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Article

Medical Tourism in the Region of Thessaly, Greece: Opinions and Perspectives from Healthcare Providers

by
Georgia Giannake
1,
Athina Economou
1,
Theodore Metaxas
1,* and
Mary Geitona
2
1
Department of Economics, University of Thessaly, 383 33 Volos, Greece
2
Department of Social & Educational Policy, University of Peloponnese, 221 31 Tripoli, Greece
*
Author to whom correspondence should be addressed.
Sustainability 2023, 15(10), 7864; https://doi.org/10.3390/su15107864
Submission received: 6 April 2023 / Revised: 8 May 2023 / Accepted: 9 May 2023 / Published: 11 May 2023
(This article belongs to the Collection Tourism Research and Regional Sciences)
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Abstract

:
Medical tourism is considered to be one of the most upcoming and profitable markets worldwide. The objective of the study is to examine the potential and challenges of medical tourism in the region of Thessaly from the perspective of healthcare providers. A cross-sectional study was conducted from May 2020 to December 2021 in all the medical, rehabilitation and elderly care facilities. A questionnaire focusing on the stances and views of healthcare facilities’ managers was constructed. Private health units are more engaged in medical tourism compared with others, and elderly care facilities are not totally involved. Health units mostly provide dialysis, orthopedics, oncology and gynecology medical tourism services. High-quality services, low costs, touristic and cultural interest and climatological conditions are reported as the main challenges for attracting tourists. Investment in facilities and actions and cooperation with banks and tax breaks are stated as the most common policies and ministries and associations as the most important bodies that can promote medical tourism. Medical tourism in the region is underdeveloped. Medical tourism can be a driver of economic growth if relevant policies are designed with the aim to strengthen and promote it.

1. Introduction

Medical tourism is a prosperous multi-billion dollar market, and many countries worldwide have been competing to reap the economic and social benefits it entails [1,2,3]. Traditionally, patients from developing countries travel to health centers in more developed countries where they receive specialized treatments that are lacking in their country of origin [4,5]. In addition, when a minimum quality of medical tourism technology and expertise is met, an arising influx of patients also travels from rich countries to poorer ones because of high-quality medical services provided at trivial costs [6,7]. This opposite flow of medical tourism is occurring due to various factors of medical tourism demand and supply that meet the needs of medical tourists, such as low waiting lists, the availability of services in less developed countries and a lack of access to treatments in the more developed country of origin [8]. Among the determining factors that urge medical tourists to seek an alternative medical tourism destination are the cost of the medical services offered, the medical staff, the reputation of the medical center–hospital and their accreditations [9]. Furthermore, other factors leading to increased demand for medical tourism services are the ease of access, the affordability of travel and the use of innovative health technologies [10].
Through the years, macroeconomic factors, such as the aging population, increasing international mobility and easier access to communication channels, have made the medical tourism market a flourishing, ever-growing industry [11]. Medical tourists’ expenditure balances are estimated 5 to 10 times more than those of the average tourist, and medical tourists always travel with an escort and stay about 2 to 3 weeks in the destination country [12]. International medical tourism revenues in 2016 were valued at USD 61,172 million and USD 105 billion in 2019 [13]. Specialist analysts estimated that, by 2023, 27 million patients will travel for medical reasons, increasing market revenues to USD 120 billion. Furthermore, projections for 2025 suggest that these revenues will reach USD 182 billion [14].
In 2019, according to a World Travel and Tourism Council (WTTC) study, Greece was ranked 25th in the medical tourism market, accounting for 0.4% of total inbound tourism expenditure and 34th out of 46 countries, as reported by the Medical Tourism Index (MTI) [15,16]. The MTI measures the performance of countries in relation to medical tourism based on the assessment of the health and tourism industry as well as on the overall environment of the host country in order to ensure the sustainability of medical tourism services [17,18]. In recent years, Greece has made progress in the promotion of sustainable medical tourism services, taking into consideration that the country was not even included in the MTI list up to 2016 [16]. Hence, Greek studies report that the climate, the natural and economic environment, the modern touristic infrastructure and the high quality of hospitality and health services may strongly support the country in being a target destination for medical tourism [5,19]. Medical services specializing in fertility, dialysis, orthopedic surgery, ophthalmology, dentistry, aesthetics, rehabilitation and recovery are perceived as the most attractive and common [5,19,20,21,22]. In 2021, the health industry was one of the most dynamic sectors of the Greek economy, accounting for 9.7 percent of the Gross Domestic Product (GDP) [23].
The region of Thessaly is located in central Greece and ranked third in the number of healthcare units and sixth in tourist accommodation facilities compared with the other regions, accounting for 7% of the total domestic population [24]. Access to the region is easy and fast and is approximately equidistant from the two major urban centers of the country (Athens and Thessaloniki). Two airports, Skiathos International Airport and the national airport of Nea Anchialos, cover international tourist demands [25]. Furthermore, the port of Volos meets the needs of tourists visiting the Sporades Islands (Skiathos, Skopelos and Alonissos), and the famous mountains of Olympus and Pelion, as well as the rocks of Meteora, make the region an excellent summer and winter destination [26]. Furthermore, the numerous luxury hotels and high-quality public/private healthcare providers in both the onshore and coastal parts of the region make Thessaly an ideal medical tourism destination.
Given the abovementioned advantages of the region, the objective of this study is to examine the potential and challenges of medical tourism in the region of Thessaly from the perspective of healthcare providers. In particular, the study attempts to shed some light on the views of healthcare managers and on policies that could contribute to the development of medical tourism in the region. Thus, the structure of the article is organized as follows. In the first and second sections, an analytical overview of the theoretical and empirical international literature on medical tourism is presented in order to build up our research hypotheses. In the third section, the methodology is presented, and further sections include an analysis of the results as well as a discussion and conclusions.

2. Literature Review

Medical tourism is referred to as a popular mass culture where people often travel to distant countries–destinations to receive medical, dental and surgical care while on holiday [9]. Based on the above, travelers who suddenly fall ill during their trip to another area or country and expatriates who return to their country of origin seeking healthcare are not considered medical tourists. The concept of medical tourism involves the provision of medical care, preventive and diagnostic services, hospitalization and surgery to improve or restore health in the short or long term. Medical tourism includes patients who combine the use of health services with holiday travel, sufferers who have chronic health problems and patients seeking specialized medical services [5,27].

2.1. Motivations for Medical Tourism

The main incentives driving individuals toward medical tourism are waiting lists, availability, lack of access to treatments in their country of residence and the quality of healthcare that is provided in the destination area [8,28]. Furthermore, incentives to seek treatment outside their borders are the ease of access, the use of modern health technologies, affordable travel and medical tourism service costs [10,29]. Each of these driving factors of medical tourism growth is discussed below. The existence and the length of waiting lists in the national health system are considered strong determinants of the demand for medical tourism [12,30]. The delays in performing surgery due to the long waiting list in the area of residence are a decisive factor in the choice of medical tourism [31]. Furthermore, the inability to access certain health services depends on technology that may not be available and legislation that makes it illegal to carry out treatments, such as stem cell treatments, artificial insemination, etc. [32].
The quality of healthcare depends mainly on operational and technological adequacy, and providers’ quality assurance is essential and achieved through accreditation by international organizations [33,34].
For the tourist market, the ease of traveling and the possibility of combining treatment with travel are two main factors that attract patients to seek treatment in other countries. While the treatment outcome and recovery are of primary importance, medical travel offers the patient the opportunity to enjoy a different tourist experience, exploring exotic destinations and different cultures. Medical tourism providers create specialized tourism packages for patients and their companions [2,5,35]. In addition, the cost of medical tourism services is an important demand factor, especially for health-uninsured patients who are often driven to search for alternative medical markets, such as plastic, cosmetic, prosthetic, dental and fertility services, whose costs are prohibitive in their countries of origin [12].

2.2. Medical Tourism Supply Factors

Medical tourism involves many agents, including health; tourism and transportation providers; health insurance organizations; medical tourism certification; and brokerage organizations [12]. An important share of medical tourism is handled by tourism professionals who are in charge of hotels, transportation and the general tourist part of the services offered to health tourists [36]. A prerequisite is the existence of luxury hotels that meet the standards required by legislation for participation in medical tourism programs [37]. The role of new technologies is very important in this field. There is extensive research regarding new technologies and applications in tourism [38] and more particularly on health and medical tourism, such as IR 4.0 technologies, including the Internet of Things (IoT), automation, robotics, virtual reality, artificial intelligence (AI), cloud solutions and big data analytics [39]. However, the most significant part is handled by the health sector, where a wide variety of health services are performed in the realm of medical tourism. These services may include diagnostic, preventive, medical, surgical, rehabilitation and recovery services as well as cosmetic and beauty services in combination with entertainment and cultural festivities in the destination country [5,31,37,40,41]. Medical tourism cannot exist without the skills, knowledge and contribution of medical and nursing staff in providing quality medical services. The combination of high-quality medical services with high standards of tourism and medical infrastructure as well as the cooperation of professionals among all involved sectors is what makes medical tourism successful and provides benefits to all parties [9]. Meeting the medical tourism industry’s high standards and enhancing its service chain can obviously contribute to sustainable tourism development [42]. Furthermore, the medical staff’s high qualifications and partnerships between tourism and health providers accredited by standard organizations enhance the development of sustainable medical tourism [18]. Furthermore, the sustainability of the tourism product mainly depends on the experience of the medical tourism providers as well as tourists [17,18,43].

2.3. Previous Studies and Hypothesis Development

Although the medical tourism industry has captured attention worldwide, there is a shortage of literature that focuses on the industry from a supply perspective. Investigating the service supplier’s perspective, nevertheless, is critical, because it is the supplier’s task to transform resources and demand requirements into value [44]. A combination of international and Greek literature was directed toward the development of three research hypotheses.
Hypothesis 1. 
The involvement of healthcare providers in medical tourism in the region of Thessaly.
As concerns the involvement of health units in medical tourism, Hanefield et al. (2013) examined inbound medical tourism, the medical tourism industry and policymaker opinions in the United Kingdom. The study results showed that in 2010, 52,000 patients sought treatment in the United Kingdom, mainly from European countries and the Middle East [45]. Furthermore, Footman et al. (2015) studied health professionals and key stakeholders in two dialysis centers in the Veneto region of Italy, showing that medical tourists’ demand for dialysis has increased, and the region has become a major medical tourist destination [46]. Moreover, Michalco et al. (2012)’s research in Hungary examined dental medical tourism in four regions and showed that medical tourism has an opportunity for significant further growth [47]. Furthermore, research in Malaysia, Singapore and Thailand on medical tourism has shown that these countries have become global leaders in medical tourism by drawing patients from around the world [29,48,49,50]. In Greece, there are several studies focusing on medical tourism. Velissariou and Tzioumis (2014)’s study examined the provision of medical tourism services in the major hospitals of Northern Greece. The research showed that the main treatments that can be provided for medical tourism are cosmetic surgery, ophthalmology, invasive surgery, hemodialysis, in vitro fertilization (I.V.F.), transplants and cardiological surgery [20]. Furthermore, the research of Theofanides and Papanikolaou (2012), which focuses on Greek private medical tourism providers, indicated that their performance was very frustrating [19]. However, there are no relevant studies focusing on the region of Thessaly.
Hypothesis 2. 
Potentials and challenges regarding the development of medical tourism in the region.
The relationship between medical tourism and economic development has attracted the attention of researchers. Perkumiene et al. (2019) showed that cooperation is one of the most important elements in the medical tourism industry in moving toward sustainability and supporting tourism development [18]. According to Hudson et al. (2012), medical tourism integration between hotels and healthcare providers produces opportunities to share experiences and offer quality services to patients, their families and other guests. The authors also state that the cooperation between hotels and healthcare providers provides benefits to both parties [51]. Hence, a study in Hungary (2012) examining dental medical tourism showed that the low cost and the high quality of services are the main factors appealing to medical tourists [47]. Kim et al. (2022) revealed that developing medical tourism may act as a basis for increasing tourism in general [52]. Pocock and Phua (2011) claim that medical tourism can bring economic benefits to countries [53]. Moreover, the research of Kim et al. (2019) on the service suppliers of South Korean medical tourism, revealed that the key success factors of medical tourism in the country are reasonable prices, the provision of tourism activities for companions and follow-up care [44]. Snyder et al. (2013) found that medical tourism expansion can create new and better-paying jobs, create new opportunities for training and quality improvements [54]. In Greece, there are a few studies examining both the potential and challenges of medical tourism development. The study by Sarantopoulos et al. (2014) focused on the opinions of five-star hotel managers, revealing that tourism companies’ satisfaction is low regarding the performance of medical tourism across Greece, and high-class hotels have the potential to develop. The same study also suggests that policies related to cooperation between healthcare providers can promote medical tourism [37]. Theofanides and Papanikolaou (2012) also showed that the most common supplementary service was the cooperation of Greek private health units with hotels for accommodation [19]. Furthermore, the research of Bartzis (2020), targeting European patients who had been recently discharged from dialysis and IVF units, reported that medical equipment appeared to be very significant to their decision [21]. Furthermore, a survey conducted in Greece (2011) on medical units showed that only one medical unit is accredited by an accreditation body. The same research also states that Greek hospitals have not yet established official agreements with top international hospitals, which could enhance the international medical profile of the country [55]. Furthermore, the research of Paraskou and Babu (2017), focusing on the medical tourists and personnel of assisted reproduction clinics, showed that policies with transparency and dynamic responses to technological changes are lacking in the country [56]. In the region of Thessaly, there is a lack of studies showing the potential and challenges regarding the development of medical tourism in the region.
Hypothesis 3. 
National bodies contributing to the promotion of medical tourism.
As concerns government support in medical tourism growth, Heungs et al. (2010)’s study in Hong Kong reports that government support is essential for the development of medical tourism and should encourage investment through public–private partnership (PPP) initiatives [57]. Furthermore, Ormond and Mainil (2015)’s study, conducted in Europe, showed that national government strategies relative to medical tourism are the key actors in medical tourism facilitation and regulation [58]. Furthermore, Ayoubian et al. (2013) claim that advertising campaigns and exhibitions executed by the relevant ministries in Iran are the responsible bodies for the promotion of medical tourism [59]. The study by Kim et al. (2019) in South Korea underlined the government’s active involvement and investment in the medical tourism industry [44]. In Greece, a study conducted in 2011 confirmed that the country has an important role to play in the market of medical tourism; however, a comprehensive national development strategy is lacking [55]. Sarantopoulos et al. (2014)’s study showed that the medical tourism industry needs active promotional programs and government support [37]. Furthermore, the study by Traouda and Bogiatzides (2021), conducted on public and private artificial kidney units in Thessaloniki, reported the lack of a well-structured and government-financed assistance program. Both studies report that Greece has the potential to be a popular medical tourism destination [22]. However, there have been no similar studies conducted in the region of Thessaly examining the national bodies that could contribute to the promotion of medical tourism.

3. Materials and Methods

3.1. Study Design and Sample Selection

A cross-sectional study was conducted from May 2020 to December 2021, collecting information from the managers of public hospitals, private health units, rehabilitation centers and elderly care units in the region of Thessaly. The duration of the study was expanded because of strict public health protocols related to the COVID-19 pandemic, implemented at all health units in the country.
The methodology chosen was stratified sampling. Stratified sampling ensures that each part of the target population is represented, that the estimation error is reduced and a sufficient number of subjects from subpopulations are present. The strata were defined as the health units of the region of Thessaly. Strata are composed of as homogeneous as possible groups of elements in the target population.
The target population of the research was defined as the health units of the region of Thessaly. Specifically,
  • Five public hospitals provide health services according to the data of the 5th Health Region of Thessaly and Central Greece [60].
  • Thirty-one private health units operate in the region of Thessaly according to the Ministry of Health, Status of Private Clinics [61].
  • Seven rehabilitation centers offer services according to the Directorate of Development Planning of the Region of Thessaly [25].
  • Seven elderly care units, according to the Panhellenic Association of Elderly Care Units (P. E. M. F. I.) [62].
Data collection was accomplished via a self-administered questionnaire. The distribution and collection of the questionnaires were implemented through the online platform Google Forms. Approval was obtained from the Scientific Council of Public Hospitals, and then, the electronic questionnaire was sent, following the approval and guidelines of the administrative office of each healthcare unit. Regarding private health units, rehabilitation centers and elderly care units, the research team requested verbal consent to conduct the survey, and then, the electronic questionnaire was sent after receiving approval from the directorates of the private health units.

3.2. Study Instrument

The relevant literature review yielded several medical tourism-related questionnaires; however, they did not fully meet the purpose of this study. Therefore, a questionnaire focusing on the stances and views of representatives of healthcare facilities was constructed in line with the study’s research goals. In particular, the sources of publications from which some of the questions were drawn are presented in Table 1. The questionnaire was addressed to the executives/managers of all healthcare facilities in the region (public hospitals, private health units, rehabilitation centers and elderly care facilities).
As far as the questionnaire’s structure, the characteristics of the health units, such as the year of establishment, the number of beds, the services and treatments offered and the country of origin, were drawn from the following studies: Theofanides and Papanikolaou’s [19] study focusing on the Greek private clinics, IVF and plastic surgery centers. On a similar note, the research of Velissariou and Tzioumis [20] explored the potential development of medical tourism in Northern Greece. Furthermore, the research of Lovelock et al. [63] examined dental tourism by analyzing the perspectives of dental professionals.
As concerns the questions related to the promotion of the units, the Medical Tourism Association (MTA) hospital survey [64] revealed that the main sources of medical tourism information for healthcare providers are the internet and related health conferences. Similarly, Heung et al. [57] pointed out that the internet and other media channels facilitate the promotion of medical tourism. The promotion of medical tourism activities and the relevant action planning are also discussed in the research study by Ajmera et al. [65]. The study focused on the study of Indian hospitals and the potential to attract medical tourists in the globalized, interconnected environment of contemporary societies.
Follow-up care after hospitalization was examined by Kowalewski et al. [66] in a study of bariatric surgeons that are experienced in medical tourism provision of services and patients that received follow-up care. In line with the above, the research of Footman et al. [46] focused on the region of Veneto, Italy, and it examined whether there is a continuity of healthcare after the consumption of medical tourism services by asking for information provided by health professionals and key stakeholders in dialysis services. Kim et al. [44] pointed out that follow-up care is a major success factor in the medical tourism market of South Korea.
The need for facility accreditation was examined by Peters and Sauer [67]; the study suggested that the most important factor that United States (US) businesses weigh in recommending care providers is accreditation. In addition, the research by Ayoubian et al. [59] studied the attraction of medical tourists to Tehran hospitals and the role of accreditation in public and private hospitals.
The role of government involvement and investment in medical tourism and the use of policies that enhance medical tourism, such as tax incentives or material incentives, are discussed in the research of Kim et al. [44]. Among other things, the researchers underlined that the primary factor in increasing the number of medical tourists is the government’s investment in the industry. Moreover, a study by Snyder et al. (2013) showed the key role of Barbados’ Ministry of Tourism and Ministry of Health in the development of medical tourism [54]. Furthermore, Heung et al.’s [57] survey of private and public hospitals and medical institutions examined the factors affecting the development of medical tourism in Hong Kong. Ayoubian et al. [59] highlighted the role of the Ministry of Health and tourism agencies in promoting medical tourism. Moreover, the research of Tham (2018) on medical tourism in Australia examined the factors that are thought to be instrumental in the future development of medical tourism [28].
Table
Table 1. Relevant studies from which questions were drawn for the empirical part of the study.
Table 1. Relevant studies from which questions were drawn for the empirical part of the study.
QuestionsPublications
Health unit
characteristics		Theofanides and Papanikolaou [19], Velissariou and Tzioumis [20], Lovelock et al. [63]
Services offeredPeters and Sauer [67], Theofanides and Papanikolaou [19], Velissariou and Tzioumis [20], Ajmera et al. [65], Lovelock et al. [63], Kowalewski et al. [66], Kim et al. [44]
PromotionMTA [64], Heung et al. [57], Theofanides and Papanikolaou [19], Velissariou and Tzioumis [20], Ajmera et al. [65], Footman et al. [46]
CooperationTheofanides and Papanikolaou [19], Ajmera et al. [65], Percumiene et al. [18]
Causes of attractionTheofanides and Papanikolaou [19], Kim et al. [44]
AccreditationPeters and Sauer [67], Theofanides and Papanikolaou [19], Ayoubian et al. [59], Velissariou and Tzioumis [20], Kim et al. [44]
Government
Support		Heung et al. [57], Theofanides and Papanikolaou [19], Snyder et al. [7], Kim et al. [44]
Future developmentTham [28]
An anonymous self-completion questionnaire was structured and developed based on reviews of the international and Greek-related literature [7,18,19,20,28,44,46,57,63,65,66,67]. A pilot study was conducted before launching the study. The questionnaire was tested on 10 representatives of health units for the improvement of the instrument and the facilitation of the data collection process. Suitable modifications and adjustments were made accordingly to correct any limitations that rose in the testing phase. Face validity and content validity were performed on the pilot questionnaires [68]. The pilot application questionnaires were not included in the final survey. The questionnaires were divided into 3 sections. The first part includes elements of the characteristics of the health units; the second part contains questions regarding involvement in medical tourism; and the third part includes questions related to policies that aim to strengthen medical tourism growth in the area. The questionnaire included closed questions. A five-point Likert scale was used for several questions. Responses ranged from 1, corresponding to “Not at all”, and 5, corresponding to “Very much”. The remaining questions were answered by “yes/no/do not know and did not answer”.

3.3. Statistical Analysis

The statistical program S.P.S.S. 25 was used to analyze the collected data and to carry out the statistical analysis. The level of research significance was set at 0.05. Descriptive statistics were based on the presentation of descriptive results with absolute numbers (N); percentage distributions related to the characteristics of the structure (public hospitals, private health facilities, rehabilitation centers and elderly care facilities); and questions related to tourism and health, as well as policies to support medical tourism. The answers were provided using a five-point Likert scale (ordinal variables) and categorical variables. There was no need for the test of normality because of the fact that ordinal variables are included in the analysis. The inferential statistics were drawn using non-parametric tests. A comparison of proportions in the respondents’ answers was made using Pearson’s chi-squared test (χ2 test). The statistical significance of the difference between two independent groups was assessed by using the Mann–Whitney U test and between more than two groups using the Kruskal–Wallis test.

4. Results

The final sample of the survey consisted of 133 participants, reaching a 95.1% response rate. In particular, there was complete participation from 5 public hospitals, 7 rehabilitation centers and 7 elderly care units, and a total of 68 questionnaires were collected by the managers of the healthcare units themselves. Out of the 31 private health units in the region of Thessaly, 6 did not wish to participate in the survey; questionnaires are sent to the remaining 25 units, and in total 65 questionnaires from executive personnel were gathered (Table 2).
The characteristics of the health units are presented in Table 3. The majority of the respondents from public hospitals were located in the region of Larisa. On the other hand, the majority of respondents from private health units, rehabilitation centers and elderly care units came from the region of Magnesia. The majority of the participants from private health units, rehabilitation centers and elderly care held the position of Director/Head of Department/Office, and from public hospitals, they held the position of Director of Medical Services. The participants from all health units stated that the health facility has a particular specialization. Finally, private health units, rehabilitation centers and elderly care units stated that they are certified by an organization, compared with a much lower coverage of 30.8% among public hospitals (p = 0.003).
As shown in Figure 1, private health units are more engaged in medical tourism compared with the lowest percentages found for public hospitals and rehabilitation centers (p = 0.002). Elderly care facilities are not engaged. Participants from public hospitals stated that the main services provided in the medical tourism context involve gynecology (11.1%), oncology (11.1%), dialysis units (7.4%) and orthopedic services (7.4%). Private health units reported that they are active in orthopedic services (15.3%) and dialysis units (13.8%), and they also provide such services for obstetrics, emergency medicine and urology (16.9%). Rehabilitation centers mainly provide services regarding the rehabilitation of the nervous system (17.6%) and orthopedic rehabilitation (17.6%).
As shown in Figure 2, public hospitals stated that they wish to further expand the provision of medical tourism services in the fields of cardiology, bariatric surgery and hyperbaric oxygen treatment. The executives of private health units similarly aim to further expand into bariatric surgery, psychiatric/psychogeriatric neurology, pathology and cardiology. Executives from the rehabilitation centers stated their intention to operate on degenerative diseases of the central nervous system. Elderly care units, although not engaged in medical tourism, declared their intention to be active in degenerative central nervous system (CNS) diseases, orthopedics and chronic pain management. It is worthwhile to mention that public hospitals expressed a higher concern for dealing with cardiovascular diseases (p = 0.001), cancer (p = 0.001) and hyperbaric oxygen treatments (p = 0.001) compared with private health facilities. Similarly, elderly care facilities want to deal more with cardiac rehabilitation (p = 0.047) compared with rehabilitation centers, while the latter expressed their interest in providing services regarding orthopedic rehabilitation (p = 0.014) and degenerative CNS diseases (p = 0.025) in the medical tourism context.
Executives of public hospitals (88.9%), private health units (81.5%), rehabilitation centers (70.6) and elderly care units (79.2%) believe that attracting medical tourism is a profitable investment for the health units. Approximately 90% of all units declared that medical tourism could contribute to the creation of new jobs. The majority of respondents from public hospitals, private health units and rehabilitation centers mentioned the high quality of service (24%; 28%; and 37%, respectively), as well as the low cost (33.3%; 24%; and 20%, respectively), as the main reasons for attracting tourists in the region. Elderly care facilities mentioned tourism and cultural interest (35%) as well as climatological conditions (22.5%) as the main reasons. Furthermore, up to 80% of the participants from all health units believe that medical tourism can contribute positively to the economic development of the region of Thessaly (p = 0.974). Nevertheless, public hospitals (25.9%), private health units (38.5%), rehabilitation centers (35.3%) and elderly care units (41.7%) feel moderately optimistic that, in the next 5 years, there will be growth in medical tourism in the region of Thessaly (p = 0.262). It should be also noted that all health units mentioned that tourist accommodation (3.46 ± 0.99) and entrainment and catering businesses (3.19 ± 1.07) are adequately developed in the area.
Moreover, policies proposed by all respondents that could enhance the growth of medical tourism are the financing of actions (4.30 ± 0.87); investments in facilities (4.23 ± 0.84); tax breaks (4.08 ± 0.95); training seminars (3.89 ± 1.00); the creation of an electronic register of health tourism providers (3.75 ± 0.98); cooperation with banks (3.74 ± 1.08); and the creation of a national medical tourism committee/council with representatives from ministries, agencies and provider associations (3.55 ± 1.14). It should be noted that the participants from rehabilitation centers (50%) and private health units (43.3%) stated that their staff is trained to provide medical tourism services, compared with a much lower percentage in public hospitals (24%), and elderly care facilities are not trained at all (p = 0.001). Furthermore, an international patient department/office had 25.8% of private health facilities, as did 14.3% of rehabilitation centers, compared with 0% for public hospitals and elderly care facilities (p = 0.001). The bodies that can promote the growth of medical tourism mentioned by all healthcare providers are the Ministry of Tourism (4.12 ± 1.02), the region/local government (4.10 ± 1.06), the Ministry of Health (3.99 ± 1.02), associations of hospitals/rehabilitation centers/health professionals (3.94 ± 1.08) and other relevant ministries (3.50 ± 1.18).
Statistically significant differences were found between the structures regarding policies that could enhance regional medical tourism activity. In particular, participants from public hospitals were more likely to consider the creation of an electronic register of health tourism providers to be a policy that could enhance medical tourism activity compared with other structures. Similarly, participants from rehabilitation centers were more likely to consider the creation of a national medical tourism committee/council with representatives from ministries, agencies and provider associations to be a policy enhancement, as shown in Table 4. However, there was no difference in the views of the health units with respect to several other policies that might enhance the growth of medical tourism: tax breaks, investment in facilities, training seminars, financing of actions and cooperation with banks.
Furthermore, as shown in Table 5, participants from elderly care facilities were less likely to think that the Ministry of Tourism, as an institution, can contribute to the promotion of medical tourism compared with the remainder (p = 0.400). Similarly, rehabilitation centers were less likely to state that the region/local government can contribute (p = 0.223) to the promotion of medical tourism activities. However, there was no difference between the views of the health units’ participants as to other actors that may contribute to the promotion of medical tourism: the Ministry of Health, relevant ministries and associations of hospitals/rehabilitation centers/health professionals.

5. Discussion

The aim of this study was to examine the potential and challenges of medical tourism in the region of Thessaly from the perspective of healthcare providers. It is estimated that about 40% of private health units in the region of Thessaly are involved in medical tourism, compared with 10% of public hospitals and 20% of rehabilitation centers. Elderly care facilities are not engaged in medical tourism. Furthermore, the participants from rehabilitation centers and private health units stated that their staff is trained to provide medical tourism services, as compared with a much lower percentage in public hospitals and elderly care facilities that are not trained at all. Furthermore, an international patient department/office had more private health facilities and rehabilitation centers compared with public hospitals and elderly care facilities. The high quality of services, low costs, touristic and cultural interest and the climatological conditions were mentioned as the main challenges for attracting tourists to the region. In addition, all healthcare providers declared that tourist accommodation, entrainment and catering businesses are adequately developed in the area. Furthermore, it was found that, although medical tourism activity in the region is not high, about 6 out of 10 of the total units consider targeting medical tourism to be a profitable investment that can further create job openings.
The final results show that dialysis services, orthopedic services, oncology and gynecology in all structures and rehabilitation centers are significant factors influencing the medical tourism field in the region of Thessaly. Although the majority of the sample consider the contribution of medical tourism to the region of Thessaly to be high, they are pessimistic about its development in the next 5 years. As far as policies are concerned, investment in facilities, the financing of actions, tax breaks, cooperation with banks and training seminars are the most commonly proposed policies to enhance medical tourism. Participants from public hospitals are more likely to consider the creation of an electronic register of health tourism providers as a policy that could enhance medical tourism activity compared with other structures. Moreover, participants from rehabilitation centers are more likely to consider the creation of a national medical tourism committee/council with representatives from ministries, agencies and provider associations to be a policy enhancement. Furthermore, ministries and associations were mentioned as bodies that can contribute to the promotion of medical tourism. Participants from elderly care facilities were less likely to think that the Ministry of Tourism, as an institution/body, can contribute to the promotion of medical tourism compared with the remainder. Similarly, rehabilitation centers are less likely to state that the region/local government can contribute to the promotion of medical tourism activities. The majority of the respondents highly assessed the contribution of medical tourism to regional economic growth. Nevertheless, they are quite pessimistic regarding future development prospects for medical tourism in the region.
Our findings are in line with the Greek and international literature findings. Regarding the engagement of private health units in medical tourism, the findings are in line with Nazem and Mohamed’s study [48], which showed that private hospitals have a high degree of satisfaction with their business activity in medical tourism. Furthermore, Pocock and Phua’s [53] research shows that medical tourism is predominantly dominated by the private sector because of profitability. The same results converge with studies conducted in Thailand, Malaysia and India, showing the significant contribution of the private health sector to the promotion of medical tourism [29,34,36,48,53,69]. Furthermore, several studies in Hungary, Italy and the United Kingdom [12,45,46,47] confirm that involvement in medical tourism can be profitable. The findings of Traouda and Bogiatzidis’s [22] research show that Greece has the potential to emerge as a popular medical tourism destination by providing quality medical services, particularly dialysis services. Furthermore, numerous international studies highlight the lure of medical tourism services in orthopedics, knee arthroplasty, cardiovascular diseases and oncology [40,70,71,72].
The majority of general tourists visiting Thessaly choose this specific area mainly because of the high quality of hospitality services, climatological conditions, the culture and the low cost. These are also reported as the most challenging drivers for the development of medical tourism by other studies conducted in the United Kingdom, South Korea and India [12,73,74]. Regarding the role of governments in promoting medical tourism, Ormond and Mainil [58], exploring governing strategies in relation to medical tourism worldwide, report that governments at the national, local and supranational levels recognize that medical tourism is beneficial to economic development and introduce policies to promote it, such as tax breaks, investments in facilities, subsidies and the funding of activities. Hence, studies conducted in Greece confirm that medical tourism contributes positively to economic development at the local and national levels [19,20,21,22,37]. Moreover, international studies report that the promotion of medical tourism contributes to the development of a country’s tourism, the empowerment of health systems and increases in revenue and employment [18,44,51,52,54,75].
Some practical implications can arise from the present study for the further development of medical tourism in the region and the country. As to governmental policies, one is the creation of a national committee for medical tourism in order to unify and coordinate medical tourism planning and decision-making at a national level. Coordinated actions and synergies between the public and private sectors would enhance the promotion of medical tourism. Favorable tax and funding conditions for investors are important policies whose introduction should be taken into consideration. Furthermore, issues related to the certification and accreditation standards are considered crucial. Finally, the creation of an electronic register including data on medical tourists, contracted doctors and medical procedure prices can assist in the development of medical tourism.

Study Limitations

Despite all efforts to address the weaknesses of this research, certain shortcomings still exist. First, this research was carried out in the region of Thessaly and not at a national level. Therefore, the findings should be viewed with caution under this caveat. Thus, further research on the other regions and across the country is needed. The variation between the actual attitudes and views of healthcare providers may have led to an overestimation of responses, which is a second limitation that arose while analyzing the data. Third, the subjective and biased responses that may be inferred from the use of a questionnaire can be seen as an additional limitation of the study.

6. Conclusions

Medical tourism in the region of Thessaly has not developed as much as it should. Participants from all health units strongly believe that medical tourism can contribute positively to the economic development of the region of Thessaly. Nevertheless, they do not feel optimistic that, in the next 5 years, there will be growth in medical tourism in the region. The development of the medical tourism sector entails benefits for the region of Thessaly. Medical tourism can be a driver of economic growth if relevant policies are designed with an aim to strengthen and promote it as part of a larger, concise developmental tourism policy program regarding Greece.

Author Contributions

Conceptualization, G.G.; Methodology, G.G., A.E. and M.G.; Validation, A.E. and T.M.; Investigation, G.G.; Resources, M.G.; Data curation, T.M.; Writing—original draft, G.G. and M.G.; Supervision, A.E.; Project administration, A.E. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

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Sustainability 15 07864 g001 550
Figure 1. Engagement in medical tourism services.
Figure 1. Engagement in medical tourism services.
Sustainability 15 07864 g001
Sustainability 15 07864 g002 550
Figure 2. Intention of (a) public hospitals and private health units and (b) rehabilitation and elderly care units to expand into medical tourism.
Figure 2. Intention of (a) public hospitals and private health units and (b) rehabilitation and elderly care units to expand into medical tourism.
Sustainability 15 07864 g002
Table
Table 2. Final sample.
Table 2. Final sample.
StructureN%Number of Participants
Public hospitals5100%27
Rehabilitation centers7100%17
Elderly care units7100%24
Private clinics3180.6%65
Total 95.1%133
Source: Authors’ calculations.
Table
Table 3. Sample characteristics.
Table 3. Sample characteristics.
Public HospitalsPrivate Health UnitsRehabilitation CentersElderly Care
Units
N (%)N (%)N (%)N (%)
Location
Karditsa1 (3.7)2 (3.1)1 (5.9)2 (8.3)
Larisa15 (55.5)24 (37)5 (29.4)3(12.5)
Magnesia10 (37.0)32 (49)6 (35.2)16 (66.7)
Trikala1 (3.7)7 (10.8)5 (29.4)3 (12.5)
Position
Chairman/CEO/Member of the Board of Directors2 (7.4)11 (17)4 (23.5)2 (8.3)
Director/Head of Department/Office12 (44.4)34 (52.3)12 (70.5)18 (75.0)
Director of Medical Services13 (48.1)20 (30.7)1 (5.9)4 (16.7)
Specialize
Yes15 (55.6)42 (64.6)11 (64.7)11 (45.8)
No12 (44.4)16 (24.6)5 (29.4)11 (45.8)
Do not know 7 (10.8) 2 (8.3)
Accreditation
Yes8 (30.8)55 (73)12 (85.7)16 (66.7)
No11 (42.3)7 (11.1)2 (14.3)4 (16.7)
Do not know7 (26.9)1 (15.9)3 (17.6)4 (16.7)
Source: Authors’ calculations.
Table
Table 4. Comparison of health providers with policies to promote medical tourism.
Table 4. Comparison of health providers with policies to promote medical tourism.
Health ProvidersElectronic RegisterNational CommitteeTax BreaksInvestments in FacilitiesTraining SeminarsFinancing of ActionsCooperation with Banks
Mean (S.D)Mean (S.D)Mean (S.D)Mean (S.D)Mean (S.D)Mean (S.D)Mean (S.D)
Public hospital4.00 (±0.89)3.74 (±1.18)4.18 (±1.01)4.52 (±0.71)3.92 (±1.23)4.24 (±0.93)3.96 (±0.98)
Private health units3.81 (±0.93)3.64 (±1.00)4.02 (±1.02)4.18 (±0.90)3.84 (±0.89)4.23 (±0.88)3.73 (±1.19)
Rehabilitation centers3.88 (±0.96)3.94 (±1.00)4.31 (±0.70)4.12 (±0.70)4.29 (±0.85)4.65 (±0.61)3.75 (±0.87)
Elderly care units3.25 (±1.07)2.87 (±1.29)3.96 (±0.86)4.13 (±0.85)3.67 (±1.05)4.29 (±0.91)3.52 (±1.04)
p-value0.0130.0070.2760.0630.1730.5300.293
1 = not at all; 5 = very much.
Table
Table 5. Comparison of health providers with bodies meant to promote medical tourism.
Table 5. Comparison of health providers with bodies meant to promote medical tourism.
Healthcare ProvidersMinistry of HealthMinistry of TourismRelevant MinistriesRegion/Local GovernmentAssociations
Mean (S.D.)Mean (S.D.)Mean (S.D.)Mean (S.D.)Mean (S.D.)
Public hospital4.00 (±1.23)4.04 (±1.22)3.62 (±1.16)4.16 (±1.21)3.88 (±1.23)
Private health units4.08 (±0.95)4.25 (±0.86)3.52 (±1.18)4.14 (±1.06)4.04 (±1.03)
Rehabilitation centers3.86 (±1.17)4.07 (±1.38)2.92 (±1.50)3.69 (±1.25)3.69 (±1.32)
Elderly care units3.81 (±0.81)3.90 (±0.94)3.68 (±0.89)4.19 (±0.68)3.90 (±0.91)
p-value0.2910.4000.2510.2230.437
1 = not at all; 5 = very much.
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Giannake, G.; Economou, A.; Metaxas, T.; Geitona, M. Medical Tourism in the Region of Thessaly, Greece: Opinions and Perspectives from Healthcare Providers. Sustainability 2023, 15, 7864. https://doi.org/10.3390/su15107864

AMA Style

Giannake G, Economou A, Metaxas T, Geitona M. Medical Tourism in the Region of Thessaly, Greece: Opinions and Perspectives from Healthcare Providers. Sustainability. 2023; 15(10):7864. https://doi.org/10.3390/su15107864

Chicago/Turabian Style

Giannake, Georgia, Athina Economou, Theodore Metaxas, and Mary Geitona. 2023. "Medical Tourism in the Region of Thessaly, Greece: Opinions and Perspectives from Healthcare Providers" Sustainability 15, no. 10: 7864. https://doi.org/10.3390/su15107864

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