information centers or spa museums. Another aspect that may influence a negative perception, is the erroneous image of Romania as a “poor country” because of economic interests owned by media across Europe.

6 The General Recommendations Are Based on Several Directions to Improve the Quality of Romanian Health Tourism and Medical Tourism (a Part of This), Such as

The best solutions could be applied through the transfer of best practices from countries that are known in health tourism and medical tourism in terms of high level of promoting, high level of quality of services and the revenues obtained. Analyzing the most requested destinations for medical tourism and their specifics, we can observe how in Thailand, Bangkok Hospital, had served annually more than 500,000 tourists and in India, the Government investing $3.6 billion for medical tourism. The clinics of Singapore have the best methods of diagnosing cancer in the world and the most accreditations of functioning. In Malaysia there is the best-kept secret of medical tourism (Enache et al. 2013). At a nationwide, we may follow in certain strategic directions, how were modernized and restructured the resorts in Portugal, especially that 17 resorts that were fully restored and looks like new (Teixeira 2012). Through the identification of the best practices, we can exchange ideas and experiences with world-renowned centers in medical tourism. We can also establish new alliances between some ministries, organizations and institutions that have impact in the promotion of medical tourism and health tourism. We have to increase the capacity for monitoring the spas and use the E-marketing of medical tourism services in order to provide services at a lower price, on-time and in a personalized way.

7 Conclusions and Discussions

Romania has a huge health tourism potential that deserves to be exploited thanks to the existing natural resources and to the easy access to them. Romanian medical tourism is emerging and deserve special attention from international business community. We need reliable investors and strategic partnerships to develop and implement innovative solutions in order to modernize the Romanian health tourism. To analyze properly the trends in health tourism, we should observe and associate this, with medical tourism. Medical tourism remains an essential component of health tourism. Both terms interact and coexist simultaneously, even if there are still specialists that have contradictory opinions. Health tourism includes as some specialists said, several segments, namely: medical tourism, balneal tourism, thalassotherapy, hydrotherapy, spa and fitness. Medical tourism and health tourism are based on the therapeutic potential of natural factors and it is obvious that these areas are interconnected, the first it is based on spa resources and the second on the balneary resources. Often, balneology and spa forms a complex medical treatment. Medical tourism and health tourism may represent an engine of economic recovery and may improve the quality of health services.