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World Tourism Organization (UNWTO) and their Role in Medical Tourism

In an era of globalized healthcare, the concept of medical tourism has gained significant traction. Individuals are increasingly crossing borders to seek medical treatments, leading to the emergence of a booming industry. At the forefront of this movement stands the World Tourism Organization (UNWTO) , a key player in promoting and regulating international tourism. This article delves into the UNWTO’s profound impact on medical tourism, shedding light on its initiatives, collaborations, and aspirations for the future.

Overview of the World Tourism Organization (UNWTO)

Established in 1975, the UNWTO serves as the leading international organization responsible for promoting sustainable and responsible tourism. With a mission to foster tourism’s positive social, economic, and environmental contributions, the UNWTO has become a central force in shaping global tourism policies and practices. Leveraging its influence, the organization has taken on an active role in the realm of medical tourism.

Before exploring the UNWTO’s involvement, let us understand the phenomenon of medical tourism. Simply put, medical tourism involves individuals traveling to another country to receive medical treatment or procedures. Seeking better quality care, cost savings, or access to specialized treatments, patients often choose popular destinations renowned for their healthcare facilities and expertise.

Recognizing the potential of medical tourism, the UNWTO has proactively taken steps to foster its growth. The organization has launched various initiatives and programs aimed at facilitating collaboration among stakeholders, including governments, healthcare providers, and travel agencies. By fostering partnerships and knowledge-sharing platforms, the UNWTO has created a conducive environment for the development of medical tourism.

Furthermore, the UNWTO conducts extensive research and data collection efforts to provide valuable insights into the medical tourism landscape. This information helps destinations understand market trends, identify opportunities, and make informed decisions to attract medical tourists. By generating reliable data, the UNWTO plays a vital role in guiding policymakers and stakeholders in the medical tourism sector.

Benefits and Challenges of Medical Tourism

The rise of medical tourism brings both benefits and challenges. Economically, medical tourism injects revenue into destinations, boosting local economies and creating employment opportunities. Additionally, the influx of medical tourists often leads to the enhancement of healthcare infrastructure and services, benefitting both local residents and visitors.

However, ethical and legal considerations must be addressed. Patient safety, quality control, and adherence to medical ethics are critical aspects that need careful attention. The UNWTO, in collaboration with other organizations, strives to establish ethical guidelines, regulations, and accreditation systems to safeguard patient interests and maintain industry integrity.

Case Studies and Success Stories

To exemplify the impact of UNWTO’s involvement in medical tourism, several successful case studies come to the fore. Destinations such as Thailand, India, and Costa Rica have emerged as leading medical tourism hubs, leveraging their quality healthcare facilities, skilled professionals, and supportive government policies. The UNWTO has actively supported these destinations, showcasing their successes and disseminating best practices to foster sustainable medical tourism development worldwide.

Future Outlook and Opportunities

Looking ahead, medical tourism is poised for significant growth and evolution. Technological advancements, such as telemedicine and virtual consultations, are reshaping the industry, providing new opportunities for patients and healthcare providers alike. The UNWTO continues to monitor these developments and actively seeks to embrace emerging trends and innovations to promote inclusive and accessible medical tourism.

The World Tourism Organization (UNWTO) has emerged as a pivotal force in the realm of medical tourism. Through its initiatives, research efforts, and collaborations, the organization has contributed to the growth and development of this burgeoning industry. As the world continues to seek cross-border healthcare solutions, the UNWTO remains committed to shaping a sustainable and responsible medical tourism landscape, benefiting patients, destinations, and healthcare providers alike.

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Choi, H. 2010 Promotion and Activation of Medical Tourism as a New Growth Engine in Jordan. Unpublished Internal Report. Seoul: Korean International Cooperation Agency.

Google Scholar  

Deloitte 2008 Medical Tourism: Consumers in Search of Value. Washington DC: Deloitte.

Lunt, N., R. Smith, M. Exworthy, S. Green, D. Horsfall, and R. Mannion 2011 Medical Tourism: Treatments, Markets and Health System Implications: A Scoping Review. Paris: Organization for Economic Co-operation and Development.

Picard, A. 2011 Transplant Waiting Lists and Dialysis Costs Grow as Kidneys Supply Lags Behind. The Globe and Mail www.theglobeandmail.com/life/health-and-fitness/ (10 August 2013).

Reisman, D. 2010 Health Tourism: Social Welfare through International Trade. Cheltenham: Edward Elgar.

Book   Google Scholar  

USDHHS 2012 Health, United States, 2011 with Special Feature on Socioeconomic Status and Health. Hyattsville: Centers for Disease Control and Prevention, US Department of Health and Human Services.

Whittaker, A. 2008 Pleasure and Pain: Medical Travel in Asia. Global Public Health: An International Journal for Research, Policy and Practice 3:271-290.

Article   Google Scholar  

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Choi, H.C. (2016). Medical tourism. In: Jafari, J., Xiao, H. (eds) Encyclopedia of Tourism. Springer, Cham. https://doi.org/10.1007/978-3-319-01384-8_129

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Healthcare Development & Architecture

Medical tourism sustainable development.

Since the 1980s different industries have committed to mitigate or potentiate negative and positive impacts under the concept of sustainable development. Today medical tourism is a growing industry and like any other activity is generating both impacts. But is medical tourism a tool for the sustainable development of a region? ‍

The primary motivation of a medical tourism patient is to travel outside of the area of residence for reduced prices higher quality and quick access to medical care.As a result medical travel has created a social cultural and economic phenomenon that generates positive and negative impacts in built-up areas in natural areas and in communities. ‍

Some Impacts of Medical Tourism

Impacts occur in three main areas:.

Environmental impacts: Medical tourism makes use of natural resources. Their indiscriminate use without good practices will contribute to its depletion.In some cases the medical tourist performs leisure activities at a destination and establishes incentives for the protection and use of natural resources especially in countries like Costa Rica and Columbia -- where nature and cultural tourism are important sectors in the economy.

Social impacts: Medical tourism has a positive social impact by allowing millions access to enhanced health services at affordable prices thus improving their quality of life and creating jobs cultural enrichment and technological advances within the community. ‍

All medical tourism providers and doctors must take into account the principles of environmental economic and social sustainability.

One of the most noticeable negative impacts is how the local community in some countries becomes antipathy to medical tourists who are perceived to have greater availability to services and are treated differently.

Economic impacts: Economic impacts of health tourism are remarkable for its multiplier effect. For example in Colombia the ratio is 1:5 meaning that for every dollar spent on healthcare the medical traveler spends $5 within the tourism industry -- at hotels restaurants transportation and travel agencies and malls (MCIT 2013). ‍

When these economic benefits are not equally distributed throughout the host region social inequality may result. Also tourism contributes to the inflation of prices in the destination and may affect the quality of life for people with less purchasing power. ‍

Sustainable Development

In 1987 the United Nations the Brundtland Commission defined sustainable development as meeting the needs of the present without compromising the needs of future generations. Although this concept initially focused on the environment by 1992 sustainable development perspectives began to change and instead focused on three pillars: economic progress social justice and environmental preservation. ‍

• Economic progress: Refers to the allocation and efficient management of public and private investments and resources that not only generate economic profitability to the company but also efficiency in terms of macrosocial benefits (Sachs 2008). ‍
• Social justice: Relates to building a civilization with greater equity in the distribution of earnings in a way that reduces inequality between rich and poor by protecting and ensuring the participation of local communities (Sachs 2008). ‍
• Environment preservation: Refers to the rational use of natural resources taking into account the balance of ecosystems and the conservation of non-renewable resources and biodiversity (Sachs 2008). ‍

Sustainable Medical Tourism

The World Tourism Organization defines sustainable tourism development as tourism that takes into account current and future economic social and environmental impacts in order to meet the needs of visitors industry the environment and communities. ‍

Sustainable development and tourism is based on three main pillars which must take into account tourist satisfaction industry environment and community. ‍

• Environmental sustainability: Optimizing the use of environmental resources and helping to conserve natural resources and biodiversity. Also environmental sustainability should promote a better understanding of the importance of the diversity of ecosystems and improve monitoring of the environmental impact caused by production activities. ‍
• Social sustainability: Respect the socio-cultural authenticity of host communities ensuring the preservation of cultural assets and traditional community values. Additionally social sustainability must take into account the dimensions that improve the quality of life of the local community such as access to education health employment and dwelling. ‍
• Economic sustainability: Promoting and ensuring longterm economic activities in which socio-economic benefits are equally distributed among all agents generating stable employment opportunities and contributing to poverty reduction. ‍

The World Tourism Organization affirms that a sustainable balance must be established among these three pillars to guarantee long-term sustainability. ‍

Medical tourism may contribute to the generation of sustainable development if along its entire service chain the three pillars of sustainable tourism development are considered. In other words all providers and actors of medical tourism have to take into account the principles of environmental economic and social sustainability. All providers and actors must ensure a meaningful experience for the tourist and host community promoting sustainable practices in their activities. ‍

The application of these principles to medical tourism is key to enhancing the quality of life of millions worldwide environmental protection poverty reduction and economic and social development of the region. ‍

From Theory to Practice

How can sustainable medical tourism be practiced? ‍

Firstly in the medical tourism chain of service stakeholders must be aware of the importance of being sustainable not only economically but also environmentally and culturally. Awareness helps to identify both positive and negative impacts created and on which actions must be taken to mitigate or potentiate. Actions must be oriented to accomplishing the company mission and vision and also must include people who are responsible for performance and compliance deadlines. ‍

Promoting a sustainable activity generates high value for companies not only in the acquisition of savings practices but also through social responsibility perceptions of stakeholders who generate differentiation and add value to services. ‍

Almost half of all consumers are willing to pay more for products from companies that demonstrate a commitment to social responsibility (Nielsen 2012). ‍

Bibliography

Medical Tourism and Wellness MCIT 2013 Recuperado el 22 de Julio de 2013 de Sitio web de Programa de Transformación Productiva http://www.ptp.com.co/Turismo_Salud_Bienestar/Turismo_de_salud_bienestar.aspx

Rivas Garcia J. & Magadán Díaz M. Los indicadores de sostenibilidad en el turismo Revista de Economía Sociedad Turismo y Medio Ambiente 26- 61 2007.

Sachs J. D. Common Wealth: Economics for a Crowded Planet Penguin Press 2008.

Shayon S. Report: Nielsen Defines the Socially Conscious Consumer Recuperado el 22 de Jul de 2013 de Brand Channel: http://www.brandchannel. com/home/post/Nielsen-Report-Corporate-Citizenship-040312.aspx 3 de Apr de 2012.

Sustainable Development of Tourism World Tourism Organization (s.f.) Recuperado el 22 de Jul de 2013 de Definition http://sdt.unwto.org/es/ content/definicion

Sustainable Tourism Training the Trainers Programme UNESCO Regional Bureau of Science and Culture in Europe (BRESCE) pp.33-43 2009.

About the Author

Ángela Tatiana Castro Lotero is CEO and founder of Clinical Travel a travel agency specializing in medical and wellness tourism in Colombia. Castro has a professional degree in hotel and tourism business management from Externado University of Colombia. She has led the positioning of the Coffee Triangle in Colombia as a global health destination. Castro developed her thesis in lodging specializing in medical tourism. Social Responsibility -- Clinical Travel is a nonprofit organization that integrates health and tourism services promoting a sustainable and inclusive tourism committed to environmental conservation economic progress and social justice. http://clinicaltravel.co/

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Holistic healing: exploring integrative medicine and wellness retreats, meeting the surge: the growing demand for knee replacement surgeries and advances in the field, innovations in medical technology: how cutting-edge technology drives medical tourism, stem cells have powerful anti-aging properties, new shift for thailand’s medical travel landscape as mta launches new moves, continue reading, medical tourism events and conferences: a marketing goldmine, global provider network: a new solution to open up the true potential of medical tourism and overcome growth-limiting factors, medical tourism moonshot: breaking the barriers to quality healthcare, featured reading, dominican republic’s giant strides to becoming a global leader in medical tourism, exploring niche markets in medical tourism, medical tourism magazine.

The Medical Tourism Magazine (MTM), known as the “voice” of the medical tourism industry, provides members and key industry experts with the opportunity to share important developments, initiatives, themes, topics and trends that make the medical tourism industry the booming market it is today.

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Home > Books > Advances in Health Management

Low-Cost Health/Medical Tourism of Italians

Submitted: 26 January 2017 Reviewed: 31 May 2017 Published: 23 August 2017

DOI: 10.5772/intechopen.69954

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In recent years, becoming a form of spatial mobility of people is mainly called “medical tourism or health tourism”. In Italy the adoption of the expression “turismo sanitario” is often used as an international expression synonymous with “medical tourism or health tourism”: this situation raises a number of conceptual problems. In fact, the Italian public health service is one of the most developed in the world and is distinguished by many nations to the fact to offer its citizens free of charge and many health care services. In this situation, the Italian citizen in need of medical care is not convenient to travel to other places and is not obliged to do so. In fact, the Italian citizen tends to move for medical and health care that the Italian public health service does not deliver at no charge: such as dental care, we will deal with this case illustrating some examples of dental tourism low cost of the Italians. However, from our point of view, tourism period may be coupled to the trips to the health or well-being only in cases where the journey is “voluntary.” All this will be discussed in this paper.

• turismo sanitario
• health care and low cost
• health and holiday

Author Information

Tullio romita *.

• Università della Calabria, Rende, CS, Italy

Antonella Perri

*Address all correspondence to: [email protected]

1. Introduction

Expressions like medical tourism or health tourism are very widespread nowadays and for the past 10 years are used to indicate the geographical (territorial) mobility of people moving around the world looking at this way of meeting together the motivations and needs that deal with health and well-being, with needs related recreation, knowledge, and holidays. This kind of mobility has grown more and more over time due to the (considerable) opportunity of visibility by World Wide Web about global health opportunities. In fact, due to World Wide Web, people have the possibility to communicate in real time and the ability to move faster and faster and economically in space, especially through low-cost air transport.

In the contest of health and wellness, there is a real competition between touristic destinations that are increasing their product offerings in order to gain significant shares of this type of tourism market.

However, within the analysis and study of the phenomenon, the first difficulties refer to the theoretical and conceptual problems it generates, especially in the Italian case, the use of the term “health tourism.” In this work, we will analyze this particular issue and the low-cost medical tourism of Italians. 1

2. For a definition of “health/medical tourism”

The term “health/medical tourism” has its origin in those countries where coverage of the cost of medical care is borne by the public or where there is no public health services guaranteed by the state.

This situation is found in several of the Western world rich countries, such as many of the major English-speaking countries (the United States of America), where, in fact, and for a very long time, you can observe a great mobility of people who need medical care and that move within their own country, or even abroad, to the medical service research that, at least of equal quality, offers a more advantageous cost. 2

However, in countries like Italy where, as always, there is a national health service, that is, where the state offers its citizens the opportunity to care for free or at low cost, and where all the different types of medical services are, or should be, guaranteed locally or, in any case, in the vicinity of the closest spatial urban centers, the health tourism expression has never been, and still it is not today, similarly applicable, on the contrary, said in these terms, it seems inappropriate, that is, because the main reason for medical mobility is determined or because the severity of the person's health situation is such that to resolve it, he must move toward national public specialized centers of medical excellence or because the place where he lives the public health presents evident criticality in the quality of medical services.

Obviously, the reference just mentioned on the Italian situation does not apply to all citizens, in the sense that existing excellent medical services are provided in private health facilities, people who can afford it, that is, those with greater economic capacity, they may decide to opt for this type of medical facilities and not for those public ones.

It is favorable to point out that in Europe we have tried to regulate the sector of health services with specific European directive of 2011, 3 establishing the rules for cross-border healthcare, under which European citizens are now allowed to cure themselves freely even in countries other than their own.

In any case, what our opinion appears at this point is necessary that it is to reflect on at least two issues. The first one is whether expressions indicating the so-called “medical tourism” indicate the same phenomenon, even if with different shades, at the international level; the second one is if the mobility of people determined to respond to medical and health needs is in fact appropriate to pair the word “tourism.”

Regarding the first question, there is to say that, in the “literature,” this kind of tourism is almost always considered substantially equivalent to those of Anglo-Saxon term of “health travel,” “medical tourism,” or even “Health & Medical Tourism.” 4 In fact, however, this situation seems to represent a simplification not useful to understand the differences.

For example, in the Anglo-Saxon world, we are faced with health services, in many cases, paid services and that's why you go looking for economically viable healthcare solutions; this situation assumes the possibility of physical movement, and in these cases, for the same quality of medical service, the choice of where to go can also depend on the attractiveness of the tourist places and/or of the availability of tourist services and leisure. In the Italian case, however, even if a national health service exists, the prevailing gratuity brings the citizen to move to different places than those in which he lives only in the case of particular services or nonexistent or poors at the local level.

In short, from a substantive point of view, the Italian expression “turismo sanitario” does not have the meaning exactly similar to those attributed to the expressions used in the international arena such as “health travel” or “medical tourism.” Therefore, in our opinion not even conventionally, in the case of the Italian medical tourism, it appears appropriate to use dogmatically such an expression to propose a comparison with other international experiences, particularly with Anglo-Saxon ones, where, unlike the Italian system, the health services are of private nature, and for that, they are a substantial economic burden to the citizen.

The second issue on which we have set ourselves to reflect on it is whether it is in fact appropriate to use the term “tourism” to indicate the physical mobility of people toward health services, which is currently widespread.

Indeed, technically the use of the term “health tourism” depends by the definition of tourism generally adopted, developed, and proposed by the UNWTO, 5 according to which 6 : “Tourism is a social, cultural, and economic phenomenon, which entails the movement of people to countries or places outside their usual environment for personal or business/professional purposes. These people are called visitors (which may be either tourists or excursionists; residents or nonresidents) and tourism has to do with their activities, some of which involve tourism expenditure.” In this regard, it is worth to highlight that the definition of tourism over time has greatly expanded its conceptual meaning, and today, there is a tendency, in fact, to consider tourists even those who move for instrumental purposes (for example, for work reasons), and this leads to a census as a tourist movement, practically all types of travelers regardless the motivation that determines the journey.

In other words, to be tourism, to be able to label a particular territorial mobility of people as a tourist, it would be enough for the presence of a condition: the journey to a destination other than the one where you normally live. While visitors/hikers, even if today conceptually considered tourists, they remain statistically and economically very difficult to evaluate due to the absence of at least one night in an accommodation facility.

Anyway, the definition of tourism provided by the UNWTO and with it, a large capacity to consider substantially as tourism, as we have said before, almost all streams of people who move to places other than their own for us is clearly very difficult to recognize as valid the “health tourism” expression; we see a paradoxical situation in part, in the sense that it seems almost an oxymoron. Here, we try to explain what we mean.

Indeed, contemporary society no longer offers the certainties of modernity and even try to frame the conceptual and theoretical point of view of tourism phenomenon, precisely because social phenomenon of globalized mass and in continuous expansion, it becomes an increasingly difficult operation and contains full of obstacles. However, we think to have some certainties.

In a study of sociology on tourism very well-known internationally and still widely used today, Cohen [ 6 ] identified and defined the tourism role based on some dimensions. In other words, according to this scholar, any traveler could call himself a tourist in the presence of the following dimensions: (1) the stay of tourists should be temporary (for this reason they are different from other types of travelers as they have a residence that makes them traceable); (2) the tourist makes a round trip (this distinguishes it from the travelers who move to other places, such as immigrants, permanently); (3) the visitor makes a journey that is not completed in the same day (what differentiates it from hikers travelers); (4) the tourist traveling along pathways that, however, do not occur frequently; (5) tourists in traveling do not pursue instrumental goals (what distinguishes it from business travelers, for example, businessmen, missionaries, politicians, etc.); (6) the tourist is a person who decides to embark on the journey in a totally voluntary way (what distinguishes him from all the travelers who become obliged, for example: victims of political persecution, political prisoners, the prisoners, the sick, etc.) [ 7 ].

Cohen's work, although of extremely useful and epistemological interest, we have no difficulty in admitting that by virtue of the important changes that have affected the tourism phenomenon in time, it is no longer present and, moreover, “… It is limited in the real tourist experience. A series of figures traveler would remain outside in which the tourism component has ample space. Consider, for example, hikers, those who decide to spend a day on a farm or under an umbrella at the beach, or even the congressman who takes the opportunity to learn about a new location, it is these situations which are now generally considered to be a constituent part of tourist flows.” [ 7 ].

Even taking into account the above, by comparing the contents of Cohen's tourism dimensions and the definition of tourism role by UNWTO and adopting a more conceptual flexibility; however, it seems to emerge a broad convergence about who the tourist is and what tourism is. So given things, the aspect that even the definition of tourism UNWTO does not capture is “the voluntary nature of the trip.”

This, in our view, remains central to really understand what tourism is distinguishing it from what tourism is not and who tourist is from who is not even when the journey that is accomplished is not voluntary? Can trips really be included in tourist flows that they are required to do?

Using the definition UNWTO, the answer would be, probably, yes! While in the past, the entire mobility made with mostly recreational purposes and entertainment was considered tourism; today, there is a tendency to see the presence of tourist aspects in all types of mobility, and for that, we can conclude on the basis of over-simplifying phrases such as that included in the definition given above by the UNWTO tourism: Tourism is a social, cultural, and economic phenomenon, which entails the movement of people to countries or places outside their usual environment for personal or business/professional purposes.

Indeed, however, can we really think that a person who is working as a sales representative and that every day, he travels for hundreds of kilometers by car, traveling from city to city, even sleeping and eating at several hotels and restaurants, can be counted as tourist mobility? Or that the person who moves from his home to go to work for 6 months a year in another place and in doing so also sleeps and eats in various hotels and restaurants, can it be counted as a tourist mobility? Or also, and more simply, can it be considered a tourist the parent obligated to visit a university student son in need of help, and in doing so, he spent a short time in a holiday complex located in a distant city? From our point of view, the answer to these questions is probably not! The voluntary nature of the trip remains an essential element of tourism; otherwise, we are talking about something else and not of tourism. 7

Also, since it does not solve the problem of voluntariness of the trip, we think that the simplification of Henderson [ 8 ] is not very useful and that it has encouraged the definition of the various areas of “health tourism” dividing the search for cures into four categories: (1) the area of disease conditions (all forms of surgical interventional, diagnostic investigations, etc.); (2) the wellness area that can encompass the so-called alternative medicines as well as spa treatments and fitness; (3) the area of esthetic enhancement through plastic and cosmetic surgery; (4) the breeding area for fertility treatments and assisted reproduction.

Ultimately, based on the principle of voluntariness of the journey becomes really difficult to see if and when it is possible in the Italian case, the use of the term “health tourism,” an expression, in our opinion, that to represent the phenomenon is more just separate into two further expressions: “medical trip” and “wellness tourism”:

With the “medical trip” expression, we could indicate all those travel experiences that individuals make because in any case obliged, the motivation of the travel to seek health care controls and/or medical treatment that they are necessary to the control or to the resolution of a disease, though the related medical and health care services are available at the place where he usually lives;

With the “wellness tourism” expression, we could, however, indicate all volunteer's trips that people make for not essential medical services but for the care of the psycho-physical wellness of their appearance. Among other things, it is worth noting that in the Italian case, the public national health service does not recognize the costs of nearly all of these treatments, which are therefore the sole responsibility of the citizen, and even if the choice of the medical structure in which “you receive care” is important, it is important too, the identification of the place where to go that sometimes convinces in particular the offer of “tourist” services associated, in other words to mix business and pleasure.

In the first case, that one of “medical trip,” we find ourselves faced with a necessary journey, where the only motivation is the need for appropriate treatment, maybe only available in certain cities and medical facilities. Although for these purposes, you may need to go in very desirable locations, or use the magnificent tourist services, it is difficult to think that this kind of travel experience is actually a tourism experience. In the second case, that one of “wellness tourism,” are faced with travel volunteers, either because not necessary from a medical point of view or because the health services are generally widespread or available in the places where you live, in any event, services not absolutely necessary for the very survival of the person. Moreover, in the case of “medical trip,” the challenge to attract the attention of the person as a “traveler” is not based on the tourist attractiveness of the destination, but on the presence of medical facilities and onto high quality or unique health services (in this case, the choice of where and how to stay will depend more easily by logistical and/or economic parameters). While in the case of “wellness tourism,” not only the choice is based on availability and quality of services and healthcare type structures, but also on the attractiveness of the tourist destination, on the different and qualified availability of tourism services, and reachability of the destination (the most obvious case is that of dental care, where in the last decade has developed an international challenge, with dozens of different offer packages that include in addition to medical care, travel, accommodation, excursions in the area, and an increasingly wide range of additional services for leisure).

In conclusion, we recognize as not useful and misleading using the term “health tourism,” at least in the Italian case. The reasoning led us first of all to separate the expression into two parts to start to understand more fully the phenomenon: we think we can establish that the “medical trip” is obligated by its nature, and therefore, it is not considered as tourism, as is the related traveler cannot be considered a tourist but, a “person in need of medical care”; the “wellness tourism” is, however, more properly defined as “health tourism,” because the more easily the nature of the trip is voluntary and the ability to care about their psycho-physical wellness reconciles with the tourist experience that assumes knowledge of the places where you are traveling and the development of relations and knowledge relations with host populations. 8

3. The so-called “health tourism” market

Evaluate the value of world market of so-called “health tourism” is not easy for two reasons.

The first one is a question of conceptual character. As we wrote before, to establish with reasonable accuracy what actually “health tourism” is, it is possible only when you come to a shared definition of the meaning. However, for the purposes of this paper, we assume that health tourism like all mobility that is determined by motives that concern as well as medical care dedicated to the more general welfare of the people. The second reason is the scarcity of systematic studies of this type of mobility, for which you will use what we currently have.

Bearing in mind the considerations just made, we say that already about 10 years ago, the American company Deloitte Research [ 10 ] predicted a rosy future for the US health tourism, which it imagined would touch the six million citizens compared to about eight hundred thousand in 2007, for a global turnover estimated at several billion dollars annually.

The same Deloitte [ 11 ], in a later study calculated “… that every year seven million people in the world travel because of health reasons, already generating a turnover of 100 billion dollars, which will become 150 in 2018” [ 12 ]. In addition, according to another study dated 2016, “… the revenue generated from medical tourism already amounted to 12 billion euro in Europe … Italy has a market share of 2 billion, which could reach 4, by implementing the “provision of health and tourism services offered to foreigners.” 9

The so-called health tourism is today a social and economic phenomenon of great importance in fact recently, and for the first time in one of the most important fairs of world tourism, which was the FITUR 2015, a specific space it has been reserved right to health tourism.

However, the Italian Association for Medical Tourism Development (IAMT) has published on its website [ 13 ], a brief illustration of the background of health tourism. In particular, the variables that determine the majority of the customer mobility flows are the quality of the delivered treatments; better access to health services; the absence of waiting lists; the ability to bind to a health need for the satisfaction of a tourist needs; travel opportunities; the cost of treatment, which is a significant variable for a given segment of the market; the confidentiality, especially for esthetic interventions. In addition, with regard to the health tourism numbers, it notes that about 15 million tourists patients in 2017 will decide to resort to medical treatment abroad, and that the major destinations of health tourism for many tourists are Costa Rica, India, Israel, Malaysia, Mexico, Singapore, South Korea, Taiwan, Thainlandia, Turkey, and United States of America.

There are more than 200,000 Italians who are traveling because of sanitary issues. At least, a quarter of this, 200,000 Italians ask for medical care dentistry. Most treatments in specialized health tourism dental are in Eastern European countries, Croatia, Hungary, and Romania (with Albania that's growing up). For the Italians, it is easy to get there in these countries, especially if they live near the airport. It is quite clear that these are countries where the cost of dental care is much lower than in Italy. Often the dentists (in these countries) have even studied abroad. The promotion of health treatment is very aggressive and aims almost exclusively on the Web support; in addition, all medical treatments are combined, with the basic tourist services like accommodation, food, shuttle service, etc. and excursions in the area who takes care to these tourists who speak Italian.

Precisely of this type of health tourism, we will deal in the next section.

4. Low-cost medical tourism of Italians

In this section, we will deal with the case of the health travels of Italians to foreign destinations where there are specialized institutions in dental care.

Thousands of Italians are contacting low-cost dental clinics in countries belonging mainly to Eastern Europe, and as we have mentioned before, it is a growing phenomenon.

Countries such as Croatia, Bulgaria, Romania, Slovenia, Poland, and Albania are in the last years the European leaders in dental health tourism market.

In recent years, we are seeing a proliferation of so-called low-cost dental centers, or commercial chains, mostly franchised, offer dental services at low prices.

Several clinics offer “all inclusive packages” at very low prices. In the “all inclusive,” beyond the costs directly attributable to the dental expenses in the strict sense, in many cases, the costs of travel, the stay in the place where the clinic and excursions in the area is located are included.

The very low cost relative to the “all inclusive package,” is due, according to what these clinics confirm, to the fact that “everything costs less” than the other countries of Western Europe: the rental of commercial premises, the average salary of a dentist, the cost of electricity, water, heating, expenses for advertising, administrative costs, taxes [ 14 ]. Indeed, the Italian president of the National Council of dentists, Dr. Giuseppe Renzo, in a 2015 interview said that “Italians look for alternative health services to cope with the crisis period” and because of the high prices of dental care in Italy according to Istat “over 8 million citizens would prefer not to heal mouth and teeth.” In fact, in an article in the Italian newspaper “Il fatto quotidiano” in talking about low-cost dental tourism is reported an interview with an Apulian lady who alleged that she was aware of the possible risks to go to Albania to dental care, but the Italian prices would not have permitted to care of her teeth; moreover, it would have taken little time to arrive in Albania, and that she was very satisfied with the reception saying “they treat me like a queen, they cuddle me, they offer me the stay and make me visit the castles” [ 15 ]. Furthermore, Dr. Renzo stated that “dentistry in Italy is based in large part on a private network of professional firms whose basic costs are on average four times higher than those faced by professionals from other countries. The tax is 22% compared to 4; VAT cannot be deducted; the costs for collaborators are a weight on the cost, but their presence is essential to ensure safety and hygiene” [ 16 ]. On the other hand, the Italian dentists assign to the low cost of dental services low quality [ 17 ], mainly with respect to sanitary regulations, the respect of clinicians time, and the necessity of subsequent checks [ 18 ].

The dental tourism in recent years has made its history to Albania. There are several clinics on the Albanian territory, as many are also, the individual dental practices. Among the different realities encountered in our research, we wanted to analyze the case of “Dentists in Albania–Viaggiare e sorridere” [ 19 ].

In their Web page, they immediately show the fact that in Albania many of them speak, even correctly, the Italian (75% of the population) putting the possible Italian customer at ease and reassuring him, as well, also, they reassure on professionalism and quality of materials used (that they define high), they perform the relevant certifications and that they offer 5 years Warranty [ 20 ].

Albanian dentists reassure the potential customers on the qualitative aspect of their services, explain why their prices are so low compared to Italian dentists, attributing the reason to lower taxes, saying that in Albania tax pressure affects 10% while in Italy 55%, and the lower labor costs are due to a lower cost of living. In their opinion, it would lead to savings for the Italian patient tourists by 60% compared to what they could spend in Italy.

Another element that it should entice potential Italian customers to turn to them is the so-called word of mouth. In fact, on the website, dozens of testimonials were published that highlight the quality of services offered, the main motivation of the trip, that is, the economic issue and the tourist aspect. A witness, in fact, declares: “I hope nobody feels offended, I want just to tell my experience: in Italy, our doctors charge 4 times the cost of performances more than the Albanians, often abusing of the good faith of our patients and of our lack of information with the result of a medical service of the third world! This is what happened to me in Italy. That's why I want everyone to know about my experience with Viaggiare e sorridere. In Albania, for three certified dental implants made in Europe and the extraction of teeth 3, I spent EUR 1,400.00, and I was operated by a skilled doctor, who teaches Dental Implantology at the University of Tirana and by her husband too. The intervention lasted only 55 minutes as opposed to Italy, in fact the Italian dentists to justify the excessive price make you go several times ending up losing even 3 months. I saw people from all social backgrounds enter in this clinic equipped with the best three-dimensional machinery and hygiene at par with the best clinics in the world, I saw people, which they hugged each to other and then they decided to exchange they phone numbers, people pleased to have found a smile without signing a mortgage. A unique professionalism, many money saved and the stay is free, as also the taxi for and by Tirana to airport on arrival and departure and outings to discover the beauty of their land with the company of reception staff who speak Italian. A real holiday of well-being, which is why I thank and advise everyone the clinic Viaggiare e sorridere” [ 21 ]. Among other things, each patient/tourist who has left his testimony has left their contact information in case any potential customer wants to know more.

In Albania, low prices are not the only element to attract customers' attention, there are other elements as: a detailed range of interventions and services offered, the curriculum of some dentists and professionals who are part of the medical staff and not, the reviews (all positive) of their patients/tourists; “Dentists in Albania” also uses the “card” of the holiday, offering, among other things, a free stay for two people, and both the transfer to the hotel and the reception service: at the airport, there will be an attendant who will speak properly in Italian and that he will welcome them, he will be available to patients-tourists from 9 AM to 21 PM to resolve any problems on the stay or even to play the role of tour guide of the city. In addition, the reception agent will be available 24–24h contacting him by telephone. Even before the trip, they offer their availability to clients in the organization of the trip, advising how to reach Tirana “stress-free and save a lot of money.” The tourist aspect is repeatedly quoted on the website where, among other things, you can read “beyond to low-cost professional dental care, you will have the opportunity to take a holiday in a wonderful city like Tirana, all without spending just a euro for the stay and benefiting of all the services that you want.”

It is some years now, that some of these dental clinics have opened offices in Italy where they exclusively, do free visits with the purpose of provide quotes. Among them, there is the case “Dentists Croatia low-cost,” which opened an office in Verona for “a free estimate, to explain the treatments, prices, to answer all your questions freely, and to give you all the information related to your stay in Croatia.”

For free, no-obligation appointments call us at our number “…Cell…Email…” [ 22 ]. Also in this case, the bus trip, starting from some cities reported on the website, is free. It is to be noted that accommodation is free sometimes subjected to the cost of the performance that a patient goes to support it and, in any case, the patient's accommodation does not happen in a hotel but in an apartment. In particular, the dental office specifies: “During your dental care, we offer a FREE comfortable apartment in the center of RIJEKA/RIVER Croatia near the sea with five beds. The apartment is free if you spend at least € 1000/1500 in dental care” [ 23 ].

Actually, in this case, by some researches carried out on the Web, it is not a dental clinic, but it concerns a real travel agency that manages the health travels. Indeed, by analyzing other websites offering low-cost dental care in Croatia, we realized that another website had the same addresses of “Dentists Croatia low-cost,” and it is the following website www.viaggideldente.info [ 24 ]. The latter, it is known as the “Tour operator of dental savings,” offering free travels by bus from some cities in northern Italy, low-cost dental care “in the best dental practice in Croatia” [ 25 ] and the opportunity to book your stay at favorable prices in the apartment.

However, the proliferation of dental clinics and dental low-cost studies in recent years has become an increasingly important phenomenon, and, therefore, the online offering of low-cost dental tourism is really impressive. Even in Italy dental centers specialized low cost are springing to try to attract these patients/tourists who want to be cured at a lower price. Although, now, as we have seen, competition in the European scenario, in terms of cost and quality, it really is ever more.

5. Conclusion

In our discussion of the issue, we refer to the patient/tourist in terms of an exaltation of humanity. We refer to the person and his emotional sphere, which led him to travel to search for a better state of health [ 26 ]. Rests in the economic and marketing logic and activates processes for which he becomes a consumer, but he remains a person driven by doubts, fragility, and hope to the pursuit of happiness.

The medical treatment related to dental care is among the categories of health (medical) tourism, which refers to disease conditions and to ones of the esthetic improvement.

The research shows that the main reasons why Italians do dental care abroad are due to saving time and money. As well as because distance, communication, and knowledge of the language are not a real problem. Finally, using in a wise way the Web, there is no needs either of large economic investments to create promotion nor advertisements [ 27 ].

Italy is not among the top destinations for foreign health tourism, even if relying on a health care system, it is between the most efficient in the world. Italy was always been one of the most important tourist destinations in the world. Because of this, it is possible to arrange strategies that allow Italy to grow up the market related to the health tourism.

Acknowledgments

The authors would like to thank Dr. Lucia Groe. This research was supported by her who provided expertise and comments that greatly improved the manuscript.

• 1. The European Directive 2011/24 of 9 March 2011
• 2. Schael T, Rinaldi P. Globalizzazione in sanità. Il paziente diventa turista. VoiceCom news. 2010:37-46. marzo
• 3. Schael T, Ballotta P. Strategie di attrazione per il turismo sanitario in Italia, XVII Convegno Nazionale. Rome: AIES; 2012
• 4. Rossi A. Strategie per il turismo sanitario. Le componenti di una strategia di internazionalizzazione dei servizi sanitari. Health & Medicine, Marzo. 2014
• 5. UNWTO. Glossary of tourism terms, Last update: February 2014. Available from: http://www2.unwto.org/en [22-02-2017]
• 6. Cohen E. Who is a Tourist? A conceptual clarification. The Sociological Review. 1974; 22 (4):527-554
• 7. Romita T. Argomenti di sociologia del turismo, Working Paper n.78. Università della Calabria; Messina; 2010. pp. 9-10
• 8. Henderson JC. Healthcare tourism in Southeast Asia. Tourism Review International. 2004(7):111-122
• 9. Lunt N, Horsfall D, Hanefeld J. Handbook on Medical Tourism and Patient Mobility. Elgar; UK; 2015
• 10. Deloitte. Medical Tourism: Consumers in Search of Value. Deloitte Center for Health Solutions; New York; 2008 (See www.deloitte.com/centerforhealthsolutions )
• 11. Deloitte. 2014 Global Health Care Outlook. Shared Challenges, Shared Opportunities. New York; 2014. pp. 1-24 (Web)
• 12. http://www.lastampa.it/2016/09/21/italia/cronache/turismo-sanitario-anche-litalia-una-eccellenza-C8OG1I0WQf3OoFT7JCjtyH/pagina.html . Available from: [22-02-2017]
• 13. http://www.iamt.it/?page_id=37
• 14. http://turismodentale.al/Turismo-Dentale/Perche-prezzi-piu-bassi/perche-prezzi-piu-bassi.html
• 15. http://www.ilfattoquotidiano.it/2017/01/15/albania-patria-del-turismo-dentale-low-cost-le-protesi-con-la-vacanza-intorno-odontoiatri-italiani-concorrenza-al-ribasso/3212554/
• 16. http://www.ilgiornale.it/news/sirena-delle-cure-low-cost-farebbe-bis-soltanto-paziente-su-1085991.html
• 17. http://www.odontotecnici.net/news/2009/097articolo2009.htm
• 18. http://www.dentistiassociati.org/impianti-dentali/turismo-dentale-i-dentisti-in-croazia-sono-unopportunita-o-un-rischio/
• 19. http://www.dentistiinalbania.com/
• 20. http://www.dentistiinalbania.com/garanzia-sicurezza-igiene-orale/
• 21. http://www.dentistiinalbania.com/testimonianze-dentisti-dentista-estero-croazia-ungheria-romania/
• 22. http://dentistacroazia.eu/it/il-nostro-ufficio-a-rimini-per-preventivi-gratis.html
• 23. http://dentistacroazia.eu/it/appartamento-in-croazia-gratis.html
• 24. www.viaggideldente.info
• 25. https://www.viaggideldente.info/appartamento-a-fiume-rijeka.html
• 26. Fondazione ISTUD. Dalla sanità tradizionale a percorsi di nuova economia: la sanità low cost: rapporto di ricerca, XI edizione del “Programma scienziati in azienda”, Stresa; 2010
• 27. Garcìa-Altès A. The development of heath tourism services, Annals of Tourism Research. 2005; 32 (Jan):262-266
• Paragraphs “Introduction”, “For a definition of health/medical tourism” and “Conclusions” are by Tullio Romita; Paragraphs “The so-called ‘health tourism’ market” and “Low-cost medical tourism of Italians” are by Antonella Perri.
• It is also fair to add that mobility is not only directed to having a quality medical service at or higher, but also to search for the so-called “second opinion” as a confirmation of a diagnosis or treatment.
• For a discussion about the cross-border healthcare scheme, see Ref. [1].
• In this regard compares, for example, Refs. [2–4].
• The UNWTO acronym stands for “United Nations World Tourism Organization” the corresponding Italian acronym is OMT (Organizzazione Mondiale del Turismo).
• The tourism definitions provided by the UNWTO are so many, since tourism is a social phenomenon that continually changes its character, the definitions have gradually over time adapted to ongoing social changes. The definition given refers back to 2014 and it is within the “Glossary of tourism terms” UNWTO [5].
• An interesting aspect that should be investigated, is that inherent to the paradox mentioned by Lunt et al. [9] that one side he talks about the voluntary nature of the trip, but on the other, highlights the preference of patients to be treated close to home. This in our view would justify an attitude obvious and immediate that equal of quality medical, patients, even for economic reasons, tend to choose the closest specific center.
• In this paper, our intention is to consider the tourist as a person with an emphasis on the human and the emotional aspect. Not included in the health consumer commodification process, but as a person who seeks a better state of health.
• Forum on the Internationalization of the Italian Health 2016, Rome; Report Observatory Private Consumption in Health (OCPS), SDA Bocconi, Milan.

© 2017 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3.0 License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Demographics and Trends for Inbound Medical Tourism in Germany for Orthopedic Patients before and during the COVID-19 Pandemic

Tizian heinz.

1 Department of Orthopaedic Surgery, Julius-Maximilians University Wuerzburg, Koenig-Ludwig-Haus, Brettreichstrasse 11, 97074 Wuerzburg, Germany

Annette Eidmann

Axel jakuscheit.

2 Distance and Independent Studies Center, Technical University Kaiserslautern, Erwin-Schroedinger-Straße 57, 67663 Kaiserslautern, Germany

Maximilian Rudert

Ioannis stratos, associated data.

The raw data we used for the current data analysis can be found in the open repository github ( https://github.com/ioannis-stratos/G-DRG_1 (accesed on 18 September 2022)).

Medical tourism is a rapidly growing sector of economic growth and diversification. However, data on the demographics and characteristics of the traveling patients are sparse. In this study, we analyzed the common demographic properties and characteristics of the inbound medical tourists seeking orthopedic medical care in Germany for the years 2010 to 2019 compared to a domestic group. At the same time, we examined how the COVID-19 pandemic outbreak of 2020 changed the field of medical tourism in Germany. Calculations were performed using administrative hospital data provided by the Federal Statistical Department of Germany. Data were analyzed from the years 2010 to 2020. A total of six elective orthopedic surgery codes (bone biopsy, knee arthroplasty, foot surgery, osteotomy, hardware removal, and arthrodesis) were identified as key service indicators for medical tourism and further analyzed. Factors including residence, sex, year, and type of elective surgery were modeled using linear regression analysis. Age and sex distributions were compared between patients living inside Germany (DE) or outside Germany (non-DE). Between 2010 and 2020, 6,261,801 orthopedic procedures were coded for the DE group and 27,420 key procedures were identified for the non-DE group. Medical tourists were predominantly male and significantly younger than the domestic population. The linear regression analysis of the OPS codes over the past years showed a significantly different slope between the DE and non-DE groups only for the OPS code “hardware removal”. With the COVID-19 pandemic, an overall decline in performed orthopedic procedures was observed for the non-DE and the DE group. A significant reduction below the 95% prediction bands for the year 2020 could be shown for hardware removal and foot surgery (for DE), and for hardware removal, knee arthroplasty, foot surgery, and osteotomy (for non-DE). This study is the first to quantify inbound medical tourism in elective orthopedic surgery in Germany. The COVID-19 pandemic negatively affected many—but not all—areas of orthopedic surgery. It has to be seen how this negative trend will develop in the future.

1. Introduction

Medical tourism (MT) is defined as the process where patients travel outside the geographic borders of their home region or home country to obtain medical care. The driving force for medical travel includes but is not limited to the affordability of medical procedures, easier access to care and health, as well as more developed and specialized medical care in foreign regions [ 1 ]. Many authors subcategorize MT into domestic, inbound, and outbound. Domestic MT refers to patients who seek medical treatment outside their hometown or home region but stay within the geographic borders of their country. Inbound MT includes patients that cross borders into a specific foreign country to receive medical care, whereas outbound medical tourists leave their home country for medical care abroad [ 2 ]. As a result, a nation can treat patients traveling from other countries (inbound medical tourism), while at the same time, the citizens of this nation can seek medical treatment abroad (outbound medical tourism).

Patients are increasingly transforming into informed consumers, who choose their own providers out of a broad market place that is not limited to geographical borders. MT has also become a prominent phenomenon in the European Union (EU). The financial and economic impact of EU citizens seeking medical care in Germnay has generated an estimated economic volume of about 200 million EUR per year, thereby being one of the highest of all EU member states, not yet including international patients from outside the EU seeking medical care in Germany [ 3 ]. This demonstrates that MT, though a relatively young branch of international trade, has advanced into a billion-dollar market during the last decades, attracting the interest of the scientific community as a potential sector of economic growth and diversification [ 4 ]. MT is already contributing 1% (aproximatelly 10 billion EUR) to the publicly financed EU health market [ 5 ]. Germany is actively participating in this market. From a global point of view, Germany is ranked as the 12th most attractive MT destination among 46 countries [ 6 ]. Schmerler also characterizes Germany as one of the leading destinations for inbound medical tourists among the U.K., U.S., Russia, Australia, and the UAE [ 7 ]. Additionally, Germany has a good reputation among medical travelers, making it one of the most popular destinations of medical care seekers [ 4 ]. Against the background of Europe being a popular destination for MT, it is of outmost importance to analyze and screen inbound patient flows for the establishment of a framework towards controlled cross-border healthcare, thereby enhancing the related benefits of MT, while at the same time recognizing and minimizing potentially adverse effects.

Predominantly, surgical departments are popular destinations for medical tourists [ 8 , 9 ]. Specifically, orthopedic surgery departments have a substantial financial benefit from inbound MT. According to Lunt et al. [ 8 ], orthopedic surgical treatments are frequent medical services for inbound medical tourism. Moreover, procedures such as elective hip and knee replacement, arthroscopy, and spinal surgery are commonly pursued by medical travelers [ 10 ]. During the COVID-19 pandemic, non-essential travel to Germany was restricted by the government during the year 2020. Recent reports show that medical tourism in Germany declined compared to previous years and further reduced after the year 2020 [ 11 ].

The intention of this study was twofold: Firstly, it was the aim of this analysis to investigate how travel and healthcare-related organizational restrictions in Germany due to the COVID-19 panedmic would translate to a visibly altered framework of MT. Secondly, the trend and development of MT in the orthopedic field in Germany was to be investigated. Therefore, the demographics and frequency of selected orthopedic services provided to medical tourists were analyzed for the years 2010–2020.

2. Materials and Methods

2.1. source data.

Calculations were performed using the case-based hospital statistics dataset 23141-0103 from the Federal Statistical Department of Germany (title: Operations and procedures for inpatients: Germany, years, sex, age groups, patient’s place of residence, operations and procedures; https://www-genesis.destatis.de , accessed on 27 September 2022). The data were retrieved on 30 June 2022. The dataset 23141-0103 contains every surgical procedure coded in any hospital in Germany, as well as patient demographic data (sex, age, and permanent residence). Analysis focused from 2010 to 2020. The search also included the year 2020, which marked the beginning of the COVID-19 outbreak’s global travel restrictions.

2.2. OPS Codes and Surgical Procedure Identification

Each surgical procedure coded in the 23141-0103 dataset is based on the “Operation and Procedure Classification System” (OPS). The OPS is currently the official coding system for medical procedures in Germany. The monohierarchical classifications of the OPS System organize medical procedures into classes of different hierarchical levels: chapters are divided into groups, groups into categories; categories usually have subcategories. Due to this detailed structure, the entire OPS catalog contains 1685 OPS codes in the four-digit hierarchy level. Out of these 1685 codes, we identified six OPS codes that are clearly associated with elective orthopedic surgical procedures. These “elective orthopedic OPS codes” were bone biopsy by incision (OPS-1-503; bone biopsy), implantation of endoprosthesis of knee joint (OPS-5-822; knee arthroplasty), operations on metatarsals and phalanges of the foot (OPS-5-788; foot surgery), osteotomy and corrective osteotomy (OPS-5-781; osteotomy) and removal of osteosynthesis material (OPS-5-787; hardware removal), and arthrodesis (OPS-5-808; arthrodesis).

2.3. Data Processing

A table containing grouped demographic data and OPS codes was generated from the 23141-0103 dataset. The table contained the following data: elective orthopedic OPS codes (with 6 subcategories: “OPS-1-503”, “OPS-5-822”, “OPS-5-788”, ”OPS-5-787”, “OPS-5-808”), age (with 22 subcategories: “under 1”, “1–5”, “5–10”,…,”85–90”, “90–95”, “over 95”), sex (two subcategories: “male” and “female”), year of acquisition (11 subcategories: “2010”, “2011”, …, “2018”, “2019” and “2020”), and permanent residence (18 subcategories: “16 German states”, “foreign”, and “unknown”). All tabled data were unpivoted using R (RStudio v.1.3.1093; Boston, United States). The category “permanent residence” was rearranged into 2 subcategories: “Germany” (DE; 8,195,795 OPS codes) and “abroad” (non-DE; 38,624 OPS codes). Data from “unknown” residence (14,478 OPS codes) were excluded from the analysis. Furthermore, the age category was rearranged into 4 subcategories: “0–17”, “18–39”, “40–64”, and “over 65”. Data summarization was performed using the visual analytics software Tableau Desktop (Tableau Software, v. 2021, Seattle, WA, USA).

2.4. Statistical Analysis

A linear regression model was used to describe and model both the effects of sex and the number of orthopedic OPS-coded procedures for the non-De and the De groups over time. The slopes of the correlation lines were compared, and p -values were calculated to test the null hypothesis. To elucidate if the observed data from the year 2020 were within the statistical expectation, a regression analysis was performed for the years 2010–2019. The year 2020 was excluded from the calculation. The 95% prediction bands of the best fit line were calculated for the years 2010 to 2020 based on the values from 2010 to 2019. After this, the observed values for the year 2020 were added to the diagram. A statistically significant decline in the procedure of interest was assumed if the observed procedure volume for the year 2020 was below the 95% prediction band.

To identify differences between group frequencies and group distributions, Pearson’s Chi-squared test was applied (comparison of age distributions for the non-De and De groups). All statistical calculations were performed using the GraphPad Prism program v. 9.3 (GraphPad Software; San Diego, CA, USA). The statistical significance level was set at p = 0.05.

Between 2010 and 2020, 6,308,937 orthopedic procedures were coded for patients with permanent residence in Germany and 27,420 key procedures were identified for patients with permanent residence outside Germany. A total of 13,859 procedures were performed on male patients and 13,561 on female patients in the non-DE group vs. 2,161,838 for male patients and 4,147,099 for female patients in the DE group. The proportion of female patients was significantly higher in the DE group compared to the non-DE group (ratio ♀/♂ non-DE: 1.0/1; DE: 1.9/1; x 2 = 3208, df = 1; p < 0.001). The COVID-19 pandemic did not have an impact on the sex ratio between the non-DE and the DE groups (ratio ♀/♂ for the period 2010–2019 for the non-DE group: 1.0/1; and for the DE group: 1.9/1; for 2020, for the non-DE group: 0.8/1; and for the DE group: 1.7/1; x 2 = 0.936, df = 1; p = 0.33). The most frequently coded orthopedic procedures in descending order turned out to be “hardware removal”, “knee arthroplasty”, and “foot surgery” for the DE and the non-DE groups, respectively ( Table 1 ). A statistical analysis of the distribution of surgical procedures showed a significant difference between the DE and the non-DE groups (χ 2 = 6661, df = 5, p < 0.001): surgical procedures, including knee arthroplasty and foot surgery, were underrepresented, whereas hardware removal and osteotomies were overrepresented in the non-DE group compared to the DE group ( Table 1 ).

Number of OPS codes for both groups between 2010 and 2020.

Total number for six OPS codes (bone biopsy, knee arthroplasty, hardware removal, arthrodesis, osteotomy, and foot surgery) for the years 2010–2020 subdivided for the DE and the non-DE groups, as well as the percentage of the sum (in parenthesis). Χ 2 = 6661, df = 5, * p < 0.001 vs. non-De.

A linear regression analysis of the six different OPS codes only showed a significantly different slope between the DE and non-DE groups for the OPS code “hardware removal” ( Table 2 ), indicating an upward trend in the DE group compared to a decreasing number of hardware removals in the non-DE group over the years.

Results of the linear regression analysis for both groups (DE and non-DE).

Linear regression analysis for the “relative count to 2010” for the period 2010–2019 for the DE and the non-DE groups (complementary table to Figure 1 ). Values are given for the non-DE and the DE groups (slope, intercept on the y-axis, R 2 , as well as level of significance) for simple regression lines.

During the outbreak of the COVID-19 pandemic, a special focus was placed on the year 2020. For this, we concentrated on the change in the total number of OPS codes, as well as the relative count ( Table 3 and Table 4 ). The number of “bone biopsy” procedures performed in the DE group was almost at the same level in 2020 as in 2019 (aproximately 12,200 procedures per year). A moderate decrease in bone biopsies was observed among medical tourists (52 procedures in 2019 vs. 43 procedures in 2020; Figure 1 and Table 4 ). For the OPS codes “hardware removal” and “foot surgery”, both the DE and non-DE groups fell below the 95% prediction interval, indicating a statistically significant volume decline both for inbound and domestic patients ( Figure 1 and Table 4 ). At the same time, the procedures coded as “knee arthroplasty” and “osteotomy” only fell below the 95% prediction interval for the non-DE group, showing a statistically significant decline only for medical tourists ( Figure 1 and Table 4 ). A decline was also observed for the arthrodesis procedure both for the DE and non-DE groups, but only being statistically significant for the DE group.

Relative change for each orthopedic procedure for the years 2010–2020. The relative count for each surgical procedure (bone biopsy, knee arthroplasty, hardware removal, arthrodesis, osteotomy, and foot surgery) was expressed as a fraction (in %) of each value (per year and group) divided by the corresponding value (per group) for the year 2010. Data for the non-DE group are given in the diagram with blue circles (“○”), and data for the DE group are marked with black squares (“▢”). The straight blue line represents the linear regression of the non-DE group, whereas the straight black line illustrates the linear regression of the DE group. The 95% prediction intervals of each dataset are given as dotted lines (small dotted line for the DE group and big dotted line for the non-DE group). The values for the year of 2020 are displayed in red color. The absolute values can be found in Table 4 .

Comparison of relative procedure counts for the years 2010–2019 and 2020.

Comparison of the mean relative counts and the relative increases per year of the six different OPS codes for the years 2010 to 2019 with the observed relative count of the pandemic year of 2020. Significant differences between the observed relative count 2020 vs. the mean relative counts from 2010 to 2019 (* p < 0.05; t -test).

Total count for surgical procedures for the years 2010–2020.

Numerical representation of the total count of the six different OPS codes for the years 2010 to 2020.

Regarding the age distribution of domestic and inbound patients, there were statistically significant differences for patients undergoing bone biopsy, hardware removal, and arthrodesis, with inbound patients yielding an overall younger age at time of surgery ( Figure 2 for relative values and Table 5 for absolute values) (χ 2 = 29.02, df = 3, p < 0.01).

Relative count for orthopedic procedures per age group. The relative count for each surgical procedure (bone biopsy, knee arthroplasty, hardware removal, arthrodesis, osteotomy, and foot surgery) was expressed as a percentile fraction of the age subgroup (<17, 18–39, 40–64, or >65) divided by the sum of all subgroups. The absolute values can be found in Table 5 . Pearson’s Chi-squared test (DE vs. non-DE; Chi-squared; * p < 0.01).

Total count for orthopedic procedures per age group.

Numerical representation of the total count of the six different orthopedic procedures per age group.

4. Discussion

Nowadays, travel and tourism are among the most valued leisure activities worldwide. With MT, a relatively new branch under the umbrella sector of travel and tourism has emerged with both economic, social, and political implications. However, a sharp definition of MT is still lacking, hampering ongoing research on this topic, often by conflating MT with health tourism and medical travel [ 12 , 13 ].

Traveling for the enhancement of one’s health and well-being is not a new phenomenon, as it dates back far to ancient times. The Sumerians (about 4000 BC) were probably the first to build health complexes around hot springs, attracting people from all around for the proposed therapeutic effects of thermal medicine [ 14 , 15 ]. The ancient Greeks set the fundamentals of health tourism and healthcare travel, attracting people from far away to the Temple of Asclepius, which in those times had transformed into a vivid health center with baths, hot springs, gymnasiums, and snake farms [ 15 , 16 ]. Still today, spa tourism, wellness tourism, and pilgrimage is as present as ever before, with a significant contribution to the whole health tourism sector [ 17 ]. Nevertheless, a clear distinction between MT and health tourism should be made. While health tourism usually summarizes different forms of traveling for health-related reasons, including spa and wellness tourism, offshore surgery, and dental procedures, the scope of MT is of a more confined nature [ 18 ]. Many authors have suggested that the remit of MT should include invasive procedures such as surgery, as opposed to wellness and spa tourism, where the focus is typically put on preventive care and lifestyle treatments [ 19 , 20 , 21 ]. At the same time, not all tourists that undergo invasive treatments and procedures abroad can be assigned to medical tourism, as shown by Wongkit and McKercher, who found 39.7% of surveyed visitors to Thailand that underwent medical procedures did so without the intention of receiving medical care at the time of departure from their country of residence [ 22 ]. By definition, MT should therefore include the intention of undergoing medical procedures abroad as the primary reason for traveling. Cohen has developed a fivefold topology addressing this issue: (1) “mere tourist”; (2) “medicated tourist”; (3) “medical tourist proper”; (4) “vacationing patient”; (5) “mere patient” [ 23 ]. The vacationing patient visits the country of destination with the primary intention of getting medical care, but the trip entails some vacationing activities as well. The mere patient travels with the sole intention of getting medical care and does not take part in vacationing activities. The mere patient and the vacationing patient are collectives that can be clearly assigned to medical tourism. Due to the nature of the elective orthopedic procedures analyzed in this study, patients should be assigned to the latter two (mere patient and vacationing patient).

The reasons for seeking medical care abroad are diverse and range from better medical care to easier accessibility to lower overall costs. In particular, the steep price difference of medical care between developed countries and developing countries is often cited as the driving force of patient flows from industrial states to less developed states for medical procedures. In particular, medical services are estimated to cost one fifth to one tenth in India compared to industrial countries [ 24 ]. At the same time, a patient flow from developing countries to industrial states is observed, which is often generated by wealthy people from developing countries seeking the high-quality care of high-tech medicine in countries such as the USA, Western Europe, and the UK. For Germany, this is well demonstrated by a high number of inbound Russian patients seeking medical care in the eastern part of Germany, especially in the state of Saxony [ 20 ].

However, data on the demographic characteristics of patients and the type of medical care that is typically sought after are still sparse. [ 25 ]. Moreover, treatment of the musculoskeletal system is thought to belong to the second most common treatment modalities that foreign patients engage in [ 10 , 26 , 27 ].

As a result of the conducted study, an important discrepancy regarding the age and gender distribution was found between inbound patients and domestic patients residing in Germany. Patients from abroad seeking medical treatment in Germany were overall of a younger age with a predominance of the male gender. This finding is in line with the current literature. Guy et al. also found a male predominance in a survey asking 194 American residents for their willingness to seek medical treatment abroad [ 28 ]. Noree et al. further demonstrated a male predominance among traveling patients seeking medical care in Thailand [ 26 ]. The reason for this phenomenon is still unclear and of ongoing research. However, the discrepancy between male and female patients getting proper medical care is not completely new and is more commonly known as “gender bias in medicine”, describing an overall male predominance in receiving medical care, despite a balanced distribution of diseased males and females [ 29 ]. The possible reasons for this gender inequality may be seen in hindering socioeconomical and familial circumstances in the country of origin that account more for the female than for the male population. Identical patterns of age and gender distribution for traveling medical tourists are described for host countries such as Egypt, Iran, and India [ 30 , 31 , 32 ]. Overall, for the analyzed period of 2010 to 2020, there was an upward trend for the majority of procedures evaluated, indicating a growing trend for medical tourists seeking healthcare abroad [ 33 ].

With the outbreak of the COVID-19 pandemic, an overall drop in performed procedures was seen for the domestic population in Germany, as well as for medical tourists seeking healthcare in Germany. However, the data of this study suggest that the decline in performed elective orthopedic procedures turned out to be of a higher degree for the inbound tourists seeking medical care. Depending on the elective procedure of interest, there were great differences in volume changes, with the OPS-coded “bone biopsy” yielding the least decline both for the DE and non-DE groups. Such differences and variance within the elective orthopedic procedures can be explained by the inconsistent definition and perception of elective and urgent procedures during the COVID-19 pandemic. Therefore, as bone biopsies tend to have a strong correlation with the field of cancer surgery, rendering it a more urgent procedure, it is natural that this kind of surgery was least hampered by the COVID-19 pandemic. At the same time, the overall higher decline in elective orthopedic surgery for traveling tourists can be explained by the wide national and international travel restrictions during the pandemic, hampering arrival and medical care at the country of destination. This is well in line with the data on travel and tourism during the COVID-19 pandemic, showing a 67% decline in international arrivals in Western Europe from January to December 2020 compared to data from the previous year [ 34 ]. Due to the severe restrictions on aviation activities during the pandemic, it is conceivable that the remaining medical tourists were probably from nearby countries within the European Union, especially less developed countries from Eastern European, which can be easily reached by car, train, or bus. As elective procedures had to be postponed during the pandemic, it might also be possible that the incoming medical tourists were more often considered urgent cases requiring prompt treatment.

One limitation of our study is the small number of OPS codes we evaluated (six in total). For our study, it was important to exclude patients who visited Germany as regular tourists and had to undergo an emergency surgical therapy in a German orthopedic hospital. The data provided by the Federal Statistical Office do not distinguish between emergency treatment and elective surgical therapy. For this reason, we had to carefully select the OPS codes. The six OPS codes that we analyzed here are commonly used by orthopedic surgeons in their clinical practice only for elective surgical interventions. Furthermore, we must clearly emphasize that one OPS code does not always correspond to one patient. It frequently happens that several OPS codes are coded for one patient during one operation.

5. Conclusions

The exact economic value of MT in the national and global context remains elusive due to inconsquent data collation and data structure. However, by the growing interest and research in the field of MT, the economic, financial, and regulatory impact of MT is thought to increase. Moreover, MT is subjected and prone to global instablities and crises, as with the onset of the COVID-19 pandemic, a greater decline in performed orthopedic procedures was observed for inbound traveling patients than for the domestic population. Therefore, intensive efforts should be initiated by German hospitals and healthcare providers to preserve the MT sector in the post-COVID-19 era.

Abbreviations

Funding statement.

This publication was supported by the Open Access Publication Fund of the University of Wuerzburg.

Author Contributions

All authors contributed to the study’s conception and design. I.S. performed data collection and analysis. I.S. wrote the first draft of the manuscript. T.H. was responsible for the final data analysis and interpretation. T.H. was responsible for data graphing and drafting the final manuscript. A.E. was involved in the review process of the manuscript and language style editing. T.L. was involved as initiator of this study and contributed to the idea and final manuscript. A.J. contributed to the literature research and supervision of this study. M.R. was involved in the final drafting and was a major contributor to the manuscript. All authors commented on previous versions of the manuscript. All authors have read and agreed to the published version of the manuscript.

Institutional Review Board Statement

The analysis was waived by the local Ethics Committee of the University of Wuerzburg (protocol number 2 021 090 602). All methods were carried out in accordance with relevant guidelines and regulations, including the Declaration of Helsinki.

Informed Consent Statement

Not applicable.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

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• UNWTO Tourism Definitions | Définitions du tourisme de l’OMT | Definiciones de turismo de la OMT

As an outcome of the work of the Committee on Tourism and Competitiveness (CTC), the 22nd Session of the General Assembly held in Chengdu, China (11–16 September 2017), adopted as Recommendations (A/RES/684 (XXII)) some operational definitions used in the tourism value chain, as well as a set of operational definitions on some selected tourism types. Along with the operational definitions the Committee has also focused on identifying the key quantitative and qualitative factors for tourism competitiveness under two categories: 1. Governance, management and market dynamics; and 2. Destination appeal, attractors, products and supply. It is aimed that these operational definitions provide UNWTO members and other tourism stakeholders with a comprehensive and concise, operational, applicable and globally relevant conceptual framework on some concepts used in the tourism value chain and on some selected tourism types to set the scene and contribute to establish a common ground for a harmonized understanding.

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