Medical Tourism in the Region of Crete, Greece: Perspectives from Healthcare Providers, Hotel Managers, and Medical Tourists

Abstract

Medical tourism is a rapidly growing sector, and could become a major driver of tourism in Greece. This research examines the status quo and the potential of medical tourism on the island of Crete, Greece. A cross-sectional study was conducted from January 2021 to February 2022, with the administration of questionnaires. The study involved the participation of 97 hotel managers from four- and five-star hotels, 515 doctors representing various specialties, and 890 medical tourists. Hotel managers overwhelmingly (90+%) believe that medical tourism can significantly contribute to the domestic economy, as well as that the domestic market is ready for the provision of medical tourism services on a larger scale, while more than 70% of the tourists asked would be interested in travelling to Greece to receive medical treatment. IVF, eye surgery, and dental services are the ones that would interest tourists the most, which are also aligned with the services commonly provided by the doctors questioned. Thus, according to the perspectives of doctors, hotel managers, and tourists, medical tourism has the capacity to grow significantly and contribute to the development of the Greek economy. The government should assume a supportive role, facilitating medical tourism processes by addressing the administrative, financial, and promotional aspects.

1. Introduction

Medical tourism, a phenomenon closely tied to the forces of globalisation [1], has emerged as a result of heightened accessibility to cost-effective air travel alternatives and enhanced cross-border digital communication channels. At the global scale, medical tourism is a sector that is supported by a population of 617 million citizens, experiencing a yearly expansion of 3.9%, and carrying an estimated value of USD 513 billion. The medical tourism business is seeing rapid growth on an international basis, resulting in a substantial revenue of USD 20 billion for various places worldwide [2]. The globalisation of health services is a direct outcome of the use of cutting-edge technology in strategic medical tourism marketing [3]. These advancements have enabled medical practitioners in one nation to effectively promote their services to potential patients located in foreign territories [4]. Concurrently, the escalated movement of healthcare professionals across international borders for educational pursuits has led to a scenario in which medical practitioners rendering services in middle- and low-income economies possess comparable qualifications to their counterparts in high-income Western European and American nations. This trend has been paralleled by an upsurge in foreign direct investments targeting the healthcare providers situated in host countries [5]. The escalating endorsement of healthcare portability is notably conspicuous in Europe, where heightened patient mobility prompted the formulation of a European Union directive addressing cross-border healthcare [6]. This confluence of factors, alongside a rise in out-of-pocket expenditures on healthcare within numerous high-income nations during a period of economic turmoil, synergistically form an ideal market for medical tourism.

Yet, an understanding of medical tourism remains limited. Little information is available about which patients choose to travel and why, and why others do not. Data on the patient flows and resources spent remain uncertain [7]. “This has hampered efforts to understand the economic costs and benefits to countries experiencing inflows and outflows of patients. Similarly, for the medical tourism industry, the role of private providers brokers and marketing remain a black box” [8]. Although there has been an increased focus on this matter in the last ten years, the complete impacts on patients and health systems remain not entirely understood. This study, apart from presenting the perspectives of the “protagonists” of medical tourism in Crete (tourists, medical professionals, and hotel managers), also highlights the capacity of the health system in the study area to address the needs of medical tourism. This issue has not been studied before, although Crete is a key region for medical tourism in Greece.

Crete could justifiably be considered the region of Greece that has made the most strides toward the creation and development of medical tourism services. On the world-famous tourist island, which has ideal climatic conditions and a rich cultural heritage, making it a suitable place to combine vacations and use health services simultaneously, the first Greek medical tourism centres have already been established, operating in various fields such as ophthalmology and endocrinology, serving patients with kidney failure and more.

A series of factors that coexist on the island of Crete offer great prospects for the successful combination of health services and tourism. First of all, Crete—like several other Greek regions—has ideal climatic conditions and a rich cultural heritage, making it a suitable place to combine vacations and the simultaneous use of health services [9]. Furthermore, the island has many high-quality clinics, a university hospital, nine hospitals in total, and a plethora of distinguished doctors of various specialties, as well as high-standard hotels [10]. Moreover, high-class hotels are willing to invest in medical tourism, since they have the capacity and know-how to develop it [11].

It should be noted that tourism is one of the main sources of income for Crete, as it comprises almost 48% of its regional GDP, while it amounts for 23% of the overall tourism revenues in Greece [9]. Given the crisis in traditional forms of tourism, and the favourable factors mentioned above that exist on the island, the prospects for further development of medical tourism services are extremely high.

In this paper, a discussion is made on medical tourism in Greece with a particular focus on the island of Crete and, specifically, on the forces of financial development. First, a literature review on the topic of medical tourism is provided. Then, a conceptual approach is presented followed by an empirical analysis. The empirical analysis focuses on the contribution of hotel managers and health providers and the way these can develop a tourist market in Greece and, more accurately, on the island of Crete. By shedding light on these dimensions, this research aims to provide actionable insights for policymakers, investors, healthcare providers, and the tourism industry at large, fostering a holistic and financially prosperous medical tourism ecosystem in Crete.

2. The Literature Review

The literature review aims to present the current state of understanding regarding medical tourism. It specifically intends to enhance comprehension of the incentives driving patients, the context of the medical tourism industry, the extent of medical travel, and the implications of medical travel for existing healthcare systems.

The term “medical tourism” was initially coined in 1973 by the International Union of Tourist Organizations (IUTO), the precursor to the World Tourism Organization (UNWTO). It pertains to “the provision of health services that use a country’s natural resources, especially mineral, water and climate” [12]. In a perfectly succinct way, the World Tourism Organization describes medical tourism as the activity of travellers who elect to travel overseas in order to undergo various types of medical treatment, encompassing a comprehensive spectrum of medical services [13].

In recent decades, there has been a global increase in the movement of patients, healthcare professionals, medical technology, financial investments, and varying regulatory systems among countries. This phenomenon has led to novel healthcare consumption and production patterns. This emerging trend is primarily attributed to the growing trade in healthcare, involving the cross-border mobility of patients seeking medical treatment, commonly known as “medical tourism” [4]. Medical tourism encompasses instances where individuals choose to travel internationally in pursuit of medical treatment, spanning a broad spectrum of medical services, which most commonly include dental care, cosmetic surgery, and fertility treatments. Notably, patients from more affluent and developed nations frequently travel to less developed countries for healthcare services, motivated by the low-cost treatments available in the latter, coupled with economical flight options and the availability of online information sources [14,15].

It is important to clarify that health tourism and medical tourism are two different concepts, despite the fact that both address the health sector. For the existence of medical tourism, the existence of health tourism is a necessary condition [14]. More specifically, in accordance with the Greek Law 4582/2018, health tourism encompasses medical tourism, thermal tourism, and wellness tourism. More analytically, medical tourism pertains to the movement of visitors or tourists who are grappling with health concerns or chronic diseases to a selected tourist destination. The primary purpose is to access health services provided by lawfully operating primary or secondary healthcare facilities. This is aimed at disease prevention, diagnosis, treatment, and the enhancement or preservation of personal well-being. Tourists/visitors, during their stay, combine medical treatment, information, transportation, and entertainment with activities at the tourist destination for themselves and their companions. In other words, health tourism and medical tourism are alternative forms of tourism [16].

Furthermore, the advancement of medical tourism presents a distinctive prospect for prospective investors, capitalising on the global upsurge in medical tourism and the escalating profitability within this sector. Particularly noteworthy projections suggest that the medical tourism market’s magnitude is poised to expand significantly, ranging from USD 115 billion to USD 346 billion between 2022 and 2032 [17]. An evaluation conducted in 2013 by the World Medical Tourism & the Global Healthcare Congress projected that the aggregate medical tourism market could potentially contribute up to 16% of the comprehensive revenue generated by the broader tourism industry by the present year. This market exhibits the potential to provide a substantial economic impetus to the Greek economy, contingent on the allocation of adequate attention and effective cultivation [18].

Investing in wellness tourism offers immense benefits to investors in the global wellness tourism industry. Wellness tourism, by definition, encompasses tourist activities strategically oriented toward augmenting and enriching an individual’s holistic well-being, encompassing physical, psychological, and spiritual dimensions. This mode of tourism entails participatory engagements in a spectrum of activities ranging from yoga, spa treatments, meditation, and Pilates, to visits to thermal spring retreats. Additionally, the emerging inclination towards interactions with local inhabitants of the travel destination, who have encountered diverse cultures and experiences, contributes to the enhancement of personal well-being [19]. Particularly notable, the wellness tourism sector has exhibited remarkable growth, recording a valuation of USD 814.6 billion in 2022. Projections indicate a trajectory of sustained expansion, envisaging a compound annual growth rate (CAGR) of 11.8% from 2023 to 2030 [19].

Medical tourism is a significant issue for the European Union (EU). If the indirect productivity benefit of medical tourism is omitted, the empirical data imply that medical tourism overestimates a host country’s economic contribution by about 27% [20]. As Greece is a member of the EU, it is crucial to consider the challenges the EU encounters in relation to medical tourism and in what ways the EU can potentially contribute to the emerging market in Greece. One of the challenges that Europe is currently facing regarding health tourism is how to balance two goals: the first one is to ensure that goods and services, that are provided across borders, are of adequate quality, and the second one is to ensure that the freedom of movement is not limited by one’s health, meaning that healthcare is accessible when one travels abroad. Therefore, the question that needs to be addressed is whether European citizens can be confident that they will receive high-quality healthcare services whenever they are needed outside their home country [21,22]. The initial measure to be taken is to guarantee that every country has efficient policies for ensuring the quality of healthcare services. These policies should encourage healthcare that is suitable, effective, tailored to the patient’s requirements, and patiently oriented [23].

The adoption of cutting-edge medical technology has the potential to elevate patients’ impressions of medical tourism and increase the industry’s overall growth rate. Understanding and acknowledging these features is crucial to the success and acceptance of medical tourism. Suitable policies should be established at every level, including the overall healthcare system [24,25,26]. This involves implementing mechanisms that can guarantee the quality of the key components of the healthcare system, such as pharmaceuticals (through the process of registration and licensing), technology (through an HTA or Health Technology Assessment), and healthcare professionals (through training and lifelong education) [27]. Some national policies may be influenced by European frameworks, for example, in the case of the approval of pharmaceuticals, which has been largely determined by the activities of the European Medicines Agency (EMA).

At a clinical level, policies should be in place to improve the procedures and the results of healthcare such as developing and implementing monitoring systems like quality indicators and patient surveys, and quality assurance systems to ensure that the quality of care is maintained and improved over time [28,29]. These systems typically include clinical governance arrangements and audit processes. Furthermore, organisations, facilities, and practitioners have various options, frequently optional, to evaluate the quality of healthcare they offer. These options may entail evaluation by peers or comparison with other providers. Such mechanisms include peer review, accreditation, and involvement in European initiatives such as the ISO-9000 [30] and EFQM [31,32,33,34].

Despite acknowledging the numerous constraints in the data available, it is evident that there is significant diversity among and within EU member states in terms of their strategies and implementation of programs to guarantee the quality of healthcare [35]. However, there are certain elements that are universally or nearly universally applicable, mainly those linked to the safety of pharmaceuticals. Nevertheless, in different fields, for example, when it comes to the quality of clinical activities, there is significant heterogeneity, such as the level of obligation for these activities or their voluntariness. Moreover, there is variability in the degree to which information systems have been developed to facilitate quality assurance initiatives. This encompasses the technicalities of patient databases and their utility in the context of disparities in data protection legislation interpretations [35].

According to data from the EU medical tourism database, it is estimated that in 2014, medical tourism in the EU included about 56 million trips within the country and a little over 5 million trips from international visitors. This adds up to a total of 61 million trips related to medical tourism in EU countries for that year. Medical tourism makes up around 4.3% of all entries into EU countries. This means that medical tourism trips only make up about 5.8% of all trips within a country and about 1.1% of trips from other countries [21].

Wellness tourism takes the lead in the realm of health tourism in the EU, accounting for approximately two-thirds to three-quarters of the entire market. In 2014, the earnings generated from medical tourism in the EU summed up to EUR 47 billion, comprising 4.6% of the entire tourism revenue and 0.33% of the EU’s Gross Domestic Product [21]. When compared on an average scale, the contribution of medical tourism remains relatively modest, given the substantial tourism markets possessed by leading players both within and outside the EU. While the exact count of medical travellers arriving from non-EU nations remains undisclosed, it is presumed to make up around 6% of the comprehensive tourism market [21,36]. A substantial portion—over three-quarters—of the revenue generated from medical tourism within the EU originates from merely five countries: France, Germany, Italy, Sweden, and Poland. Meanwhile, countries such as Finland, Bulgaria, Germany, Spain, and Ireland excel in offering top-notch wellness amenities and lodging facilities. Notably, the highest demand for accommodations featuring health and wellness provisions is observed in Central and Eastern Europe, in addition to Spain and the Southern Baltic Coast. It is important to highlight that the most substantial portions (>10%) of the medical tourism market are witnessed in Finland, Latvia, Slovakia, Hungary, and Portugal [21].

In summary, empirical investigations indicate that medical tourism holds significant potential for bolstering the Greek economy [37]. Particularly within the context of Greece grappling with economic challenges, juxtaposed against its status as a nation both confronting adversity and harboring globally renowned specialists, the prospects for reaping advantages from this undertaking are discernible. Pertinently, medical tourism stands to yield favourable outcomes by extending the tourist season, thereby achieving an equitable dispersion of tourist influx both spatially and temporally. Operating as a notably lucrative industry (with a market size estimated at USD 115.6 billion in 2022 and expected to surpass USD 346.1 billion by 2032), medical tourism further contributes to its positive influence [17]. Noteworthy is the demographic shift that has taken place, wherein the 65+ age cohort constitutes around 20% of Europe’s overall population [38]. This demographic transition unequivocally positions medical tourism as a dynamic sub-sector within the tourism domain. Consequently, this demographic cohort emerges as a prominent force in shaping contemporary travel patterns, characterised by the convergence of time availability, requisite financial means, and a palpable inclination for intra- and inter-country travel [39].

3. Materials and Methods

The primary purpose of this research is to record and analyse the knowledge and perceptions of the hotel managers and healthcare providers regarding the current dimensions and prospects of medical tourism in Crete. In particular, issues of infrastructure, organisation, and operation of medical tourism in Crete, development prospects, and investments were investigated. In addition, the potential of Crete to bring about satisfaction in the ranks of visitors in relation to medical tourism was studied. Finally, the research also aimed to investigate the demand side, which is reflected in the tourists, to see if they have a positive view of Crete as a medical tourism destination. The research hypotheses were based on exploring the views and attitudes of hoteliers, doctors, and tourists regarding medical tourism.

The empirical analysis of this research is presented on the special case of medical tourism in Greece and on Crete in particular. The primary methodological approach employed in this study involved the administration of questionnaires. A cross-sectional study was conducted from January 2021 to February 2022. The study’s length was extended due to the strict public health regulations associated with the COVID-19 epidemic.

The first target group that was interviewed were the hotel managers. In particular, a primary survey was conducted on 97 hotel managers of 4- and 5-star hotels on the island of Crete, out of the 218 that exist on the island. The second target group was the medical profession. Corresponding questionnaires were answered by 515 doctors of various specialties, out of the 1500 registered in the lists of the medical associations of the four prefectures of Crete. The final target group focused on the medical tourists. For this particular group, 890 questionnaires were answered.

The distribution and collection of the questionnaires were carried out electronically. The questionnaires were sent to the electronic addresses of the hotel managers and doctors and were then returned back to the researcher electronically. In addition, after sending the questionnaires, the hotel managers and doctors were contacted in order to provide a brief, informative discussion on medical tourism.

Finally, the data from the questionnaires were extracted from different statistical programs for each responding group and were subsequently subjected to statistical analysis, facilitating a comprehensive descriptive analysis of the research findings. The first questionnaire answered by the hotel managers was carried out through the Qualtrics Survey Platform, while the doctors’ questionnaire was distributed and evaluated via Google Forms. The questionnaires concerning tourists were disseminated to the respondents by the Mediterranean Agronomic Institute of Chania (MAICH) at Chania’s international airport. Regarding the questionnaires answered by the tourists, their analysis was evaluated via the IBM SPSS Statistics Standard Edition v26. The surveys were conducted according to GDPR guidelines.

4. Results

4.1. Empirical Analysis on Medical Tourism on the Island of Crete, Greece

4.1.1. The Hotel Managers

As mentioned above, 97 hotel managers of four- and five-star hotels in Crete, out of the 218 that exist on the island, replied to our questionnaire.

About half of the respondents were university graduates (47.42%), and four out of ten had a postgraduate or doctoral degree (39.18%), with 7.22% being graduates of vocational training institutes. Also, 6.19% responded that they were high school graduates (

Table 1. Educational background and years of professional experience of the hotel managers.

Educational Background
#	Answer	%	Count
1	High School	6.19	6
2	Vocational Training	7.22	7
3	University	47.42	46
4	Masters–PhD	39.18	38
	Total	100	97
Years of Professional Experience
1	0–3	17.71	17
2	4–5	22.92	22
3	6–10	23.96	23
4	11+	35.42	34
	Total	100	96

). Concerning their professional experience in the field, more than one out of three (35.42%) respondents had 11 years or more of experience, while 17.71% had up to 3 years of experience. Also, almost one out of four had 4–5 years of experience (22.92%), as well as 6–10 years (23.96%) (Table 1).

Moreover, the replies of the hotel managers showed that 9 out of 10 consider that medical tourism can be a driving force for the development of the Greek economy, as well as of the Greek region (

Table 2. Medical tourism as a driver of the country’s development.

#	Answer	%	Count
1	Yes	89.7	87
2	No	6.2	6
3	No Reply	4.1	4
	Total	100	97

).

In terms of the support and development of medical tourism, almost all hotel managers (95.83%) believed that they should be supported by the competent bodies, but also by the state (89.58%). In order for medical tourism to thrive in Crete and with it the development of the economy, the opinions of the hotel managers varied, since their answers showed that there must be tax exemptions (63.9%), financing through NSRF programs (58.8%), easier lending from banks (50.5%), as well as support and promotion by local authorities, the municipality and the regional administration (

Table 3. Entrepreneurship development in medical tourism.

#	Answer	%	Count
1	Tax Deductibles	63.9	62
2	Financing Actions Through NSRF	58.8	57
3	Favourable Business Lending	50.5	49
4	Other	7.2	7

).

Regarding the local market of Greece and the extent to which it can support medical tourism, nearly 60% of the hotel managers considered the Greek market ready to provide medical tourism services and, in addition, a very large percentage of hotel managers, almost three out of four (70.84%) believed that the market will support this form of tourism (

Table 4. Readiness of the local market for the provision of medical tourism services.

#	Answer	%	Count
1	Yes	59.8	58
2	No	27.8	27
3	No Reply	12.4	12
	Total	100	97

).

Equally, regarding the state of tourism in Greece, three out of four hotel managers considered it to be better than in previous years. Also, almost one in two considered that Greece cooperates a lot with other countries, while one in four considered that this happens only to a moderate degree. The above information may also explain the fact that three out of four hotel managers answered that it is necessary to invest in medical tourism. Also, concerning the promotion of Greek medical tourism abroad, the opinions of hotel managers were divided between promotion either through the media, international exhibitions and conferences, or through the internet.

4.1.2. The Medical Profession

Half of the doctors who responded to the survey were active in the prefecture of Heraklion (51.2%), one out of four in the prefecture of Chania (25%) and one out of ten in the prefectures of Rethymnon (12.6%) and Lasithi (11.2%). The positions held by the doctors who participated in the survey were as follows: 33.2% of them were medical staff, 23.7% were managers, 40.3% were owners, and 2.8% were members of the board of directors. Finally, regarding the years of experience of doctors in their field, 44.6% of the respondents answered that they had been working for 11–20 years, 35.7% for 21–30 years, 11.7% for up to 10 years, and 8% for 31 years and above (

Table 5. Demographic characteristics of medical professionals.

Location of Office/Clinic/Hospital
#	Answer	%	Count
1	Chania	25	129
2	Rethymno	12.6	65
3	Heraklion	51.2	263
4	Lasithi	11.2	58
	Total	100	515
Position at the Office/Clinic/Hospital
1	Medical Staff	33.2	171
2	Managers	23.7	122
3	BoD Members	2.8	14
4	Owners	40.3	208
	Total	100	515
Years of Professional Experience
1	0–10	11.7	60
2	11–20	44.6	230
3	21–30	35.7	184
4	31+	8	41
	Total	100	515

).

From the answers given by the doctors, it seems that they are positive to invest in medical tourism, since more than 80% of them considered that there is a great need to invest in this sector. Also, 95.3% were in favour of the opinion that medical tourism will help the development of the Cretan region.

Regarding the development and support of medical tourism, 9 out of 10 doctors believed that it should be strengthened by the competent agencies and, more specifically, they answered that for the development of the project, local private initiative agencies, the region, and the municipalities should be actively involved. In fact, 4 out of 10 doctors supported the idea that the above agencies should act collectively and jointly. As for how entrepreneurship in medical tourism will develop, the doctors made three main propositions: Financing through NSRP programs was supported by the majority of the doctors, standing out at a rate of 86.4%, followed by the introduction of more flexible banking policies (67.11%) in combination with policies regarding tax exemptions (56.8%). Also, a large percentage of the doctors, 9 out of 10, believed that the state should strongly support the development of medical tourism, while about 5% were moderately in favour of this opinion.

In the area of the local market, two out of three doctors believed that Crete is ready to offer medical tourism services, with only 18.2% having the opposite opinion. The percentage was even higher when asked if the local community was able to support the project in question, with 84.6% answering that it can do so to a large extent.

Another important parameter concerns the nature of the health services provided. Subsequently, most doctors answered that the services provided in their work organisations were pathological (61.4%), while to a lesser extent surgical (33.8%), clinical (29%), and laboratory (29%) services. On the other hand, only 13.8% answered that dental services were provided (

Table 6. Health services provided in clinics/dispensaries/hospitals.

#	Answer	%	Count
1	Pathological	61.4	316
2	Surgical	33.8	174
3	Labrotary	29	149
4	Dental	13.8	71
5	Clinical	29	149
6	Others	11	57

).

4.1.3. The Medical Tourists

Concerning the medical tourists, 7 out of 10 were positive about visiting Crete for medical tourism, a percentage which is highly satisfactory. The number of tourists who responded to the respective questionnaires was 890. Out of those who answered the questionnaires, 37.36% were men and 62.64% were women. A total of 18.56% of the respondents were aged 16–24, while 16.31% were aged 25–34, 19.46% were aged 45–54, 21.93% belong to the 45–54 age group, 16.20% to the 55–64 age group, and, finally, 7.54% were aged 65 and above (

Table 7. Demographic characteristics of tourists.

Age
#	Answer	%	Count
1	16–24	18.56	165
2	25–34	16.31	145
3	35–44	19.46	173
4	45–54	21.93	195
5	55–64	16.20	144
6	65+	7.54	67
Income
1	Under 18,000	6.70	50
2	18,001–30,000	17.43	130
3	30,001–45,000	16.09	120
4	45,001–60,000	13.54	101
5	60,001–80,000	12.06	90
6	80,001–100,000	11.53	86
7	100,001–120,000	8.45	63
8	Over 120,000	14.21	106

).

Moreover, out of the 890 medical tourists, 746 (84) answered about their income. A total of 6.70% of respondents had an annual income of less than EUR 18,000, 17.43% of them EUR 18,001–30,000, 16.09% EUR 30,001–45,000, 13.54% EUR 45,001–60,000, 12.06% EUR 60,001–80,000, and 11.53% EUR 80,001–100,000. Those who received EUR 100,000–120,000 per year amounted to 8.45% and those who had annual earnings of more than EUR 120,000 amounted to 14.21% (Table 7).

The countries of residence of the tourists surveyed are as follows: Norway, 13.03%; Italy, 1.80%; Germany, 5.62%; the United Kingdom, 14.72%; Ireland, 1.24%; Finland, 8.20%; Sweden, 13.48%; Russia, 0.34%; Denmark, 12.02%; Poland, 7.30%; France, 3.26%; Estonia, 1.69%; Ukraine, 0.11%; Belarus, 0.22%; Romania, 0.90%; and from another country, 0.34%.

Concerning their willingness to visit Crete as medical tourists, 70.3% of the respondents were positive. It is interesting to examine this willingness based on their age and income. In the age groups between 35–64 years, the desire rates were between 70–75%, while in the age groups 25–34, just below 70 (68.28%). In regards to the age groups 16–24 and 65 years and over, the rates decreased slightly (

Table 8. Interest in medical tourism among tourists based on age and income.

		Age													Total
		16–24		25–34		35–44			45–54		55–64		Above 65
Potential Medical Tourist	Yes	103		99		129			146		105		43		625
	No	62		46		44			49		39		24		264
	Yes %	62.42		68.28		74.57			74.87		72.92		64.18		70.30
	No %	37.58		31.72		25.43			25.13		27.08		35.82		29.70
Total		165		145		173			195		144		67		889
		Income													Total
		Under 18,000	18,001–30,000		30,001–45,000		45,001–60,000	60,001–80,000		80,001–100,000		100,001–120,000		Over 120,000
Potential Medical Tourist	Yes	28	87		79		70	68		64		46		90	532
	No	22	43		41		31	22		22		17		16	214
	Yes %	56.00	66.92		65.83		69.31	75.56		74.42		73.02		84.91	71.31
	No %	44.00	33.08		34.17		30.69	24.44		25.58		26.98		15.09	28.29
Total		50	130		120		101	90		86		63		106	746

). Therefore, we can conclude that age plays a minor role, but health professionals should be aware that the dynamic age groups are between 35–64 years old. This is to be expected in a way, since the majority of people younger than 35 years of age have relatively much less health problems, so they do not need to seek any medical treatment.

As far as the annual income is concerned, 56% of those with an annual income of less than EUR 18,000 stated that they would travel to Crete for medical tourism. This percentage is not negligible, but it increased by about 10% when the annual income was between EUR 18,000–60,000. These percentages generally ranged between 65–70%. Moreover, it seems that those who receive EUR 60,000–120,000 per year were even more willing to seek the services offered, with the percentages of these individuals ranging between 70–75%. Finally, those with an annual income of over EUR 120,000 were 84.91% positive about visiting Crete for medical tourism, 10 percentage points higher than the previous income group (Table 8). Therefore, income seems to play a role in tourists’ choice of whether to visit Crete to receive relevant services.

The tourists from Western and Northern Europe, as well as the Mediterranean, were the most positive about going to the island of Crete for medical tourism services. From the answers, it also occurs that the main target age should concern people 35–64 years old and, regarding the income, it appears that the higher the income, the higher the person’s desire to receive medical tourism services. Tourists with an annual income of at least EUR 18,000 should be primarily targeted.

4.1.4. Popularity of Medical Tourism Services in Crete

It is crucial to examine whether tourists’ preferences for health tourism services converge with the medical services available on the island. The table below summarises the answers given by the hotel managers, medical professionals, and medical tourists to the respective questions.

Eye services (82.2%) and IVF (72.8%) were the most popular health services requested by medical tourists, which are broadly offerd in Crete according to medical proffesionals and hotel managers. In general, Crete has the capacity to accommodate the needs of medical tourists visiting the region, as shown in the table below (

Table 9. Supply and demand of medical tourism services.

Group	Hotel Managers		Medical Professionals		Medical Tourists
Answer	%	Count	%	Count	%	Count
IVF	68	66	71.4	368	72.8	648
Eye Services/Surgeries	74.2	72	86.2	444	82.2	732
Cardio Diagnostic Services/Surgeries	46.4	45	34.8	179	41	365
Elective Medicine/Cosmetics, etc.	26.8	26	39	201	19.6	174
Well-Being/Hydrotherapy, etc.	30.9	30	38.6	199	29.4	262
Haemodialysis Services	42.3	41	90	464	53.1	473
Dental Services	50.5	49	53.3	274	48	427

).

5. Discussion

The objective of this research was to investigate the opportunities and obstacles associated with medical tourism in the Crete region, as seen by hotel managers, healthcare professionals, and medical tourists. More than 90% of the hotel managers believe that medical tourism can boost the domestic economy and that the domestic market is ready for larger-scale medical tourism services, while more than 70% of tourists are interested in travelling to Greece for medical treatment. Tourists choose IVF, eye surgery, and dental procedures, which the physicians questioned provide. According to medical professionals, managers of hotels, and tourists, medical tourism may flourish and boost the Greek economy. The government should assist medical tourism by handling administrative, financial, and promotional issues. Tax deductibles, financing through National Strategic Reference Framework (NSRF) programs, and favourable lending conditions are required for medical tourism to grow in Crete, based on the findings of the study. Promotional strategies include emphasising national tourism attractions, intensifying online marketing efforts, organising seminars and conferences, and exploring other suitable channels [40,41]. Furthermore, the government should ensure the integration or diffusion of technologies that protect the consumer, since medical data are very sensitive. Blockchain technology provides a privacy-enhancing method that facilitates the diversification of records and imposes restrictions on the accessibility of sensitive data, such as the private data of individuals engaged in medical tourism. The use of blockchain technology in medical tourism has the potential to provide many advantages, including enhanced accessibility to healthcare providers, expedited and secure payment mechanisms, heightened assurance of data protection and privacy, and the establishment of reliable evaluation mechanisms [42,43,44].

The role of the tourism industry as a pivotal driver of the Greek economy is widely acknowledged. In 2019, travel and tourism amounted to 21.2% of the overall GDP [45]. Over recent years, Greece has demonstrated a notable expansion in its tourism sector, with medical tourism not falling behind in that respect. The principal factor underpinning the prominence of medical tourism in Greece resides in the juxtaposition of cost-effectiveness and high-calibre healthcare provisions. An inherent advantage of Greece over other health tourism destinations lies in its capacity to facilitate health travellers in integrating their treatment protocols with leisure experiences and wellness amenities. As a result, Greece has ascended to a prominent position among the pre-eminent global medical tourism destinations [46]. Consequently, the number of non-Greeks and of repeat patients who have received medical treatment in Greece on multiple occasions is extremely high as there is an increasingly growing private hospitals sector [11].

It is posited that medical tourism aims to alleviate the repercussions of the Greek economic downturn, capitalising on the nation’s competitive edge in offering healthcare services distinguished by both affordability and high quality [47]. More precisely, Greece has emerged as a favoured destination for patients requiring dialysis, evident from the widespread presence of dialysis centres throughout the country. Nevertheless, Greece has the opportunity to further grow the provision of other medical services, such as fertility treatments, eye treatments, cosmetic surgery, rehabilitation treatments, and dental treatments. In light of this context and recognising the pivotal significance of tourism, particularly within the sphere of medical tourism, a strategic blueprint becomes imperative to improve medical tourism services in Greece [48].

Within this context, a meticulously devised strategic blueprint must initially grapple with the capacity of Greek public hospitals to seamlessly integrate medical tourism services. Greek public hospitals currently lack the necessary preparedness to partake in this endeavour, with a prominent factor being the evident deficiency in personnel resources and training [49]. Conversely, there exists a counterpoint perspective suggesting that Greek public hospitals could conceivably contribute to this endeavour, contingent upon specific conditions [50,51]. Foremost among these prerequisites is the attainment of certification coupled with rigorous staff training, which would benefit the growth of medical tourism in Greece.

An additional dimension to consider within the potential strategic plan for medical tourism in Greece revolves around the role of the government, which has elicited varying viewpoints among the majority of respondents. A substantial portion maintains a skeptical stance towards significant state intervention, advocating for limited involvement. Conversely, proponents of a heightened state role contend that such engagement should aim at streamlining medical tourism operations. To exemplify, fostering collaboration between the public and private healthcare sectors could be encouraged by the government. Nonetheless, the most impactful action within the government’s purview is the establishment of public–private partnerships and the formulation of a well-structured legal framework conducive to the flourishing of medical tourism enterprises. One plausible avenue for the government’s engagement is to liaise with foreign embassies to advocate for medical tourism services, orchestrate conferences, streamline passport and visa issuance, and potentially reduce Value Added Tax (VAT) to bolster Greece’s competitive stance in this domain. Moreover, incentivising airline companies and travel entities to participate in this initiative could prove beneficial, warranting due consideration from the government. A forward-looking strategic blueprint for the enhancement of the Greek medical tourism sector must squarely address pivotal financial challenges; these encompass several critical aspects, including the imposing 24% Value Added Tax (VAT) rate, the absence of certification for Greek hospitals [49], the absence of agreements with foreign insurance funds, the exemption of private insurance companies from charges for services rendered in public hospitals, and the non-issuance of visas by Greece. The underlying origins of these inefficiencies are rooted in the systemic deficiencies of the Greek state apparatus, compounded by the lack of robust legislative frameworks and the absence of a coherent national stance on this matter. The government’s disinterest in harnessing medical tourism as a catalyst for economic advancement further exacerbates these issues.

The medical tourism offerings within Greece should encompass a spectrum of services, including in vitro fertilisation (IVF), dental care, orthopaedic surgery, ophthalmic surgery, cardiac treatment, plastic surgery, haemodialysis, spa therapies, robotics-assisted interventions, rehabilitation programs, and geriatric tourism provisions. Regarding the involvement of public hospitals, viewpoints diverge concerning their capacity to effectively contribute to medical tourism services. Several respondents assert that public hospitals are presently unprepared to partake in this initiative, with a key contributing factor being the inadequacy of staffing resources. Conversely, proponents of their potential participation underscore that it could indeed be viable under specific conditions. Foremost among these prerequisites is the attainment of appropriate certifications and the comprehensive training of their personnel, constituting pivotal measures that stand to enhance the overall landscape of medical tourism in Greece.

Greece currently accounts for only 3% of the world’s medical tourism, while Turkey, Poland, and the Czech Republic account for 13%, and Belgium for 8% [52]. It is estimated that Greece could attract at least 100,000 “patient travellers” every year for the next five years, generating revenues of more than EUR 400 million per year [53]. The numbers are interesting, especially for a country like Greece that looks forward to tourism: its contribution to the GDP is expected to exceed EUR 43 billion in 2023. But Greece has another advantage that has to do with the cost of providing these services. Stressing that when 46% of the global turnover of medical tourism is spent exclusively on dental treatment, in Greece the cost of these dental operations is 20–30% of the corresponding cost at the destination of international patients. Estimates also show 60–90% lower healthcare costs and shorter waiting lists compared to the equivalent in the United Kingdom, Canada, or the United States. Based on a Medical Tourism Magazine study and the Medical Tourism Index 2020–2021, Greece ranks 34th out of 46 countries and 9th in Europe as a destination for medical tourism [52].

Various national policy initiatives have endeavored to support and facilitate the growth of medical tourism inside their respective nations. The expanding area of medical tourism is seen by several nations as having opportunities for economic expansion [14]. For example, Hungary and Poland have actively endeavored to showcase their respective strengths as destinations for medical tourism through their participation in major international trade fairs, advertising in foreign media, and providing assistance for related activities as part of their strategies for economic development and tourism. More analytically, medical tourism in Poland is supported by entrepreneurs, with a significant number of clinics being state owned and providing services to both domestic patients and those seeking dental and aesthetic treatments from outside. The establishment of the Polish Medical Tourism Chamber of Commerce and its collaboration with the Polish Association of Medical Tourism exemplify the Polish government’s aspiration to harness the opportunities presented by medical tourism. The Polish government is making concerted efforts to use the opportunities presented by its recent entrance into the European Union in order to effectively compete with more geographically distant locations for attracting European medical tourists. Hungary has furthermore endeavored to use the prospects arising from its European Union entry to cultivate a medical tourism sector. Although it is evident that a significant number of clinics providing medical services to international patients are privately owned, it is important to acknowledge the involvement of the Hungarian government in this context. A brief examination of medical tourism websites indicates that a diverse array of operations are aggressively promoted to attract travelers [14].

6. Conclusions

The major aim of this paper was to add to the existing literature regarding the current state of medical tourism in the region of Crete. Previous research explored the dynamics of medical tourism in other regions of Greece and the development prospects; however, it did not focus on the island of Crete. To add more knowledge, this paper presents a cross-sectional study, which involved the participation of hotel managers, doctors representing various specialties, and medical tourists, in order to explore their perspectives. Crete is an ideal destination for medical tourists, as it has the capacity to offer high-quality medical services that are in line with the medical needs of tourists, while it is also an excellent and popular tourist destination. Both hotel managers and medical professionals see considerable potential for the development of medical tourism on the island, provided that a strategic development plan is implemented by the local and national authorities.

The government should adopt a central role in coordinating and collaborating with potential investors and participants within the medical tourism sector. This necessitates the implementation of suitable legislative measures and the establishment of public–private partnerships. It would prove advantageous for the government to allocate medical facilities and hospitals to private entities for utilisation. The government’s supporting role should focus on facilitating medical tourism processes by addressing the administrative, financial, and promotional aspects. Last but not least, one way to help medical tourism grow is to create an online database detailing everyone who seeks medical care abroad, the physicians who treat them, and the costs of their procedures [49]. To facilitate these efforts, the establishment of a dedicated medical tourism department within the Greek Ministry of Health could be considered. Moreover, a pivotal phase involves targeting, signifying the strategic identification of countries to which the tourism product will be marketed. Optimal choices encompass European Union nations, geographically proximate regions within Europe, and countries with a pronounced presence of Greek diaspora communities.

7. Study Limitation and Future Research

This study was conducted specifically in the region of Crete, rather than being conducted on a national scale. Therefore, additional research pertaining to other regions and nationwide is required. Furthermore, a potential limitation of the study lies in the individual and biased responses that may be derived from the utilisation of a questionnaire. Acknowledging the regional specificity and potential response biases in our study underscores the necessity for future investigations to adopt a more comprehensive, nationwide scope and employ methodological strategies that address the nuanced nature of individual responses.