Sustainable Approaches to Medical Tourism: Strategies for Central Macedonia/Greece

Abstract

The study of health and medical tourism is a multifaceted and intricate field. Nevertheless, it is a swiftly expanding global industry with considerable economic prospects. This sector involves the exchange of services, blending two of the world’s major domains: healthcare and tourism. This research aims to evaluate the strengths of medical tourism service providers in the Central Macedonia Region while shedding light on various challenges that could impede the sector’s growth. Additionally, it investigates crucial sustainability factors and opportunities within the Greek medical tourism industry that can effectively address obstacles, both domestic and international, to enhance sustainable medical services. The study delves into the reasons why the Central Macedonia Region can attract both local and international medical travelers seeking healthcare solutions. With this aim in mind, both Systematic Literature Review (SLR) and primary quantitative research methods were employed. The SLR aimed to locate pertinent scientific literature, which, when integrated with the outcomes of the quantitative research, facilitated the analysis, description, and interpretation of data for the formulation of conclusive findings. In brief, this article aims to contribute scientific value by engaging in interdisciplinary research and demonstrating originality through innovative approaches to sustainable development. It seeks to make a significant contribution to the field by presenting practical strategies and insights that strike a balance between the economic advantages of medical tourism and the crucial considerations of environmental and social impact.

1. Introduction

In the contemporary context, medical tourism has emerged as a rapidly expanding sector within the thriving global tourism industry. This growth is fueled by various socio-economic and sustainability factors that motivate individuals in their pursuit of happiness and an enhanced quality of life, considering the principles of sustainable development and social sustainability goals set by the United Nations. However, this type of tourism faces several challenges, with one of the primary hurdles being the diverse conceptual approaches and definitions.

The main objective of this research paper is to offer a concise and comprehensive understanding of this complex concept, which plays a significant role in the global tourism landscape. This is accomplished through a two-part methodology: firstly, a literature review that employs a descriptive, comparative, and exploratory approach to establish a theoretical framework in this field of study. This involves selecting key concepts to define categories, facilitating a condensed representation of diverse approaches to the subject. Secondly, by analyzing and investigating the case study on the development of Medical Tourism in the Region of Central Macedonia (from now on RCM), various perspectives are explored to identify and describe different issues, encompassing those related to health, wellness, medical tourism, well-being, and quality of life.

Particularly, the overarching objective of this research is to gain a better comprehension of the concepts of medical tourism, health, and wellness tourism, as well as to explore strategies for developing tourism in the Region of Central Macedonia. This is achieved through the collection of reliable and comparable data, an examination of the push and pull factors that influence engagement in health and medical tourism, and an assessment of the impact of health and, more notably, medical tourism on local healthcare systems.

In pursuit of this goal, this research delves into the scope of medical tourism and takes an active role in generating inputs for a successful strategy to harness the potential of an emerging medical tourism destination, with a particular focus on the medical tourism of RCM. This study seeks to compile a thorough analysis of the medical tourism process and its micro-level response, presenting a well-informed perspective on the medical tourism process while enhancing knowledge and familiarity for further exploration.

As it appears from this research, Central Macedonia has the potential to function as a central East–West hub for medical tourism, offering comprehensive service of green health packages with competitive costs and high quality, combining other tourist services. The arrival of medical tourists could not only revitalize the healthcare infrastructure of the region but also contribute to economic and infrastructure development. However, sustaining these benefits in the long term necessitates addressing the significant challenges that this nascent industry presents to Greece. Therefore, a systematic approach is adopted to uncover the potential and challenges of the medical tourism industry within the context of services and the community.

In summary, this research aims to enhance understanding in areas related to medical tourism policy making, patient mobility (both domestic and international), the business of medical travel, and the geography of medical tourism. These efforts are aimed at supporting a robust research community focused on harnessing the potential of an emerging medical tourism destination.

1.1. Medical Tourism

Medical tourism involves individuals traveling for health services outside their local environment. The exploration of health and medical tourism presents a nuanced area of inquiry. Investigating this phenomenon requires input not solely from medical and health research but also from the domain of tourism studies [1]. For this reason, definitions range from formalistic, broad explanations to more minimalist descriptions like “any travel for health improvement” [2].

Medical tourism, within the context of health and wellness tourism, refers to the practice of individuals traveling across borders or within their own country to seek medical treatments, procedures, or healthcare services. These services often encompass a wide range of medical and wellness interventions, including elective procedures, specialized surgeries, preventive care, and alternative or complementary therapies. The primary motivations for engaging in medical tourism include seeking cost-effective healthcare options, accessing treatments not readily available in one’s home country, or experiencing a combination of medical treatment and leisure or recuperation in a different cultural or scenic environment [3,4,5].

The recent expansion of the medical tourism sector can be attributed to several factors, including internationalization, technological advancements, increased treatment options, cost savings, and the integration of medical services with leisure travel [1,2].

Key drivers for this game of expansion include sustainability factors such as cost savings, advanced healthcare, cutting-edge technology, innovative treatments, modern medical equipment, enhanced hospitality, personalized care, and the offer of different quality versions of the product [6,7,8].

However, defining medical tourism proves challenging due to the wide range of medical services, diverse patient profiles, the overlap with leisure travel, and the distinction between healthcare and tourism. Various attempts have been made to define it, and terms like medical tourism, health tourism, and wellness tourism are sometimes used interchangeably [9,10].

Some consider medical tourism as part of health tourism, while others emphasize the difference between the two. The concept of medical tourism involves serious medical interventions, while health tourism encompasses wellness and non-medical services [11,12].

The terminology is also influenced by the severity of ailments and the purpose of travel, with some defining medical tourism as addressing severe health issues, while others focus on relaxation and satisfaction. Regardless of definitions, the sector’s revenues are increasing globally [13,14].

Domestic medical tourism is also significant, and the term encompasses a wide spectrum of activities, from invasive procedures to passive health and wellness tourism. The data are often uncertain and complicated by varying interpretations and limited formal literature [7,15,16].

1.2. Sustainable Medical Tourism

Researchers have shown interest in the connection between medical tourism and economic development. Perkumiene et al., 2019 [10] demonstrated that collaboration stands out as a crucial element within the medical tourism industry, playing a pivotal role in advancing sustainability and bolstering the development of tourism.

Sustainability factors refer to elements or aspects that contribute to the long-term viability and resilience of a system, process, or industry. In the context of the phrase you provided, sustainability factors within the Greek medical tourism industry could include practices that promote environmental, economic, and social sustainability. For example:

  i.

Environmental Sustainability: This might involve initiatives to minimize the ecological impact of medical tourism, such as reducing carbon emissions, minimizing waste, and promoting eco-friendly practices.

 ii.

Economic Sustainability: This could include measures to ensure the economic stability and prosperity of the medical tourism industry over time. It may involve creating financial models that support ongoing growth and development.

iii.

Social Sustainability: This aspect may focus on ensuring that the benefits of medical tourism are distributed equitably among the local communities, promoting cultural sensitivity, and safeguarding the well-being of visitors and locals.

Incorporating sustainability factors in the context of the Greek medical tourism industry could involve strategies and practices that not only enhance the quality of medical services but also contribute to the long-term health and resilience of the industry and its surrounding environment [7,10,12].

In conducting a literature review on medical tourism in Central Macedonia/Greece, with a specific focus on its connection to sustainable development issues, a deficiency in the existing literature becomes evident, with only a limited number of studies available. The present research serves to address and bridge this gap in the literature to which other relevant research has been referred [8,17,18,19].

2. Medical Tourism in Greece

To begin, it can be stated that Greece encompasses all four essential elements for specialized tourism: “Sea, Sun, Sand, and Surgery” [13]. Nevertheless, the field of medical tourism was uncharted territory for Greece until recently. Before 2011, it was not considered a significant player in this sector, as indicated by international forecasts from the Medical Tourism Climate Survey [20] (2011, as cited in Korovesi, 2016:98).

In the same year, McKinsey and Company’s research in Athens, titled ‘Greece 10 years ahead’ [21] (2011:70–71), emphasized that Greece, while positioned to be a significant player in the rapidly growing medical tourism market, lacked a comprehensive national development strategy for this sector. Notably, only a few medical facilities in Greece held accreditation from the Joint Commission International (JCI), unlike numerous facilities in other countries, such as Turkey and Italy. This demonstrated that Greece’s medical tourism industry was underdeveloped, with only a few private Greek clinics offering such services [22].

Another study, the “Development of Medical Tourism in Greece” (2012) by the Institute of Social and Preventive Medicine [23] of the Hellenic Chamber of Hotels [24], argued that medical tourism presented an opportunity for Greece, a country with the potential to excel in this domain. The study highlighted the need for clear development goals and the implementation of a national strategy.

In 2014, Greece gained recognition in the field of health tourism, ranking 18th out of 85 countries for the range and quality of medical services offered, demonstrating a substantial increase in the number of hospitalizations. According to the same study, Greece was ranked 14th among the best destinations in a five-year projection in terms of the number of patients expected to visit the country, surpassing countries like Poland and Brazil (Medical Tourism Climate Survey, 2014, as cited in Korovesi, 2016:99) [20].

In 2019, Greece held the 25th position in the medical tourism market, representing 0.4% of the total inbound tourism expenditure, according to a study by the World Travel and Tourism Council (WTTC). Additionally, the country was ranked 34th out of 46 nations, as indicated by the Medical Tourism Index (MTI). The MTI evaluates countries’ performance in medical tourism by assessing the health and tourism industries, along with the overall environment of the host country, with a focus on ensuring the sustainability of medical tourism services. Recent years have witnessed Greece making strides in promoting sustainable medical tourism services. Notably, the country was absent from the MTI list until 2016. Greek studies underscore the favorable factors contributing to its potential as a medical tourism destination, citing the climate, natural and economic environment, modern tourist infrastructure, and high-quality hospitality and health services. The medical services garnering the most attention and popularity include those specializing in fertility, dialysis, orthopedic surgery, ophthalmology, dentistry, aesthetics, rehabilitation, and recovery. By 2021, the health industry emerged as one of the most dynamic sectors in the Greek economy, constituting 9.7 percent of the Gross Domestic Product (GDP) [11,12,15].

In addition, empirical research by Theofanides and Papanikolaou [22] underscored that medical tourism in Greece was notably underdeveloped, with only 22 out of 270 private IVF and plastic surgery clinics engaged in providing these services. This underdevelopment was primarily due to several factors:

(a) The lack of effective networking between Greek private medical units and intermediaries, such as domestic and foreign travel agents, foreign doctors, foreign clinics, and insurance companies.

(b) Inadequate promotion of Greek medical facilities in foreign markets.

(c) The absence of specific international certification for health organizations, with most Greek medical units holding general ISO certifications.

(d) Minimal support and financing from the Greek state.

(e) A lack of strategic orientation, both from the private and public sectors, with insufficient long-term planning and foreign market analysis.

(f) A challenging business climate exacerbated by Greek political and economic instability, ongoing changes in tax legislation, and bureaucratic impediments affecting investments.

Moreover, a notable concern was the absence of a well-structured and government-funded aid program [24].

Despite these challenges, a study by McKinsey and Company (2011) [21] highlighted Greece’s comparative advantage over other European Member States in this specialized sector. Particularly in the context of the economic crisis, medical tourism could emerge as a lucrative industry. The study estimated that within a decade (2012–2022), medical tourism could contribute EUR 450 million annually to the Greek economy and create 11,000 new jobs. Additionally, Greek medical tourism could gain market share in Russia, the Balkans, the Middle East, selected European countries, and the UK. Cyprus, Turkey, Malta, and Bulgaria were identified as direct competitors to Greece in the field of medical tourism [6,25,26].

Greece, known as one of the world’s top tourist destinations, could capitalize on its reputation by expanding its medical services. This could involve blending first-class hotels, natural beauty, ancient and medieval attractions with advanced medical services, and experienced doctors. This opportunity was well-received, as 50% of respondents in a survey expressed an intention to expand medical tourism services in Greece [22].

Similarly, a scientific survey conducted nearly a decade later found that 69.9% of respondents believed that Greece had the potential to become a popular medical tourism destination, indicating substantial growth in the industry, at least until the onset of the COVID-19 pandemic. Additionally, a positive correlation between age and tourism behavior was revealed through data analysis, with younger patients being better informed about medical tourism compared to older ones [23].

Cosmetic surgery emerged as one of the most popular services offered by Greek medical units, as it was easier for patients to associate it with recreational tourism. Rehabilitation and dialysis centers also experienced consistent demand, likely because Greece’s infrastructure in these areas was well-suited for these services. Conversely, services related to eye care, cardiovascular treatments, and IVF showed lower demand [22,27].

According to other estimates [23,28,29], medical tourists primarily sought orthopedic, oncological, aesthetic, cardiology, neurological–neurosurgical treatments, as well as fertility procedures in Greece. These medical tourists were typically aged between 45 and 55, had medium to high incomes, stayed for an average of seven days, and were accompanied by a companion. Their average spending during their visit, including their companion, was approximately EUR 5000, significantly higher than the average tourist’s spending of EUR 1500 for the same duration. A study by Intuition (2014) [22] suggested that visitors from Greece’s top four countries of origin had unmet health needs, indicating potential for medical tourism due to factors like economic barriers, wait times, and geographical constraints.

Notably, there was a rapid increase in the demand for in vitro fertilization (IVF) in Greece between 2012 and 2016, making it a notable reference center for medical tourism [10,30].

Furthermore, the most common complementary services included partnerships with hotels for accommodation beyond the treatment period [22]. In contrast, there was less demand for services involving cooperation with travel agencies or hosting close family members. Notably, all the Greek medical units in the sample advertised through the Internet, but not all had organized advertising campaigns in foreign markets. Furthermore, only one in ten medical units cooperated with foreign intermediaries. This contrasted with the view presented by Spasojevic and Susic [31], which underscored the importance of intermediaries for the development of medical tourism and as a link between foreign patients and Greek medical facilities.

In summary, the evidence suggests that Greece’s efforts in the medical tourism sector are still in their early stages. While neighboring countries such as Turkey are already reaping the benefits of the medical tourism market, Greece is, for the most part, on the fringes of this global development [31].

2.1. Region of Central Macedonia

2.1.1. Demographics

Central Macedonia, Greece’s largest northern region, spans 18,811 sq. km, with a population of 1,792,069. It includes Thessaloniki, Serres, Katerini, Veria, and Giannitsa. Bordering North Macedonia and Bulgaria to the north, it shares boundaries with Eastern Macedonia, Thrace (east), Western Macedonia (west), and Thessaly (southwest). The region boasts flat terrain, many rivers, and economic development in agriculture and industry. Olympus, Greece’s highest mountain, stands at 2918 m. Thessaloniki serves as a key gateway to the Aegean and Balkans. The region features continuous, sandy coastlines suitable for water sports. The climate exhibits notable temperature fluctuations, with January and February as the coldest months and July and August as the warmest. Rainfall occurs in autumn, early winter, and spring, with mountainous regions experiencing colder winters and coastal areas displaying milder Mediterranean climates [23,32,33,34].

2.1.2. The 15 Thermal Springs in the RCM

In 2017, Deputy Governor Mr. Thanos reported a rising tourist influx in Central Macedonia, emphasizing spa tourism. There are 15 thermal springs. Spa tourism, a key part of health tourism, now attracts a wider range of visitors, including younger, educated individuals, not just for treatment but also for relaxation. Mr. Kouskoukis, a dermatology professor and president of the Hellenic Academy of Spa Medicine, highlighted Greece’s natural healing springs but stressed the need for modern health resorts and infrastructure investments to tap into the global health tourism market, particularly MediSpa services, where Greece can play a prominent role [23,35,36].

2.1.3. The Health Sector in Greece and the Position of RCM

Greece’s healthcare system, strained by economic turmoil, prompted reforms. Hospitals are central, with 45% private and 65% public beds, notably concentrated in Attica and Central Macedonia [37]. Greece boasts a high doctor-to-population ratio but low nurse numbers, and brain drain affects medical staff [38]. Recent data indicate that RCM ranks second in doctors after Attica, a potential boost for medical tourism [39].

In a 2019 census of clinics, RCM had 16% of Greece’s clinics [39,40]. Furthermore, RCM is second in the healthcare sector [37,41]. Thessaloniki’s strategic location, infrastructure, and medical resources offer potential for medical tourism [42]. In 2020, RCM received EUR 40 million for healthcare infrastructure [43]. It is noteworthy that the ‘Papageorgiou General Hospital’ in Thessaloniki is a non-profit legal entity operating under private law, providing a wide range of services, including prevention, diagnosis, treatment, and rehabilitation. Moreover, positive developments in 2021 included plans for a new oncology hospital in Thessaloniki [41]. These factors could enhance the prospects for medical tourism in the region.

2.1.4. The Private Health Services Sector

ICAP’s research in 2006 highlighted the robustness of Greece’s private healthcare sector, with ongoing rapid growth. The 2018 study focusing on private health units indicated a recovery in 2018 after five years of recession, citing a 1.5% increase in total revenue. This resurgence was notable despite challenges posed by fiscal adjustments and reorganization in the sector [44].

However, the market experienced an 8% contraction in 2020, attributed to the COVID-19 pandemic [45]. This global health crisis spurred collaborative efforts in the innovation system, enhancing the Health sector’s development prospects worldwide and in Greece [46].

Notably, the RCM, particularly Thessaloniki, hosts advanced healthcare facilities. The ‘Interbalkan Medical Center’ stands out as Southeast Europe’s largest modern private hospital, offering comprehensive medical services, advanced technology, and over 800 staff members. Another significant player, the Euromedica Group, operates an extensive network of primary and secondary care facilities, including diagnostic centers, private clinics, assisted reproduction units, and rehabilitation centers across Greece, notably in Thessaloniki (Euromedica Group website).

3. Materials and Methods

3.1. Research Methodology

There are a variety of methods by which we can measure the effects of the research object of health and health tourism, such as the following [47]:

• Qualitative method (qualitative research): based on the collection of data, feelings and motivations that cannot be measured directly.
• Quantitative method (quantitative research): based on statistical analysis of research data that leads to reliable results.

Data collection and classification methods fall into 5 categories: direct observation method, telephone interview method, face-to-face interview method, sending a questionnaire and using secondary sources.

For this study, through primary and secondary research, we will attempt to capture the current state of health and wellness tourism at national and international levels, assess domestic and international market trends, as well as the growth prospects of the said industry in the RCM in synergy with other available touristic resources of the area. The main thrust of the research is the preservation and protection of the special cultural and natural characteristics of RCM.

3.2. Definition of More Specific Research Objectives and Research Questions

The objectives of the study are as follows:

• Record profile and composition of domestic tourism.
• Identification of tourism demand trends and potential opportunities for its development in new market segments.
• Exporting proposals, development strategies and ways to improve and enrich the tourist product as a tourist destination through Greek-speaking target customers.
• Evaluation of the already offered tourist product of RCM.
• Collection of factors influencing the choice of RCM as a medical tourism destination.
• Investigation and identification of possible SWOT analysis factors for RCM.

Therefore, this study aims to identify the preferences of potential medical tourists of RCM in the context of socio-demographic determinants. The in-depth analysis of the literature on medical tourism and sustainability factors, especially on issues related to medical services in the health and welfare units of RCM, made it possible to develop the following Research Questions (RQ) used in the study carried out:

• From the consumer’s perspective, what are the strengths and opportunities for the development of tourism in the Region of Central Macedonia? This question aims to understand the positive aspects and growth potential perceived by consumers, providing insights into factors that can contribute to the advancement of tourism in the region.
• From the consumers’ perspective, what are the weaknesses and threats to the development of tourism in the RCM? By exploring weaknesses and threats, this question seeks to identify challenges and potential obstacles from the viewpoint of consumers, helping to pinpoint areas that may require improvement or strategic intervention.
• For which medical procedures are consumers willing to undergo in the RCM? Focusing on consumer preferences for specific medical procedures provides valuable information for healthcare providers and policymakers, aiding in the development of targeted medical tourism services.
• Do consumers’ opinions about the strengths and opportunities for the development of tourism in the RCM differ according to their gender? By considering gender-specific perspectives, this question acknowledges potential variations in how strengths and opportunities are perceived, contributing to a more nuanced understanding of consumer viewpoints.
• Do consumers’ opinions about the weaknesses and threats to the development of tourism in the RCM differ according to their gender? Similar to the previous question, exploring gender-based differences in the perception of weaknesses and threats adds depth to the analysis, recognizing potential variations in concerns among different demographic groups.
• Do consumers’ opinions on the undertaking of medical procedures in the RCM differ based on their socio-demographic characteristics (gender, age, marital status, and education)? This question extends the investigation to broader socio-demographic characteristics, acknowledging the potential influence of factors such as age, marital status, and education on consumer opinions regarding medical procedures. This comprehensive approach allows for a more thorough understanding of the diverse perspectives within the consumer population.

3.3. Research Methods

The research undertaken was quantitative, focusing on the exploration of trends and explanations. As a result, the data were measurable and observable across various variables. For the research implementation, a sample research design was employed to determine the characteristics, behavior, and trends of domestic medical tourism.

Data collection in the context of this research was carried out through primary quantitative and secondary research. The goal was to study the development of medical tourism in the health and welfare units of RCM. Data collection and classification methods were executed by creating a structured questionnaire and utilizing secondary sources.

In terms of the primary quantitative research, a structured questionnaire had been prepared. The questionnaire consisted of closed-ended questions to facilitate data quantification and utilization. The questions included double-choice, multiple-choice, and Likert scale options. Particularly, to obtain more up-to-date data and additional information and to gain a more comprehensive understanding of domestic tourism, a quantitative survey was planned to be developed at the level of domestic tourism visitors using a structured questionnaire.

Systematic Literature Review

Conducting a Systematic Literature Review (SLR), the goal was to comprehensively identify scholarly literature addressing the application of medical tourism in Greece and worldwide. Additionally, scrutinizing sustainable medical tourism approaches, given that the sector is in its early stages of development in Greece, it is crucial to pinpoint the aspects that guarantee the sustainability of the industry. The SLR process adhered to the methodology recommended by Tranfield et al., 2003, [48], facilitating the mapping and evaluation of scholarly literature [49]. The search specifically mostly encompassed peer-reviewed articles published in academic journals, following Saunders et al.’s, 2016, [50] assertion that such sources are the most valuable and reliable for literature reviews. The outcomes of the scholarly research review, within the realm of medical tourism and sustainability factors, were used throughout the text of this paper.

Certain aspects of the SLR include:

• Time horizon: 2006–2023
• Database identification for literature review: Electronic databases: Emerald, SAGE Journals, Science Direct, Springer Link and Wiley. Additional databases: EBSCO and Google Scholar (to validate preceding searches).
• Keywords: “medical tourism”, “health tourism”, “sustainable medical tourism”, “sustainable health tourism”, and “medical tourism” with “sustainable”.
• Actions: Identical manuscripts were identified and excluded. A thorough manual examination was undertaken to eliminate irrelevant publications from the current study. Subsequently, an in-depth analysis was conducted on the remaining articles to fulfill the primary objectives.

Note: In numerous instances, it was deemed essential to individually search bibliographic references, given the multidimensional nature of the study subject.

In addition, Greek and foreign language literature, as well as statistical data from national and foreign bodies such as the Greek Statistical Authority (ELSTAT) [29] and the Greek Health Tourism Council (ELITOUR) [24], along with articles and related studies, etc., were used. The objective was to extract data on demand and supply, as well as the prospects for the development of medical tourism in the RCM.

3.4. Questionnaire Structure

To pursue the research objectives, a primary quantitative survey was designed at the visitor level using a structured questionnaire with a combination of questions from 2 other surveys [36,51,52]. The types of closed questions used are double choice, multiple choice, Likert scale and importance scale.

The questionnaire includes 25 questions that are classified into 4 different groups according to the purposes of the research, its objectives and the research hypotheses. The groups concerned the following:

• Demographics (Questions 1–7). The data of these questions are categorical (nominal data) and concern the following: gender, age, education, employment, marital status, permanent residence and monthly income.
• Questions about consumer behavior in tourism (Questions 8–14). They include questions about social media preferences, vacation duration, accommodation, travel during COVID-19, and travel for medical and/or wellness and health reasons.
• Questions that delve into the topic of health tourism in the Central Macedonia Region (Questions 15–21). Data on consumer preferences are expressed on a five-point Likert scale so that respondents can indicate the level that best represents them. They include questions concerning, for example, preferences in the RCM prefectures, medical operations, interventions and activities.
• Questions that focus on the SWOT analysis on the topic of Health tourism in the RCM (questions 22–25). Data on consumer preferences are also expressed on a five-point Likert scale so that respondents can indicate the options that best represent them. The purpose of the questions is to form a SWOT analysis on the subject of study from the point of view of the consumer public.

3.5. Conducting the Quantitative Research

The researchers conducted the research by electronically distributing questionnaires between 15 October and 15 November 2022—a timeframe when most individuals were not on vacation. A total of 333 questionnaires were completed. The data collection exclusively occurred through electronic means, utilizing methods such as email distribution and sharing in both internal and external social network groups. Respondents filled out the questionnaires using the Google Forms platform.

3.6. Analysis of Survey Data

Data obtained from questionnaire distribution were coded and analyzed using the IBM SPSS 26.0 statistical package. The analysis comprised two stages: initial analysis involving Descriptive Statistics, followed by Inductive Statistics. For categorical variables, absolute and relative frequencies were calculated, while ordinal variables also had median values and interquartile ranges determined. The second part of the analysis explored relationships between examined variables.

3.7. Reliability and Validity of Research Instrument

An investigation into the reliability of the questionnaire was deemed crucial. The internal consistency among individual questions within the questionnaire was assessed using the Cronbach-alpha index. Notably, acceptable values for this index exceed 0.7, with values close to 1 indicating extremely high reliability [53]. Upon calculating the index, a value of 0.93 for the entire questionnaire was obtained, signifying exceptionally high reliability in the constructed questionnaire for this research.

4. Results

4.1. Results of Statistical Analysis

4.1.1. Results of Descriptive Statistics

First, the results obtained using Descriptive Statistics are going to be presented. Thus, for the categorical variables, the absolute and relative frequency for each of their categories will be presented. For the ordinal variables, in addition to the absolute and relative frequencies, the median value and the interquartile range, two statistics suitable for describing Likert-type variables, will also be presented.

Various comments arising from the observation of the statistical analysis of the research are presented below.

As can be concluded from

Table 1. Distribution of responses to the listed questions and their descriptive measures.

Questions: How Would you Characterize RCM as a Tourist Destination?	Frequency, N (Percentage %)										M.V. (I.R.)
	Strongly Disagree		Disagree		Neutral		Agree		Strongly Agree
It offers popular and attractive destinations	6	1.8%	12	3.6%	43	12.9%	157	47.1%	115	34.5%	4 (1)
It is a safe destination.	6	1.8%	3	0.9%	33	9.9%	163	48.9%	128	38.4%	4 (1)
It offers many cultural sites.	5	1.5%	4	1.2%	29	8.7%	151	45.3%	144	43.2%	4 (1)
Would you consider traveling to a Prefecture of RCM for medical reasons and/or wellness and health reasons?	9	2.7%	20	6.0%	81	24.3%	116	34.8%	107	32.1%	4 (2)

M.V.: median value; I.R.: interquartile range.

, the participants agree that RCM offers popular and attractive destinations, that it is a safe destination and that it offers many cultural sites. They also mentioned that they would consider traveling to a prefecture of RCM for medical and/or wellness and health reasons.

As can be concluded from

Table 2. Distribution of responses regarding preferred travel counties and their descriptive measures.

Which of the Following Prefectures of RCM Would you Prefer?	Frequency, N (Percentage %)										M.V. (I.R.)
	Strongly Disagree		Disagree		Neutral		Agree		Strongly Agree
Imathia	7	3.6%	21	10.8%	74	37.9%	69	35.4%	24	12.3%	3 (1)
Thessaloniki	6	2.6%	6	2.6%	33	14.3%	87	37.7%	99	42.9%	4 (1)
Kilkis	17	9.1%	28	15.1%	93	50.0%	32	17.2%	16	8.6%	3 (0)
Pella	8	3.5%	11	4.8%	65	28.1%	87	37.7%	60	26.0%	4 (1)
Pieria	9	4.4%	11	5.4%	75	36.6%	75	36.6%	35	17.1%	3 (1)
Serres	12	5.6%	17	8.0%	67	31.5%	71	33.3%	46	21.6%	3 (1)
Chalkidiki	14	6.1%	8	3.5%	34	14.8%	78	33.9%	96	41.7%	4 (2)

M.V.: median value; I.R.: interquartile range.

, the most mentioned prefectures were the Prefecture of Thessaloniki, the Prefecture of Pella and the Prefecture of Halkidiki (Median = 4). On the contrary, the Prefecture of Imathia, the Prefecture of Kilkis, the Prefecture of Pieria and the Prefecture of Serres were mentioned to a lesser extent (Median = 3).

The participants would travel to RCM for medical purposes or wellness/health if suggested by a doctor or family/friends (Median = 4). On the contrary, they maintained a neutral attitude regarding the possibility of travel following recommendations from an insurance company, from advertising in the press or TV spots, from advertising in hospitals, hotels or medical facilities, and the Internet (Median = 3) (see

Table 3. Distribution of responses to questions about possible travel for medical or wellness/health purposes, following recommendations and descriptive measures thereof.

Would you Travel to RCM for Medical or Wellness/Health Purposes if Suggested by the Following?	Frequency, N (Percentage %)										M.V. (I.R.)
	Strongly Disagree		Disagree		Neutral		Agree		Strongly Agree
Physician	3	0.9%	8	2.4%	37	11.2%	159	48.0%	124	37.5%	4 (1)
Insurance company	47	14.2%	61	18.4%	111	33.5%	87	26.3%	25	7.6%	3 (2)
Family or friends	8	2.4%	10	3.0%	64	19.3%	167	50.5%	82	24.8%	4 (2)
Advertising in the press or TV spots	51	15.4%	49	14.8%	133	40.2%	84	25.4%	14	4.2%	3 (2)
Advertising in hospitals, hotels or medical facilities	38	11.5%	44	13.3%	131	39.6%	95	28.7%	23	6.9%	3 (1)
Internet	34	10.3%	43	13.0%	131	39.6%	101	30.5%	22	6.6%	3 (1)

M.V.: median value; I.R.: interquartile range.

).

The high success rate seems to be the main reason cited for choosing RCM to perform a medical procedure (Median = 5) (see

Table 4. Distribution of answers to the questions concerning the reasons for choosing the RCM for a medical procedure and their descriptive measures.

How Important are the Following Statements to Choosing the RCM for a Medical Procedure?	Frequency, N (Percentage %)										M.V. (I.R.)
	Strongly Disagree		Disagree		Neutral		Agree		Strongly Agree
Cost of medical intervention	8	2.4%	7	2.1%	48	14.4%	146	43.8%	124	37.2%	4 (1)
Cost of travel arrangements	7	2.1%	10	3.0%	58	17.4%	169	50.8%	89	26.7%	4 (1)
Insurance coverage	9	2.7%	6	1.8%	65	19.5%	156	46.8%	97	29.1%	4 (1)
Innovative processes	3	0.9%	10	3.0%	73	21.9%	127	38.1%	120	36.0%	4 (1)
High success rate	3	0.9%	4	1.2%	29	8.7%	120	36.0%	177	53.2%	5 (1)
High-quality medical facilities and medical staff	3	0.9%	7	2.1%	33	9.9%	136	40.8%	154	46.2%	4 (1)
Distance from the place of permanent residence	10	3.0%	21	6.3%	81	24.3%	136	40.8%	85	25.5%	4 (2)
Greece is a member of the European Union	10	3.0%	23	6.9%	96	28.8%	119	35.7%	85	25.5%	4 (1)
Recovery at a holiday destination	5	1.5%	23	6.9%	100	30.0%	126	37.8%	79	23.7%	4 (1)

M.V.: median value; I.R.: interquartile range.

).

The participants would travel to RCM to perform all the mentioned interventions (Median = 4) (see

Table 5. Distribution of responses to the questions regarding the trip to the RCM to perform procedures and their descriptive measures.

Would You Travel to RCM to Perform the Following Procedures?	Frequency, N (Percentage %)										M.V. (I.R.)
	Strongly Disagree		Disagree		Neutral		Agree		Strongly Agree
Robotic surgery	24	7.2%	19	5.7%	81	24.3%	119	35.7%	90	27.0%	4 (2)
In Vitro Fertilisation (IVF)	30	9.0%	26	7.8%	91	27.3%	113	33.9%	73	21.9%	4 (1)
Natural Medicine and Rehabilitation	11	3.3%	15	4.5%	74	22.2%	151	45.3%	82	24.6%	4 (1)
Ophthalmology	14	4.2%	17	5.1%	78	23.4%	136	40.8%	88	26.4%	4 (2)
Dentistry	19	5.7%	25	7.5%	92	27.6%	117	35.1%	80	24.0%	4 (1)
Plastic surgery	25	7.5%	26	7.8%	109	32.7%	101	30.3%	72	21.6%	4 (1)

M.V.: median value; I.R.: interquartile range.

).

The participants would travel to RCM to visit thermal springs and spas to take part in cultural visits—museums and walking tourism (Median = 4). However, they maintained a neutral stance regarding the possibility of a visit by the RCM for participation in activities related to meditation and holistic therapies (Median = 3) (see

Table 6. Distribution of responses to the questions regarding travel to RCM to participate in activities and their descriptive measures.

Would You Travel to RCM to Participate in the Following Activities?	Frequency, N (Percentage %)										M.V. (I.R.)
	Strongly Disagree		Disagree		Neutral		Agree		Strongly Agree
Thermal Springs and Spa	9	2.7%	5	1.5%	34	10.2%	140	42.0%	145	43.5%	4 (1)
Cultural visits and museums	4	1.2%	7	2.1%	30	9.0%	162	48.6%	130	39.0%	4 (1)
Walking tourism	5	1.5%	12	3.6%	35	10.5%	159	47.7%	122	36.6%	4 (1)
Meditation	55	16.5%	46	13.8%	97	29.1%	89	26.7%	46	13.8%	3 (2)
Holistic treatments	32	9.6%	32	9.6%	120	36.0%	96	28.8%	53	15.9%	3 (1)

M.V.: median value; I.R.: interquartile range.

).

4.1.2. Results of Inductive Statistics

In the second segment of our research analysis, we delved into the interconnections among the variables under scrutiny. Initially, a normality test was executed on the variables in question to determine whether parametric or non-parametric statistical tests were appropriate. Subsequently, to explore the relationships among the variables based on the research questions, we employed non-parametric statistical tests, namely the Mann–Whitney and Kruskal–Wallis tests, at a 5% level of statistical significance.

In cases where the Kruskal–Wallis test yielded a statistically significant result, we proceeded to conduct paired Mann–Whitney tests for a more detailed examination of that specific finding. Notably, a result was considered statistically significant when the p-value was less than 0.05.

To start with, it was examined whether the opinions of consumers regarding the strengths and opportunities for the development of tourism in Health and Welfare Units in the RCM differ according to their gender.

Observing the individual average classes (see

Table 7. The Mann–Whitney test results to investigate possible differences in the sample’s views regarding the strengths of the development of medical tourism in the RCM, according to gender.

Participants’ Views on the Strengths of the Development of Medical Tourism in the RCM	Man		Woman		U	p
	M.V. (I.R.)	M.R.	M.V. (I.R.)	M.R.
Operation of important Public Health and Welfare Units	4.5 (1)	177.84	4 (1)	161.15	9431.0	0.132
High level of health services in the Private Sector	4 (1)	166.73	4 (1)	165.07	10,386.0	0.881
Numerous rehabilitation centers and private clinics	4 (2)	169.92	4 (2)	163.94	10,111.5	0.595
State-of-the-art medical equipment	4 (1)	144.78	4 (1)	172.80	8710.0	0.011
Competitive prices	4 (2)	159.38	4 (1)	167.66	9965.5	0.460
International certifications and a full range of services	4 (1)	147.67	4 (1)	171.78	8959.0	0.031
Central Macedonia: a crossroad of East and West	4 (1)	155.62	4 (2)	168.98	9642.0	0.238
Airport and heliport nearby	4 (2)	164.65	4 (2)	165.80	10,419.0	0.919
Possibilities of combination with other forms of Tourism	4 (1)	164.28	4 (1)	165.93	10,387.0	0.882
The recent increase in tourist traffic in Greece	4 (1)	160.42	4 (1)	167.29	10,055.5	0.546

MV: median value; IR: interquartile range; MR: median range.

), it appears that women reported to a higher degree than state-of-the-art medical technological equipment and international certifications, as well as the full range of services, are strong points for the development of medical tourism in the RCM, relative to male consumers. The opinions of the participants regarding the other possible strengths of the development of medical tourism in the RCM were not found to differ according to their gender (p > 0.05).

Following the same rationale as the analysis presented in Table 7, similar Mann–Whitney tests were conducted, resulting in the following conclusions (to conserve space, the tables have been omitted, with only the relevant conclusions being reported):

1. Potential disparities in the perspectives of the sample were explored regarding the opportunities for the advancement of medical tourism in the RCM based on gender. Men reported to a higher degree that demographic aging and the increase in the number of retirees are opportunities for the development of tourism in health and welfare units in the RCM. On the contrary, women seem to consider more that long waiting times in the health systems of other countries, better quality service provision compared to public hospitals and the development law, as well as incentives for the creation of health structures, are opportunities for the development of medical tourism in the RCM. The opinions of consumers regarding the other considered opportunities for the development of medical tourism in the RCM did not seem to differ according to their gender (p > 0.05).

2. The study examined possible divergences in the sample’s viewpoints concerning the factors impeding the growth of medical tourism in the RCM, according to gender.

Women emphasized more strongly that inadequate state support, lack of disability infrastructure, deficiencies in public sector health and welfare units, and bureaucracy for non-EU patients are hindrances to the growth of medical tourism in the RCM. However, there was no significant difference between the opinions of male and female participants regarding other potential obstacles to the development of medical tourism in the RCM (p > 0.05).

3. Views regarding threats to the development of medical tourism in the RCM, according to gender.

Women expressed a stronger viewpoint on the economic crisis, insufficient planning for promoting medical tourism within the national strategic plan, bureaucratic hurdles, legislation related to medical tourism, and restricted bank financing as significant threats to the advancement of medical tourism in the RCM. However, participants’ opinions on other potential threats to medical tourism development in the RCM did not show gender-based differences (p > 0.05).

Differentiation of Responses of Participants Regarding the Conduct of Medical Services in the RCM, Depending on Various Socio-Demographic Factors

In the last part, Mann–Whitney and Kruskal–Wallis tests were conducted. It was investigated whether the responses of consumers regarding the conduct of medical services in the RCM are differentiated, taking into account various socio-demographic factors.

a. Views regarding the conduct of medical services in the RCM, according to gender by the Mann–Whitney test. Females showed a higher inclination to travel to the RCM specifically for Robotic Surgery compared to male participants. However, when it came to other evaluated medical services in the RCM, there did not appear to be a notable difference in opinions based on gender among the participants (p > 0.05).

b. Views regarding the conduct of medical services in the RCM, according to age by the Kruskal–Wallis test. Based on the findings, consumers’ responses about considering traveling to RCM for IVF operations (χ² = 24.12, p < 0.001) varied based on their age. Yet, opinions among participants concerning other evaluated medical services in the RCM did not display any notable differences based on their age. (p > 0.05).

c. Views on conducting medical procedures in the RCM and their age, by the Mann–Whitney test. Continued investigation into the association between the mentioned variable and age using the Mann–Whitney test revealed that consumers aged 55 and above showed less favorable responses concerning the prospect of traveling to RCM for an IVF operation compared to other participants. This was evidenced by their lower mean ranks in this particular variable.

d. Opinions of the sample regarding the conduct of medical services in the RCM, according to education (Kruskal–Wallis test). Consumer responses regarding the potential for traveling to RCM specifically for Robotic Surgery operations (χ² = 8.38, p = 0.039) exhibited variance based on their training. Nevertheless, participants’ viewpoints regarding other evaluated medical services in the RCM did not appear to diverge based on their education level. (p > 0.05).

e. Views regarding the conduct of medical procedures in the RCM and their training by the Mann–Whitney test. University graduates displayed more positive responses regarding the potential to travel to RCM to undergo Robotic Surgery compared to other consumers.

f. Opinions of the sample regarding the conduct of medical services in the RCM, according to family status, by the Kruskal–Wallis test.

Consumer responses regarding the potential for traveling to RCM for Robotic Surgery, Physical Medicine and Rehabilitation, and Plastic Surgery showed differences based on their family status. However, the opinions of participants concerning other evaluated medical services in the RCM did not showcase variance based on their marital status (p > 0.05).

g. Views regarding the conduct of medical procedures in the RCM and their family status through a Mann–Whitney test.

Individuals who were married exhibited a more positive outlook toward the prospect of traveling to RCM for Robotic Surgery, physical medicine rehabilitation, and plastic surgery procedures compared to other consumers, as evidenced by their higher average ranks.

5. Discussion

The medical tourism market in Greece remains constrained, primarily driven by domestic tourists seeking spa experiences or responding to extraordinary events, such as the care of war victims. Notably, an exception to this limited development is evident when considering holiday tourists in Greece who find themselves in need of hospitalization or healthcare services due to health issues or accidents. The fact that medical tourism in Greece mainly concerns domestic tourism was also confirmed by the results of the statistical analysis of the present quantitative research. It was also confirmed that despite the underdeveloped state of medical tourism in Greece [31], there is potential for it to catalyze economic growth if appropriate policies are formulated to enhance and promote it. Health facilities primarily offer medical tourism services in areas such as dialysis, orthopedics, oncology, and gynecology. The main challenges reported for attracting tourists include the provision of high-quality services, cost-effectiveness, tourist and cultural appeal, and favorable climatic conditions [8,12,36,54].

5.1. Strategic Management and Development of Medical Tourism in the RCM

The strategic management and development prospects of medical tourism in the RCM involve several key steps outlined in the Health Tourism Development Strategy) for Central Macedonia [23]. These steps encompass targeting and segmenting the medical tourism market within Health/Welfare Units in Central Macedonia, integrating various health services, rehabilitation, treatment of chronic diseases, leisure tourism, and specialized tourism for the elderly. Furthermore, the strategy emphasizes the development of the RCM cluster operations to promote the area as a distinct tourism destination. This includes destination branding and marketing efforts, ensuring the presence and functionality of necessary medical and nursing services in the regions of interest for medical and long-stay tourism.

5.1.1. Promotion and Development of Medical Tourism: Cluster in the Region of Central Macedonia

Central Macedonia, with its robust medical infrastructure, well-trained staff, quality hotel services, central location, and diverse tourist offerings, is an ideal region for medical tourism development. Establishing a medical tourism cluster in this region is essential to attract a global tourist community interested in specialized medical services. The creation of this cluster not only enhances the economic size of businesses but also generates high-value services throughout the year, creating employment opportunities and improving the standard of living in the RCM.

The Medical Tourism Cluster initiative in Central Macedonia, coordinated under ELITOUR [24], aims to internationalize medical tourism businesses and establish a competitive destination for medical, rehabilitation, wellness, senior, and disabled tourism. This initiative leverages the region’s strengths, including excellent climate, hotel facilities, combined tourist services, accessibility through extensive road networks and transportation hubs, and medical infrastructure, including rehabilitation centers and thermal springs.

Furthermore, alternative forms of medical tourism, including rehabilitation and wellness tourism, are being developed to cater to specific demographics, such as the elderly and people with disabilities. Countries like Germany, Finland, Sweden, the UK, the USA, Japan, Singapore, and South Korea have implemented strategies to promote medical tourism infrastructure, rehabilitation, and wellness tourism. Strengthening medical tourism through strategic actions can have a positive multiplier effect on the economy, injecting new money, creating jobs, and boosting the national economy. These strategies are essential for positioning RCM as a leading international medical tourism destination [25,54].

5.1.2. Porter’s 5 Forces Model

Porter’s 5 Forces model can be applied within the context of medical tourism in the decision-making centers of RCM to assess the potential for domestic market players to establish a competitive advantage on a global scale.

Threat of New Business Entry: Various factors serve as incentives for venturing into new businesses, particularly in the medical tourism industry. These include:

  i.

The ability to attain economies of scale in producing and marketing health and wellness tourism services.

 ii.

Diversification of tourism offerings.

iii.

Access to multiple distribution channels.

iv.

Government policies favoring industry support.

 v.

The prevailing industry structure (e.g., monopoly or oligopoly).

vi.

Sustained growth even during economic downturns.

It is worth noting that the threat of new entrants is substantial in the emerging field of medical tourism in the RCM. Greece has yet to establish itself as a recognized medical tourism destination, unlike neighboring countries like Turkey. Furthermore, the absence of a comprehensive regulatory framework setting standards and certification criteria for medical services in Greece creates opportunities for new entrants. The medical tourism sector demands substantial investments, necessitating meticulous planning and significant initial capital, especially for facilities and equipment. Additionally, the ease of access to online marketing channels further facilitates the entry of competitors seeking to attract new medical tourists.

Nonetheless, the medical tourism industry experiences annual international growth due to high demand for various global destinations [55]. In Greece, despite economic challenges, tourism enterprises focusing on foreign visitors can thrive and expand. Improved economic conditions and a more stable Greek banking system enhance creditworthiness, opening doors for substantial capital investments. Although the supply of tourism businesses outstrips demand, as indicated by SETE (2016) [56], the medical tourism sector offers profitable opportunities for investors seeking to participate in this industry.

5.1.3. PEST-DG Analysis and the Connection with Sustainability Factors

In the era of globalization, businesses grapple with heightened uncertainty. To transform risks into opportunities, corporate leaders must scrutinize the myriad factors influencing their operating environment through the application of established standards. At the macro-environmental level, a comprehensive data approach known as PEST-DG is employed. It serves as the foundation for assessing the parameters that define the broader external environment, thus shaping the national and global strategy within which RCM’s medical tourism sector operates:

i. Politico-legal: This dimension is intricately tied to political stability and bureaucratic intricacies at the national level, alongside pressures for austerity policies from the European Union. Strict legislative frameworks at both domestic and European levels could potentially impact medical tourism services. Furthermore, unfavorable tax policies for Greek businesses may put them at an economic disadvantage. The political stability of Greece is also a crucial sustainability factor, with potential reforms aimed at tax relief and reducing bureaucratic hurdles, thereby enhancing the development of the Greek economy and medical tourism [57,58].

ii. Economic: The COVID-19 health crisis poses a significant threat on both national and global scales, impacting liquidity and consumption patterns. Greece’s prolonged economic and banking crisis has led to limited bank lending, foreign investments, and high unemployment rates. However, Greece has shown a robust recovery from the pandemic, as noted by Moody’s. The connection with sustainability factors lies in the acknowledgment that the recovery is not just about bouncing back from the immediate impacts of the pandemic but involves aspects that contribute to the long-term health and resilience of the country. Yet, high energy prices, inflationary pressures, and rising interest rates may impede household purchasing power and investments [34,59].

iii. Socio-cultural: These factors center on people’s perceptions of medical tourism’s concept and benefits. Greek culture places great importance on hospitality, making government initiatives for tourism and medical tourism reforms well-received. The connection here is in recognizing that the emphasis on hospitality in Greek culture can be considered a sustainability factor for the tourism and medical tourism sectors. A welcoming and hospitable environment not only attracts tourists but also contributes to the overall positive experience of medical tourists. This positive experience, in turn, can support the sustainability of the tourism and medical tourism industries by fostering a good reputation, encouraging repeat visits, and generating positive word-of-mouth recommendations. Moreover, a shifting demographic composition towards an aging population increases medical demands, favoring the health sector’s development and, by extension, medical tourism. Changes in social values, leisure activities, and consumption behaviors due to the pandemic necessitate adaptability in strategic planning, particularly in social responsibility and sustainable development [60].

iv. Technological: Investments in modern medical equipment and robotic technology enhance the Greek medical tourism product, making it more appealing. The use of modern medical equipment, with a focus on sustainability, has the potential to enhance the quality of healthcare services, possibly resulting in improved patient outcomes and more effective utilization of resources. Rapid technological advancements in Internet services and social media enable effective marketing of RCM’s medical tourism. Digital transformation allows the industry to attract skilled professionals from around the world and engage an increasingly digital-savvy public, especially in health-related areas such as telemedicine and digital patient records [61,62].

v. Demographic: Demographic data collection offers critical insights, considering shifts in population composition due to refugee inflows and the aging native population. These data inform future labor market and educational needs, the purchasing power of various population groups, and their geographic distribution. The connection with sustainability factors lies in recognizing that sustainable development involves understanding and addressing demographic changes in a way that supports long-term economic, social, and environmental well-being [33].

vi. Global: Identifying international markets with an interest in sustainability factors and medical tourism is crucial. The connection lies in recognizing that the sustainability of medical tourism involves not only attracting international markets but also doing so in a way that aligns with environmental, economic, and social considerations. Grand View Research (2022) [6] presents global medical tourism market trends for 2022–2030, highlighting the dominant roles of neighboring countries like Turkey and Spain in the Mediterranean. Particularly in 2022, the global medical tourism market was valued at USD 9.7 billion, and it is projected to experience a noteworthy compound annual growth rate (CAGR) of 25.2% (2023–2030). Anticipated to witness substantial expansion in the forthcoming years, the medical tourism industry is driven by technological advancements in healthcare, enhanced affordability, and a growing demand for specialized treatments. A rising number of individuals are opting for medical services abroad due to these factors, contributing to the market’s continuous growth. The primary catalyst for this expansion is the high cost of health services in individuals’ home countries. Furthermore, the industry is propelled by an increasing demand for procedures that are often not covered by insurance, including gender reassignment surgeries, reproductive therapy, dental reconstruction, and aesthetic surgery [12].

Greece is considered highly attractive for medical tourism, with the potential to add EUR 27 bn to the Greek GDP post-COVID-19. Investment interest in the medical tourism sector has been expressed by a Dubai group for the Municipality of Katerini and Australians, further indicating potential investment opportunities in Greece and RCM. Amidst the intense competition, the sector can offer customized and innovative products to customers, collaborating with knowledgeable partners and suppliers on both national and global fronts [24].

5.1.4. S.W.O.T Analysis

S.W.O.T analysis (see

Table 8. S.W.O.T analysis.

Strengths	Weaknesses	Opportunities	Threats
Operation of important Public Health and Welfare Units	Insufficient support from the state	Demographic aging	Bureaucracy
High level of health services in the Private Sector	Lack of marketing strategy and actions	Increasing number of retirees	Crises: health, refugees and energy
Numerous rehabilitation centers and private clinics	Lack of networking with international and national medical tourism intermediaries	Cooperation between medical centers and travel agents	Economic crisis: lack of resources and political instability
State-of-the-art medical technology equipment	Unorganized promotion of Greece	The high percentage of uninsured people	Lack of planning for the promotion of medical tourism within the national strategic action plan
Competitive prices	Bureaucracy for non-EU patients	Combination of medical care and exploration of the area	Strong competition from other countries
International certifications and a full range of services	Lack of PWD infrastructure	Long waiting times in the health systems of other countries	Legislation regarding medical tourism
Central Macedonia: a crossroads of East and West	Limited certification by international organizations	Better service provision compared to public hospitals	A small number of tourists for medical reasons
Airport and heliport nearby	High cost of care/accommodation compared to competing countries	Development Act and incentives to create health facilities	Limited bank financing
Possibilities of combination with other forms of Tourism	Deficiencies in the health-welfare structures of the public sector	International visibility and networking through the Internet
The recent increase in tourist traffic in Greece	Small family businesses

) delves into the surroundings of the RCM, pinpointing its strengths and weaknesses within, as well as the opportunities and threats arising from the external landscape. Using the insights gained from this analysis, the company devises and puts into action its strategic plans. In this instance, the findings were categorized by examining the responses of 333 participants in the current survey for RCM (see Section 4.1.2), specifically relying on median values, as it employs a Likert-type measurement scale.

In the following consolidated table, the ranking was made based on the answers of the respondents of the present survey for the RCM, and in particular based on the median values since it is a Likert-type measurement scale.

5.2. Interconnection between Sustainable Development Goals (SDGs) and S.W.O.T Analysis

The UN’s 2030 Sustainable Development Goals represent a continuum of reflections, commitments, and collaborative actions aimed at eradicating poverty and hunger, upholding the human rights of all individuals, fostering gender equality, empowering women and girls, and ensuring the sustainable preservation of the planet and its natural resources. Sustainable development is a dynamic and ever-evolving concept that emphasizes meeting the current generation’s needs without compromising the well-being of future generations [33,35,63,64].

Specifically, social sustainability involves the quality of an organization’s relationships with its stakeholders. Within this framework, medical tourism holds the potential to advocate for transformations that align with some of the UN’s 2030 Sustainable Development Goals [33,35,63]. These particular goals encompass social, economic, and environmental objectives aimed at improving human well-being and environmental health. In this context, an effort is made to establish a connection between the SDGs and the aforementioned SWOT Analysis of Medical Tourism in Central Macedonia, Greece:

Strengths:

• Operation of important Public Health and Welfare Units: Contributes to SDG 3 (Good Health and Well-being) by providing essential healthcare services.
• High level of health services in the Private Sector: Enhances SDG 3 by improving the quality of healthcare services.
• Numerous rehabilitation centers and private clinics: Supports specialized care, aligning with SDG 3.
• Competitive prices: Affordability may reduce inequalities in access to healthcare, supporting SDG 10 (Reduced Inequalities).
• International certifications and a full range of services: Fosters global partnerships, contributing to SDG 17 (Partnerships for the Goals).
• Central Macedonia: a crossroads of East and West: Geographical advantages can foster global partnerships, impacting SDG 17.
• Possibilities of combination with other forms of Tourism: Diversify the tourism sector, creating economic opportunities in line with SDG 8 (Decent Work and Economic Growth).
• The recent increase in tourist traffic in Greece: Boosts the tourism sector, aligning with SDG 8.

Weaknesses:

• Insufficient support from the state: This may hinder healthcare infrastructure development, impacting SDG 3.
• Lack of marketing strategy and actions: Hinders international promotion of medical tourism partnerships, affecting SDG 17.
• Bureaucracy for non-EU patients: Risks unequal access to medical services, potentially impacting SDG 10.

Opportunities:

• Demographic aging: Offers opportunities for specialized healthcare services, supporting SDG 3.
• Combination of medical care and exploration of the area: Boosts tourism and job opportunities, contributing to SDG 8.
• Development Act and incentives to create health facilities: Encourages healthcare infrastructure development, aligning with SDG 9 (Industry, Innovation, and Infrastructure).
• International visibility and networking through the Internet: Facilitates global partnerships, supporting SDG 17.

Threats:

• Economic crisis: lack of resources and political instability: May impact the availability and quality of healthcare services, posing a threat to SDG 3.
• Strong competition from other countries: Challenges Greece’s position in international medical tourism, impacting SDG 8 and SDG 17.
• Limited bank financing: Poses a threat to the growth of medical tourism, impacting SDG 8.

In summary, the strengths of medical tourism in Central Macedonia have positive impacts on health outcomes, economic growth, and partnerships, aligning with several SDGs. However, weaknesses and threats pose challenges that need strategic addressing to ensure sustainability.

5.2.1. Sustainable Factors in the Context of Medical Tourism within Central Macedonia/Greece

The results of statistical analysis of the current study (see Chapter 4) reveal that the interplay between competitive pricing, the delivery of high-quality medical services and state-of-the-art medical equipment significantly influences the choice of a destination for medical tourism. This perspective is corroborated by the existing literature, which focuses on the following sustainability factors:

1. Cost Savings: Cost savings drive individuals to pursue medical tourism, opting for treatments abroad to reduce out-of-pocket expenses, especially for elective procedures and those not covered by insurance [65,66,67]. Central Macedonia’s competitive pricing compared to other medical tourism destinations could contribute to this direction.

2. Advanced Healthcare and Innovative Treatments: Medical tourists seek access to cutting-edge treatments and modern medical equipment in healthcare destinations, attracted by the prospect of obtaining innovative services at a lower cost than in their home countries [3,65,68,69]. This appeal is further heightened by advantages such as avoiding extended wait times and the availability of comprehensive travel packages. RCM provides cutting-edge and specialized medical treatments, and the healthcare facilities in the region are recognized for delivering advanced medical services. This can attract individuals seeking distinctive healthcare solutions, ensuring the provision of high-quality services.

3. Enhanced Hospitality and Personalized Care: Enhanced hospitality and personalized care are vital for medical tourists as they contribute to a positive patient experience, foster trust, and address individual needs, ultimately ensuring a more comfortable and reassuring healthcare journey in unfamiliar surroundings. These factors also play a crucial role in building a positive reputation for medical tourism destinations, attracting more patients and providing a competitive edge in the industry [3,65,68]. RCM could emphasize hospitality and personalized and patient-centric care, providing a welcoming and supportive environment for medical tourists.

4. Offer of Different Quality Versions of the Product: it is crucial for medical tourists as it allows them to choose treatments based on their preferences, needs, and budget constraints. This flexibility enhances the overall patient experience and accommodates a diverse range of individuals seeking healthcare solutions [4,8,22]. The region provides diverse healthcare options, allowing medical tourists to choose from different quality versions of medical services based on their preferences and requirements.

5.2.2. Negative Impact of Medical Tourism on Locals, the Environment and SDGs

Global and local research has indicated that in the foreseeable future, medical tourism could become a valuable addition to the tourism portfolio, offering substantial advantages to the Greek economy. It has the potential to extend the tourist season and foster the growth of domestic medical services. Nevertheless, the repercussions of medical tourism are multifaceted, presenting an opportunity for a diminished carbon footprint while posing risks to infrastructure if not meticulously planned [36,70,71,72]. To preemptively address potential issues, it is crucial to underscore the conceivable adverse impacts of medical tourism on local communities, the environment, and SDGs:

• Strain on Local Healthcare Systems: Local communities often face increased demands on healthcare resources due to the influx of medical tourists. This surge can lead to extended waiting times and diminished accessibility for residents, affecting the overall effectiveness of local healthcare systems. Consequently, progress towards SDG 3 (Good Health and Well-being) may be hindered by the strain imposed on these systems.
• Health Inequality: The prioritization of medical tourists can result in unequal access to healthcare services for residents. This prioritized allocation exacerbates existing health inequalities within the community, presenting a direct conflict with the principles of SDG 10 (Reduced Inequalities).
• Rising Healthcare Costs: In certain instances, heightened demand and competition for medical services within the context of medical tourism may contribute to an escalation in healthcare costs. This rise in costs has the potential to deepen poverty levels, impeding progress towards SDG 1 (No Poverty).
• Cultural and Social Impact: Cultural and social disruptions may emerge as a consequence of an influx of tourists with diverse customs and languages. These disruptions can impact the well-being of local communities, potentially conflicting with the objectives of SDG 11 (Sustainable Cities and Communities).
• Environmental Impact: The environmental toll of increased travel for medical tourism is notable, with heightened carbon emissions and resource consumption. This impact contradicts the aspirations of SDG 13 (Climate Action) and SDG 15 (Life on Land), as it contributes to environmental degradation.
• Loss of Local Identity: Over-commercialization and a focus on catering to tourists may erode the authentic cultural identity of local communities. Such commercial pressures can conflict with the preservation efforts outlined in SDG 11, specifically aiming to maintain cultural heritage.
• Land Use and Infrastructure Strain: The rapid growth in medical tourism can strain local infrastructure, introducing challenges such as heightened traffic, increased pressure on utilities, and conflicts over land use. These challenges pose a potential disruption to progress towards SDG 9 (Industry, Innovation, and Infrastructure) and SDG 11 by impacting sustainable development efforts.

6. Conclusions

6.1. General Conclusions

As a result of globalization, digital transformation, and escalating healthcare expenses, international medical tourism is undergoing unprecedented growth. In this context, Central Macedonia is strategically positioned to leverage global opportunities in medical tourism, notably given Greece’s historical significance as the birthplace of Hippocrates, the trailblazer of medical science. Greece has revealed ambitious initiatives, concentrating on significant investments in the medical tourism sector to strengthen its economy.

The government plays a pivotal role in fostering medical tourism development. It should act as a regulator, facilitator, and promoter of private investments in healthcare. Streamlining bureaucracy for both domestic and international medical travelers is essential, especially in the context of ongoing digital transformation. Proposed measures include simplifying the Greek Development Law, offering tax incentives to service providers, and reducing import duties on medical equipment. Public and private sector agencies should collaborate to not only showcase Greece’s attractions but also spotlight its medical infrastructure. Centralized strategic planning is crucial to identify opportunities in the global medical tourism markets.

Furthermore, a collaborative effort among tourism, health, and information and communication technology agencies is imperative for medical tourism development and effective patient care. Building essential supporting infrastructure, such as intermediary and transport services, is essential to facilitate tourism in Greece’s Health and Welfare Units, particularly in Central Macedonia.

This research advocates for an integrated approach to developing medical tourism and health and wellness tourism in Central Macedonia. The suggested strategies encompass enhancing RCM’s reputation as a premium medical tourism destination, creating and promoting innovative medical tourism products, ensuring high-quality treatments at reasonable costs, providing comprehensive online and offline informational resources, and attaining accreditation/standards for treatment quality assurance. Additionally, it emphasizes understanding the needs and preferences of existing target markets. Anyways, the region’s efforts should be guided by the SDGs to create a balanced and sustainable medical tourism sector.

Crucially, an essential endeavor that requires collaboration among public and private sectors, as well as domestic and foreign academic institutions, is imperative, with a dedicated emphasis on sustainability factors. This collaboration is vital for the systematic exploration and exploitation of medical tourism opportunities in Greece.

6.2. Proposals for the Development of Medical Tourism in the RCM

The primary goal of the study is to elevate the region to a top-tier tourist destination by augmenting its current spa facilities with a range of new and diverse medical tourism offerings. Furthermore, the objective is to seamlessly incorporate the exceptional and innovative medical services offered by Central Macedonia’s Health and Welfare Units with various alternative forms of tourism. These alternative tourism forms may include health and wellness services, which can be intricately linked with unique tourism experiences supported by the region’s cultural and geographical resources. Importantly, some of these forms complement each other and harmoniously converge into distinct products.

Additionally, several recommendations are provided with the ultimate aim of establishing Central Macedonia as a competitive medical tourism hub: Expansion of services in less infrastructure-intensive medical specialties such as patient rehabilitation, plastic–aesthetic surgery, ophthalmology, dentistry, orthopedics, artificial insemination, cardiac surgery, and transplantation. In the initial phase, it is crucial to focus promotional efforts on specific specialties to optimize resource utilization and achieve success in the markets.

Notably, for in vitro fertilization, a strategic approach involves collaborating with foreign hospitals or gynecologists from countries where legal obstacles hinder the procedure. Foreign doctors could recommend Central Macedonia as a solution for couples facing fertility issues.

Targeting patient origin as a criterion, considering factors such as follows:

  I.

the utilization of existing tourist flows;

 II.

legal restrictions in certain countries;

III.

proximity in terms of culture, religion, and geography, and;

IV.

regions with a strong Greek presence or diaspora (e.g., Germany),

 V.

countries with a significant focus on sustainability concerns (e.g., Sweden).

Τhe target countries include Cyprus, Balkan states, European and Scandinavian countries, Arab nations, the United Kingdom, the United States, Australia, Russia, and former USSR republics.

It is recommended to work with major tour operators in these countries to create complete eco-wellness packages, with accommodation, entertainment, transportation and medical care for middle-aged and elderly people who love Greece/RCM and its attractions but are now looking for medical tourism experiences. Particularly, it would be advisable to infuse green health packages into the landscape of medical tourism in the region. This strategic integration could incorporate various elements to ensure a sustainable and holistic experience for medical tourists. Using the data of this research, some recommendations could be the following:

(1) Eco-friendly Accommodations: It would be proposed to collaborate with local hotels and resorts to offer eco-friendly lodging options, emphasizing sustainable infrastructure and green building practices.

(2) Nature-based Healing Therapies: Integrating medical treatments seamlessly with eco-friendly practices in wellness retreats is a recommended approach, providing a comprehensive health experience. Crafting health packages that incorporate nature-based therapies, such as eco-therapy and sea bathing, is a wise choice that leverages the natural landscapes of Central Macedonia, enhancing the overall well-being of participants.

(3) Including activities like yoga, meditation, and mindfulness in serene, natural settings would be a thoughtful addition.

(4) Culinary Wellness Experiences: It would be beneficial to design health packages featuring locally sourced, organic, and sustainable food options, promoting a health-conscious and eco-friendly diet.

(5) Sustainable Transportation Options: Including eco-friendly transportation alternatives, such as electric or hybrid vehicles, in health packages is a recommended strategy to minimize the carbon footprint of medical tourists. Communicating the positive impact of their visit on local sustainability efforts would be a prudent step.

(6) Community Engagement and Cultural Immersion: It would be advisable to create packages that foster engagement with local communities, facilitating cultural exchange and understanding.

(7) Supporting local artisans and businesses through partnerships and inclusion in health package offerings is a recommended practice.

(8) Educational Eco-Tours: It would be important to offer educational tours that showcase the region’s commitment to sustainable practices, biodiversity, and environmental conservation efforts.

(9) Green Certification for Healthcare Facilities: Encouraging healthcare facilities to obtain green certifications by adopting sustainable practices in their operations is advisable. Highlighting these certifications as part of the appeal for medical tourists seeking environmentally conscious healthcare options is a recommended strategy.

By incorporating these suggestions, Central Macedonia can position itself as a sustainable and appealing destination for medical tourism, offering not only quality healthcare but also an environmentally friendly and culturally enriching experience.

Apart from the above, there is also a suggestion to encourage medical tourism within the country: The present research questionnaire revealed that a significant percentage of Greeks have already traveled within Greece or abroad. This suggests the potential for the development of domestic medical tourism, with other Greek regions lacking significant Health/Care Structures as potential targets. Emphasis should be placed on health and nature-centered tourism, as the demographic profile and education levels of potential users have expanded.

Moreover, it would be proposed to create a digital platform for networking, interaction, and mediation: Proposing the creation of a structured interface to connect all stakeholders, including medical tourists, health and welfare units and wellness facilities, sustainable self-care, hospitality establishments, certification bodies, global electronic medical tourism guides, local entities, and medical centers abroad to facilitate information exchange, coordination, and service provision to medical tourists. A key innovation of this platform is to promote patient engagement in health communities to collaboratively enhance the value of medical tourism services in Central Macedonia and Greece. This platform could serve as an effective feedback mechanism to address challenges, transform them into opportunities, and devise promotional strategies that satisfy all stakeholders involved. In any case, it is recommended to integrate digital health platforms for remote consultations and follow-ups, reducing the need for unnecessary travel and promoting a more sustainable approach to healthcare.

6.2.1. Theoretical and Practical Implications of the Findings

Theoretical and practical consequences of the findings of medical tourism, emphasizing sustainability factors in Central Macedonia, Greece, could offer key insights for researchers, policymakers, and academics in the realms of medical tourism, sustainable tourism, and regional development. Here are some of the following implications:

Theoretical Implications

At a theoretical level, this research could be a trigger for the following topics:

(1) Integration of Sustainability into Medical Tourism Theories: Acting as a catalyst for fellow researchers, it could encourage exploration into integrating sustainability into medical tourism theories. Given the pivotal role sustainability plays in the success of medical tourism in the region, researchers might delve into how environmental and social sustainability can be incorporated into conceptual frameworks traditionally centered on economic aspects.

(2) Tourism Destination Development Theories: The research underscores the significance of natural beauty and cultural heritage in attracting medical tourists. This underscores the necessity to reassess and modify current theories of destination development, incorporating sustainability as a crucial factor for both attracting and retaining medical tourists.

(3) Innovation Theories in Sustainable Health: By identifying opportunities for research and innovation in green technologies within the realm of medical tourism, there arises a need for theoretical frameworks exploring the intersection of sustainability and health innovation. This exploration could pave the way for developing models guiding the integration of green technologies into medical facilities.

(4) Theories on Policy Development and Governance: The critical role of government support for sustainability surfaces as a key finding. Theoretical implications extend to a more profound examination of the interplay between policy development, governance, and the promotion of sustainability in the medical tourism sector. This might involve constructing theoretical models illustrating the intricate relationship between government policies, sustainability initiatives, and the overall success of medical tourism.

Practical Implications

The practical implications are presented about aspects of the SWOT analysis:

(a)

Investment in Sustainable Infrastructure:

Strengths: Leverage the region’s commitment to sustainability through investments in eco-friendly healthcare facilities, accommodations, and transportation. This will enhance Central Macedonia’s appeal as a green medical tourism destination.

(b)

Promotion of Eco-Wellness Packages:

Opportunities: Create and market specialized holistic sustainability packages that seamlessly integrate medical treatments with sustainable tourism activities. Showcasing the region’s natural beauty and cultural heritage in these packages can attract a niche market of environmentally conscious medical tourists.

(c)

Government Incentives for Sustainable Practices:

Strengths and Opportunities: Collaborate with the government to establish incentives for healthcare facilities and tourism businesses to adopt sustainable practices. These incentives may include tax breaks, grants, or recognition programs, fostering widespread adoption of sustainable development initiatives.

(d)

Education and Training Programs:

Weaknesses: Overcome the lack of awareness and potential resistance by implementing targeted education and training programs. These initiatives should focus on healthcare professionals, local communities, and businesses, emphasizing the advantages of sustainable practices and fostering an environmental responsibility culture.

(e)

Certification for Green Healthcare Facilities:

Weaknesses: Introduce and promote certifications for healthcare facilities meeting specific green standards. This will bolster the credibility of medical services in the region, assuring environmentally conscious medical tourists.

(f)

Collaboration with Sustainable Brands:

Opportunities: Cultivate partnerships with eco-friendly brands in the healthcare and hospitality sectors. Collaborating with reputable sustainable brands can enhance the region’s green image and attract a wider audience of conscientious consumers.

(g)

Development of Green Technologies:

Opportunities: Invest in the research and development of sustainable living and health technologies within the healthcare sector. This encompasses energy-efficient equipment, waste reduction strategies, and sustainable building practices, aligning with the region’s commitment to innovation.

(h)

Integration of Traditional Healing Practices:

Strengths: Harness the region’s cultural heritage by integrating traditional healing practices into medical tourism offerings. This approach can elevate the overall experience for medical tourists seeking holistic and sustainable healthcare approaches.

(i)

Promotion of Sustainable Transport:

Opportunities: Advocate for and invest in sustainable transportation options for medical tourists, such as electric vehicles or public transportation. This aligns with the region’s green focus and contributes to a more environmentally friendly overall experience.

(j)

Crisis Preparedness Strategies:

Opportunities: Highlight the role of sustainable practices in crisis preparedness, emphasizing how green initiatives contribute to a resilient healthcare system, particularly during global health crises. This serves as a unique selling point for the region.

(k)

Community Engagement Programs:

Weaknesses: Address the lack of community engagement by involving local communities in the development and promotion of sustainable medical tourism. Implement community outreach programs to address concerns, build support, and ensure that the benefits of green medical tourism are shared across the local population.

6.3. Suggestions for Future Research

Abundant research prospects abound in the domain of Medical Tourism in Greece and Central Macedonia. These investigations should initiate an exploration of sustainability factors in macroeconomic policies targeted at stabilizing the Greek economy. In the context of medical tourism, incorporating sustainability elements into economic strategies can contribute to the long-term health and resilience of the industry, ensuring that it remains economically, socially, and environmentally sustainable over time. Concurrently, they should extend to micro-level marketing strategies crafted to create, evaluate, promote, and deliver customized medical services. These research initiatives can also aid Medical and Wellness Providers, hoteliers, tourism companies, and visitor bureaus in more effectively meeting the needs of medical travelers, all with the overarching goal of advancing the sector while concurrently tackling concerns related to sustainable growth.

Moreover, given the early stage of tourism development within health and welfare units in Central Macedonia and Greece, there is a promising avenue for future research, namely, the exploration of potential synergies between the natural environment, tourism, health, and wellness sectors. While traditionally treated as distinct areas of study, merging these domains allows for an examination of the interplay between tourism’s impact on environmental conservation and management and how these concepts can be interwoven with alternative forms of tourism (e.g., sports, culinary), contributing to overall health and well-being.

In addition, ethnographic studies focusing on medical tourists warrant further investigation to unearth specific needs and experiences within particular medical tourism communities.

Finally, there are specific recommendations for future research that could center on the following themes:

a. Future Consumer Behavior Theories: As we look forward, it becomes apparent that understanding consumer preferences remains pivotal for the success of medical tourism. Future research endeavors could explore how evolving theories of consumer behavior, particularly those tied to sustainable tourism, shape the decision-making processes of individuals seeking medical treatments in environmentally conscious destinations. This involves anticipating the motivations and barriers associated with making sustainable choices in the realm of medical tourism.

b. Future Resilience Theories in Sustainable Tourism: In the coming years, there is a growing need to integrate resilience theories into models of sustainable tourism, with a specific focus on medical tourism destinations. This future research could unravel how sustainable practices contribute to the resilience of these destinations, especially in times of global health crises. Anticipating and preparing for such challenges will be crucial for the sustained success of medical tourism.

c. Future Collaboration Theories in Sustainable Medical Tourism: Looking forward, the identification of opportunities for collaboration with eco-friendly brands and international partners necessitates the development of future theoretical frameworks. These frameworks would aim to elucidate the dynamics of collaborations within the context of sustainable medical tourism. Understanding how partnerships contribute to the long-term sustainability and prosperity of destinations is likely to be a key focus of upcoming research in this field.