impact of health tourism

UN Tourism | Bringing the world closer

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• Exploring Health Tourism

The ETC/UNWTO publication on Exploring Health Tourism aims to provide a better understanding of the growing segment of wellness and medical tourism. The study introduces the evolution of health-related tourism products and services from all around the world and provides insights into the current situation of the industry, as well as the future potential. It also includes a comprehensive taxonomy that serves as a common reference for tourism destinations operating in this field, as well as a practical toolkit to assist NTOs and DMOs with their planning and management of health-related tourism activities.

Click here   for the Executive Summary of this publication.

ISBN : 978-92-844-2020-9

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Please note you do not have access to teaching notes, health risks, pandemics and epidemics affecting tourism: understanding covid-19 pandemic.

Pandemics and Travel

ISBN : 978-1-80071-071-9 , eISBN : 978-1-80071-070-2

Publication date: 3 September 2021

Tourism activity is a global industry and, as such, it is subject to global risks. International travel has developed exponentially over the last few decades. At the same time, diseases have increased their geographical spread influenced by ecologic, genetic and human factors. Currently, the increasing virus, epidemic and pandemic outbreaks represent some of the most negative consequences of globalization, causing deaths and significant economic losses due to the negative impacts they have on the tourism industry, one of the sectors that have been the most affected by health crises.

This work presents insights on the epidemics, pandemics and virus outbreaks that have occurred throughout the twenty-first century and how those occurrences have affected the tourism industry and the global economy. A brief literature review on health risks in tourism is presented, followed by a clinical perspective to help people understand the differences between endemics, outbreaks, epidemics and pandemics. Then, the study offers a presentation of the most significant pandemics in recent human history and a deep analysis of the COVID-19 disease. Finally, the effects that the different pandemics, epidemics and outbreaks that occurred in the present century had on tourism are explained, and the challenges tourism has to face are presented and discussed.

• Health risks
• Epidemics and pandemics
• Impacts on tourism
• Virus outbreaks
• Challenges for tourism industry

Acknowledgements

This work was funded by national funds through FCT – the Portuguese Foundation for Science and Technology (UID/ECO/00124/2013 and Social Sciences DataLab, Project 22209), POR Lisboa (LISBOA-01-0145-FEDER-007722 and Social Sciences DataLab, Project 22209), POR Norte (Social Sciences DataLab, Project 22209) and under the projects UIDB/05583/2020 and UIDB/04084/2020. Furthermore, we would like to thank CEGOT – Geography and Spatial Planning Research Centre, and Research Centre in Digital Services (CISeD), the Polytechnic of Viseu and the Faculty of Arts & Humanities of the University of Coimbra for their support.

Abrantes, A.M. , Abrantes, J.L. , Silva, C. , Reis, P. and Seabra, C. (2021), "Health Risks, Pandemics and Epidemics Affecting Tourism: Understanding COVID-19 Pandemic", Seabra, C. , Paiva, O. , Silva, C. and Abrantes, J.L. (Ed.) Pandemics and Travel ( Tourism Security-Safety and Post Conflict Destinations ), Emerald Publishing Limited, Leeds, pp. 7-28. https://doi.org/10.1108/978-1-80071-070-220211002

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Why Patients Are Turning to Medical Tourism

Statistics, Benefits, and Risks

Planning Ahead

Frequently asked questions.

Medical tourism is a term that refers to traveling to another country to get a medical or dental procedure. In some instances, medical tourists travel abroad seeking alternative treatments that are not approved in the United States.

Medical tourism is successful for millions of people each year, and it is on the rise for a variety of reasons, including increasing healthcare costs in the United States, lack of health insurance, specialist-driven procedures, high-quality facilities, and the opportunity to travel before or after a medical procedure.

According to a New York Times article from January 2021, pent-up demand for nonessential surgeries, as well as the fact that many Americans lost their health insurance during the coronavirus pandemic led to a surge in medical tourism once other countries re-opened.

However, there are specific risks that come with traveling overseas for surgery. If you're thinking of pursuing a medical procedure in another country, here's what to know about the benefits and the risks.

Medical Tourism Benefits

The most common procedures Americans go abroad for include dental care, cosmetic procedures , fertility treatments, organ transplants , and cancer treatment.

This is not to be confused with having an unplanned procedure in a foreign country due to an unexpected illness or injury.

Among the reasons a person might choose to go abroad for a medical procedure are:

Lower Costs

Medical tourists can save anywhere from 25% to 90% in medical bills, depending on the procedure they get and the country they travel to. There are several factors that play into this:

• The cost of diagnostic testing and medications is particularly expensive in the United States.
• The cost of pre- and post-procedure labor is often dramatically lower overseas. This includes labor costs for nurses , aides, surgeons , pharmacists, physical therapists , and more.
• High cost of malpractice insurance—the insurance that protects medical professionals against lawsuits—in the United States.
• Hospital stays cost far less in many overseas countries compared to the United States. In other words, quality care, hospital meals, and rehabilitation are far more affordable abroad for many people.

For someone who doesn't have insurance , or someone having a procedure that is not covered by insurance , the difference can be enormous.

Popular Countries for Medical Tourism

Dominican Republic

South Korea

Culture and Language

Many immigrants prefer to have treatments and procedures done in their country of origin—a sensible decision, considering just how much language barriers alone can affect the quality of their care.

Furthermore, at least 25% of immigrants and noncitizen residents in the United States are uninsured, compared to 9% of American citizens. Children with at least one noncitizen parent are also more likely to be uninsured.

Practicalities aside, many people choose to have their procedure done in their country of origin simply because it allows them to be close to family, friends, and caretakers who can assist them through their recovery .

Insurance Incentives

Some insurance companies have started promoting medical tourism. The reason behind this is simple: savings for the insured means savings for the insurance provider and vice versa.

Several insurance providers, including Aetna have programs specifically geared at promoting safe medical tourism. Some insurance providers even offer financial incentives for medical tourism, like discounts on medical bills .

That said, many insurance companies will not pay for surgery performed outside of the country unless it is an emergency.

Luxury and Privacy

Medical tourism is a lucrative business for many countries, and much of the money brought in by medical tourists is reinvested into the local economy and health infrastructure.

The effect of this is apparent in the spa-like luxury that some foreign hospitals offer, providing medical tourists the opportunity to be pampered during their stay for a fraction of the cost they would pay at home.

Some facilities offer hospital rooms that are more like a hotel suite than a traditional hospital room. Other hospitals offer one-on-one private nursing care, which is far more generous and attentive than the staffing ratios that most hospitals allow.

Medical tourists who seek that added layer of privacy can find it abroad. Many can return home from their "vacation" without anyone knowing they had a procedure at all.

Vacation in a Foreign Country

Medical tourists often take advantage of their stay in a foreign country to travel for pleasure by scheduling a vacation before or after their procedure.

This is an especially inexpensive way to travel to a foreign country, especially if their insurance provider is paying for the flight and the cost of staying is low. 

While it seems logical to recover on a beach or in a chalet by the mountains, keep in mind that it's important not to jeopardize your recovery.

Swimming isn't recommended until your incisions are completely closed. You may not feel up to doing much more than napping in the days following your procedure, either.

Don't let your vacation disrupt your recovery. Any time you have a procedure done, especially a surgery, it's important to listen to your body, take your medications as directed, and follow your doctor's recommendations closely.

Bypassing Rules and Regulations

Some travelers seek surgery abroad to bypass rules that are set in place by their own government, insurance company , or hospital. These rules are typically in place to protect the patient from harm, so getting around them isn't always the best idea.

For example, a patient may be told that their weight is too low to qualify for weight loss surgery . A surgeon in a foreign country may have a different standard for who qualifies for weight loss surgery, so the patient may qualify overseas for the procedure they want.

Talented Surgeons

Surgeons in certain countries are known for their talent in a specific area of surgery. For example, Brazilian surgeons are often touted for their strong plastic surgery skills .

Whereas in the United States, insurance companies might only cover cosmetic procedures if it is medically necessary, cosmetic surgery is often free or low-cost in Brazil's public hospitals—giving cosmetic surgeons there ample practice.

Thailand is reported to be the primary medical tourism destination for individuals seeking gender reassignment . It is often easier to qualify for surgery and the cost is significantly reduced. Surgeons are performing the procedures frequently, and as a result, many have become quite specialized in them.

It is often surprising to many medical tourists that their physician was trained in the United States. Not all physicians are, of course, but a surprisingly high percentage of them working in surgery abroad are trained in English-speaking medical schools and residency programs and then return to their home country. These physicians often speak multiple languages and may be board certified in their home country and a foreign country, such as the United States.

Medical tourism isn’t limited to countries outside of the United States, either. Many people travel to the United States for medical care due to the country's cutting-edge technology, prescription medication supply, and the general safety of healthcare.

Medical Tourism Risks

The financial and practical benefits of medical tourism are well known, and you may even know someone who had a great experience. Nonetheless, the downsides of medical tourism can be just as great if not greater. Sometimes, they can even be deadly.

If you are considering a trip abroad for your procedure, you should know that medical tourism isn't entirely without obstacle and risks. These include:

Poorly Trained Surgeons

In any country—the United States included—there will be good surgeons and bad. And just as there are great surgeons abroad, there are also some surgeons who are less talented, less trained, and less experienced.

Regardless of what procedure you are getting or where, you should always do some preliminary research into the surgeon or physician who will be treating you as well as the hospital you will be treated at.

In the United States, it is fairly easy to obtain information about malpractice lawsuits , sanctions by medical boards, and other disciplinary actions against a physician.

Performing this research from afar can be challenging, especially if you don't speak the local language. Yet countless people take the risk anyway, without knowing whether the physicians who will treat them are reputable.

A physician should be trained in the specific area of medicine that is appropriate for your procedure. For example, you should not be having plastic surgery from a surgeon who was trained to be a heart doctor. It isn’t good enough to be a physician, the physician must be trained in the specialty .

Prior to agreeing to surgery, you should also know your surgeon’s credentials : where they studied, where they trained, and in what specialty(s) they are board-certified. Do not rely on testimonials from previous patients; these are easily made up for a website and even if they are correct, one good surgery doesn’t mean they will all be successful.

Quality of Staff

Nurses are a very important part of healthcare, and the care they provide can mean the difference between a great outcome and a terrible one.

A well-trained nurse can identify a potential problem and fix it before it truly becomes an issue. A poorly trained nurse may not identify a problem until it is too late. The quality of the nursing staff will have a direct impact on your care.

Once again, it's important to research the hospital staff where you will be having your procedure done. Read the reviews but don't trust them blindly. If you can, seek out a recommendation from someone who can vouch for the medical staff where you will be going.

Quality of the Facility

While researching healthcare facilities for your procedure, you want to learn not just about the quality of the facilities themselves, but about the country's healthcare system as a whole.

In some countries, there is a marked distinction between public hospitals and private hospitals. In Turkey, for example, private hospitals are considered on-par with hospitals in the states, while many locals will advise you to steer clear of public hospitals if you can.

You will also want to seek out facilities that are internationally accredited. In the United States, the Joint Commission evaluates hospitals and certifies those that provide safe, quality care. The international division does the same for hospitals outside the United States.

Once you have a few options for potential facilities, you can start to investigate specifics. For one, you should find as many pictures and reviews of the facility as you can. Ask yourself whether the facility is state of the art or whether it seems dirty and outdated.

You will also need to find out if the facility has ICU level care available, in case something goes wrong. If not, there should be a major hospital nearby so that you can be transferred quickly.

To learn more about a healthcare facility, consider joining expat groups on social media for the city or country you will be traveling to. Ask the group for recommendations, or inquire about any positive or negative experiences they may have had at a particular facility.

Flying Home After Surgery

Any surgery comes with risks, including infection and blood clots . Flying home increases the risk of blood clots, especially on long-haul flights that are longer than four hours.

Try to avoid flying home in the days immediately after surgery; waiting a week will decrease the chances of developing a blood clot or another serious complication during the flight.

For longer flights, plan on getting up and walking up and down the aisles each hour to improve blood flow in your legs. You might also benefit from wearing compression socks with your doctor's approval.

If you are taking blood thinners or are at-risk of blood clots , be sure to talk to your doctor about how you can reduce your risk of blood clots after your procedure and while traveling.

Furthermore, you should know the symptoms of blood clots and stay alert.

Unplanned Illness

Any time you travel abroad, you run the risk of catching an illness that you have never been exposed to or that your body is not prepared to fight off. This is especially a concern when spending time in a foreign hospital.

If you have a sensitive stomach, you may also want to think long and hard about having surgery abroad. The food is often very different in foreign hospitals, and in some areas, there is a risk that even the water will be upsetting to your body.

Having diarrhea or postoperative nausea and vomiting makes for a miserable recovery experience, especially if you do not have a friend or family member nearby who can help you through it.

Before you travel abroad, check with your doctor to see if you need any vaccines to travel to your destination or if there are any foreign illnesses you should be aware of. Picking up an illness abroad, particularly after your surgery, can potentially be life-threatening.

Language Barriers

If you are having surgery in a country where English is not the primary language, you will need to make preparations in order to be able to communicate with the staff.

You may be pleasantly surprised to learn that the staff speaks your primary language well. If not, then you will need to consider how you will make your wishes and needs known to the surgeon, the staff, and others you will meet.

Whether you are at home or abroad, remember to speak up and advocate for yourself to make sure your needs are met. If you don't speak the local language, download a language translation app on your smartphone and don't hesitate to use it to communicate your needs. Hiring a translator is another option.

A Word About Transplant Tourism

Transplant tourism is one area of medical tourism that is strongly discouraged by organ and tissue transplant professionals in multiple countries. Most international transplants are considered “black market” surgeries that are not only poor in quality, but ethically and morally wrong.

China, for example, the country that is believed to perform more international kidney transplants than any other country, is widely believed to take organs from political prisoners after their execution.

In India, living donors are often promised large sums of money for their kidney donation, only to find out they have been scammed and never receive payment. Selling an organ in India is illegal, as it is in most areas of the world, so there is little recourse for the donor.

Then there is the final outcome: how well the organ works after the surgery is complete. With black market transplants, less care is often taken with matching the donor and recipient, which leads to high levels of rejection and a greater risk of death. Furthermore, the new organ may not have been screened for diseases such as cytomegalovirus , tuberculosis , hepatitis B , and hepatitis C . It is often the new disease that leads to death, rather than the organ rejection itself.

Finally, transplant surgeons are often reluctant to care for a patient who intentionally circumvented the donor process in the United States and received their transplant from an unknown physician.

It is important to arrange your follow-up care prior to leaving your home country.

Many physicians and surgeons are hesitant to take care of a patient who received care outside the country, as they are often unfamiliar with medical tourism and have concerns about the quality of care overseas.

Arranging for follow-up care before you leave will make it easier to transition to care at home without the stress of trying to find a physician after surgery .

Just be sure to inform your follow-up care physician where you are having your procedure done. After you return, they will also want to know what prescription medications you were given, if any.

What are popular countries for medical tourism? 

Mexico, India, Costa Rica, Turkey, Singapore, Canada, and Thailand are among the many countries that are popular for medical tourism.

How safe is medical tourism?

Medical tourism is generally considered safe, but it's critical to research the quality of care, physician training, and surgical specialties of each country. There are several medical tourism organizations that specialize in evaluating popular destinations for this purpose.

What countries have free healthcare? 

Countries with free healthcare include England, Canada, Thailand, Mexico, India, Sweden, South Korea, Israel, and many others.

A Word From Verywell

If you are considering medical tourism, discuss the risks and benefits with your doctor, and consider working with your insurance provider to arrange a trip that balances financial savings with safety. (Also, before you embark on a trip overseas for your procedure, make sure you are financially prepared for unexpected events and emergencies. Don't go abroad if you don't have enough money to get yourself home in a crisis.)

A medical tourism organization such as Patients Without Borders can help you evaluate the quality and trustworthiness of healthcare in various countries. Making sure a high level of care is readily available will lead to a safer, more relaxing experience.

Centers For Disease Control and Prevention. Medical Tourism: Getting medical care in another country . Updated October 23, 2017.

University of the Incarnate Word. Center for Medical Tourism Research .

Patients Beyond Borders. Facts and figures .

Kaiser Family Foundation. Health coverage of immigrants . Published July 2021.

Paul DP 3rd, Barker T, Watts AL, Messinger A, Coustasse A. Insurance companies adapting to trends by adopting medical tourism . Health Care Manag (Frederick). 2017 Oct/Dec;36(4):326-333. doi: 10.1097/HCM.0000000000000179

Batista BN. State of plastic surgery in Brazil .  Plast Reconstr Surg Glob Open . 2017 Dec;5(12):1627. doi:10.1097/GOX.0000000000001627

Johns Hopkins Bloomberg School of Public Health - Global Health Now. Brazilians' risky right to beauty . Published May 2018.

Chokrungvaranont P, Selvaggi G, Jindarak S, et al. The development of sex reassignment surgery in Thailand: a social perspective .  Sci World J . 2014 Mar;2014(1):1-5. doi:10.1155/2014/182981

The Joint Commission. For consumers .

Centers for Disease Control and Prevention. Blood clots and travel: what you need to know . Reviewed February 2021.

Hurley R. China harvested organs from political prisoners on substantial scale, says tribunal . BMJ . 2018 Dec;363(1):5250. doi:10.1136/bmj.k5250

Ambagtsheer F, Van Balen L. I'm not Sherlock Holmes: suspicions, secrecy, and silence of transplant professionals in the human organ trade . Euro J Criminol . 2019 Jan;17(6):764-783. doi:10.1177/1477370818825331

Centers for Disease Control and Prevention. Transplant Surgery. Key facts . Reviewed January 2019.

By Jennifer Whitlock, RN, MSN, FN Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.

The health impact of tourism on local and indigenous populations in resource-poor countries

Affiliation.

• 1 James Cook University, School of Nursing, Midwifery and Nutrition, Douglas Campus, Townsville QLD 4811, Australia. [email protected]
• PMID: 18760250
• DOI: 10.1016/j.tmaid.2008.05.005

In the vast Travel Health literature there is still a considerable dearth on tourism's impact on local communities. This review attempts to remedy the situation. Its focus is on potential health impacts on populations living at tourist destinations outside the industrialised world. To facilitate a better understanding of how health is linked to tourism today, a brief overview of the historical and theoretical evolution of tourism is presented. Ecotourism is given special attention as it is perceived as a version of the industry that is more benign on environment and people. After discussing Indigenous Tourism, a variety of potential health implications is outlined. These follow a previously suggested classification of indirect and direct impacts, with the indirect impacts being based on economic, environmental, socio-cultural and, more recently, political impacts, and the direct impacts originating from immediate encounters between tourism and people. Finally, the urgent need for more research is highlighted, and some solutions to minimize health impact are suggested.

Publication types

• Developing Countries
• Environmental Health
• Health Status*
• Public Health*
• Socioeconomic Factors

Our Response to COVID-19 →

Medical Tourism Impact It's More Than Obvious

The progress of the Medical Tourism phenomenon has had enormous impact not just for the patient alone but it has also influenced economic, social, environmental, business and medical sectors. Dr. Prem Jagyasi, renowned researcher and consultant puts light on both the positive and negative impacts of medical tourism which are more than obvious.

Today, diseases are part of everybody’s existence; however, man still hasn’t accepted defeat at the hands of syndromes that afflict him as he continues the battle for living a healthy life in the face of insurmountable odds and healthcare crises. In this quest for existence, distance is a small hurdle and matters least when it comes to resurgence from imminent fatalities, hence traveling to foreign countries for healthcare purposes has been and is predicted to be a rising trend for years to come.

As per recent research, the four most popular reasons given for why patients travel abroad to receive medical treatment were ‘Affordability (costly in home country)’ at 88%, ‘Accessibility (waiting period is high)’ at 66%, ‘Better quality (care and support services are better quality than the home country) at 38% and ‘Availability (not available in home country) at 46% (Download or read complete research online at www.Dr.Prem. com). With these important reasons, the growth of Medical Tourism is inevitable; hence it is important to understand the positives and negatives of this growing trend across all sectors.

IMPACT ON GLOBAL HEALTHCARE

Innovation in healthcare solutions.

Innovation for the most part stems from exigencies. When it comes to healthcare solutions, there is a great demand for innovation, a close second only to nanotechnology! The most basic of primary needs, arises during rare medical predicaments that are either not curable in a person’s own country or, are way out of his budget. To meet these innovation requisites, countries are currently meting out a variety of specialized treatment options, irrespective of their development status. So, Americans coming to India, Thailand or Singapore for a cardiac surgery, when similar or even advanced technology is available at home…is definitely not odd any longer.

Enhancements in Healthcare Solutions

Hospitals in any region always provide some amount of basic service to local inhabitants. But these therapies remain stagnant for years together without any attempts at amendment or modernization. Enter foreign nationals to avail some frequent treatment, and the entire scenario transforms. The same clinic with barely any essentials now has state-of-the-art medical equipments, advanced diagnostic facilities, a 24-hour emergency service center, customer helpdesks offering international toll free calling, a fully equipped ICU, and advanced surgical amenities etc. Such is the effect of healthcare tourism on a nation’s therapeutics industry.

Enhancements in number of Healthcare Professionals

With enhancements in remedial services, comes the demand for people who can administer them. Health tourists constantly prefer to consult doctors of high repute, with well-known prowess in the required medical field, whose skills have already benefited patients with similar medical conditions. The enormous need for proficient personnel breeds more specialists who cater to this escalating requirement. The number and eminence of medical experts and healthcare staff goes a long way in ensuring the success of not just the particular healthcare unit but also the nation that harbors them.

International Standards in Healthcare Solutions

Apart from the physician’s status, a potential foreign medical tourist looks at numerous other aspects of the medical establishment, to which he entrusts his wellbeing. Quality as a facet of healthcare is justifiably emphasized today, by the patients who are conversant within the therapeutic sector. As per industry standards, accreditations from authorized bodies are recognized and accepted. Other variations which monitor quality and accountability standards are also improved upon and utilized. National accreditations, which have their own stringent parameters, are also improving upon international standards to meet international patient requirements and expectations.

Improvisation in Knowledge Processes

Dispensation, storage & interpretation of available medical records and data files; a process termed ‘Knowledge Processing’ has made the medical system transparent beyond medical authorities worldwide, to respective patients as well. Prior to the global focus on health tourism, the importance of this process was not felt as keenly as it is today. With the advent of the World Wide Web, medical proceedings, subject data and case histories of patients around the world is now available to doctors operating in any country. It provides them with excellent opportunities to interpret, assimilate, improve and enhance the overall health services afforded.

Emergence of supporting/subsidiary Healthcare Infrastructure

Globalization of medicine has brought in its wake, the emanation of several other allied international sectors like healthcare insurance, vast selection of tourism getaways, varied choices of traveling and unlimited options for hospitable lodging in the country that one chooses to get treated in. Besides, the banking sector has facilitated advancing of loans, comfortable payback schemes, credit card facilities; easy access to internet payment gateways, abundant foreign currency exchange centers and other painless international banking procedure to help foreign tourists. Such programs have completely ruled out affordability or inaccessibility to capital, as a hinDr.ance to disease alleviation. Besides, obtaining medical visas is now an effortless procedure.

The emergence of global healthcare is incomplete without these associated factors that contribute in equal measure to its accomplishments.

POSITIVE IMPACTS ON A NATION

Social impact.

When established as an industry, medical tourism is significantly instrumental in molding the society of a nation. It contributes not just in terms of enhanced, speedier or affordable healthcare, but also lends itself to infrastructural betterments, more employment opportunities with an increased propensity towards overall wealth creation. In nations that are still in the developing stages, such improvisations pave the way towards industrial growth to cater to the burgeoning demands of the foreign health seekers. A developed nation, on the other hand gains prominence as a popular healthcare destination and people start thronging in for the medical attention.

Financial Impact

Manufacturing industries, foreign investments, business exports, agricultural, mineral products or information technology services, are currently among the most prominent and largest contributors to any nation’s Gross Domestic Products (GDP). Going by recent media reports, medical tourism will soon top the charts as a key money grosser pitching in significant contribution in GDP for a nation which affords such facilities. Plainly, it has enormous potential as a service-sector industry and private hospitals stand to gain the most from it, provided they invest in the appropriate medical infrastructure and adequately promote their capabilities. As more and more foreigners troop into the country to avail cheaper, better and faster remedies for their illnesses, the chances of financial gain with a higher return on the basic investment is then guaranteed.

Industrial Impact

Several industries, closely associated with the world health tourism sector are significantly impacted by its growth and development. These closely allied industries which are promoted as a result of the surge in medical tourism get a new foundation and recognition in the global sphere and are forever retained in memories, standing a chance of benefiting through future investments:

All medical tourists do not visit a country with the express purpose of a treatment or surgery. They also intend to tour the country’s other historical or natural attractions. This trend is growing as tourists tend to invest the amount they save in healthcare, during sight-seeing. This serves as significant revenue for the tourism industry and forms a portion of total profits of the industry.

• Pharmaceutical

The pharmaceutical industry is very closely associated with the field of medical science. When one undergoes treatment or surgery in one country, he is bound to take over-the-counter Dr.ugs sold in the same area. This increases the sale of medicines in a directly proportional manner such that, the number of surgeries or treatment conducted directly adds to the profits of the pharmaceutical company of the country that is a prominent medical tourism destination.

• Medical Tourism Facilitator

Because of the complexity of this decision-making process, some medical tourists seek help from travel agents or the international patient departments of hospitals, or concierge service providers. While all these agencies can act as effective intermediaries, none can offer a comprehensive medical tourism support services in the same manner as a one-stop medical tourism facilitator. This is an agency staffed by a team of professionals who are equipped to offer a seamless combination of what would otherwise be complicated arrangements within medical tourism.

• Public and Private sectors

The medical tourism industry is served both by private as well as public sector industries. While the public sector contributes to the overall infrastructure and associated processes like permitting medical visa, clearing foreign passports, facilitating foreign exchange etc; the private sector totally takes over the comfort & hospitality department as well as the healthcare facilities.

The kind of medical care and amenities provided by private sector industries is generally far more superior to that offered by government establishments. Under such situations, a public-private partnership tends to equalize profits, adds to overall infrastructural benefits and caters to the needs of the foreign medical tourist, in a balanced manner making the overall procedure smooth, rapid and economical.

Intellectual Impact

A country that prospers in the healthcare tourism industry will experience less of the ‘Brain-Dr.ain’ phenomenon which commonly portrays the exit of trained professionals from their home country to a foreign nation availing better employment and financial opportunities. This phenomenon quite frequent among the medical community, is easily plugged because medical tourism pays ample impetus to the treatment of rare global disorders, as a lifetime vocation Intelligent or expert medical professionals generally look up to such challenges, as they get the required job satisfaction and financial fulfillment even when stationed in their native country.

Political Impact

When one country serves as a major tourism destination for another and there is constant exchange of treatment and revenue between them, the political links between those nations are affected in a positive manner. Stronger bonds between those nations are forged when the host nation provides the foreign tourists with several amenities besides conducive medical treatment.

NEGATIVE IMPACT ON A NATION

Healthcare impact.

With patient travels, there is significant risk of corresponding bacterial travel. Recent superbug research has created significant alert. All industry professionals must understand the negative impact of communicable diseases. Hence, good strategies should be developed by global organizations to protect spread of such diseases. Understanding and control is vital.

Environmental Impact

It is true that medical tourism escalates the per capita rates of the host country but it escalates several other detrimental factors as well. For infrastructural growth, the natural greenery or forest cover of a region is compromised in order to accommodate more buildings, hospital facilities, roads, treatment or diagnostic centers etc. To supplement the above, there is a continuous discharge of polluted air, solid -toxic medical waste, litters of sewage consisting of oil and chemicals. Architectural, noise and visual pollution also has a direct negative impact on the atmosphere.

Health tourism also creates a dearth of local resources like power, food stock, fuel and other unredeemable natural resources, which could already be in short supply within the host country. Water, another non-replenishable natural resource, is commonly misused in hotels, spas and swimming pools through careless personal use by tourists. This not only generates large volumes of waste water but also leads to water shortages and depletion of natural water sources.

Treatment Impact

With an increased number of health tourists, the hospital adopts the policy of being paid in accordance to an overseas system. Such a structure, even though economical to a foreigner, tends to be expensive for the native. As a result, all sections of people within a particular nation are not able to avail the advanced treatment options available within the country. This creates a negative impact on the health infrastructure of a country.

Economical Impact

Healthcare tourism in most countries runs through private institutions. Currently the private sector in most developed countries accounts for a larger number of surgical procedures, treatment operations, and ultimately in the overall number of patients from all over the globe. Thus the revenue generated by this sector is much greater compared to that generated by the government or the public sector. The latter shows low expenditure in healthcare sector, poor management of resources, corruption, infrastructure shortfalls, slower growth, etc., to name a few. The uncontrolled growth of the private sector leads to inequalities and profit imbalance across both sectors.

Ethical & Legal Impact

There are significant chances that many medical tourism hospitals would tap into unethical practices to grab international patients, such as organ transplants, restricted regional treatments or several other medical services which are restricted, regulated or controlled in one region.

Legal issues are also likely to rise as this industry presents unique problems and challenges for both consumers as well as providers.

Medical Tourism doesn’t only provide benefits to international patients; it extends a wide spectrum of benefits to many industries such as the healthcare industry, travel & tourism, commercial sector, government relationships, international accreditation sector, amongst others.

Both positive and negative impacts of medical tourism on healthcare, economic, social and environmental sectors creates opportunities and challenges for this growing industry which require cohesive collaborative work between various stakeholders.

About the Author

Dr. Prem Jagyasi is a Chartered Management, Healthcare Marketing and Medical Tourism Consultant. Providing high-profile consultancy services to Government Authorities and Private Healthcare organizations, he is noticeably leading medical tourism consultant. He also serves Medical Tourism Association, as an Honorary Chief Strategy Officer. He can be reached at [email protected] | www.DrPrem.com

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Health tourism: an opportunity for sustainable development

1 Health Innovation Division of Campania Region (DG04), Federico II University and Hospital, Naples, Italy

2 Research and Development Unit, Federico II University Hospital, Naples, Italy

L Leonardini

3 Programma Mattone Internazionale Salute, Italian Ministry of Health, San Donà di Piave VE, Italy

M Kucharczyk

4 AGE Platform Europe Network, Brussels, Belgium

5 Caritas Coimbra, Coimbra, Portugal

W van Staalduinen

6 Academy on Age-friendly Environments BV, Gouda, the Netherlands

J Ganzarain

7 Azienda per i Servizi Sanitari n.5 “Bassa Friulana”, Udine, Italy

8 Azienda ULSS n. 4 Veneto Orientale, San Donà di Piave VE, Italy

AM Carriazo

9 Junta de Andalucia, Seville, Spain

G Tramontano

10 Health Innovation Division of Campania Region (DG04), Federico II University and Hospital, Naples, Italy

11 Center for Gastrology, Brussels, Belgium

12 Relations with European and extra-European countries Division, Campania Region, Naples, Italy

A Costantini

13 Azienda Sanitaria Locale Napoli 3 Sud, Castellamare di Stabia NA, Italy

M Ciliberti

14 Azienda Sanitaria Locale Napoli 2 Nord, Frattamaggiore NA, Italy

A d’Amore

15 Azienda Sanitaria Locale Napoli 1 Centro, Naples, Italy

16 Istituto Nazionale Tumori Pascale, Naples, Italy

17 Regional Coordination of Tourism Districts of Campania, Naples, Italy

T Dello Ioio

18 Parco regionale dei Monti Lattari, Castellammare di Stabia NA, Italy

19 Federalberghi Terme, Rome, Italy

20 Federterme, Rome, Italy

G De Cesare

21 Centro Mediterranea Diagnostica Srl, Castellamare di Stabia NA, Italy

22 Mediterranean Federation for Advancing Vascular Surgery, Naples, Italy

D Tramontano

23 Department of Molecular Medicine and Medical Biotechnology, Federico II University, Naples, Italy

A Postiglione

24 General Directorate for Health Protection and the coordination of Regional Health System, Campania Region, Naples, Italy

25 Regional Ministry for Tourism, Campania Region, Naples, Italy

26 Department of Heart Surgery, San Giovanni di Dio e Ruggi d’Aragona Hospital, Salerno, Italy

27 Department of Pneumology and Addictology, Montpellier University Hospital Center, Montpellier, France

In February 2017, the “Programma Mattone Internazionale Salute” (ProMis), that is the Italian Program for Internationalization of Regional Health Systems of the Ministry of Health (MoH), presented the first version of its Position Paper on Health Tourism, which embeds a first shared approach to the recommendations expressed by the European Committee of Regions (CoR) on “Age-Friendly” tourism. The CoR stresses the importance of local and regional authorities in the coordination of multi-sectoral policies such as healthcare, social assistance, transport, urban planning and rural development in relation to the promotion of mobility, security, accessibility of services, including health care and social services.

“Age-friendly” tourism is an example of an innovative tourist offer that strives to meet the health needs of the entire “traveling” population, with an integrated and cross-sector approach that involves various organizations operating in sectors such as healthcare, accessibility and transport.

The aim of the workshop was to explore the interest of the stakeholders to participate in a systemic action in the field of “health” tourism, and to identify priority implementation areas that offer opportunities to take advantage of validated, innovative experiences that strengthen the accessibility to health and social services in regional, national and international contexts.

This effort provides the opportunity to take advantage of aligning the European Structural and Investment Funds (ESIF) to the development of tourism, coherently with the needs and resources of local and regional health authorities.

I. INTRODUCTION

Europe is the first tourist destination in the world, with the highest number and variety of destinations. The tourism industry is a key sector of the European economy, generating more than 10% of EU GDP and employing 9.7 million people and involving 1.8 million businesses. The 2007 International Convention on the Rights of Persons with Disabilities promotes “Tourism accessible to all”, promoting travel for the older adults and people with special access needs, as an integral part of any responsible and sustainable tourism policy. In the European tourism strategy the European Commission sets the objective of improving the accessibility of tourism services to sensitize the interested parties to generate greater know-how on the demand and profiles of travelers with specific needs and to evaluate the economic impact of the age-friendly tourism and patient-friendly [ 1 ]. Older adults represent a very important market share, but they also require an adaptation of services to take account of the specific needs. The same applies to the growing number of tourists with reduced mobility (recently estimated at 127 million people), people with disabilities or those suffering from chronic illnesses, whose needs must be integrated into the provision of tourism services [ 1 ]. Tourism for the older adults and people with special access needs presents difficulties with regard to social and health care, in particular due to the lack of integration between the health systems of the Member States and the tourism sector. This makes tourist destinations less accessible for people suffering from diseases.

II. THE EMERGING MARKETS FOR HEALTH TOURISM IN THE SILVER ECONOMY

The workshop represents a follow-through of the satellite meeting held in Brussels on February 2018, to outline a collaborative work that to be carried out by ProMIS, the Reference Sites Collaborative Network (RSCN) of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) [ 2 – 6 ], in the effort of transforming the challenge of an ageing population into a sustainable opportunity for development. The vision of the ProMis working group on Health Tourism, set up jointly by 9 Italian regions coordinated by Campania, that was shared with the RSCN of the EIP on AHA, has been laying the ground for a new model based upon a shared consensus [ 7 ].

Ageing is one of the greatest social and economic challenges facing the EU [ 8 ]. The ageing population includes several groups, with their own need-patterns: active, fragile and dependent, igniting age-specific spending priorities and patterns that are a part of the general consumer economy, and are identified as “Silver Economy”. The Silver Economy is driven by the emergence of a new consumer market and by the need to improve the sustainability of public expenditure linked to ageing, as goods and services for active and healthy ageing are likely to impact on the efficiency of healthcare and social security systems, increasing their sustainability [ 9 ].

The tourism sector provides opportunities arising from the improvement of health services to residents, that could strengthen a personalized service offer targeting tourists as well. This could be exploited to increase attractiveness of internal areas as well as of out of season offers, more sustainably by including activities that positively impact health. Indeed, the turnover generated by health tourism is around 2 billion Euro, and could further grow [ 10 ].

The European directive 2011/24/EU on cross-border healthcare [ 11 ] represents a further growth opportunity for European health system and an extraordinary vehicle to strengthen the ties between the commercial enterprises and the health sector of the Member States (MS). According to Directive, healthcare providers should make available relevant information to help individual patients to make an informed choice, including treatment options, cross-border service availability, quality and safety of healthcare provided in the MS of destination. The efforts of the stakeholders are being channelled into platforms, networks and partnership to influence policy makers and accelerate the action towards implementation of innovative approaches. Age-Platform Europe is a non-governmental organization (NGO) representing older adults at the EU level, inspired by the will of older people to become considered in the elaboration of an “age-friendly” market offer for the different social-economic context. Silver economy, silver tourism and active and healthy ageing are its key-words [ 9 ].

The diversity of older people goes across the different age-ranges that express diverse needs in terms of accessibility of services and socioeconomic backgrounds, physical impairments, illnesses, disabilities, gender differences, loneliness, social exclusion.

Healthy life years versus overall life expectancy can be translated into services for older adults, as well as the need to support mobility, and services that are health and well-being targeted.

People aged 50+ spend a quite large amount of money in tourism, and probably health tourism is a “niche” market, where also age-friendly tourism should look at.

Silver tourists like to travel with companions, extend the visits to family and friends, are not interested in “all inclusive” packages, like wellness, recreation and health related offer (rheumatism, balneotherapy, dermatology, etc.), gastronomic tour. They are interested in history and commemorations.

Interestingly, they prefer autumn and spring rather than high season, when longer stays can mitigate the feeling of loneliness and isolation, especially where the offer for health services is provided and represents an added value. Older adults can be tourists, but also guests: becoming actively involved in the set-up of a personalized offer for tourism among peers might become a new approach to set up the tourist offer.

An important focus is on accessibility although it is not only about built infrastructure but also about transfer and access to health services.

People use more and more ICT devices especially when they travel, hence need to adapt new technologies for the needs of older people.

Since the physical and psychological vulnerability, real or perceived, of older people, there is the need to ensure a feeling of safety by strengthening service offer across the domains that directly or indirectly impact health and wellbeing. Going beyond to improve the tourism offer needs to focus on social goals of tourism, also taking into account people with lower income, with disabilities, and opportunities arising in remote areas. Disease prevention and health promotion applied to active ageing can be adapted to specific needs: ex. Sports, physical activity, food and nutrition with a life-course approach. Integrated care also can improve the service offer, coupled with strategies and initiatives for AHA at the national and regional levels to facilitate service provision to residents and tourists. In this perspective, the engagement of municipalities is key to ensure availability of social services as well as multi-organization commitment to ignite the involvement in this new sector of the tourism market [ 12 – 13 ].

III. ADDRESSING THE GAPS ON “SMART HEALTHY AGE-FRIENDLY ENVIRONMENTS” (SHAFE)

SHAFE is a cross-sectoral Thematic Network involving health, social care, the building industry and the ICT industry, coordinated by Caritas Coimbra and AFEdemy, with over 120 organizations with thousands of stakeholders. It was built on the work of the EIP on AHA and was approved by the European Commission for 2018. The network was launched to focus on aligning technological development with the building industry for smart environments in terms of policy and funding, enhancing a more efficient health care system that may add better quality for less investments.

The specific goal of SHAFE was to provide recommendations that may improve the quality of life of older adults and the places in which they live through the effective implementation and broad adoption of innovative and sustainable eHealth and mHealth solutions. This work focused mainly on intelligent environments to support patients suffering from chronic diseases and impairments - through the use of robotics, domotics and intelligent communications with formal and informal care [ 14 ].

The Network also provided good practices that blend health and care services, connecting tools and building environment. Cities and rural environments are addressed, to allow people to age well without any constraints [ 15 ]. SHAFE highlights that age-friendly tourism requires an integrated and cross-sector approach, involving many different stakeholders. Most facilities are not equipped for people with specific needs for health: hence the need for coherent investments to improve accessibility to tailored service provision.

IV. TRANSFERABLE ELEMENTS EMERGING FROM THE GOOD PRACTICES IN HEALTH TOURISM

The HoNCAB is European project addressing cross-border healthcare.

One of the specific objectives of the project [ 16 ], was to investigate existing experiences of cross-border care, with a focus on “direct” cross-border healthcare and “health tourism”. The project highlighted some transferable elements to health tourism, and the need for new regulation to support care service provision that is digitally supported, to:

• - Patients traveling purposely to receive specific health care services;
• - Patients traveling for tourism;
• - Emergency services.

Another example of good practice was the pilot experience of social and inclusive tourism coordinated by the ULSS 4 Eastern Veneto, aimed at tourists with special needs that involved 10 municipalities in Veneto coast. The project made available several sport activities for disabled people. This has been possible thanks to the organization provided by the management of the local health agency, strongly endorsed by Veneto Region.

Montpellier and surrounding municipalities also validated a good practice to screen for fall prevention initiative available at Balneotherapy centers [ 17 ]. This intervention study foresaw balneotherapy/thermal cure embedding a fall prevention exercise approach on 1471 patients.

The Gastrological Approach to Malnutrition represents a primary nutritional approach to prevent and treat malnutrition in the older adults and in patients affected by diseases that alter the perception of taste, based on an integrated vision developed by “Food and Nutrition” Action Area of the Action Group on “Lifespan Health Promotion and prevention of age-related Frailty and Disease” (A3 AG) of the EIP on AHA [ 18 – 20 ]. The Center for Gastrology (Leuven, Belgium) developed a tool to profile individual taste disturbances in order to prescribe recipes to personalize meals for cancer patients. Through an IT platform, a multidisciplinary team of doctors, nutritionists and cooks interfaces with the patient to realize a personalized nutritional intervention, which considers the specificity of the disease, safeguarding the taste and quality of food. The gastrological approach has an cultural embeddedness, therefore this finding opens up promising perspectives in the context of health tourism.

The “Pizza Pascalina” exploits the communication power of food to disseminate a message of healthy lifestyles. Its Mediterranean style recipe includes products that are rich in anti-oxidants and carotenoid that reduce proliferation of cancer cells in “in vitro” studies, as well as extra-virgin olive oil that is rich in polyphenols, that are protective against cardiovascular risk and cancer, and crucifer vegetables that are rich in sulphur agents. Although many studies demonstrated the positive effects on health of the Mediterranean Diet (MD), the adherence to this food regimen is still too low, reducing the health gain related to MD [ 21 ].

The MD has been recognized by UNESCO as an Intangible Heritage of Humanity in 2010. In addition in 2012 the MD has been included by the FAO at the top of the list of the most sustainable diets in the planet [ 22 ]. The double recognition of healthy diet and life style generated a new approach to this cultural heritage by the stakeholders who are progressively recognizing that it may become a new tool to develop green economy and sustainable tourism.

MD relates to the territorial development based on immaterial assets such as the emblematic communities. The aim of the MD.net Interreg MED project is to identify routes and activities of international cooperation aimed at stimulating local development of the MD emblematic communities. The focus of Campania in this project is the Cilento area.

V. PROJECTS BLENDING AND FUNDS COMPLEMENTATION TO SUPPORT HEALTH SERVICES

Our health system asks for changes in the way healthcare is delivered, organized and financed across the Europe. Health authorities are looking for ways to put more emphasis on prevention and shift activities from hospitals to primary and community, integrating services across the levels of care and between social and healthcare. These efforts focus on people needs and take advantage of the potential of digital technologies.

In order to deliver the expected benefits, two very important preconditions are needed:

• - sufficient mobilisation of investment,
• - capacity to design and implement the new care models.

The fundamental elements to engage in such investment mobilisation are:

• Long term investment strategies, integrating infrastructure, innovative technologies and new care models;
• Integrated investment strategy requires to blend financing from different sources;
• Investments blending requires the development of partnerships with new stakeholders, new investors, implementing a different way to manage the new financing instruments.
• Contracting and payment models need to be considered in conjunction with the planned investment, to assess efficacy.

DG Sante, has been carrying “European Structured Funds for Health” initiative to map all the structured fund actions of National and regional authorities that have been supporting health in the current financial framework, showing the diversity and the creativity of the projects to be supported by the structured funds.

Next Multiannual Financial Framework (MFF) will start after 2021, when the structural funds will continue very strongly to be an opportunity for those that want to invest in health and in what is important for health: it is pivotal for regions to engage in the process of programming as early as now.

A number of support instruments in form of loans or instruments for investors (European funds for strategic investments - EFSI) is going to continue being an opportunity in the next multiannual financial framework.

The reform process paralleled by the right knowledge on how to implement new models of care is needed to make sure that the implementation can be successful. Therefore it is important to develop technical support and capacity building for regional authorities, through networking between authorities through the EU Health programme. In the next MFF, projects will be financed to identify the transfer and replication of best practices to new locations and in particular those addressing chronic disease.

A strategic approach should be developed to make the best use of the digital transformation of health and care. In recent policy paper [ 23 ], specific actions from the EU/national level have been identified to facilitate the wide use of digital tools for citizens and patients centred care.

VI. THE CHALLENGES OF WELLBEING AND TOURISM FOR HEALTH SYSTEMS

Health tourism is an opportunity of sustainable development that can be declined along several directories, taking advantage in Europe of the cross-border availability of services for health. Sharing data and allowing data retrieval for specific citizens is an important enabling factor to the set-up of personalized offer for health to strengthen the tourist offer.

There is clearly a need to profile the “tourist clients” in order to set up adequate offers and business models, implementing the activities for example of thermal stations for health promotion and disease prevention while strengthening their use for residents, to open to tourists as well.

Enabler to the exploitation of the health tourism market is the need to balance accessibility and equity, and to be careful in maintaining the communication with the patient/tourist to support inclusive tourism.

There have been several initiatives trying to support value-based collaborations among Mediterranean countries/regions, highlighting the potential role of Campania as a coordinator in the framework of Mediterranean collaboration.

The Mediterranean Federation for Advancing Vascular Surgery (MeFAVS) aims to promote and strengthen the cooperation between the reference organizations involved in Vascular Surgery and the countries of the Mediterranean basin: in particular Italy, France, Spain, Greece, Portugal, the Balkan area, Lebanon, the Middle East, the United Arab Emirates, Egypt, Morocco, Tunisia and other countries that face/are close to the Mediterranean. MeFAVS addresses the need of sharing the know-how in vascular surgery and build bridges among health systems, working jointly to bridge the differences and foster the progress of vascular surgery throughout the Mediterranean area.

There is an urging need of framing the service provision for health to the different traveling populations (tourists, patients migration, wellness, etc.), highlighting whenever possible the offer of new, special services.

An important directory develops along the valorisation of the offer deriving from the networking between thermal locations. It is very important to identify the need for services expressed by the tourist demand, strengthening the offer according to the evolving changes depending on the tourist fluxes. This translates for service providers in the mobilization of an incoming economic flux that also impacts beyond the health system. The development of policies for health tourism are multi-sectoral, where health services are an enabler. Strengthening the offer directed towards special health needs also in terms of health promotion is the key to take advantage of the opportunity for sustainable development of health tourism.

Safety, quality, accessibility of services for baby-boomers and older adults can be achieved by a structured public/private network that is capable of providing services along the emergency, chronicity and wellbeing.

It is pivotal to design and implement a targeted communication plan on the services that are available, and how they can be accessed, according to a sustainable business model. The need for a strengths and weaknesses assessment is urgent to identify the priority actions to undertake.

VII. OPPORTUNITIES FROM THE INDUSTRIAL SECTOR

The trends for health tourism in Italy are in constant growth, thanks to a number of initiatives that valorise the different offers. The industrial sector expressed the need for greater clarity in administrative processes that can stimulate sustainable development and investments. The approach towards administrative simplification of Campania region for touristic activities takes advantage of a “silent-assent” rule, aimed at increasing attractiveness for investors. Often the wealth of the territories suffers from lack of coordination, networking and adequate communication activities that impact on the use of local resources. Campania Touristic Districts are aimed at creating a de-centralized offer for tourism. They are moving in the field of communication, and are exploring intercontinental avenues where it is possible to move as a cluster and not in a fragmented way.

The viewpoint of the industrial sector focuses on the objective to strengthen the attractiveness of the Italian health sector. In the specific case of the thermal sector it is more immediate to identify the specific fields of application for specific target populations, eg. fall prevention initiatives. Prevention is not financed by the Health System, nonetheless it could be possible to re-invest part of the avoided cost in health tourism. The thermal services focus on the tourism for wellbeing and prevention of diseases, through a number of interventions that span from health promotion to cure. It is important to identify a shared strategy for the sector in order to compete at the international level for tourist influxes, such as the setup of an European Grouping of Territorial Cooperation (EGTC).

VIII. CONCLUSIONS AND REMARKS

The health care system should no longer be regarded as a cost-generating sector, but rather as a driving force for the economy. Quality health benefits and services can attract citizens who are concerned about maintaining health and well-being as well as patients in search of high-quality services, thus contributing to the development of the tourism market. In this framework, the phenomenon of health tourism is promising as a global positioning of the tourist sector in Italy and in the EU, for sustainable economic development.

There is a need to define a normative regulation, which supports the development of health tourism, in synergy with the other sectors that are directly or indirectly involved in the effort of strengthening the attractiveness of the entire national territory, taking into account the ongoing digital transformation of health and care.

Health tourism can have a tangible development: in this sense it is necessary that the world of health and tourism sit together to agree on the development of a common planning, that takes into account the strengths and peculiarities of each sector, in a synergic and virtuous perspective. It is therefore essential that both sectors share experiences and integrate each other’s excellence while maintaining the focus on citizens and on the demographic evolution. The aim of such a new model should allow both the maintenance of quality and sustainability of health and social services, as well as stimulating the tourism attractiveness of proposing areas, integrating digitally supported well-being and health promotion services, encouraging active and healthy ageing.

Let us take a walk to the sustainable tourism practices: a qualitative study through the lens of tourism experts

• Research Article
• Published: 04 January 2024
• Volume 31 , pages 12892–12915, ( 2024 )

Cite this article

• Vikas Arya 1 ,
• Vilte Auruskeviciene   ORCID: orcid.org/0000-0002-1563-4052 2 ,
• Srishti Agarwal 3 ,
• Priyanka Kokatnur 3 ,
• Harish Kumar 4 &
• Rajeev Verma 5  

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The rising opportunities of sustainable tourism have brought many policies to control the exploitation of the environment and increase the reach of luxurious, safe, and authentic experiences to the different segments of tourists. This study seeks to prioritize the variables influencing the development of sustainable tourism and pinpoint key success factors that align with the Sustainable Development Goals (SDGs). It adopts a tri-dimensional framework encompassing economic, social, and environmental aspects, further delineated into eleven sub-dimensions, to provide a quantitative evaluation of sustainable tourism. We conducted interviews with 26 tourism industry experts hailing from eight countries, analyzing their responses using interval type-2 fuzzy sets. The results underscore the critical role of specific components in advancing sustainable tourism. In the economic dimension, “financial resources and tourism costs” emerge as vital factors. In the social dimension, “health and safety” takes center stage, while “green infrastructure” plays a pivotal role in the environmental dimension. These findings underscore the significance of these aspects in promoting sustainable tourism. Furthermore, this study explores the strategic importance of sustainable tourism equity in shaping tourism planning and development for emerging markets.

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All authors contributed to the study’s conception and design. Vikas Arya conducted the analysis of data and provided an interpretation of the findings. Vilte Auruskeviciene wrote the manuscript draft and ensured consistency in referencing and citation formatting. Srishti Agarwal collected data, collaborated with Vikas Arya to analyze the data, and contributed to the discussion of the findings. Priyanka Kokatnur contributed to the research methodology development and data collection. Harish Kumar provided insights to the theoretical and managerial aspects of the study and contributed to the discussion section. Rajeev Verma conducted a literature review and collaborated with Vilte Auruskeviciene to integrate the literature review into the manuscript. All authors provided comments on previous versions of the manuscript, and they all read and approved the final manuscript.

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Arya, V., Auruskeviciene, V., Agarwal, S. et al. Let us take a walk to the sustainable tourism practices: a qualitative study through the lens of tourism experts. Environ Sci Pollut Res 31 , 12892–12915 (2024). https://doi.org/10.1007/s11356-023-31503-7

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Hazy skies over Accra: Harsh harmattan season in Ghana leads to health hazards, poor air quality

Severe, dry winds during the harmattan season are not new in Ghana. But experts with the country’s environmental agency say climate change is intensifying these weather conditions, leading to increased respiratory problems and poor air quality in Accra, the country’s capital. 

• By Ridwan Karim Dini-Osman

Air quality levels have been bad in Accra since December as harmattan season kicks in across Ghana. The data coming in shows the situation is not improving.

When dispatch rider Efo Pascal recently returned to Accra on his motorbike from one of his delivery rounds, he came back with a dusty black sweater and helmet. 

“Since the whole of last week and this week, the dust is too much, and it is really bad. This is my first delivery today yet, see how dirty I look,” he said.

Ghana is in the grip of this year’s harmattan season — characterized by dry, dusty winds between the end of November through March — as winds from the Sahara desert reach West Africa.

Since December, the skyline in Accra has been hazy with excessive dust flying in the air.

Last week, Accra’s air quality was labeled hazardous by the Ghana Meteorological Agency, the Environmental Protection Agency and other air quality monitoring platforms. The harmattan season is not new to Ghana, but experts say climate change is intensifying these harsh weather conditions and leading to increased health hazards. 

Pascal said that driving at night has become dangerous due to visibility problems. And his health, too, is taking a hit. He said he’s already been to the hospital twice in the past two weeks due to breathing problems. 

“Breathing was really hard for me, especially at night.” Efo Pascal, dispatch rider, Accra, Ghana

“Breathing was really hard for me, especially at night. I had pains in my chest, and I was coughing,” he said as he pulled medicine out of his pocket. “The doctor said I had some infections from the air. That’s why they gave me antibiotics,” he said.

Yet he still struggles with his breathing. 

Last August, a team of scientists published new research indicating a substantial correlation between air pollution and antibiotic resistance, resulting in about 480,000 premature deaths in 2018.

Pascal said he fears his health may deteriorate. And he’s not the only one. 

Patience Denu, a teacher at the Fountain Basic School in Accra, said the current dry weather is making some children sick. Inside the school courtyard, children usually run around or chat with friends during recess — but the weather is taking a toll. 

“They [the children] are always complaining of headaches.” Patience Denu, teacher, Fountain Basic School, Accra, Ghana

“Their faces, all dry, their lips are breaking and all that. Because of that, they are always like, ‘My head…I’m feeling tired…’ They are always complaining of headaches,” she said.

Denu said the situation is making schoolwork tedious. When the children don’t feel well, she said the children have to spend a few days at home. The school may shut down if the situation does not improve, she added. 

Emmanuel Osei Waziri, who recently dropped off his children at school, said he’s worried. 

“The dust is everywhere, and it’s hard to shield them from it. How do I even tell if it is not already affecting their lungs? We are still monitoring whether we may have to keep them at home for some time until the air becomes normal,” he said.

Surge in respiratory illnesses

Some hospitals are now seeing a surge in respiratory tract infections among children.

At the Child Health Emergency unit of the Korle Bu Teaching Hospital in Accra, Mabel Okine said her 2-year-old has been coughing excessively and having breathing difficulties in the last two weeks.

“This is the third time I am bringing her to the hospital. We have tried prescriptions and even home remedies, but she is still not getting better. I sell water by the road and usually strap her on my back. So I think the air has entered her system,” she said.

Pediatrician Dr. Frank Owusu Sekeyere said they are recording 30 respiratory tract infection cases per day compared to just six cases every two months before the harmattan season started. 

“So, the children are coming in with either a runny nose or they are snorty, coryza [acute mucous] and then, they are also coughing. And then sometimes, they also come with signs of respiratory tract infections.” Dr. Frank Owusu Sekeyere, Korle Bu Teaching Hospital, Accra, Ghana 

“So, the children are coming in with either a runny nose, or they are snorty, coryza [acute mucous], and then, they are also coughing. And then sometimes, they also come with signs of respiratory tract infections. What we also see is that fine particles in the air are worsening preexisting conditions. The situation is quite disturbing,” he said.

‘Health effects of climate change are very real’

Accra now sits alongside Delhi, in India, as one of the most highly polluted cities in the world. The fastest-growing African city of 4 million people sees a daily influx of 2.5 million business commuters. And the city is already grappling with the effects of climate change due to rapid urbanization and industrialization.

Selina Amoah, head of environmental quality at the EPA, said this year’s harmattan season is worse than years prior. 

“From our monitoring locations along the roadside, we realized that the pollution levels are high — and this is largely due to climate change. Rising temperatures, changing wind patterns, and increased desertification have all contributed to the severity of the weather,” she said.

The expansion of desert areas has led to an increase in dust that is then carried by the harmattan winds. 

Amoah said climate change can influence the intensity and duration of the harmattan season, potentially leading to more severe dust storms or altered patterns of dust transport. This can also have a detrimental impact on air quality.

“The only thing we can do now is to take precautions to stay safe.” Selina Amoah, head of environmental quality, Environmental Protection Agency, Accra, Ghana

“The only thing we can do now is to take precautions to stay safe,” Amoah said. They are encouraging people to stay indoors and wear a mask if they must go outdoors. They are also asking the public to refrain from burning garbage outside and to use water to douse their surroundings in dusty areas.

Dirty air results in  4 million deaths annually around the world. In Ghana, this translates to at least 28,000 premature deaths every year. Yet, just  1% of global development aid is spent on tackling air pollution.

Akosua Kwakye, with the World Health Organization office in Ghana, said that air pollutants and greenhouse gasses often come from the same sources — coal-fired power plants and diesel-fueled vehicles.

“What we are experiencing in Ghana shows that the health effects of climate change are very real.” Akosua Kwakye, World Health Organization, Accra, Ghana

“What we are experiencing in Ghana shows that the health effects of climate change are very real. There’s evidence to indicate that issues like respiratory infections, cardiovascular diseases and even some cancers are attributable to the events of climate change,” she said.

In 2022, the World Bank disclosed that global health-related damages linked to outdoor air pollution reached $8.1 trillion, equivalent to approximately 6.1% of the global gross domestic product. And the burden disproportionately affects low- and middle-income countries like Ghana.

Experts like Kwakye say that Ghana should begin to embrace green initiatives to include cleaner, renewable energy sources, phase out subsidies that promote use of polluting fuels, and plant more trees. 

But Emmanuel Appoh, an environmental scientist at the University of Ghana who inspects sensors at an Air Quality Evaluation facility, said the latest data shows no signs of improvement any time soon.

“The current state of air quality is very unhealthy, and you have a lot of dust in the atmosphere. It is not encouraging at all. Hopefully, this does not lead us into a public health crisis,” he said.

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