Exploring Health Tourism

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Exploring Health Tourism
${protocol}://www.e-unwto.org/doi/book/10.18111/9789284420209 - Saturday, February 02, 2019 5:38:54 PM - IP Address:186.83.134.86

Copyright © 2018, World Tourism Organization (UNWTO) and European Travel Commission (ETC)
Copyright cover photo: © Ksenija

ISBN UNWTO: printed version: 978-92-844-2019-3 electronic version: 978-92-844-2020-9
ISBN ETC: printed version: 978-92-95107-27-4 electronic version: 978-92-95107-28-1
DOI: 10.18111/9789284420209
Published by the World Tourism Organization (UNWTO) and the European Travel Commission (ETC).
First printing: 2018.
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Citation: World Tourism Organization and European Travel Commission (2018), Exploring Health Tourism, UNWTO, Madrid,
DOI: https://doi.org/10.18111/9789284420209.
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Table of contents
Acknowledgments 7
Foreword 9
Executive summary 11
Chapter 1 Introduction 17
1.1 Purpose of the study 17
1.2 Methodological approach 19
1.3 Study overview 20
Chapter 2 Analysis of macro-environmental factors 23
2.1 Political factors 24

2.1.1 Working and leisure time 25
2.1.2 Supported holidays 26
2.1.3 Health care systems 27
2.1.4 State support and incentives 29
2.2 Economic factors 30
2.3 Socio-cultural factors 33
2.4 Technological factors 36
2.5 Natural factors 40
2.6 Legal factors 43
2.7 In a nutshell 46
Chapter 3 Development of a taxonomy for health tourism 47
3.1 Preliminary remarks 47
3.2 Discussing definitions around heath tourism 49

3.2.1 Health tourism 51
3.2.2 Wellness tourism 53
3.2.3 Medical tourism 59
3.3 Recommended definitions 63
3.4 In summary 64
Chapter 4 The health tourism market 67
4.1 Preliminary remarks 67
4.2 Market size of health tourism: some estimates 68
4.3 The supply of health tourism 71

4.3.1 Hospitals and clinics 72
4.3.2 Resorts and hotels 76
4.3.3 Spas 79
4.3.4 Facilities based on natural resources 83

4.3.5 Retreats 88
4.3.6 Conclusions 90
4.4 Demand for health tourism 91

4.4.1 Motivations for health tourism 92
4.4.2 Cultural, regional and national differences 97
4.5 Demand for wellness tourism 100

4.5.1 Motivations, segments and profiles 101
4.5.2 Flows of wellness tourism 106
4.6 Demand for medical tourism 108

4.6.1 Motivations, segments and profiles 109
4.6.2 Flows of medical tourism 112
4.6.3 Conclusions 115
4.7 Managing and marketing health tourism 116

4.7.1 Policy making and regulation 117
4.7.2 Networks in health tourism 123
4.7.3 Health tourism regions and destinations 127
4.7.4 Marketing and branding 131
4.7.5 Health tourism distribution 136
Chapter 5 Conclusions and recommendations 141
5.1 Expectations 141
5.2 Management and planning 142
5.3 Marketing and research 143
5.4 Segments and motivations 143
Chapter 6 Development of health tourism – toolkit for implementing

a Health Tourism Development Strategy 145

Toolkit for implementing a Health Tourism Development Strategy 146
Annexes
Annex 1 List of interviewees 155
Annex 2 Word cloud health tourism scenarios for categorization 157
Annex 3 Grouping of the scenarios from the word cloud exercise 159
List of examples, figures and tables 163

List of abbreviations and acronyms 165
References and bibliography 169

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Acknowledgments
This study was prepared by Dr László Puczkó, The Tourism Observatory for Health, Wellness and
Spa by Xellum & Resources for Leisure Assets, and Dr Melanie Smith, Budapest Metropolitan
University & Pärnu Kolledz/University of Tartu, in collaboration with Mr Keith Pollard, International
Medical Travel Journal, LaingBuisson International. The study was commissioned by the European
Travel Commission (ETC) and the World Tourism Organization (UNWTO).
This study forms part of ETC’s ongoing Market Intelligence Programme and was carried out
under the supervision of ETC’s Executive Unit on behalf of its Market Intelligence Committee and
UNWTO’s Tourism Market Intelligence and Competitiveness Department. Our thanks go to all
involved, including Ms Stefanie Gallob and Ms Jennifer Iduh (ETC Executive Unit), and Ms Sandra
Carvao, Ms Julia Baunemann and Mr Michel Julian (UNWTO).
The European Travel Commission and the World Tourism Organization would like to thank all
contributors from ETC’s Market Intelligence Committee and UNWTO, for their valuable input
throughout the preparation process, starting from the previous working paper. Special thanks go
to Ms Emöke Halassy (Hungary) for her dedication to the project.
We would like to acknowledge the support of all institutions and experts involved that provided
interviews, country data and case study information. Our thanks go as well to the international
experts who participated in the roundtable on health tourism convened by ETC and UNWTO
in Budapest with the support of the Hungarian Tourism Agency, for their important consensus-
building role.
Last but not least, we would like to express our appreciation to the International Medical Travel
Journal, LaingBuisson International, for their support and sponsorship to this research.
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Foreword
In recent years health, wellness and medical tourism have grown exponentially. Both established
and emerging destinations are increasingly tapping into the potential of this tourism segment
in looking to diversify, increase revenue or tackle seasonality. Yet health tourism is still poorly-
defined; data on it is fragmented and definitions and concepts of it vary significantly across
countries. There is an essential need to better understand wellness and medical tourism in order
to effectively seize its growth potential for sustainable tourism development.
This report Exploring Health Tourism, prepared by the World Tourism Organization (UNWTO)
and the European Travel Commission (ETC) with the support of the International Medical Travel
Journal – LaingBuisson International, proposes a consistent conceptualization of health tourism
and explores travellers’ motivations when looking for health-related services.
The study includes the first taxonomy to describe and define the intricacies of travelling for
health purposes, as well as a practical toolkit for national tourism organizations and destination
management organizations wanting to develop health tourism.
We trust this information will provide tourism destinations, companies and institutions with a
better understanding and a more accurate picture of health tourism. The following guidelines and
reference case studies are designed to help them leverage opportunities to seize the potential of
this emerging, complex and rapidly-changing global tourism segment.
Zurab Pololikashvili Peter de Wilde

Secretary-General, President,
World Tourism Organization (UNWTO) European Travel Commission (ETC)
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Executive summary
The growing segment of health tourism
Health, wellness and medical tourism have grown exponentially in recent years and are
becoming increasingly relevant in many established and emerging destinations around the world.
Yet, the health tourism segment is still not well defined, with differences based on geographical and
linguistic characteristics and the large and wide variety of related cultural traditions. Furthermore,
data is fragmented and limited.
Health tourism is considered nowadays to be an emerging, global, complex and rapidly changing
segment that needs to be comprehended to a greater extent in order to leverage opportunities
and better address challenges.
The purpose of this study prepared by the European Travel Commission (ETC) and the World
Tourism Organization (UNWTO) is threefold:
1. To achieve a better understanding of heath tourism at a global level, through the identification
of current practices from stakeholders involved in the promotion of health tourism;
2. To propose a comprehensive taxonomy with a consistent terminology to define and describe
the intricate system of travelling for health purposes; and
3. To provide a practical toolkit for national tourism organizations (NTOs) and destination
management organizations (DMOs) wanting to develop health tourism.
The recommended definitions included in this study represent the culmination of a process
starting with a working paper, the discussions and conclusion from the roundtable on health
tourism convened by ETC and UNWTO in Budapest with the support of the Hungarian Tourism
Agency, and the work carried out by the UNWTO Tourism Competitiveness Committee.
Defining health tourism: recommended taxonomy and definitions
Tourism (and travel) is an activity that can contribute to the creation or improvement of wellbeing.
Health tourism covers those types of tourism which have as a primary motivation, the contribution
to physical, mental and/or spiritual health through medical and wellness-based activities which
increase the capacity of individuals to satisfy their own needs and function better as individuals in
their environment and society.

Health tourism is the umbrella term for the subtypes: wellness tourism and medical tourism.
Wellness tourism is a type of tourism activity which aims to improve and balance all of the
main domains of human life including physical, mental, emotional, occupational, intellectual and
spiritual. The primary motivation for the wellness tourist is to engage in preventive, proactive,
lifestyle enhancing activities such as fitness, healthy eating, relaxation, pampering and healing
treatments.
Medical tourism is a type of tourism activity which involves the use of evidence-based medical
healing resources and services (both invasive and non-invasive). This may include diagnosis,
treatment, cure, prevention and rehabilitation.
The 22nd Session of the UNWTO General Assembly held in Chengdu, China (September 2017),
adopted as Recommendations the below definitions of health tourism, medical tourism and
wellness tourism.
Factors shaping health tourism
Time spent on leisure activities (including health care and prevention) has increased over time.
More available time and increased disposable income devoted to leisure activities (e.g., travel,
entertainment, health care, personal wellbeing) are supporting healthy lifestyle motivations.
Medical tourism is particularly driven by over-burdened health care and public health insurance
systems. Long-term care (LTC) expenditure has risen over the past few decades in many advanced
economies, with ageing population requiring more health and social care.
Urbanization is a major challenge for public health. According to the United Nations, over half of
world’s population live in cities, a proportion that is expected to increase to two-thirds in 2050.
Urban living associated health condition and chronic diseases are leading to a growing need and
demand for healthier trips, natural alternatives and escapism.
Certain legal directives are also perceived as influential, especially those in medical tourism,
like the European Union (EU) Directive on cross-border mobility. The Directive 2011/24/EU on
patients’ rights in cross-border health care “clarifies that patients are entitled to seek health care
abroad, including for planned care, and be reimbursed for it, in principle without having to seek
prior authorisation”1.
The global nature of financial markets fuels rapid developments, especially in the hospitality
and spa market. Increasing investments (often as foreign direct investment) are taking place in
medical tourism as well, mainly in the form of investments in technology and know-how. However,
the concept of brain drain is quite common especially in the medical tourism industry (i.e., doctors
and other health care professionals choose to work in medical tourism rather than treating local
residents).
1 European Patients Forum (2011), EU Directive 2011/24/EU on the application of patients’ rights in cross-border healthcare:
Legislation Guidance for Patient Organisations (online), available at:
www.eu-patient.eu/globalassets/policy/crossborderhealthcare/2013-11-18_cbhc_guidance-final.pdf (27-06-2017).
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Rapid technological developments and inventions also influence travel for health purposes.
For instance, faster and less invasive, non- or minimal invasive technology (e.g., laparoscopy) in
beauty and medical treatments. Technology and innovation companies with global outreach can
influence the development of medical tourism locally.
Apps, wearables (or hearables) have the potential to change how users will consider health and
health management in future years. M-health (mobile health) and e-health smarts solutions and
real-time information can help health care providers to define personal treatment plans.
Protection of personal health data (i.e., privacy), information and malpractice legislation in
health (especially in medical) tourism is paramount.
The market of health tourism
In line with the continuous expansion of world tourism, an increasing number of people is travelling
for health purposes. Flows have been facilitated by affordable, accessible travel and readily
available information over the Internet.
Due to limited, fragmented and often unreliable data, as well as varying definitions of health tourism
and its components, it is difficult to estimate the size and growth of health tourism as a market.
Some estimates by industry bodies point to USD 45.5 billion to USD 72 billion market size of
medical tourism (Patients Beyond Borders) or USD 100 billion (Medical Tourism Association).
Depending on the source estimates of the value of the medical tourism market differ greatly.
Most countries that engage in delivering care to medical tourists do so to increase the level of
foreign exchange earnings coming into their country and to improve their balance of payments
position.
Supply of health tourism
The supply of health tourism is already very wide from hotels with spas facilities, to wellness
hotels and thermal baths to specialized hospitals and clinics. There are several types of facilities
that can provide services in many areas of health tourism (e.g., wellness cruises can also provide
services such as spas, IVF clinics, dental or plastic surgery clinics). Operators in the health tourism
supply can range from providers, brokers or hotels to certification, accreditation and insurance
companies.
Since a globally accepted typology of service providers is not available, the size and capacity of
the actual supply (probably apart from hotels and hospitals) is not well seized.
The hospitality industry recognized the growing demand and interest in health or wellbeing, and
an increasing number of operators either have reshaped their services or launched new brands
adapted to the new demand trend (e.g., in the form of healthy options).

Demand of health tourism
Although populations in western countries, as well as countries in the Far East are facing rapid
ageing, global data still show that half of the world’s population is younger than 30 years of age.
Young people represent a potential demand for health related tourism in the near future.
Cultural traditions, natural assets and heritage play a significant role in defining demand and
motivations.
International wellness travellers tend to be savvy and lead a wellness lifestyle. They seek healthy
services and prefer lifestyle-based treatments.
Domestic health tourism is significant in several countries. This is especially true in countries
where the government still subsidises national or domestic health tourism (e.g., thermal medical
bath treatments) through social tourism.
Medical tourism involves people travelling expressly to access medical treatment. People travel
for wellness to maintain or enhance their personal health and well-being, and wellness services
focus on healing, relaxation or beautifying of the body that is preventive and/or curative in nature.
The key drivers for medical tourism are the lack of insurance and services (in the patients’ home
country), lower costs, better quality care, procedures unavailable at home and shorter waiting
periods.
Medical tourism has historically been from lower to higher income countries, with better medical
facilities and more highly trained and qualified professionals. However, this trend is now reversing
and most recently hubs of medical excellence have developed which attract people regionally.
Many countries participate in medical tourism as importers, exporters or both.
The main importing countries (those where the medical tourists come from) are in North America
and Western Europe. The main exporting countries (those who provide the services to medical
tourists) are located across all continents, including Latin America, Eastern Europe, Africa and
Asia. Countries and/or hospitals tend to be specialized in certain procedures.
Management and marketing
Social policies and public as well as private initiatives aiming at the improvement of the general
wellbeing of citizens also support travelling for health purposes.
National and regional policies and initiatives are often paving the way for domestic and/or
international health tourism (e.g., investment, incentives or regulations), especially if supported
and facilitated by a relevant organization, e.g., industry co-established cluster or governmental
department.
Distribution in health tourism is quite unique. In medical tourism, facilitators (and not traditional
tour operators) play an important role. In wellness tourism (especially in retreat-based or spiritual
tourism) small but rather specialized tour companies provide packaged services or operate
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distribution platforms. The online distribution (e.g., online travel agencies) has not yet developed
(or applied) a terminology that would support distribution on a larger scale.
Conclusion and recommendations
Health tourism is certainly one of the fastest growing forms of tourism at the time. The analysis of
the supply and demand in the health tourism market brings up relevant issues that need attention
such as the different typologies of service providers and the lack of reliable and comparable data
and evidence-based information, making hard to benchmark performance at country, destination
or individual facility level.
NTOs, DMOs and the industry at large would benefit from improved data collected and developed
under a harmonized conceptual framework with clear definitions. This would ensure comparability,
more accurate measurement and better management. Health tourism is still a niche market and
it is important not to over-inflate or double count statistics.
The concept of supported or co-funded holidays (or social tourism) is often related to accessible
tourism: it is a different form of travel aiming at the improvement of health or wellbeing of the
beneficiary travellers (families, young people or senior citizens), at least partially. These travellers
can generate additional revenue, but also may help to reduce health cost through prevention
measures and decreased pharmaceutical consumption.
Sustainability and responsibility have become key criteria in health tourism, which often relies on
natural resources and assets. When managing health tourism it is certainly important to have a
sustainable approach in terms of development, planning and impact management. It is also critical
to observe regulations and ethics. The incorporation of sustainable practices and corporate social
responsibility the inclusion of local communities, the Sustainable Development Goals as guiding
framewok for both public and private stakeholders, are key fundamentals for the long-term viability
of the health tourism related industry and maximizing benefits for local communities.
Destinations should look at the impact of health tourism on the quality of life of residents. The
wellbeing of local residents is equally important as the health improvement of tourists. Monitoring
economic, social and environmental impacts need dedicated attention and resources.
As part of a health tourism strategy, destinations should look into travel facilitation issues:
–– Visa policy, enhanced connectivity, safety and security, mobility framework for people with
disabilities;
–– Diversification of source markets and segments;
–– Attraction of investment;
–– Establishment of a regulatory framework, including legislation, incentives and standards;
–– Quality of service and infrastructure;
–– Training and skills development;
–– Accreditation and certification of health tourism facilities and practices; as well as
–– Product development, involving e.g., the meetings industry or gastronomy.
Health tourism can help tackling seasonality, as it does not necessarily follow a seasonal pattern
compared to other tourism segments. It tends be less seasonal, and can be integrated into

365-day destination strategies. Health tourism can also contribute to tourism dispersal, as many
wellness and medical facilities can be located in city outskirts and rural areas.
Collaboration and partnerships are key among the different stakeholders involved in the health
tourism value chain: destinations, authorities, local communities, accommodation and transport,
providers, facilitators. Health tourism can be better integrated into tourism policies overall. The
successful public-private initiatives to promote health tourism put in place in some of the leading
health tourism destinations, and which can be considered best practices, could be replicated
in other countries. Co-opetition in health tourism can also have a trickle down effect on know-
how and technological transfer. Finally, cooperation with international organizations concerned
becomes essential.
Hospitality and the health care industry can learn from each other through the exchange of
know-how and practices, in order to optimize the delivery of services and ensure a quality tourism
experience. The hospitality industry can also complement wellness and various related tourism
services in the supply of accommodation, gastronomy and others.
Destinations should pay attention to product-segment matrices. New product concepts are
emerging and market intelligence produced by NTOs and DMOs and the design of innovative
digital marketing strategies can help attracting new market segments such as millenials or LGBT.
Segmentation and motivation modelling should incorporate new approaches such as lifestyle-
based segmentation and ’tribal marketing’.
Technology advances and mobile applications such as eHealth and mHealth (or Artificial
Intelligence and robotics in the near future) can bring new solutions and opportunities to health
care, including real-time monitoring of patient vital signs and mobile telemedicine, as well as how
tourism service providers communicate and relate to their guests.
The toolkit for health tourism development included in the full study should facilitate, guide
and support step-by-step NTOs and DMOs in their effort of developing and managing any form
of health tourism.
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Chapter 1
Introduction
The new phase in human evolution represents a culmination of thousands of years

of human history during which many different cultures, philosophies, traditions and
technologies have attempted to address the questions of life, ageing, illness and death.
It seems that all people have tried to tackle the question of: How to live well in the world?
Cohen, M. (2010)1
Health tourism as a concept and product is not new, contrary to common belief. It has been deeply
rooted back to many societies and cultures for decades if not centuries. People have been using
thermal waters since the Roman times, and sought pain relief by visiting climatic destinations
and resorts. Patients have been visiting healers, doctors and spiritualists since the early days of
humankind.2 Yet, health tourism has become a modern and contemporary phenomenon, as well
as an attractive business opportunity. Health care, wellness and spa operators are increasingly
focusing on this growing segment of tourism, as well as many countries and destinations. However,
many questions have remained unanswered, especially in terms of common terminologies,
definitions and taxonomies.
1.1 Purpose of the study
Health tourism is now understood to be an emerging, global, complex and quickly changing
phenomenon that needs to be better understood in order to increase possibilities and better
address challenges. In both established and emerging destinations guidelines are needed to
successfully initiate and support the required development.
As part of their joint research programme, the European Travel Commission (ETC) and the World
Tourism Organization (UNWTO) commissioned a study on health tourism, which goal is to meet the
needs of tourism administrations, boards, destination management organizations and operators.
As a primary objective, the development of a taxonomy is especially relevant to define the scope
of health tourism and to facilitate data collection and research on supply and demand.
The purpose of this study is to provide the tourism sector with insights regarding the complex
phenomenon of health tourism. The study introduces the evolution of health-related tourism
products and services from all around the world. Users are provided with insights into the current
1 Cohen, M. (2010), ‘Spas, Wellness and Human Evolution’, in: Cohen, M. and Bodeker, G. (eds.), Understanding the Global
Spa Industry: Spa management, Routledge, London, pp. 3–25.
2 Smith, M.K. and Puczkó, L. (2013), Health, Tourism and Hospitality: Spas, Wellness and Medical Travel, Routledge,
London.
18 Exploring Health Tourism
situation of the industry, as well as the development potential both at national and destination
level. The aim of the study is threefold:
–– To achieve a better understanding of health tourism at a global level, through the review of
current practices and future plans from both public and private tourism stakeholders;
–– To provide a comprehensive taxonomy that serves as a common reference for tourism
destinations operating in this field; and
–– To map all publicly available data sources that support destinations in monitoring the
evolution of the demand and supply.
The study has global coverage but due to the rich history, tradition, and the advanced stage of
health tourism development in many European countries, special attention was paid to the state
of affairs and development trends in Europe.
The study is a first attempt to set a coherent conceptualization of health tourism and define the
motivations behind travellers looking for health-related services. The taxonomy was first presented
in a working paper, in order to receive feedback from the different stakeholders that could help
fine-tuning and ultimately validate the proposed definitions.
The taxonomy and key findings of the working paper were discussed at a roundtable of international
experts held in Budapest, Hungary, in June 2016. The ETC-UNWTO roundtable ‘Exploring Health
Tourism’ aimed at better understanding and exploring the growing segment of wellness and
medical tourism. The roundtable gathered experts from the World Health Organization (WHO),
the European Union (EU), the World Travel and Tourism Council (WTTC), the European Spas
Association, the Global Wellness Institute and Spaincares, as well as representatives from the
health-related tourism sector from Hungary, Lithuania, Malaysia and Mexico3.
The 22nd Session of the UNWTO General Assembly held in Chengdu, China (11–16 September
2017), adopted as Recommendations the proposed definitions of health tourism, medical tourism
and wellness tourism included in this study (UNWTO Committee on Tourism Competitiveness).4
It is aimed that these operational definitions provide UNWTO, as well as ETC 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.
3 Full list of participants: the World Health Organization, the European Commission, the European Parliament, the World
Travel and Tourism Council, the European Spas Association, the Global Wellness Institute, Spaincares, the Malaysia
Healthcare Travel Council, the Mexican Council for the Medical Tourism Industry, the Lithuania Medical Tourism Cluster,
the Lithuania State Department of Tourism, the Hungarian Tourism Agency, the Hungarian Hotel Association, the Danubius
Hotels, Xellum and Intuition Communication.
4 UNWTO Committee on Tourism Competitiveness, http://cf.cdn.unwto.org/sites/all/files/pdf/ctc_definitions_en_web.pdf and

http://marketintelligence.unwto.org/content/competitiveness-commitee-ctc.
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Introduction
1.2 Methodological approach
The field of health tourism is quite complex, constituted by different understandings and
classifications according to sectors, countries, companies and industry organizations. The study
therefore applies a detailed approach to data and information collection and analysis. The research
includes both primary and secondary data collection methods and considers both industry and
academic resources. One of the main objectives of this study was to produce a clearer and more
comprehensive taxonomy for health tourism and its related subsectors (e.g., wellness and medical
tourism). In order to achieve this, the following methods were used to collect data, information and
industry intelligence:
–– An extensive review of existing secondary literature was undertaken, including academic
papers, books, industry reports, specialized trade journals and case studies. This review
provided the framework for the PESTLE analysis, as well as a basis for suggested definitions
and for the market overview which was then supplemented and corroborated using primary
data.
–– In-depth interviews with a carefully selected range of experts from the spa, health,
wellness and tourism sectors (altogether 30 expert interviewees from 18 countries, plus
representatives of global associations, initiatives and companies). Interviewees were asked
to define key terms such as health, wellness and medical tourism and its connection to
tourism demand. They were also asked questions about policy, management, regulatory and
legal issues. A list of interviewees is presented in annex 1.
–– A word cloud survey methodology aimed at national tourism organizations (NTOs) and
industry representatives. The survey included 28 participants from 21 NTOs and 7 industry
representatives. Participants were given a number of different scenarios related to health
services used by tourists in different countries and were asked to categorize and comment
on the service and types of tourists. This made possible to assess how products, services,
packages and tourists can be typologized and the rationale behind it. A detailed description
of the methodology is available in annex 2 and annex 3.
In addition, several key social media platforms and sites in medical and wellness tourism were
analysed in order to illustrate key information searching patterns of users, patients and travellers.
The case studies and examples included in this study were chosen as examples of good practice
or to highlight interesting issues that exist at global, regional, national, destination and/or site level.
This includes case studies showing the growth of health tourism different types of health tourism
services; destination management; good practice in sustainable management; government policy,
regulation and legislation; innovations in technology; and uniqueness in health tourism products
and services. Occasionally, more than one case study or example has been given from the same
country to emphasize different issues in health tourism or to show developments at national,
as well as local level. Boxed examples and case studies are given from more than 25 countries
covering the different world regions. However, in addition to these, many shorter examples are
given throughout the study to illustrate the great diversity of health tourism developments that
exist around the world.
1.3 Study overview
The study begins by presenting the results of the so-called PESTLE analysis which identifies the
most relevant and influential changes and trends taking place in contemporary societies and their
influence on leisure and tourism. The PESTLE analysis includes the following factors: political,
economic, social, technological, legal and environmental.
Following the PESTLE, the study provides an overview of both existing and suggested definitions
based on the research findings. The taxonomy chapter oversees at the broader picture and the
relationship between wellbeing and health. The analysis culminates in a new set of recommended
definitions for each of the main forms and subsectors of health tourism (note: the words form
and sector were used for the supply side, and the word segment was used for the demand side
overview). This includes:
–– Health tourism;
–– Wellness tourism; and
–– Medical tourism.
It could be argued that holistic retreat, spiritual and spa tourism are also important subsectors,
but not all research respondents agree that such forms of tourism exist and should be included in
mainstream typologies. Definitions and taxonomy are devised based on the primary motivation of
tourists. Facility-based definitions, such as spa or retreat tourism are not recommended since in
other forms of tourism, e.g., in cultural tourism ‘museum’ tourism is not registered either.
The study introduces and discusses the nature of supply and demand for those forms of tourism
which are considered to be the most important. Not only international but domestic travel, as well
as complementary services related to health tourism were also included in the analysis:
–– Supply side:
–– Main forms of supply (medical, wellness); and
–– Types of facilities (hospitals/clinics, hotels/resort, spas, thermal baths, retreats).
–– Demand side:
–– Key motivations of health tourists;
–– Cultural and national differences in demand;
–– Major segments for health and consequently wellness and medical tourism; and
–– International flows in wellness and medical tourism (outbound and inbound countries).
Data collected mainly for the health tourism market chapter was closed in August 2018.
The last part of the study focuses on organizational, management and marketing aspects. Since
the scope of the study has an NTO and DMO perspective, the overview on management looks at
the following areas in particular:
–– Relevant policies (e.g., health, tourism, social);
–– Organizational structures (e.g., the ‘Kurdirektion’ concept, medical and wellness clusters
and destinations);
–– Management and marketing (communication) strategies and tactics at destination level; and
–– Monitoring and regulatory systems.
21
Introduction
A toolkit for health tourism development and management is included. This toolkit was created
to facilitate and direct the planning and management of activities by NTOs and DMOs should they
be interested in developing health tourism.
23
T
Chapter 2
Analysis of macro-environmental factors
This section provides an analysis of the different factors that are shaping (or are expected to
influence) the consumption and growth of health tourism related activities.
The emphasis is mainly on advanced economies, including most of Europe, North America,
Australia and New Zealand. It is however recognized that many citizens in other parts of the world
(e.g., the Middle East, Asia, Central and South America) also enjoy higher standards of living with
increased disposable income dedicated to health and travel. Since travelling for health purposes
plays an important role in several European countries, special attention was paid to information
and data relating to Europe and other factors that may affect European countries in particular.
It is often the case that people who are engaged in a healthy living style and leisure time are more
likely to be attracted by health tourism destinations such as spas, wellness hotels or retreats.
However, many people also become health tourists upon recommendations of doctors, in which
case their government provides financial support. In addition, they may be sent on a wellness
incentive trip or to experience occupational wellness activities by their employer. External factors
such as an economic recession may lead to an increased need for health and wellness-enhancing
trips, as a way to relieve stress and renew energy. This section explores the factors which
influence the propensity to engage in health tourism in the form of a PESTLE analysis, taking into
consideration political, economic, social, technological, and environmental factors.
Figure 2.1 PESTLE analysis
Political
Environmental Economic
PESTLE
Legal Socio-cultural
Technological
This information is mainly derived from secondary data sources but opinions from interviewees
about which factors they thought influence the market are also included. Many interviewees
mentioned the importance of legislation, such as regulations for practitioners and for various
drugs and treatments. Many believe that information and communication technologies (ICT)
and especially social media plays a major role, not just for information provision but also for
diminishing face-to-face contact (e.g., cyber-consultations, tele-education, second opinion on-
line). Governmental support and investments were considered to be some of the most important
factors.
Certain directives were also perceived as influential, especially those in medical tourism, like the
European Union (EU) Directive relating to cross-border mobility (i.e., patients travelling from one
country to another within the EU to receive treatments which may not be available in their own
country). Consumers were observed to become more educated not only about their health but
also on the numerous options available. The need to develop more sophisticated and competitive
destinations, facilities and treatments and to segment the market properly became more evident.
Since environmental factors tend to be interrelated and interdependent, factors were grouped
under the most fitting umbrella (i.e., it is understood that several factors could be listed under
more than one umbrella term).
2.1 Political factors
This section includes those factors which influence peoples’ propensity to engage in leisure and
tourism activities and the extent to which healthy living is becoming important in many societies
and countries. These trends are often supported by government initiatives and funding, as well as
by regional and international organizations. As mentioned earlier, the primary focus of this section
Analysis of macro-environmental factors 25
is on Europe and advanced economies, but some global examples are also given to illustrate
differences around the world.
Figure 2.2 Key factors in the political environment
Working and
leisure time
State Supported
incentives holidays
Political
environment
Cross-border
Healthcare
patient
systems
mobility
2.1.1 Working and leisure time
People in the developed world devote more time for leisure activities (e.g., travel, entertainment,
health care, personal wellbeing and compact health programmes), a trend which can support
healthy lifestyle motivations. Campaigns of raising awareness of healthy lifestyles are an important
political measure in several Organisation for Economic Co-operation and Development (OECD)
member countries (e.g., some governments are developing policies to decrease obesity).1
Furthermore, many governments started campaigns against obesity. Often these initiatives are
aimed at school-age children, with initiatives like changing the school environment and canteen
menus, as well as including health and lifestyle education in the curriculum.
Raising awareness in the corporate world supports the demand for wellness services in dailylife
and creates demand for the so-called lifestyle-based services (e.g., life coaching, healthy cooking).
This forecast has become a reality as research has shown that for each dollar spent on wellness
programs, large companies from the United States of America got back USD 3.27 in reduced
health costs, and USD 2.73 in costs connected to absenteeism.2 Up to 20% of spa and wellness
1 Organisation for Economic Co-operation and Development (2014b), Obesity Update (online), available at:
www.oecd.org/health/Obesity-Update-2014.pdf (26-07-2017).
2 Huffington, A. (2014), ‘Big Business Finally Learns That Wellness Is Good Business’, Huffingtonpost, 07-05-2014 (online),
available at: www.huffingtonpost.com/arianna-huffington/big-business-finally-lear_b_5559758.html (08-07-2017).
demand registered in wellness and spa operations (except day spas) comes from local customers,
which indicates the role of health-oriented demand during leisure time.3
2.1.2 Supported holidays
The concept of supported or co-funded holidays (or ‘social tourism’) often related to accessible
tourism, is a different form of travel aiming at least partially at the improvement of the health or
wellbeing of the beneficiary travellers. Different forms of state support can be seen in Europe:
holiday vouchers, specific accommodation or funds for disadvantaged social groups.4 In five
European countries (France, Hungary, Italy, Romania and one non-EU member, Switzerland),
systems based on holiday vouchers exist. Some 40% of the EU population, mostly due to financial
reasons, did not engage in tourism, which justifies the attempts made by governmental and non-
governmental organizations.5
The objective of the European Commission initiative called Calypso is to support social tourism,
mainly in low season, among seniors, young people, disabled people and families. There are
several special initiatives of Calypso. One of these is the so-called ‘social tourism opportunities
in wellness and leisure activities’ (SOWELL) with the objective of promoting wellness and leisure
tourism during off-peak seasons for young and senior travellers.6
Social tourism, as well as the growing popularity of national holiday voucher systems helps to
involve the less-mobile segments in health tourism, particularly those (often disabled and senior)
people who specifically need health tourism services. For example, thermal baths have been
one of the most popular destinations where beneficiaries could redeem their vouchers (e.g., in
Hungary or France). One study under the Calypso scheme indicated that visiting thermal baths/
hot springs is the second most popular motivation, especially for senior travellers.7
One of the final outputs of this project was an online platform designed for families and seniors
who are searching for travel options in Poland and Hungary. Another relevant initiatives the ‘Off to
Spas’ project. The main idea of the project was to create new, thermal water-related international
health tourism products (international balneology products) in spa towns of Central Europe that
could serve as a main attraction in order to bring seniors to these regions in the low tourism
seasons.8
3 The Tourism Observatory for Health, Wellness and Spa (2017), International Wellness, Spa & Travel Monitor 2017, TOHWS,
Budapest.
4 McCabe, S.; Minnaert, L. and Diekmann, A. (2012), Social Tourism in Europe: Theory and Practice Aspects of Tourism,
Channel View Publications, Ontario, Canada.
5 International Social Tourism Association (2016), The Right to Holidays: Reclaiming lost grounds (online), available at:
www.oits-isto.org/oits/files/resources/379.pdf (17-07-2017).
6 European Commission, DG Enterprise and Industry (2010b), Sowell. Social tourism opportunities in wellness and leisure
activities (online), available at: ec.europa.eu/docsroom/documents/7190/attachments/1/.../pdf. (18-06-2017).
7 Bodnár, D.; Zámbó, V. and Záray, S. (2014), Az OFF2013 magyar–lengyel európai uniós szociálturisztikai projekt eredményei
(online), available at: www.www.itthon.hu/documents/28123/10245587/02+OFF2013.pdf/db648213-cd10-4ee3-b80b-
9c3f0ee6adf2 (10-07-2017).
8 Off to Spas (2017), Hévíz: Hungary (online), available at: www.offtospas.eu (22-07-2017).
In addition, dedicated funds can be available for families and young people (or senior citizens).
There are numerous related bilateral agreements (e.g., between France, Spain and Portugal).
These funds have been in effect since 1999. Bilateral agreements aim at supporting low season
travel and social tourism, and can involve specialized health tourism service suppliers.9
It is important to highlight that according to the estimations, nearly one third of the EU population
will then be aged 65 or over in 206010. According to Eurostat, tourists aged 65 or over accounted
for more than 1 in 5 tourism nights for private purposes by EU residents aged 15 or over in 2014.
This figure was equal to this age group’s share of the population aged over 15 (22%). However,
when looking at the broader group of tourists aged 55 or over, the gap increased by 2%, as
people aged over 55 accounted for 39% of tourism nights for private purposes while their share
of the population aged over 15 was of 37%. Within the trips for personal purposes, no significant
differences were observed between the younger and older tourists regarding trips for leisure,
holidays and recreation or trips to visit relatives and friends. The category that included “other
private/personal purposes” was higher for senior travellers – this category included trips relating
to health treatment.11
The Calypso initiatives specifically support senior tourism, particularly disadvantaged seniors
such as people with disabilities and with financial constrains, and based on this programme the
European Commission launched in May 2012 a pilot phase for a “Senior Tourism Initiative”, to
define the framework conditions to enhance senior citizens to travel in Europe.12
2.1.3 Health care systems
The state of the national health care system (the ability to care for citizens) is a defining issue
in international (or domestic) health tourism. Political decisions are often necessary to decide
which part of the health care sector can be opened for tourists. These may be foreign tourists but
they could also be domestic tourists depending on distance travelled and whether they have to
stay overnight (e.g., travelling for a specific doctor or treatment not available elsewhere in their
country).
Medical tourism is particularly driven by the problems of over-burdened health care and state
insurance systems including waiting times for surgery. Recent studies show that health spending
has generally increased and now accounts for about 9% of GDP on average in OECD countries,
inequities and inefficiencies in health systems should be addressed. It is also noted that there is a
need to create a proper balance between spending on disease prevention and treatment.13
9 European Commission, DG Enterprise and Industry (2010a), Calypso Study, Final Report (online), available at:
www.ec.europa.eu/commission/index_en (16-06-2017).
10 European Commission (2012a), Ageing report: Europe needs to prepare for growing older (online), available at:
http://ec.europa.eu/economy_finance/articles/structural_reforms/2012-05-15_ageing_report_en.htm (16-06-2017).
11 Eurostat (2016), Senior tourists make longer trips, preferably in their country of residence and staying at non-rented
accommodation (online), available at:
http://ec.europa.eu/eurostat/statistics-explained/index.php/Tourism_trends_and_ageing (18-06-2017).
12 European Commission (2013b), Europe – the Best Destination for Seniors (online), available at:
www.accessibletourism.org/?i=enat.en.forums.1513 (21-06-2017).
13 Organisation for Economic Co-operation and Development (2015a), Health at a Glance 2015: OECD Indicators (online),
available at: www.apps.who.int/medicinedocs/documents/s22177en/s22177en.pdf (25-07-2017).
Figure 2.3 Health spending changes (real terms), 2001–2013
4
3
OECD
(EU)
2
1 OECD
OECD
0
(non-EU)
-1
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Source: Organisation for Economic Co-operation and Development (2015b), Slow growth in health spending but Europe lags behind (online), available at:
www.oecd.org/health/slow-growth-in-health-spending-but-europe-lags-behind.htm.
The so-called ‘new health economy’ can be described as ‘plug-and-play health ecosystem’. The
health industry is considered as a closed and highly siloed system. It is suggested that powerful
global forces are transforming the industry into a nimble, innovative and modular ecosystem serving
the consumer, with profound implications for players both new and traditional.14 Such suggested
developments in health care would certainly change how health and health care provision is
perceived. The proposed model would take into consideration care delivery, diagnostics and
therapeutics, financing, payment and regulation, as well as wellness services. The connection
and facilitation of these four domains would need to be supported by government and employers.
Another important issue is health insurance. By 2013 in most OECD countries the cover reached
up to 100%, except the United States of America, Chile and Greece being under 90%.15 In the
United States of America, 95% of the country’s population was covered by the health insurance
system under the Patient Protection and Affordable Care Act (PPACA) between 2014 and 2017.
International patient flow, apart from the faster availability of services, is also fuelled by the
different pricing, as well as the approval systems of medical interventions. International medical
tourists often seek such treatments (e.g., in vitro fertilisation (IVF) or stem cell treatments) abroad
that are not approved by their health authorities at home. It must be highlighted that the quality of
medical services, along with price is one of the key factors driving medical tourism, especially in
terms of patient care, equipment, technology, and of course, excellent doctors.
14 PriceWaterhouseCoopers (2015), The New Health Economy (online), available at: www.pwc.com/us/en/health-industries/
assets/pwc-health-research-institute-the-coming-plug-and-play-health-ecosystem-essay-dec-2015.pdf (22-06-2017).
15 Organisation for Economic Co-operation and Development (2015a).

2.1.4 State support and incentives
Several countries have made a political decision with regard to providing state support for one
or more forms of health tourism. This support can be available either for domestic and/or foreign
trips aiming primarily at medical treatments. Many governments have started to promote their
comparative advantage as medical tourism destinations at large international trade fairs, via
advertising through the foreign media, and official support for activities as part of their economic
development and tourism policy. Bilateral agreements provide a basis for international medical
tourism flow, such as post-traumatic treatments for war veterans (e.g., United States soldiers to
Germany) or for African patients to Dubai, Jordan or Malaysia.
Mainly Asian governments, as well as Turkey, focus on medical tourism with the provision of
building infrastructure, legislative support (e.g., a special visa for medical tourists) and focused
image campaigns.
Example 2.1 State support of health tourism in Malaysia
Malaysia is committed to becoming a leading health tourism destination in Asia. The Malaysia Healthcare Travel Council (MHTC),
an initiative by the Ministry of Health of Malaysia, has opened offices to promote medical facilities in Bangladesh and Indonesia,
and soon in Hong Kong, China. The number of health travellers to Malaysia has grown from 643,000 to 921,000. The bulk of the
travellers that visit Malaysia seeking health treatments are from Indonesia, India, China, Japan, the United Kingdom, Australia and
Middle Eastern countries. Overall, the industry is growing at an average rate of 12% to 14% every year, generating an expected
MYR 1.3 billion revenue in 2017. Besides the direct revenues from health travellers, the travel spending creates sizeable multiplier
effects from non-medical expenditures such as hospitality services, tourism activities, and logistics.
Source: Malaysia Healthcare Travel Council (2018), Healthcare Travel in Malaysia Setting the Standard (online), available at:
www.mhtc.org.my/media-centre/ (24-04-2018).
Governmental bodies consider information provision a key factor in the health tourism market.
Governmental bodies attempt to give proper and transparent information about treatments,
success and failure factors. One example is the Techniker Krankenkasse (TK), a German Insurance
Institution, which includes information about inpatient and outpatient care (diagnostic codes,
costs, length of stay, dates and physician codes), information about prescriptions and medical
devices, and information about patient satisfaction.
International or cross-border patient mobility is an increasingly important topic The Directive

2011/24/EU on patients’ rights in cross-border health care “clarifies that patients are entitled to
seek health care abroad, including for planned care, and be reimbursed for it, in principle without
having to seek prior authorisation. […] Not all health care is automatically reimbursed. […] what
will be reimbursed and at what level is entirely the decision of Member states. In principle, patients
are entitled to receive reimbursement for the same or similar health care, for the same amount that
would have been given in the home Member States”16.
16 European Patients Forum (EPF) (2011), EU Directive 2011/24/EU on the application of patients’ rights in cross-border
health care: Legislation Guidance for Patient Organisations (online), available at: www.eu-patient.eu/globalassets/policy/
cross-borderhealth care/2013-11-18_cbhc_guidance-final.pdf (27-06-2017).
EU Member States had time until 25 October 2013 to pass their own implementation of the
Directive. The Directive was a long-awaited step, there was a lot of debate around it, and there were
several countries in delay with the implementation.17 Although there are several forecasts saying
that the Directive will boost EU medical tourism, Tonio Borg, the former European Commissioner
for health said: “[The Commission expects that] only 1% of EU citizens will use this, because
people prefer to get health care in their own country, surrounded by friends and family”18. The
Directive, however, was expected to boost medical tourism from EU Member States. Actual data
may prove otherwise. The first report from the European Commission on the application of the
directive states that patient flows for health care abroad under the Directive are low.19 Twenty
Member States reported data on reimbursement made exclusively under the Directive. For these,
a total of 39,826 reimbursements were made, of which 31,032 were reported by Denmark alone.
Only four of these Member States reported more than 1,000 reimbursements, and eight Member
States had made fewer than 100 reimbursements and six had made no reimbursements at all. This
seems to be due to low numbers of claims rather than large numbers of refusals: the available data
suggests that roughly 85% of reimbursement claims are granted.20
Other initiatives include encouraging physicians to provide appropriate counselling for at-risk
patients, strengthening food labelling and advertising regulations, and fiscal measures to tax
unhealthy foods and reduce taxes on healthy foods. In relation to health, it is important to refer to
the attempts and regulations of several OECD countries that have achieved remarkable progress
in reducing tobacco consumption over the past few decades.21
2.2 Economic factors
The global economic and financial crisis, although it started almost ten years ago, caused
several permanent changes, which had an impact on the health tourism market both directly and
indirectly. Other factors, such as social or technological changes and trends also have certain
economic or business aspects that shall be considered.
17 European Voice (2013), Member states fall behind on cross border healthcare rules (online), available at:
www.politico.eu/article/member-states-fall-behind-on-cross-border-healthcare-rules/ (19-06-2017).
18 European Voice (2013).
19 European Commission, Cross-border healthcare, https://ec.europa.eu/health/cross_border_care/overview_en.
20 European Parliament (2015), Commission Report on the operation of Directive 2011/24/EU on the application of patients’
rights in cross-border healthcare (online), COM(2015) 421 final, European Parliament (online), available at:
eur-lex.europa.eu/legal-content/EN/TXT/?uri=celex:52015DC0421 (11-04-2018).
21 Organisation for Economic Co-operation and Development (2013b), Health at a Glance 2013: OECD Indicators (online),
available at: www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf (19-07-2017).
Figure 2.4 Key factors in the economic environment
Public
expenditure on
health care
Workplace Lifestyle
wellness changes
Economic
environment
Brain-drain Investments
One of the economic challenges is the decreasing public expenditure on health care. The growth
in health spending has slowed in most OECD countries since 2008. Total health spending fell in
11 out of the 34 OECD countries between 2009 and 2011, compared to pre-crisis levels. Countries
that were hit hardest by the economic crisis have witnessed the biggest cuts in health expenditure.
Although health expenditure represents as much as 10% in some OECD countries, there is still a
need to improve the efficiency of health care systems.22
The economic crisis has also had impacts on the ways in which people live their everyday life.
A shift towards less healthy behaviours, e.g., less healthy dietary habits, was noticeable after the
economic crisis had commenced.23
Globalization, affordable international air travel and increased price sensitivity resulted in the
so-called ‘reverse movement of health travellers’ (i.e., from east to west or from developing
to developed countries). Until a few years ago, both medical and wellness tourists from
advanced economies tended to visit emerging and developing ones. However, price is still a
major consideration for the majority of international health tourists. Hotel spas and spa hotels
are particularly affected by the bargain-hunter of international travel. Coupons or other discount
sites have also become popular even for the luxury segment. Patients or wealthy health tourists
have been looking for high quality services which lack supply in their home countries. Central and
South Americans visit the United States of America, wealthy citizens from the Commonwealth of
Independent States (CIS) (especially from Central Asia) visit the Republic of Korea, Switzerland,
Germany or the United Kingdom for medical treatments or more frequently luxury wellness and
22 Organisation for Economic Co-operation and Development (2015a).
23 Foscolou, A. et al. (2017), ‘The Impact of the Financial Crisis on Lifestyle Health Determinants Among Older Adults Living in
the Mediterranean Region: The Multinational MEDIS Study (2005–2015)’, Journal of Preventive Medicine & Public Health,
50 (1), pp. 1–9 (online), available at: www.jpmph.org/journal/view.php?number=1895 (19-06-2017).
spa services. The global nature of financial markets fuel rapid developments. Hotel brands with
spa facilities and specialized spa brands are opening all over the world. Medical or health care
cities are being built in several countries in Central and South America, in Turkey, in the Middle
East and in South-East Asia.
The hospitality industry is now demanding greater transparency and better performance
information to aid analysis of the operations. They need to triangulate their performance
measuring approaches and tools to achieve a more fitting solution that can furnish them with
more accountable data and information.24
Increasing investments (often as foreign direct investments, FDI) are taking place in medical
tourism as well, mainly investing in technology and know-how. The relaxation of restrictions on
foreign ownership in many emerging-market economies has channelled FDI into health care
sectors. This has helped to finance the building and running of modern hospitals. Destinations
such as Turkey, Malaysia, Dubai or Abu Dhabi invested heavily in improving their supply and
competitiveness.25
The concept of ‘brain drain’, i.e., departure of skilled and qualified personnel to a third country,
is quite common especially in the medical tourism industry. This means that good medical
practitioners choose to work in another country, in a different region of their country, or even cross
over into the private medical tourism sector from the public local one. One of the key branding
and patient safety messages used in hospitals and clinics is assuring that their professionals are
trained in developed countries. On the other hand, they often have to offer them incentives to
return home.
Dubai, which is not only a destination for medical tourists, but also for health care professionals,
announced plans to establish three new medical colleges and five nursing schools over the next
ten years.26
The treatment of chronic diseases (e.g., cardiovascular disease, cancer, respiratory diseases and
diabetes) puts burdens on national economies. Stress is also a major cause of health problems.
Workplace wellness (or corporate wellness or workplace health promotion) which originated back
in the 1970s can partly help to solve these problems, for example, through stress management
or life coaching programmes: “The workplace is an important location for successful prevention
strategies because employees today spend a growing amount of time at work and employers can
influence behaviour by providing a supportive environment and leveraging existing infrastructure
to offer low-cost but effective interventions”, according to the World Economic Forum.27
24 Puczkó, L. (2016), ‘Owners Demand More Accountability in Wellness/Spa Investments and Operations’, Hotel Executive,
10-07-2016 (online), available at: www.hotelexecutive.com/business_review/4806/owners-demand-more-accountability-in-
wellnessspa-investments-and-operations (19-06-2017).
25 Economist Intelligence Unit (2011), Travelling for health. The potential for medical tourism (online), available at:
www.pages.eiu.com/rs/eiu2/images/Travelling_for_health_Executive_summary.pdf (26-06-2017).
26 Kadrie, M. (2015), ‘Health care education is a lifeline for the national economy’, The National, 13-06-2015 (online), available
at: www.thenational.ae/business/economy/health-care-education-is-a-lifeline-for-the-national-economy (19-06-2017).
27 World Economic Forum (2013), The Workplace Wellness Alliance. Making the Right Investment: Employee Health and the
Power of Metrics (online), available at: www3.weforum.org/docs/WEF_HE_WorkplaceWellnessAlliance_Report_2013.pdf.
The question is to figure out how many of these workplace wellness programmes may or could
incorporate a travel component. Most of the programmes, so far, provide services either at the
workplace or in the country of residence of the employee. Companies and organizations, however,
start to explore how to develop and offer wellness programmes especially for top managers that
involve some travel, even long haul. The question remains how to separate luxury trips used as
incentives from wellness-oriented trips.
2.3 Socio-cultural factors
The health status of the traveller is not a straightforward factor among the drivers of health
tourism. The longer life expectancy, along with the higher discretional income of the elderly in
the western world created a new concept, i.e., active or fit ageing and longevity. Life expectancy
at birth continues to increase in EU countries, rising on average by 3 months each year.28 All
OECD countries have seen life expectancy at birth increase by over ten years since 1970 to
reach an average of 80.6 years.29 On the other hand, the so-called social diseases created a huge
need for different approaches (e.g., to address modern diseases such as nature deficit disorder,
technology addiction or increasing loneliness), and for prevention measures. In Asian societies,
the rapid ageing of large segments has already created issues that require governmental actions,
as well as social changes.
Figure 2.5 Key factors in the socio-cultural environment
Life
expectancy
Urbanization Ageing
Healthy diet Socio-cultural Wellbeing

and lifestyle environment initiatives
Living with Work-life

disabilities balance
Chronic
diseases and
obesity
28 Organisation for Economic Co-operation and Development (2016), Health at a Glance: Europe 2016, State of Health in the
EU Cycle (online), available at: www.oecd.org/health/health-at-a-glance-europe-23056088.htm (20-07-2017).
29 Organisation for Economic Co-operation and Development (2017), Health at a Glance 2017 (online), available at:
www.oecd.org/health/health-systems/health-at-a-glance-19991312.htm (18-07-2017).
Ageing populations and the ‘long-term care’ (LTC) expenditure (both health and social care) put
a great burden on governments. A significant share of LTC services is funded from public sources.
Governments, particularly in Asia support the establishment of retirement villages (e.g., My
Second Home Malaysia) for foreign citizens. Since they are based on a specific age group (over
55 or over 60) these developments will require special investments for LTC facilities. The increasing
retirement migration can mean increasing demand on health care services, as well as for medical
and wellness services. Retirement communities operate as mixed-use resorts or cities. Some
residents move there indefinitely, whereas some commute to and from their permanent homes.
Moreover, these communities are planned in such a fashion that residents can accommodate their
relatives and friends as well (like in the case of holiday apartments or second homes).
However, global data still shows that 50% of the world’s population is younger than 30 years of age
(over 4 billion people).30 In particular Africa, the Middle East and South America have an important
young population. This can lead to global travel with huge contrasts. In a few years, there may be
an even faster growth in family or child-orientated facilities (e.g., spas), or the younger consumers
(e.g., Generation Z). The above mentioned will depend of course on the economic status and
spending power of those countries with such young populations; however the middle and upper
classes of the BRIC countries are increasingly travelling to international destinations and will most
likely become the lead tourists of the future. For example, traditional healing practices are popular
in South America, whereas thermal/hot spring based treatments (primarily medical) are well known
and sought by tourists from CIS countries.
Social policies, as well as public and private initiatives aiming at the improvement of the general
wellbeing of citizens also support travelling for health. OECD member countries have made
considerable progress in many wellbeing areas over the past 20 years or so, including subjective
wellbeing and work-life balance.31
Work-life balance and emotional wellbeing failure can easily be connected to chronic diseases,
and lifestyle or social illnesses. The treatment and especially the prevention of these illnesses
would require lifestyle changes, and the provision of supporting wellness services. Large hotel
chains (e.g., InterContinental, Fairmont or Starwood) have already considered changes in their
service offering (e.g., healthier food options, jogging concierge or rentable gym gear) contributing
to a better work-life balance. These concepts, as well as service improvements are for the more
healthy-minded guests but not specifically for wellness or medical tourists. In some countries,
there appears to be a national trend towards encouraging the population to engage in preventative
wellbeing or wellness activities. These initiatives may come from governments, the health sector
or even from the spa industry as the case study of the Netherlands shows.
30 United Nations (2017), World Population by Age Groups, United Nations Department of Economic and Social Affairs,
Population Division (online), available at: www.population.un.org/ProfilesOfAgeing2017/index.html (27-06-2017).
31 Organisation for Economic Co-operation and Development (2017).

Example 2.2 The Growth of preventative wellness in the Netherlands
Preventive wellness has been growing in the Netherlands over the years.a Yoga has become a lifestyle product in the Netherlands.b
There are approximately 60 large wellness centres, hot baths and saunas. The demand for preventive wellness and its provision in
wellness centres is changing. A holistic lifestyle, in which movement, diet and relaxation are the focus is growing, but still a
comparatevely modest number of people is consciously involved. Yet, some companies are seeking to take advantage by
developing innovative preventive wellness concepts within Dutch wellness centres.c There is also a new and unique initiative in the
province of Zeeland which consists in developing a so-called ‘health region’. This includes health promotion aimed at residents
and the development of health tourism at the same time.d
a) Kruizinga, P. (2013), ‘Heritage and the renaissance of Domburg as a health resort’, in: Smith, M.K. and Puczkó, L. (eds.), Health, Tourism and
Hospitality: Spas, Wellness and Medical Travel, Routledge, London, pp. 379–382.
b) Gerritsma, R. (2008), ‘The Growing Yoga Community in the Netherlands How Yoga is becoming a Lifestyle Product including Tourism Activities’, in:
Smith, M.K. and Puczkó, L. (eds.), Health and Wellness Tourism, Butterworth Heinemann, Oxford, pp. 361–365.
c) Vork, J. and Lombarts, A. (2013), ‘Research on preventive wellness in the Netherlands’, in: Smith, M.K. and Puczkó, L. (eds.), Health, Tourism and
Hospitality: Spas, Wellness and Medical Travel, Routledge, London, pp. 435–442.
d) Kruizinga, P. (2016), ‘Health tourism and health promotion at the coast’, in: Smith, M.K. and Puczkó, L. (eds.), Routledge Handbook of Health
Tourism, Routledge, London, pp. 386–398.
Chronic diseases cause around three-quarters of all deaths in OECD countries. Many of these
diseases are preventable, since they are linked to modifiable lifestyles. While smoking rates
continue to decline, obesity rates have been increasing in recent decades in almost all OECD
countries, with an average of 54% people overweight, of which 19% are obese. Obesity rates
are considerably higher than the OECD average in five countries, with rates highest in the United
States and Mexico. Obesity is lowest in Japan, the Republic of Korea, Italy and Switzerland.32
Based on OECD data the growth in pharmaceutical spending slowed down in many OECD
countries in recent years. However, for many categories of pharmaceutical drugs, the quantities
consumed continue to increase, partly driven by growing demand for drugs that treat ageing-
related issues and chronic diseases.
All of these diseases could be prevented, and due to the growing need and popularity of healthy
(or at least healthier) lifestyles, as well as the support from governmental campaigns, prevention is
an important topic in everyday life and it is becoming strongly health motivated. Complementary
and alternative medicines (CAM) are enjoying increasing popularity, though there is a lack of
clinical evidence in some cases.
Health can be an important travel motivation for people with disabilities. Taking part in therapies
(e.g., balneo- and physio therapies), connecting with people living with similar conditions or
without, and the feeling of being on holiday can support their physical and mental health. The
World Health Organization reported over one billion people with disabilities in the world in 2011,
or 15% of the total population.33 International and even domestic travel can be a real challenge
for this segment; however their health status and search for solutions can also create significant
33 World Tourism Organization (2016), Manual on Accessible Tourism for All: Principles, Tools and Best Practices.
Module I: Accessible Tourism – Definition and Context (online), available at:
http://ethics.unwto.org/content/accessible-tourism (23-06-2017).
demand (both domestic and international) for health improving services and care. The segment
will become wider due to the ageing population. Wellness and medical facilities can become more
welcoming to this segment of the population, with improved planning, design, segmentation, and
targeting.
The consumption of healthy (or at least healthier) food is not a very new phenomenon. The
‘better-for-you’ (BFY) concept refers to products where the amount of unhealthy substances has
been actively reduced or removed during production (i.e., fats, sugars, salt and carbohydrates).
Besides healthy food, organic foods are also widely popular, mainly for the health-conscious
segment, and for those who care about the natural environment. The need for healthy and organic
food is likely to grow in tourism facilities all across the industry. Destination spas in particular are
known to be paying special attention to eating and nutrition.
Urbanization is a major challenge for public health. More than half of the world’s population are
now living in urban areas, a proportion that is expected to increase to 68% by 2050, according to
the United Nations Department of Economic and Social Affairs. However, city living also provides
great potential for better work, education, social, cultural and other opportunities. On the other
hand, urban regions offer so-called ‘urban penalty’, which include stress, noise, congestion, bad
air; as a result the deprived social groups have a higher rate of child mortality, die younger and
suffer from more diseases than their more affluent neighbours.34 Urban living associated health
conditions and diseases will also lead to the growing need and demand for healthier alternatives
and healthier trips. Residents have an increasing wish for escaping into nature areas, and prevent
or cure the ‘urban penalty’ in healthy touristic facilities.35
Celebrity culture has major impacts on health in behalf of the widespread media and social
media promoting it. Celebrities such as actresses, pop stars and models are often very focused
on their looks (i.e., beauty and body) which can contribute to the increase in cosmetic surgery
tourism (“me too” syndrome). There is an increasing willingness to travel for surgery which can
be attributed to the growth and acceptability of cosmetic or dental surgery in many societies.
In the last fifteen to twenty years, cosmetic surgery has gone from being the preserve of the rich
and famous to becoming acceptable and accessible to a much wider range within the different
socio-economic groups. The lifestyle of celebrities and sportsmen, however, can also contribute
to healthier living (e.g., through celebrity blogs or product endorsement).
2.4 Technological factors
The rapid technological developments have certainly been important factors in the growth of
health-motivated travel. The faster and less invasive nature of non- or minimal invasive technology
in beauty and medical treatments, for example, have become key attractions for medical tourists.
Laparoscopic surgical procedures are the cutting edge of medical technology in the 21st century.
These less invasive surgical techniques and procedures using laparoscopic surgery enable
patients to heal faster, reduce the risk of infection, and cause less tissue damage and resulting
34 World Health Organization (2010), WHO global forum: mayors and national leaders to address urban health, develop action
plan (online), available at: www.who.int/mediacentre/news/releases/2010/cityhealth_20101115/en/index.html (21-07-2017).
35 World Health Organization (2016), Global Report on Urban Health (online), available at:
www.who.int/kobe_centre/measuring/urban-global-report/en (27-06-2017).
complications. Laparoscopic surgery is also known as keyhole surgery or minimally invasive

surgery (MIS). Since these modern approaches may not be available in every country or for
every insured person, a certain part of international medical travel is driven by this technological
invention. These new surgical approaches are often linked to a certain physician or consultant,
who can become the reason behind an international medical trip.
Figure 2.6 Key factors in the technological environment

Non-
or minimal
invasive
technology
Traditional
approaches
Wearables and new
technology
Technological
combined
environment
Information
M-, E-,V- and and
tele-health communication
technology
(ICT)
Technological innovation helped Republic of Korea to become one of the leaders in medical
tourism as the case study of Republic of Korea shows.
Example 2.3 Combining traditions and new technology in the Republic of Korea
The Republic of Korea has many pioneering techniques in medical tourism, as well as a growing trend in marine medical tourism
(thalassotherapy), in addition to the thermal bath traditions. The Republic of Korea is rich in thermal springs with an own facility
and tradition known as the jimjilbang. In these bathing complexes guests can bathe, have a massage but also rest and sleep as
long as they wish in a common resting room. The country has also started developing medical tourism opportunities based on their
healing traditions (Traditional Korean medicine). The Korean Government together with leading industry representatives (e.g., LG
and Samsung) have been working hard to develop the medical tourism supply in the country (with several centres in Seoul,
Daejeon or Jeju), partially building on the large Korean population in the West Coast of the United States of America who come
home for treatments. Medical tourism became one of the key industries fostered by Korean authorities, further to a change in
legislation back in 2009. The law established a ‘medical visa’ and permitted hospitals to treat foreign patients. Medical Korea is
the specialized agency of the Korea Health Industry Development Institute (KHIDI), which provides marketing services to health
care providers, such as industry events and fairs, information services for patients (e.g., medical call center) and support to
medical care providers and facilitators.a The Republic of Korea has medical tourism clusters in Daejeon and Jeju. Wellness resorts
have developed such as the Helience Zen Town, focused on improving lifestyle habits towards greater longevity.
a) Visit Medical Korea (online), available at: www.english.visitmedicalkorea.com/english/pt/index.do (20-06-2017).

Technology also plays an important role in the beauty and wellness segment. New and effective
treatments can take place replacing old treatments or even surgery (e.g., body shape technology,
fractional therapy skin rejuvenation, permanent laser hair removal). High-tech beauty and wellness
treatments (such as snow shower from KLAFS – a company specializing in saunas and spas, or
the Gharieni products) will increasingly spread in spas, wellness centres creating new treatment
options and leisure experiences for spa guests.
Information and communication technology (ICT) developments and solutions have probably
the most significant impacts on health (e.g., Internet bookings, smart phone applications).
The need for widespread online access to accurate, relevant information on diseases and
therapies, as well as to personal health data, is essential. The so-called ‘big data’ analytics in
health care is expected to change how health care providers, researchers and insurers look at
health data. The health care sector traditionally collects and stores a large amount of data. The
digitalization of existing data and the digital management of recent data allow for better and
more efficient clinical decision support, disease surveillance, or population health management.
Big data-based, or Internet of things (IoT) and therefore improved prevention or treatment plans
can be beneficial for medical, as well as wellness tourism providers and guests alike. However,
with IT development new challenges arise, including cybersecurity and data protection issues.
Nowadays mobile applications are crucial: There are now around 165,000 health-related
applications which run on one or other of the two main smartphone operating systems, Apple’s
iOS and Google’s Android36 and smart watches and other mobile and personal technology
(e.g., wearables or hearables) have already had a major impact on health-related information and
awareness (e.g., the 10,000 steps per day recommendation became more widely recognized,
although not necessarily directly justified).
Price Waterhouse Cooper named health care as one of the top-3 biggest mobile trends for
2016.37 Social media seems to be more and more influential. 42% of consumers have used
social media to access health-related consumer reviews (e.g., of treatments or physicians).
At least 30% have supported a health cause, 25% have posted about their health experience,
and 20% have joined a health forum or community. Interestingly, however, review sites are rare
in medical tourism.38 Due to legal and liability issues, only a handful of sites provide (or permit)
on-line moderated patient reviews. There are specialized portals (e.g., Treatment Abroad, Patients
Beyond Borders, PlacidWay, medicaltourism.review or Yelp) that share useful information for
Internet surfers interested in medical services with specific tips: highlighting risks, disadvantages
of destinations, processes, providing information with a focus on values and advantages. The
wellness-orientated sites provide inspirations for healthy lifestyle in various forms: tips, articles,
mottos or experiences. They provide useful information about service suppliers and allow sharing
reviews and rankings, which are much more popular than those in medical tourism. This can be
36 The Economist (2016), Things are looking app (online), available at:
www.economist.com/business/2016/03/10/things-are-looking-app (18-06-2017).
37 PriceWaterhouseCoopers (2016), Mobile will be a top health industry trend in 2016 (online), available at:
www.economist.com/business/2016/03/10/things-are-looking-app (20-06-2017).
38 Health Research Institute (2012), Social media ‘likes’ healthcare: From marketing to social business, PwC (online),
available at: www.pwc.com/us/en/health-industries/health-research-institute/publications/health-care-social-media.html
(07-07-2017).
explained by the fact that wellness tourism is a more open, much less private experience than that
of medical tourism (and liabilities are much less expensive).
Applications can positively contribute to health-oriented travel. Service providers can use their
own applications for being permanently linked to their guests or patients. Alternatively they can
collect daily, real-time information from the status of their prospective guests or patients based
on which treatment programme can be the most accurately personalised by the time of arrival.
In addition, eHealth and tele-health solutions can improve trust between guest/patient and the
health facility, improving patient safety (and the perception of it). M-health (or mobile-health) is
also growing as the following box shows. According to the Institute for health care informatics
(IMS), mHealth is defined as ‘medical and public health practice supported by mobile devices
such as mobile phones, patient monitoring devices, personal digital assistants, and other wireless
devices’. In comparing the number of m-health applications available on the iOS platform,
the number of health and wellness applications increased over 100% from 2013 to 2015 to
reach 90,088.39 The mobile health care market is projected to reach USD 58.8 billion by 2020.40
Example 2.4 The m-health market
Portable blood-pressure monitors have been around for some time, but the idea of linking a tiny, wearable to a smartphone and
then to a software application is an example of how entrepreneurs are harnessing wireless technology to create innovative
services. By letting doctors and carers monitor patients remotely, and by making it simpler to collect vast amounts of data on the
effectiveness of treatments, the mobile-health stry, or m-health as it has become known, aims to drive down costs while improving
results for patients. The m-health market can be broken down into two broad categories. Firstly, there are the applications and
appliances used to monitor the wearer’s physical fitness. Secondly, other applications and devices link patients with a medical
condition to the health care system. Google said it was working on a contact lens containing a tiny wireless chip and sensors that
would measure and transmit the glucose levels in a diabetic patient’s tears. In December 2013, Apple was granted an American
patent on a means to incorporate a heartbeat sensor into its devices. The goal is to save money while improving health.
Source: The Economist (2014), Health and happiness (online), available at: www. economist.com/news/business/21595461-those-pouring-money-
health-related-mobile-gadgets-and-apps-believe-they-can-work (22-06-2017).
Online platforms provide opportunities to match supply and demand creating an excellent option
for the wellness and medical travel industry. In medical tourism, however, there are specialized
agents or facilitators that operate as tour operators with specific knowledge and skills in medical
services. These facilitators provide individual solutions and packages for patients and they are
responsible for the patient flow and experience not only in the destination country, but also in
getting to and from the destination. Facilitators use online platforms through which the patient can
meet his or her physician and agree to the terms and budget of the treatment plan. Facilitators
organize local transportation, accommodation and other services just like tour operators, and
knowing at the same time the steps and possible unexpected changes of the treatment plan.
39 IMS Institute for healthcare informatics (2015), Patient Adoption of mHealth (online), available at:
http://moodle.univ-lille2.fr/pluginfile.php/215343/mod_resource/content/0/IIHI_Patient_Adoption_of_mHealth.pdf
(03-05-2018).
40 Allied Market Research (2013), mHealth market is Expected to Reach $58.8 Billion Globally by 2020 (online), available at:
www.alliedmarketresearch.com/press-release/mhealth-market-is-expected-to-reach-588-billion-globally-by-2020.html
(03-05-18).
So-called ‘wearables’, i.e., gadgets that can collect and monitor key biological functions of the
body may re-define health and lifestyle. This includes not only smart watches but also other
wearable technology (e.g., smart clothing with sensors collecting information permanently). This
data can provide health and biophysical information data (either realtime or as regular data dispatch)
not only to the owner, but also medical professionals, wellness or spa personnel. Professionals
can therefore indicate symptoms or dysfunction or can overview rehabilitation processes. Service
providers can tailor-make treatment plans and wellness programmes based on the information
shared prior to the visit. Corporate wellness programmes can also capitalize on such information
and data, however health data is expected to remain confidential.
Technological achievements are not, however, always without negative consequences as FOMO
and JOMO represent hyper-experiential involvement (FOMO: fear of missing out; and JOMO: joy
of missing out). There is an accentuated trend of being hyper-connected. However, many people
have realized that being ‘disconnected’ (sometimes referred to as ‘digital detox’ in the wellness
industry) has significant benefits. This situation has become so extreme that behavioural health
hospitals have included the treatment of technology addictions.
2.5 Natural factors
Environmental or sustainability issues are crucial for the competitiveness of the tourism sector,
as it largely influences the development of medical or wellness tourism.
Figure 2.7 Key Factors in the natural environment
Responsible
use and
sustainability
Natural Climate
Water
environment change
Nature as a
source of
healing
UNWTO defines sustainable tourism as “tourism that takes full account of its current and future
economic, social and environmental impacts, addressing the needs of visitors, the industry, the
environment and host communities”41.
The effects of climate change on nature, society and economy may include various impacts,
such as damage caused by storms or by fires in wild forests; extinction of species and land loss
due to sea level rising; impact on natural water resources, food supplies, human health, and
energy costs. The most important effects of global warming include significant coastal erosion, an
increased frequency of extreme weather events (such as prolonged droughts or sudden floods), a
reduction of rainfall (between 30 and 40%), and an increase in the average temperature.42 Climate
change can have a very direct influence on all those sites and services based on natural (healing)
resources (e.g., microclimate, thermal springs, mud or peloid). In addition, the most popular spa
resorts are often located in the seaside, facing risks of being threatened the rising sea level.
Water, especially having access to safe drinking water will become a critical issue globally.
The anticipated rise of the world’s oceans will not only have an impact on the growing urban
population in coastal metropolises but also on the availability of obtaining fresh water sources.
Not independent from such global challenges, medical, as well as wellness operators also need
to pay more attention to their water usage. Rising sea level may have a direct impact on thalasso
facilities (being the closest to the coast) likewise on thermal or mineral water springs due to saline
water’s ability to infiltrate in these water bodies.
Medical and wellness tourism accommodation facilities and baths (using natural spring water)
operate several pools, and other wet areas consuming large amount of water. As an industry
standard, there is a tendency for higher standard accommodations to consume significantly higher
water volumes. Water-intensive facilities typically have landscaped grounds requiring prolonged
irrigation. Higher laundry volumes per guest per day as a result of sport and health centres, and
textile quality and/or heavy weight laundry items, including large towels at spa facilities represent
high water consumption.43 The water usage of a 5-star resort with a thermal (hot spring) spa can
reach 500 litres/day per person.
There are several industry initiatives addressing these issues, such as the Green Spa Network or
the benchmarking and operation guides for energy saving Smart Water Fund by the Australian Spa
Association, or Energy-benchmark for wellness hotels by Cluster Wellness Tyrol44, and eco-spa
certification (e.g., Ecocert).
The European Union has several initiatives for the green movement, e.g., DestiNet (Knowledge
Networking Portal for Sustainable and Responsible Tourism) and Ecotrans (European Network
for Sustainable Tourism Development), and so does UNWTO: the year 2017 was declared as
41 World Tourism Organization (n.d./a), Definition of Sustainable Tourism (online), available at:
http://sdt.unwto.org/content/about-us-5 (12-06-2017).
42 Breda, Z. et al. (2010), ‘Climate change impact on seaside tourism – Portugal and Romania: Two different case studies with
strong particularities’, Revista Economicǎ, 54, pp. 113–135.
43 Gössling, S., et al. (2012), ‘Tourism and Water Use: Supply, Demand, and Security, An International Review’, Tourism
Management, 33 (1), pp. 1–15.
44 Cluster Wellness Tyrol (2016), Cluster Renewable Energies Tyrol (online), available at:
www.standort-tirol.at/page.cfm?vpath=cluster-partners/tyrolean-clusters/renewable-energies#schwerpunkte (11-08-2017).
the “International Year of Sustainable Tourism for Development” by the United Nations General
Assembly.
The rise and growth of niche segments of LOHAS (lifestyles of health and sustainability) further
show the importance of green initiatives in the travel market, particularly in the health tourism
market. More environmentally focused products have also emerged, such as eco-spas or
adventure spas and wellness facilities, which seemingly are among the most popular facility types
of the future (taking second place after family spas).45 Some spas pride themselves on being
sustainable, and it is especially important for those that are located in a natural landscape and
utilizing natural resources. An excellent example of this is the Blue Lagoon in Iceland.
Example 2.5 A sustainable spa: the Blue Lagoon, Icelanda
Iceland is one of the most sustainable countries in the world with a Government committed to sustainable development and
tourism.b The Blue Lagoon is one of Iceland’s most famous attraction. It is a natural geothermal spa outside Reykjavik, and offers
unique spa and wellness experiences in a natural, sustainable wilderness setting. It has been awarded an Environmental Award by
the Icelandic Tourist Board. The Blue Lagoon describes itself as “a leading company in terms of green thinking” which is 100%
powered by clean thermal energy. The Blue Lagoon is seen to be part of an ecocycle, where nature and science work in harmony,
with as little environmental impact as possible. The Blue Lagoon is part of the Svartsengi Resource Park, which is a concept based
on ecological balance, economic prosperity and social progress. The Blue Lagoon has a Blue Flag award meaning that the waters
meet stringent quality standards and are monitored regularly. Architecture and design are conjointly harmonised with nature.
a) Blue Lagoon (2013), Environmental Focus (online), available at: www.bluelagoon.com/about-us/environmental-focus (08-07-2017).
b) Mynatour (2013), Iceland: A Truly Sustainable Destination (online), available at: www.mynatour.org/destination/iceland-truly-sustainable-destination
(18-07-2017).
Medical facilities are less connected to sustainability efforts in comparison to wellness or spa
operators or so it seems, although they are not short of green initiatives. Healing or therapeutic
gardens at hospitals or ‘cure’ parks of rehabilitation centres are examples of how nature can be
incorporated into the treatment plan.
The therapeutic benefits of nature have been recognized for centuries but there is nowadays a
revival of interest in reconnecting human beings with nature (e.g., ‘nature deficit disorder’46).
Example 2.6 The therapeutic benefits of nature
In the last two decades, gardens with therapeutic qualities have begun to appear in the United States of America and the United
Kingdom health care facilities. ‘Healing gardens’ are being designed to support the treatment of patients with specific conditions.
The idea that nature has a soothing, restorative effect is nothing new. From medieval monastic infirmary gardens to the landscaped
grounds of 19th century mental asylums, enlightened carers have recognized that access to the outdoors has a salutary effect on
a person’s mental and physical health. With the onset of modern medicine and its emphasis on treatment via surgery and drugs,
this knowledge was lost or deemed ‘unscientific’. High-rise construction techniques created medical settings where patients were
45 The Tourism Observatory for Health, Wellness and Spa (2013a), International Wellness & Spa Tourism Monitor 2012–2013,
TOHWS, Budapest.
46 Louv, R. (2005), Last Child in the Woods: Saving our Children from Nature Deficit Disorder, Atlantic Books Berkeley, CA.
disconnected from the outdoors. From the early 1990s a change began to happen in health care design – termed patient-centred
care, there were marked changes in the interior design of hospitals. Then, in the late 1990s, three books appeared having
documented the therapeutic value of outdoor spaces in health care. The era of the healing garden had arrived. The basics of
healing garden design relate to the issue of stress, as the relief of stress helps to bolster the immune system and stimulate the
body’s natural healing proclivity. There is credible scientific evidence demonstrating that there are four elements that can be
implemented to help reduce stress: the distraction provided by green nature; exercise; social support; and a sense of control.
Source: Design & Health (2013), Landscape design: Patient-specific Healing Gardens (online), available at:
www.worldhealthdesign.com/Patient-specific-Healing-Gardens.aspx (25-06-2017).
2.6 Legal factors
Most legal issues are very closely connected to policy measures, therefore some of the already
mentioned issues and challenges will not be repeated in this section. The legal environment is
particularly important in regards to international health tourism, although most factors discussed
are also relevant to domestic health tourism. Medical tourism generally requires stricter legal
and regulatory frameworks than the spa or wellness sectors. However, there is also the Directive
2009/54/EC of the European Union, which defines the use of natural mineral waters and protects
other natural healing resources like muds or caves.47
Figure 2.8 Key Factors in the Legal Environment
Health and
travel
legislation
Health
Visa
insurance
Legal
environment
Infections
Liability
and diseases
Bioethical Patient
law safety
47 European Commission (2009), Natural mineral waters and spring water (online), available at:
www.ec.europa.eu/food/food/labellingnutrition/water/index_en.htm (17-06-2017).
In international tourism, a country’s openness is a critical characteristic. The World Tourism

Organization (UNWTO) has been long advocating for the need to advance travel facilitation as a
means to promote tourism development and multiply its socio-economic benefits.48
Several countries (e.g., India, the United States of America, Dubai, Turkey) introduced special
visas specifically for medical tourists. Whereas other countries possess existing regulations that
can significantly limit or make it difficult for foreign medical tourist arrivals (e.g., travellers from the
Middle East or the Russian Federation to Europe). On the contrary, the Malaysia Healthcare Travel
Council (MHTC) in cooperation with Kuala Lumpur International Airport opened a welcome lounge
for medical tourists in the arrival hall of the airport. Similarly, Taiwan authorities created special
15-day health/medical tourism permits for mainlanders in 2013.
Regulatory measures also have direct impacts on health tourism. The Directive 2009/54/EC of
European Union defines the provisions applicable to the marketing and exploitation of natural
mineral waters. Other natural resources such as mud, climate or caves are important elements of
the supply only in certain countries (due to tradition, as well as to natural conditions), there are
no international standards or regulations available (not even for what can be considered a hot or
thermal spring). The legal protection of these resources, however, tends to be rather strict. Often
these are protected areas, or even belong to a national park, with limitations to build up ratios,
setting up new industries, or additional activities at the source or in the buffer zone.
Ethical, liability, health legislation and patient safety issues are particularly delicate and
important issues, especially in medical tourism. The Declaration of Istanbul (2008) against organ
trafficking was accepted by 100 countries. It was an important political step against organ traffic
and ‘transplant tourism’. There are several ethical questions, which should be addressed such
as whether foreign paying patients have priority over local state insured patients, or how the
medical records are exchanged between the home and foreign medical institutions. The European
Healthcare Fraud and Corruption Network was established to fight against acts like bribery.49
Further ethical questions concern the availability of health care to the local people. If medical
tourism grows in a poor region, doctors may trade public health care jobs in exchange for better
salaries in the private sector of medical tourism services (‘brain drain’ as mentioned earlier).
Health tourism as a terminology, although it refers to medical tourism, can be controversial as

highlighted in the United Kingdom recently. A health tourist could also be someone who travels
to the United Kingdom, and gets their treatment free on the NHS, when they should be charged
for their treatment. Whitehall research puts the cost to taxpayers of health tourism at anywhere
between GBP 200 million and GBP 2,000 million a year.50
48 World Tourism Organization (n.d./b), Facilitation of Tourist Travel (online), available at:
http://rcm.unwto.org/content/facilitation-tourist-travel (19-06-2017).
49 International Medical Travel Journal (2009), Countries tackle fraud and corruption in health tourism (online), available at:
www.imtj.com/news/countries-tackle-fraud-and-corruption-health-tourism (27-06-2017).
50 Borland, S. (2017), ‘Health tourism ‘chaos’ draining the NHS: MPs condemn ministers over millions lost on foreign patients
who don’t pay’, Mail Online, 01-02-2017 (online), available at: www.dailymail.co.uk (15-07-2017).
One of the most important legal issues widely discussed in industry events is the protection of
personal health data and information. International law does not give enough guidance and
frameworks, therefore medical service providers can use their certification to prove how solid and
closed the dataflow is. This is of great concern to almost any international (as well as domestic)
patients, since national regulations may even forbid informing close relatives about the actual state
of health of the patient, especially given the growing concern about cybersecurity and cybercrime.
In the European Union the Directive 2011/24/EU on patients’ rights in cross-border health care
supports cross-border health care. Not only the patients move across borders, but so do their
confidential personal health and medical records.
The bioethical law concerning international travel for abortion, fertility treatment, stem cell therapy
varies from country to country and some treatments are not legal in the country of origin. This is
particularly critical in the case of cross-border reproductive care.51 For example, the United States
of America is already an attractive destination for reproductive treatments with patients coming
from countries that have a ban on using IVF. Other examples include the so-called ‘experimental
therapy tourism’, such as stem cell therapy and people travelling for drug trials, or to receive drugs
that have not yet been approved in their home country. Stem cell tourism is a phenomenon where
people travel to other, often developing countries to undergo radical, experimental treatments not
offered in their own country.
Another ethical issue is the possibility of medical tourists being carriers of infections and diseases
from one country to another. Viral and bacterial infections can pass on to medical tourists in
hospitals in third country environments. The resistance of the human body to infections is related
to the geographical location and to the bacterial environment of where they are living.
In terms of legislative challenges in international patient flows, malpractice-related complications

should be mentioned. Since laws referring to medical malpractices are widely different in the
origin and in the destination countries of medical tourists, policies and strategies need to be set
to protect patients, as well as health care providers in cases of lawsuit disputes. Consent forms
have been developed for this matter. Another strategy could be the development of an alternative
dispute resolution system. Currently there is no organized international system for resolving
legal disputes of medical tourists. Medical service providers are particularly concerned about
liability and malpractice issues; this is the reason why medical practitioners in North America have
expensive malpractice insurance policies. In some other countries legislation is not as strict and
insurance policies are cheaper. In certain cases and countries, the state-financed hospitals where
foreign patients are treated stand for the claims against their doctors (whereas in private hospitals
doctors should have their own policies).
Private, self-funded insurance plans have more flexibility in terms of health care services abroad
being covered by the insurance plan. In the United States of America, however, when health
insurance works differently from Europe, then employers provide special health care packages
for their employees. Certainly, insurance companies avoid risks, therefore, a foreign medical trip
can be considered an unnecessary risk. There are several insurance companies (e.g., BUPA, Blue
Cross Blue Shield, Techniker Krankekasse) which are looking at or are already involved in travel for
51 Frischhut, M. (2017), ’Legal and Ethical Issues of Cross-border Reporductive Care from an EU Perspective’, in: Smith, M.K.
and Puczkó, L. (eds.), The Routledge Handbook of Health Tourism, Routledge, London, pp. 203–218.
health business. Existing plans as part of some preventative packages can cover wellness services,
and consequently, wellness trips too. Bilateral governmental agreements in medical tourism can
take the place of the insurance company. In such cases, there are direct agreements between
the health care providers and the government, which takes care and pays for the interventions
(e.g., this is the case with certain London hospitals and several governments).
2.7 In a nutshell
The PESTLE analysis indicates that there are many changes taking place in society, and new
trends which are having an impact on health tourism patterns. Some of the main ones are recalled
below:
–– Mobile, active, ageing consumers want to live and travel more healthily and happily;
–– Consumers are becoming more educated about their health and are more likely than ever to
use the Internet or other forms of (new) technology (e.g., smart phones, social media, review
sites, blogs) to search for information and make bookings;
–– The growth of medical tourism and travel worldwide is partly a result of the over-burdened
national health systems. On the other hand, consumers are also looking for alternative and
complementary ways to improve health. Governments are still funding some forms of social
tourism (e.g., thermal bath visits) but any decline in funding in the future will have huge
implications for many facilities and services;
–– The growth of medical tourism should happen under a normative framework that provides
consumers with safe and good quality experiences;
–– Stress in living and work environments is getting more significant, as well as over-dependence
on technology. Too much time is being spent indoors with technology sometimes leading to
conditions such as ’nature deficit disorder’;
–– There is a growing interest in re-balancing work and life and reducing occupational stress
through workplace health, occupational or corporate wellness programmes. A focus on
healthy living is becoming more prominent; and
–– Nature-based activities seem to become elements of therapies but only if those resources
and facilities are managed sustainably in the long-term.
In light of these complex and rapidly changing factors, research was undertaken to consider
which definitions and frameworks could be used for defining and typologising health tourism and
its various subsectors, followed by considerations of how they can be better managed.
47
T
Chapter 3
Development of a taxonomy for health tourism
3.1 Preliminary remarks
In recent years, academic and professional interest in health, wellness and medical tourism have
grown exponentially. However, it is important to distinguish and define what exactly is health,
wellness or medical tourism. All tourism activities ideally bring health benefits or improve happiness
though it is not enough to qualify as health tourism in official definitions and collection of statistics.
A comprehensive taxonomy is therefore needed in order to define the scope of health tourism,
to facilitate data collection and to better measure the impact of the health tourism phenomenon.
This section provides proposed definitions of key concepts which characterize health tourism. It
includes a review of the literature produced by academics and researchers, as well as industry
reports and other documents.
This section also presents a synthesis of the opinions by industry practitioners who were
interviewed as part of the research. Industry experts, representatives of leading companies and
national tourist offices were asked for their opinion with regards to the need for a global taxonomy
(a list of participants can be reviewed in annex 1). It was commonly thought that currently there are
no single, widely agreed definitions and that the existing ones are highly dependent on historical
and cultural context. Political interests and policies were also thought to influence definitions.
There was a consensus around the need to have simple or at least simplified and standardised
definitions. A word cloud exercise among NTO representatives and practitioners was also
undertaken to assess the understanding of the different concepts. A detailed description of the
methodological approach is presented in annexes 2 and 3.
The authors of the study considered given definitions from the various sources including the
primary data (e.g., interviews, word cloud) and reached a consensus based on the convergence
of ideas (e.g., those elements that were repeated the most often by respondents and did not
contradict the seminal secondary literature). The wording of the recommended definitions follows
international English practice (also synonyms such as baths or therme/terme are also introduced).
It should be noted that in various languages the translation or the equivalent of certain words or
expressions recommended may not exist, or can have a different meaning (especially when it is
translated back to English). For example, in German Wohlfühlen (well-feeling) and Wohlbefinden
(wellbeing) are often used instead of wellness; in Finnish the equivalent of wellness does not exist;
Spanish uses bienestar or Italian benessere (meaning wellbeing) in the context of health tourism.
The research team invited 30 leading industry and research representatives from all around the
world to take part in the professional interviews. Care was taken to create a balanced panel. Since
the industry is very diverse, representatives of medical, wellness, spa, holism and plastic surgery
professions were selectively chosen, with the intention of representing every continent by the
invited experts (see list of experts in annex 1).
Overall, this exercise revealed a number of important points that were then considered in the
compilation of definitions:
–– Many respondents use the terms health tourism and wellness tourism or medical tourism
inter-changeably and are unable to distinguish between them (it is later argued that medical
tourism and wellness tourism are subsectors of health tourism);
–– Many respondents argued that medical tourism is different from medical travel. This is a
common debate especially amongst health practitioners, and will be discussed in more
depth;
–– No real distinction was or could be made between wellness and wellbeing tourism (separate
definitions are given in this study but it is indeed challenging to differentiate between both
terms; the term wellness tourism is preferred);
–– Most respondents agreed that tourists should only be defined as health, wellness, wellbeing
or medical tourists, if health improvement is their primary motivation. Having a massage or
two while on a different kind of holiday (e.g., skiing) is not specifically health tourism;
–– All respondents agreed that if someone becomes sick on holiday or is involved in an accident,
that person does not become a health or medical tourists;
–– There was considerable confusion over the meaning of ’holistic’, which is used only in some
countries in the context of tourism. It was also not always clear what retreats offer either;
–– There was some uncertainty amongst respondents as to whether cosmetic surgery and
non-invasive cosmetic treatments were related to medical tourism or not;
–– There was some confusion about the categorization of health trips that were funded by
employers or even the government. These were seen to be corporate or business tourism;
–– Spirituality was included as a category but usually only when yoga, meditation or holistic
holidays were mentioned; and
–– Yoga was seen by some as a ’fun’ or ’entertaining’ activity rather than a health-related one
(most serious practitioners of yoga would disagree, due to yoga being the fastest growing
sub-niche of retreat-based tourism).
Suggestions were also made by those who were interviewed in addition to the word cloud exercise.
Some interviewee respondents thought it is better not to use the term health tourism as there is
confusion over its meaning and it is often used synonymously with medical tourism. However,
others see health tourism as an umbrella term or a continuum for other types of related tourism.
This can include medical tourism and wellness tourism.
Health tourism does not constitute a homogenous market segment: some respondents thought
that the major differences between concepts are the target markets. Some respondents believed
that there is little difference between concepts, especially wellness, wellbeing and spas. Medicine
and spirituality were considered to be more distinctive. However, the aim of tourists, customers
or patients was often seen as being the same, i.e., achieving optimum wellness or personal
happiness.
Most of the interviewees seem to have a ‘global’ view, as the majority of them work in international
environments and did not provide country or language-specific definitions. Interviewees were
sometimes specialists in one field (e.g., plastic surgery, general health care or spa) which proved
to be a limitation in terms of taxonomy and definition formulation, since they claimed to have little
understanding or knowledge of other fields.
Development of a taxonomy for health tourism 49
3.2 Discussing definitions around heath tourism
Wellbeing is considered to be a wider and more inclusive concept than health in most social
scientific and psychological research. Many studies consider health to be only one arena or
domain of wellbeing alongside many others (e.g., economic and material resources, social issues,
environment, education, political freedom, etc). Indeed, many of the indicators used to measure
wellbeing (including quality of life, life satisfaction and happiness) only include health as one
domain out of many.1 Travel can improve one’s wellbeing (78% of respondents said that the
opportunity to travel is important or very important for them to feel happy)2. However, although
tourism can contribute to improving wellbeing, the experiences tend to contribute to short-term
happiness rather than longer-term wellbeing.3
There are debates within both psychological and tourism circles about hedonic versus eudaimonic
paradigms of health and wellbeing. The hedonic approach focuses on happiness and defines
wellbeing in terms of pleasure attainment, and the eudaimonic approach focuses on meaning and
self-realization. Tourists may aspire to both, although it is recognized that eudaimonic activities
may have longer-lasting health and lifestyle benefits. Beauty spa visits are considered being
almost purely hedonic, while spiritual retreats are more eudaimonic, and lifestyle retreats would
be placed somewhere in the middle of the continuum.4
Interviewees in this research were asked to define the term ‘wellbeing’, it was considered to be a
state of being where a person has no sense of physical or psychological health problems. Words
like “contentment”, “satisfaction”, “a sense of meaning”, “feeling good”, “happiness” and “joy”
were mentioned. In addition, it was seen to be based mainly on subjective perceptions mental
and emotional rather than physical dimensions. However, social and financial domains were also
mentioned.
In many countries of the world, the word ‘wellbeing’ is used in preference to ‘wellness’ in the
context of tourism (e.g., Australia, Finland). The Finnish have no word for ‘wellness’ and have been
using the term ‘wellbeing tourism’ for more than ten years now.5 The Finnish concept of wellbeing
tourism, however, is very much focused on outdoor recreation and the healing powers of nature.
Wellness is a subsector of wellbeing tourism and that pampering or self-indulgence are just one
part of the possible product and experience range of wellbeing tourism.6 This example highlights
the difficulties of defining and marketing of tourism services, since languages and cultural
background can create special considerations, applications and adaptations of approaches.
1 Gallup (2014), State of Global Wellbeing (online), available at: www.info.healthways.com/wellbeingindex (18-06-2017).
2 Xellum (2010), 4WR: Wellness for Whom, Where and What? Wellness Tourism 2020, Xellum Ltd, Budapest.
3 Nawijn, J. (2010), ‘Happiness Through Vacationing: Just a Temporary Boost or Long-Term Benefits?’, Journal of Happiness
Studies, 12, pp. 651–665.
Filep, S. (2014), ‘Moving Beyond Subjective Well-Being: A Tourism Critique’, Journal of Hospitality and Tourism Research,
38, p. 266.
Mitas, O.; Nawijn, J. and Jongsma, B. (2016), ‘Between tourists: Tourism and happiness’, in: Smith, M.K. and Puczkó, L.
(eds.), Routledge Handbook of Health Tourism, Routledge, London, pp. 47–64.
4 Voigt, C.; Brown, G. and Howat, G. (2011), ‘Wellness tourists: in search of transformation’, Tourism Review, 66 (1/2),
pp. 16–30.
5 Konu, H.; Tuohino, A. and Björk, P. (2013), ‘Wellbeing tourism in Finland’, in: Smith, M.K. and Puczkó, L. (eds.), Health,
Tourism and Hospitality: Spas, Wellness and Medical Travel, Routledge, London, pp. 345–350.
6 Konu, H. (2014), Defining and developing wellbeing tourism, Licentiate thesis Joensuu, University of Eastern Finland.
In the Australian context wellbeing tourism is also widely used. Both wellbeing travellers and
non-travellers unequivocally associate the term ‘wellbeing’ with ‘health’.7 Past definitions have
also implied that health is a state of wellbeing.
Example 3.1 Wellbeing tourism in Australia
Australia is an example of a country which is mainly focused on wellbeing tourism. The emphasis is on spas, and holistic retreats.
Medical tourism is not yet developed in any kind of organized way, but it is worth mentioning that the number of spas has grown
significantly in the last ten years (by 129%). Australia has much in common with many other Western developed countries, for
example, the United Kingdom and the United States of America, as well as much of Europe. The most popular kinds of wellbeing
facilities are beauty spas (including water-based treatments such as the Peninsula Hot Springs in Melbourne), lifestyle resorts
(including fitness, nutrition, counselling, weight and stress management), and spiritual retreats (including meditation, yoga, Tai Chi
or reiki, for example). Some spas are exploring opportunities to source and include products that are indigenous to the area,
e.g., Hepburn Springs and Daylesford Naturals products, which is located in the most visited spa region in Australia. This can
include raw products used in treatments that are sourced in the local area, or those that have been or are currently being used by
Australia’s indigenous Aboriginal communities. For example, the spa menu at the Daintree Eco Lodge and Spa in Queensland has
been collated out of respect and with approval of the local tribal Kuku Yalanji Elders, and aims to integrate the wisdom of ancient
cultures, medicines, spirituality and healing. Australia also has a growing number of holistic retreats, especially around Byron Bay.
Source: Voigt, C.; Howat, G. and Brown, G. (2010), ‘Hedonic and Eudaimonic Experiences among Wellness Tourists: An exploratory enquiry’, Annals
of Leisure Research, 13 (3), pp. 541–562.
However, any form of travel can technically contribute to the wellbeing of the tourist, especially
if it is defined as broadly as it is in most social and psychological research studies. It also seems
to be the case that health is considered to be only one domain of wellbeing, albeit perhaps the
most important one. Therefore, the term ‘Wellbeing Tourism’ is not recommended for common
usage in the context of health tourism taxonomies, as wellbeing is not generally thought to be
a sub-set of health (rather the reverse is true), and it also runs the risk of becoming too broad
and all-encompassing. Improving wellbeing (albeit usually in the short-term) is a motivation and
sometimes just a by-product of a holiday; it is not a product in itself.
In terms of the definition of a traveller or tourist, this study concurs with UNSTAT’s recommendation:
“A traveller is someone who moves between different geographic locations for any purpose and
any duration. The purpose of introducing the concept of usual environment is to exclude from
visitors those travellers commuting regularly between their place of usual residence and place of
work or study, or frequently visiting places within their current life routine […]. A visitor is a traveller
taking a trip to a main destination outside his/her usual environment, for less than a year, for any
main purpose (leisure and recreation, business, health, education or other purposes) other than to
be employed by a resident entity in the country or place visited. Tourism comprises the activities
of all these categories of visitors. This scope is much wider than the traditional perception of
tourists, which includes only those travelling for leisure.”8
7 van den Eynde, A. and Fisher, A. (2013),’ The Social Construction of Travelling for Wellbeing in Australia’, in: Smith, M.K.
and Puczkó, L. (eds.), Health,Tourism and Hospitality: Spas, Wellness and Medical Travel, Routledge, London,
pp. 389–394.
8 United Nations Statistics Division and World Tourism Organization (2010), International Recommendations for Tourism
Statistics 2008, United Nations, New York.
Some of the activities which tend to improve wellbeing directly and consciously could include
lifestyle improvement, stress management or self-development.
It can therefore be stated that travel (and consequently tourism) is an activity that can contribute
to the creation or the improvement of wellbeing such as feelings of contentment, satisfaction
and happiness by supporting, facilitating and initiating the improvement of mental and emotional
health, work-life balance, self-realization, and the ability to connect with oneself and others.
However, it is only when such activities are intentionally consumed in a location that is specifically
provided for that purpose (e.g., typically in spas, hospitals, hotels or retreats) that they should be
considered under the umbrella of health tourism.
The research team synthesized the most relevant information, data, research findings and industry
intelligence from international and domestic health tourism. The definitions below therefore
are based on the widest available primary and secondary sources. The definitions refer to the
relationship between wellbeing and tourism and how the main forms of tourism for any form of
health motivation can be understood and then defined.
The research team formulated definitions for health, medical and wellness tourism. These
definitions, however, are recommendations and assumed to be further discussed, and eventually
further refined based on the conclusions of inter-, as well as intra-industry consultations and
governmental discussions.
3.2.1 Health tourism
It is important to select a broadly and ideally globally accepted definition of health when defining
health tourism. Most of health practitioners tend to use the World Health Organization’s definition:
“Health is a state of complete physical, mental and social wellbeing and not merely the absence
of disease or infirmity.”9 The WHO also refers to peoples’ abilities to perform family, work and
community roles; their ability to deal with physical, biological, psychological and social stress;
the extent to which they experience feelings of wellbeing, and their state of equilibrium with their
environment. “The extent to which an individual or a group is able to realise aspirations and satisfy
needs and to change or cope with the environment. Health is a resource for everyday life, not the
objective of living; it is a positive concept, emphasising social and personal resources, as well as
physical capabilities”.10
Some other generally accepted definitions of health exist such as “a condition of well being,
free of disease or infirmity, and a basic and universal human right”11, or “a dynamic state of
wellbeing characterized by a physical and mental potential, which satisfies the demands of life
commensurate with age, culture, and personal responsibility.”12 Some authors have argued that
9 World Health Organization (1948), Constitution of the WHO (online), available at:
www.who.int/governance/eb/who_constitution_en.pdf (22-06-2017).
10 World Health Organization (1984), Health Promotion: A Discussion Document, WHO, Copenhagen.
11 Saracchi, R. (1997), ‘The World Health Organization needs to reconsider its definition of Health’, BMJ, 314, pp. 1,409–1,410.
12 Bircher, J. (2005), ‘Towards a dynamic definition of health and disease’, Medicine, Health Care and Philosophy, Springer, 8,
pp. 335–341.
the spiritual dimension is missing from the definitions of health.13 This has been debated within
the WHO since the 1980s. It was argued that psychological insecurity and social malaise were
partly caused by a spiritual vacuum. In 1983, 22 member countries proposed a draft resolution
affirming that the spiritual dimension is implicit in a concept of health and sought to have this
dimension included in their strategy for Health for All. In 1998 it was recommended that the
definition should be amended to “Health is a dynamic state of complete physical, mental, spiritual
and social wellbeing and not merely the absence of disease or infirmity”. However, this was not
adopted at that time, but the growing importance of spirituality for health, even in some medical
circles was emphasized.14
The interviewees in this research generally defined health in a way that is consistent with WHO
definitions of health, and some of them actually quoted the WHO definitions or parts of them.
Clearly, any definition of health tourism should take into consideration WHO’s or other widely
accepted definitions of health. Health tourism is often seen as being the ‘umbrella’ term for
wellness tourism and medical tourism.15 However, health tourism is used by many governments as
a synonym for medical tourism.16 Those interviewees who work for or with national governments
were more likely to see health tourism as synonymous to medical tourism. Industry representatives,
however, generally do not share this belief. There were no identifiable country variations.
Early definitions included the International Union of Official Travel Organizations (IUOTO; precursor
of the World Tourism Organization) in 1973 which stated that health tourism is “the provision
of health facilities utilising the natural resources of the country, in particular mineral water and
climate”.17 One definition of health tourism which was translated from German defines it as “[…]
the sum of all the relationships and phenomena resulting from a change of location and residence
by people in order to promote, stabilize and, as appropriate, restore physical, mental and social
wellbeing while using health services and for whom the place where they are staying is neither
their principle nor permanent place of residence or work.”18
13 Larson, J.S. (1996), ‘The World Health Organization’s definition of health: Social versus spiritual health’, Social Indicators
Research, 38 (2), pp. 181–192.
14 Cummings, B. (2013), ‘Time for the W.H.O. to Revisit Their Definition of Health’, Patch, 05-04-2013 (online),
available at: www.farmington-mi.patch.com/groups/bob-cummingss-blog/p/bp--time-for-the-who-to-revisit-their-definition-
of-h00171272cc (15-07-2017).
15 Smith, M.K. and Puczkó, L. (2009), Health and Wellness Tourism, Butterworth Heinemann: Elsevier, London.
Smith, M.K. and Puczkó, L. (2013).
Smith, M.K. (2017), ‘An overview of lifesytle trends and their impacts on health tourism’, in: Smith, M.K. and Puczkó, L.
(eds.), The Routledge Handbook of Health Tourism, Routledge, London, pp. 20–31.
16 Global Spa Summit (2011), Wellness Tourism and Medical Tourism: Where do Spas Fit?, GSS, New York (online), available
at: spalietuva.lt/wp-content/uploads/2011/04/ISPA-US-Spa-Industry-Study-2011-FINAL-260911-online.pdf (27-06-2017).
17 International Union of Official Travel Organizations (IUOTO) (1973), Health Tourism, United Nations, Geneva.
18 Müller, H. and Kaufmann, E.L. (2001), ‘Market analysis of a special health tourism segment and implications of the hotel
industry’, Journal of Vacation Marketing, 7 (1), pp. 5–17.
Example 3.2 Health tourism in Jordan
Health tourism in Jordan in recent years has been mainly associated with medical tourism because of the decision to actively
promote this sector. However, there is a much longer history of other forms of health tourism (e.g., hot springs) there is now a move
into wellness and spa tourism too, especially by the Dead Sea. Jordan demostrates the range of sectors which can be included
under the term health tourism. Health tourism in Jordan dates back more than 3,000 years since the time of the Greeks and
Romans as evidenced by the Madaba map of the Fifth Century AD that shows the Dead Sea, Ma’in Hot Springs, Jordan River and
the Baptism Site of Jordan and the Holy Land.a Jordan started to invest in therapeutic tourism on the Dead Sea in the 1980s.
However, it also developed other therapeutic hot and mineral springs such as Alhimmah in the 1960s; Ma’in and Alshouna at the
beginning of the 1980s; Afra in the 1990s and Albarbaitah in the 2000s.b Jordan has been a leading country in the Middle East and
known worldwide for medical tourism for many years. Jordan was recognized by the World Bank as the leading regional destination
for health care, and the fifth medical tourism destination worldwide in 2010.c Most Jordanian health care facilities are accredited
by both domestic and international organizations. Dental tourism is one of the fastest growing sectors within medical tourism in
Jordan.d The spa business in Jordan was currently growing at 12% to 15% per year, with 11% of room nights at the Dead Sea
currently derived from spa and wellness visits. That market was expected to grow 10% per year to 2020.e
a) The Jordan Tourism Board (2012), Official Website of the Jordan Tourism Board (online), available at: www. visitjordan.com (18-06-2017).
b) Harasheh, S. (2013), ‘Therapeutic tourism on the Dead Sea of Jordan is in danger’, in: Smith, M.K. and Puczkó, L. (eds.), Health, Tourism and
Hospitality: Spas, Wellness and Medical Travel, Routledge, London, p.174.
c) Stefano, R.-M. (2012), Jordan to release its Health and Wellness Destination Guide (online), available at:
www.medicaltourismassociation.com/en/press/jordan-to-release-its-health-and-wellness-destinat.html (19-06-2017).
d Al-Hammouri, F. (2010), Medical Tourism: The Fastest Growing Industry Overview with a Focus on the Jordanian Experience, 18-03-2010, Moscow
Medical & Health Tourism Congress.
e) United States Agency for International Development (USAID) (2009), Market Assessment and Demand Forecast for the Jordan Dead Sea
Development Zone, Jordan Economic Development Program, Amman.
Although the WHO definitions of health do not adopt the word spirituality, for many
cultures (especially in Asia and the Middle East) spirituality is often viewed as an integral or even
fundamental part of health. Many tour operators (e.g., Skyros Holidays, Mystic Asia), wellness
hotels, spas and retreats are increasingly offering activities which are linked to non-religious
spiritual practices such as yoga or meditation. Several interviewees categorized yoga or
meditation holidays as spiritual, especially in the word cloud exercise. Spirituality is therefore
seen as an important aspect of health tourism and of wellbeing in general.
3.2.2 Wellness tourism
The terms ‘wellbeing’ and ‘wellness’ are often used inter-changeably, but it should be taken into
account that many languages do not even have a word for ‘wellness’ (e.g., Finnish, Hebrew).
Many would argue that it is not even an English word and that it was merely invented using the
combination of wellbeing and fitness or wellbeing and wholeness. However, the first written record
of the word in the English language stems from 1654 and then reappeared when Halbert Dunn
introduced the term into contemporary discourse.19 Dunn is often described as being the ‘father’
19 Voigt, C. (2013), ‘Towards a conceptualisation of wellness tourism’, in: Voigt, C. and Pforr, C. (eds.), Wellness Tourism,
Routledge, London, pp. 19–44.
of the wellness concept, which he described as being not the absence of disease, illness, and
stress but the presence of:20
–– Purpose in life;
–– Active involvement in satisfying work and play;
–– Joyful relationships;
–– A healthy body and living environment; and
–– Happiness.
The concept of wellness has taken on a slightly different focus since Dunn defined it in the 1960s.
Dunn’s original definition is arguably closer to the concept of wellbeing today, which has broader
connotations and close links to satisfaction, joy and happiness, as well as health.
Interviewees in this study considered that wellness is linked to health, quality of life and wellbeing.
They saw it as a balance between body, mind and soul with a relaxing, sensuous, beautifying and
pampering dimension. Fitness and leading an active life were also seen as important elements,
as were healthy nutrition, diet and natural healing factors. Wellness was seen as a mindset and
also an active or proactive process rather than a passive one involving self-responsibility. It was
considered to be more preventative than curative and something of a life-long practice, which is
orientated to maximising an individual’s potential.
In previous literature, it has generally been agreed that the concept of wellness includes a balance
of life domains which are more subjective than quality of life (which also includes standard of
living and other objective indicators). Life domains are physical, mental, psychological, social,
environmental, spiritual, occupational, intellectual and emotional.21 Most wellness tourism services
can be considered to be holistic because they address body, mind and spirit.22
20 Dunn, H.L. (1961), High-Level Wellness, Beatty Press, Arlington.
21 National Wellness Institute (2007), About Wellness (online), available at: www.nationalwellness.org (19-07-2017).
22 Voigt, C. (2013).
Figure 3.1 Wheel of wellness
Physical
Intellectual Emotional
Wellness
Social Occupational
Spiritual
Source: Smith, M.K. and Puczkó, L. (2009), Health and Wellness Tourism, Butterworth Heinemann: Elsevier, London.
Wellness is about the relationship between all of these domains which need to be seen in a holistic,
integrated and balanced way for optimum results. Of course, this is extremely challenging and
cannot easily happen within a short period of time (e.g., a holiday). However, more ‘educational’
forms of wellness tourism include those where doctors, spa therapists, counsellors and other
professionals aim to teach tourists how to improve their lifestyles and live better on a daily basis.
Wellness has become more closely associated with spas since the Global Spa Summit changed
its name to the Global Spa and Wellness Summit, and consequently to Global Wellness Summit.
It is suggested that “[…] wellness is the active pursuit of activities, choices, and lifestyles that
lead to a state of holistic health.”23 The global wellness economy is comprised of the following
industries:
–– Beauty and anti-ageing;
–– Healthy eating, nutrition and weight loss;
–– Fitness and mind-body;
–– Wellness tourism;
–– Preventative and personalized medicine and public health;
–– Complementary and alternative medicine;
–– Wellness lifestyle real estate;
–– Spa industry;
–– Workplace wellness; and
–– Thermal/mineral springs.
23 Global Wellness Institute (2017), Global Wellness Economy Monitor, GWI, Miami (online), available at:
www.globalwellnessinstitute.org/global-wellness-institute-releases-global-wellness-economy-monitor-packed-with-regional-
national-data-on-wellness-markets (28-06-2017).
Figure 3.2 Global wellness economy, 2015
Global wellness economy in 2015: USD 3.7 trillion
Complementary
and alternative
medicine: Wellness tourism:
USD 199 billion
Thermal/ USD 563 billion
mineral
springs:
USD 51
Preventive billion
and personalized
medicine and public SPA industry: Beauty and anti-aging:
health: USD 99 billion USD 999 billion
USD 534 billion
Workplace
wellness:
USD 43
billion
Wellness
Healthy eating, nutrition, lifestyle real
Fitness and
estate:
and weight loss: mind-body: USD 119
USD 648 billion USD 542 billion billion
Note: Numbers may not add due to overlap in segments.
Source: Global Wellness Institute (2017).
Spas are defined as “places devoted to overall well-being through a variety of professional
services that encourage the renewal of mind, body and spirit”.24 Wellness tourism is described
as consisting of “hedonistic indulgences of spas and alternative therapies”25. The Finnish
Tourist Board’s definition of wellness: “Wellness, above all, includes high quality concerning
place, atmosphere, settings, service, products and professional staff. It stimulates all senses
in an aesthetic environment. A wellness product is a well planned, segmented, marketed and
implemented entity, which also includes a touch of luxury”26.
It is important to define wellness tourists as those whose main motivation is to improve their health
and wellbeing, and who stay at least one night in a facility designed specifically for that purpose.27
This could be a spa, wellness hotel or retreat, for instance. Wellness tourism should be mainly
voluntary, proactive and preventative (rather than reactive and curative like medical tourism),
therefore developing lifestyle-based habits and self-responsibility are important elements. Healthy
diet can also be an important element, as the case study below shows. Wellness tourism is a more
pleasurable and fun form of tourism than when compared to medical tourism.28
24 International Spa Association (2013a), Types of Spas (online), available at: www.experienceispa.com/resources/spa-goers
(25-06-2017).
25 Henderson, J. (2005), ‘Healthcare tourism in South-East Asia’, Tourism Review International, 7, pp. 111–121.
26 Konu, H. (2014).
27 Voigt, C.; Brown, G. and Howat, G. (2011).
28 Voigt, C. and Pforr, C. (2013), Wellness Tourism: A destination perspective, Routledge, London.
There are several sub-sets of wellness which should be mentioned here. The first is holistic, the
second is spirituality and the third is medical wellness (which will be discussed later, under ‘medical
services’). The industry and NTO representatives in this study were asked to define ‘holism’. They
referred to it as a whole or global approach to healing or total wellbeing incorporating many
elements, not only the physical body. They associated ancient Greek practices when it came
to the balance of body, mind, emotion and spirit, as well as with the natural and social worlds.
Similarly, the Indian approach which includes five levels was mentioned. All physiological functions
are seen as interdependent. Treatments might include complementary and alternative therapies,
acupuncture and naturopathy.
There are two standard definitions that are used for holistic:29
1. Holistic as a whole made up of interdependent parts, most likely referred to as the mind/
body connection; mind/ body/ spirit, or physical/ mental/ emotional/ spiritual aspects. When
this meaning is applied to illness, it is called holistic medicine and includes a number of
factors, such as dealing with the root cause of an illness; increasing patient involvement; and
considering both conventional (allopathic) and complementary (alternative) therapies; and
2. Holistic as a synonym for alternative therapies. By this definition, “going holistic” means
turning away from any conventional medical options and using alternative treatment
exclusively. This meaning mainly relates to illness situations, and sometimes is used for
controversial therapies.
Holistic activities often tend to be offered at ‘retreat centres’ which are usually purpose built.
However, holistic therapies may be offered in spas and wellness hotels or resorts, as well as in
some clinics and medical centres. Holistic approaches to health may include a combination of the
following activities, therapies or treatments, for example:
–– Physical (e.g., massage, Pilates, Alexander technique);
–– Therapeutic (e.g., massage, aromatherapy, acupuncture);
–– (Alternative) Medicinal (e.g., Ayurveda, Chinese medicine, Bach Flower remedies);
–– Mental (e.g., life-coaching, stress management, transactional analysis);
–– Spiritual (e.g., meditation, yoga, Tai Chi); and
–– Healing (e.g., reiki, aurasoma, colour therapy).
In some cases, whole destinations have become focused on holistic activities, like Byron Bay in
Australia.
Example 3.3 Byron Bay, Australia – A holistic health and wellness destination
Byron Bay is often described as ‘the alternative and spiritual capital of Australia’, dedicated mainly to holistic practices. Located
in New South Wales just south of the Queensland border, Byron Bay is a small town which for years has been seen as the place
for alternative lifestyles. From the 1960s onwards, surfers have enjoyed a nature-based lifestyle, in addition, around the same time
many different therapies began to emerge, for example, massage, or even tarot readings and astrology. A consultancy study
undertaken for Byron Shire Council in 1983 determined that the ‘relaxing lifestyle’ was the most valued feature about living in the
area. Byron Bay became an important Australian tourism destination during the 1990s, as a result, the accommodation stocks
29 American Holistic Health Association (2007), Definitions (online), available at: www.ahha.org (18-06-2017).
diversified from 1950s/60s-style beach houses to backpacker hostels, luxury guesthouses and apartments. Many entertainment
venues and nightclubs were also developed. Today, there are many alternative new-age shops, including spiritual services and
new-age therapies such as meditation classes, tarot card reading, energy therapies and healing centres. Some spa and wellness
resorts and retreats were built in the mid-2000s, such as the Gaia Retreat and Spa which was developed in 2005 by Australian
celebrity Olivia Newton-John. The retreat offers health, fitness, detox and yoga packages, day spa services, and daily activities
such as yoga, Tai Chi, Chi Kung, meditation, and Pilates. Byron Bay is also well known for its detoxification and rehabilitation
retreats for addicts (e.g., the Sanctuary). It is estimated that there are 144 operations offering beauty, spa, health, wellness and
spiritual services in Byron Bay.
Source: Voigt, C. et al. (2010), Health Tourism in Australia: Supply, Demand and Opportunities (online), available at:
www.crctourism.com.au/wms/upload/resources/WellnessTourism_Ind%20Summary%20WEB%20(2).pdf (21-06-2017).
Yoga was identified as the most popular activity in retreat centres all around the world.30 Therefore,
it is worth defining yoga as a separate form of tourism, even though it is a sub-niche of holistic
and wellness tourism. Yoga classes may be offered in spas or wellness hotels, yet some retreats
are devoted specifically to yoga and even certain types of yoga (e.g., Ashtanga). Yoga retreats
are for those who want to learn and practise yoga, including postures, breathing and meditation.
It should be noted that yoga tourists tend to practise yoga for spiritual reasons, as well as physical.
The main motivations of those who participate in yoga holidays are to improve self-understanding
(82%), to enjoy a spiritual experience (61%), to be part of a community (51%), and to get fit
(45%).31 The importance of community for yoga tourists, as well as transformation of the self
is also important,32 as well as the evidence-based medical benefits of yoga, and the spiritually
transformative ones.33
The interviewees in this research were asked to define spirituality. They defined it as a broader
concept than religion. It was described variously as a state of mind which goes beyond material
and physical existence; the seeking of a higher consciousness; giving meaning to one’s life; the
search for God and sacred pursuits; deep connection to the essential self; transcendence of the
self; self-understanding and realisation; soul energy and inspiration; prayer and meditation.
Some authors have argued that spirituality is at the core of wellness.34 It is certainly an important
domain. However, a distinction must be made between religious and spiritual practices, as
spirituality in the context of wellness is not generally connected to a specific religion (although
research shows that religious people often have an increased sense of wellbeing). Some of the
activities may be similar: for example, spiritual tourism (like religious tourism) can include visiting
religious sites or buildings, spiritual landscapes, pilgrimage centres, ashrams, retreats or gurus.
However, the spiritual quest is seen as more abstract than a specifically religious one, focusing
on the balance of body, mind and spirit and the connection to oneself and the universe. Besides,
30 Sziva, I.; Kulcsár, N. and Smith, M.K. (2013), ‘The Propensity for Yoga Practitioners to Become Tourists: A Case Study
of Budapest,’ in: Smith, M.K. and Puczkó, L. (eds.), Health, Tourism and Hospitality: Spas, Wellness and Medical Travel,
31 Sziva, I.; Kulcsár, N. and Smith, M.K. (2013).
32 Ponder, L.M. and Holladay, P.J. (2013), ‘The Transformative Power of Yoga Tourism’, in: Reisinger, Y. (ed.), Transformational
Tourism: Tourist Perspectives, CABI: Wallingford, pp. 98–108.
33 Smith, M.K. and Sziva, I. (2017), ’Yoga, transformation and tourism’, in: Smith, M.K. and Puczkó, L. (eds.), The Routledge
Handbook of Health Tourism, Routledge, London, pp. 168–180.
34 Myers, J.E.; Sweeney, T.J. and Witmer, M. (2000), A holistic model of wellness (online), available at:
www.mindgarden.com/products/wells.htm (16-06-2017).
it is also about the search for a higher meaning beyond physical existence. This may also occur
through the connection to nature and landscape, as well as spiritual buildings and people. In spas
or retreats the reference to body-mind-spirit practices is becoming more common and usually
involves yoga, meditation, Tai Chi or similar practices coming from Asian tradition. A growth of
stays in Christian monasteries has been registered.
The term wellness has been (over)used so broadly in recent years in marketing and advertising
that it has often lost its original connections to health promotion and holistic health.35 It is worth
mentioning that the word ‘wellness’ (as well as ‘spa’) have become fashionable labels on various
products and in different industries. Health in general has also gained popularity at political,
social and business levels alike. Global brands and companies have recognized the (anticipated)
market value of wellness and not only sport brands (such as Nike), but companies like Nestlé
have communicated an interest to become a health and wellness company. Wellness terminology
is so widely popular that even someone’s car can be sent to a ‘car spa’ or a ‘car doctor’. It is
not impossible to witness something similar to what happened with the green/eco/sustainability
movement in the last 10 to 15 years. The green label was received well by customers and led to
the concept of ‘green-washing’ (labelling products ‘green’ although the core of the provision was
not that green).
3.2.3 Medical tourism
As mentioned above, many definitions of health tourism seem to be used synonymously with
medical tourism. However, in this section it is argued that medical tourism is just one subset of
health tourism.
The interviewee respondents were asked to define ‘medicine’ and ‘healing’ in preparation for
the creation of a definition of medical tourism. Medicine was defined as “the art and science of
promoting, preserving, maintaining or restoring health” and as “the science of studying a disease,
to diagnose it and find the right treatment to cure it”. Recurrent words or phrases included
“evidence-based”, means that scientific research was used to test and verify the impacts of a
certain medicine or treatment. “Prevention” was also mentioned in addition to “cure”, as it is
becoming increasingly important in medical circles and is deemed more cost-effective to promote
preventative methods rather than curative processes. Interventions were described as surgical or
pharmaceutical, while remedies were also being mentioned. It was stated that these should be
administered by a doctor or trained medical professional.
Evidence-based medicine (and wellness) means interventions for which it exists proven and
clinically tested scientific evidence consistently showing the improvement and how they improve
patient outcomes across larger populations e.g., thalassotherapy provides services by and
services based on the sea. Water, algae and salt are used for treating certain diseases by bathing
in mineral spring water. It is typically provided in baths where the mineral (and often thermal) water
contains certain minerals which can be absorbed through the human skin, such as silica, sulphur,
selenium and radium in high concentration. In certain destinations, the term ‘resort medicine’ is
used to indicate that medical professionals use local resources for medical (primarily rehabilitation-
oriented) programmes based on locally available resources and assets.
35 Voigt, C. (2013).
Healing was defined as “a process of getting better”, “recovery” and “a natural restoration of health
and balance of life”. This can include physical, mental, psychological and emotional dimensions.
Ideally, a definition of medical tourism would include both medicine and healing. However it is
less common for healing to be included. For example, many countries with hot springs have
curative properties commonly refered as healing (or curing) waters and they are used as a source
for evidence-based medicine (extensive related literature can be found through the International
Society of Medical Hydrology and Climatology). The most relevant countries having built on these
resources include Central and Eastern European countries, Baltic States, Former Soviet Union
countries, and many countries with hot springs which are or could be used for healing purposes,
for example South Africa, Argentina, United States of America or China. However, thermal water-
based treatments so far are rarely considered in definitions of medical tourism. Another medical
treatment that has not yet gained global acceptance is therapeutic recreation which focuses on
rehabilitating people with illnesses or disabling conditions.
There is no agreed definition of medical tourism, as methods applied by countries vary

substantially.36 Some countries count foreign patients’ visits to hospitals, whereas others count
the entry of individual patients into the country. Other countries record nationality but not place of
residence of patients, which can be problematic when migrants return to their home country for
treatment. Four modes of supply through which services can be traded are defined:37
–– Cross-border supply;
–– Consumption of health services abroad;
–– Commercial presence; and
–– Movement of medical personnel.
Medical tourism falls under Mode 2 but domestic medical tourism can also exist, of course
(i.e., moving from one part of a country to another for a certain treatment, hospital or specialist, for
example).38 However, in most studies, papers or strategies, medical tourism is considered to take
place in a foreign country. In the last couple of years, after all, domestic medical tourism has gained
increased attention in several countries (e.g., United States of America). In Central and Eastern
Europe in particular, domestic medical tourism has been flourishing for many decades, based on
evidence-based resources and treatments (e.g., thermal springs, healing muds or climate).
This definition of medical tourism is also very broad and corresponds more to a wider understanding
of health tourism including wellness: “Medical tourism is a broad term that involves travelling in
order to undergo different types of medical treatments that enhance a person’s physical or mental
wellbeing, ranging from medical intervention (elective or essential), traditional and alternative
treatments, to holistic medicine offered by spas and wellness resorts”39.
There are definitional problems within the field of medical tourism and numerous debates about
what should be included in definitions of medical tourism, many have argued that ‘medical travel’
36 World Health Organization (2013a), Medical Tourism (online), available at:

www.who.int/global_health_histories/seminars/kelley_presentation_medical_tourism.pdf (19-07-2017).
37 Chanda, R. (2002), ‘Trade in health services’, Bulletin of the World Health Organization, 80, pp. 158–163.
38 Paffhausen, A.L.; Peguero, C. and Roche-Villarreal, L. (2010), Medical Tourism: A Survey, ECLAC, Washington (online),
available at: wiwi.uni-passau.de/fileadmin/dokumente/lehrstuehle/grimm/Publikationen/Medical_Tourism_A_Survey_L111_
final.pdf (15-07-2017).
39 Paffhausen, A.L.; Peguero, C. and Roche-Villarreal, L. (2010).

is a better way of describing the phenomenon where patients travel to a destination outside their
normal place of residence to use a medical service or to have a medical intervention.40 The reason
for this debate is that most patients are arguably not in the position to enjoy most of the typical
tourist facilities of a destination, as it is not their primary purpose (e.g., especially after extensive
invasive surgery).
The possible distinction between medical tourism and medical travel are also discussed. Medical
tourism involves a trip to a place outside a person’s normal place of residence for the purpose of
receiving medical treatments, interventions or therapies.41 This approach took into consideration
the difference between travel and tourism as discussed earlier in this section.42 The patient and
whoever accompanies them also make use of the destination’s tourist infrastructure and facilities.
Many authors do not agree that having a medical treatment is enough to qualify the experience as
tourism. They would not agree to classify it as an ‘attraction’ in the conventional sense. Medical
travel means travelling for the sole purpose of having medical treatments, interventions or
therapies. Although medical travellers use transport services, accommodation and several other
services, they may not visit tourist attractions or sites. Medical tourists can only go on a tour if
they are well enough; this is why many authors only talk about medical travel.
“Medical travel is not about cost-efficient medical treatments with recreational prospects in
exotic locations. That is medical tourism.”43 However, many medical tourists combine their use of
medical intervention services with “a vacation or tourism elements in the conventional sense”,44
such as medical tourists in China, India, Jordan and Thailand who do some sightseeing, shopping
or cultural activities as part of the treatment.45
The terms ‘treatment abroad’, ‘cross-border health care’ and ‘patient mobility’ are also used,
mainly by health and medical professionals, and policy makers. Patient mobility refers to those
people who travel for medical procedures to another or a bordering country, within their own
country (i.e., another state in the United States of America), or within their geographical region
(i.e., the EU).
The following are tourists but not medical tourists and should not be counted in medical tourism
statistics. They are tourists who only take medical treatments:
–– Tourists who have an accident or illness while on holiday and have to use local medical
services – known as emergency medical services (sometimes referred to as ‘travel medicine’);
–– Tourists who decide to have a procedure while on holiday (e.g., dentistry or a cosmetic
treatment) but who did not travel to their destination with the primary motivation of doing
so; and
–– Diplomats, long-term and temporary ex-patriates, soldiers and military personnel, overseas
students (who do not travel within their country of residence for medical treatments) having
medical treatments in their temporary resident country.
40 Connell, J. (2012), ‘Contemporary medical tourism: Conceptualisation, culture and commodification’, Tourism Management,
34, pp. 1–13.
41 Smith, M.K. and Puczkó, L. (2013).
42 United Nations Statistics Division and World Tourism Organization (2010).
43 MedHalt (2016), Medical Travel or Tourism: What’s The Difference? (online), available at:
www.medhalt.com/blog/medical-travel-tourism-difference (19-06-2017).
45 Connell, J. (2012).
The latter are often counted in definitions of medical tourism to boost the statistics.46 Many
hospitals and clinics also ‘double count’ patients who visit their facility more than once during
their trip. There is also a great deal of diasporic medical travel, where immigrants go back to their
country of origin. There is a strong tendency to travel back to the home country for certain medical
procedures (due to trust, language or cultural reasons). This is a rather significant segment of
international medical travel in Asia (e.g., travelling back to Republic of Korea from west coast
United States of America).
Medical tourists are usually ill (as opposed to wellness tourists who are ‘well’ but want to improve)47.
Medical tourism is mainly curative (wellness tourism is often preventative)48. However, in the case
of cosmetic surgery and dentistry, it is debatable as to whether the tourist is to be considered ill (or
at least unwell since they are not satisfied with their looks). There is also a growth in many forms
of preventative health care which are supervised by doctors (e.g., in longevity centres). Some
countries or regions are becoming internationally known for their cosmetic surgery, for example
several countries in Central and South America.
Medical tourists are those who decide to travel across international borders to receive some form
of medical treatment.49 Treatments may span the full range of medical services, but the most
common are dental care, cosmetic surgery, elective surgery, and fertility treatment. There are
other definitions of medical tourism which have been used within an industry context, for example:
“People who live in one country travel to another country or travel within their country to receive
medical, dental and surgical care while at the same time receiving equal to or greater care than
they would have in their own country, and are travelling for medical care because of affordability,
better access to care or a higher level of quality of care”.50
This is a useful definition, nonetheless it is debatable as to whether medical tourism should also
include preventative health care, healing methods and natural resources (e.g., thermal water)
based treatments. The evidence base for the latter is only accepted in certain countries. Many
types of healing are not accepted as medical practices universally (e.g., energy healing in the
Philippines). Medical tourists do not necessarily have to be ‘ill’ if cosmetic dentistry and surgery
are included in definitions, as they almost always are. Many would still argue that ‘medical travel’
is a better description for those people who go abroad with the sole motivation of having medical
treatments and interventions. However, in this study it is recommended to only use the term
medical tourism.
In recent years, the term ‘medical wellness’ has been used mainly in German-speaking
environments. However, it was also mentioned by several of the interviewees in this study, that
medical wellness is “‘the integration of wellness and medical activities, treatments and services
– medical indication requires the involvement of medical practitioners”. Nevertheless, it was also
46 Youngman, I. (2014), ‘The issues in measuring medical tourism numbers’, International Medical Travel Journal, 20-03-2014
(online), available at: www.imtj.com/articles/2014/medical-tourist-or-international-patient-what-am-i-30197 (18-06-2017).
47 Global Spa Summit (2011).
48 Hall, C.M. (2013), Medical Tourism: The ethics, regulation, and marketing of health mobility, Routledge, London.
49 Lunt, N. et al. (2011), Medical Tourism: Treatments, Markets and Health System Implications: A scoping review, OECD,
Paris.
50 Medical Tourism Association (2013), Healthcare Clusters, Medical Clusters and Healthcare Associations (online), available
at: www.medicaltourismassociation.com/en/healthcare-clusters.html (22-06-2017).
suggested that this is a smaller market in comparison to wellness tourism or medical tourism. The
term medical wellness can be used to integrate the concepts of health and wellness51 while others
define medical wellness as the practice of health and medical care relating to proven wellness
outcomes. A more specific definition of medical wellness is an approach to delivering care that
considers multiple influences on a person’s health and consequently multiple modalities for treating
and preventing disease, as well as promoting optimal wellbeing.52 Some industry practitioners
have argued that the term ‘medical wellness’ is confusing and that ‘structured wellness’ may be a
better term, but this is a relatively new debate.
Medical wellness means that patients are either supported and their benefits have been proven
by scientific medical research or that a medical doctor has prescribed or directed some of the
activities. This may become especially important in longevity centres where ageing citizens wish
to learn how to prolong their lives using a variety of techniques which are prescribed by a doctor
after an initial examination or diagnosis, but are practised by the recipient long after they have
stopped being supervised by the doctor or have left the longevity centre (e.g., the Pritikin Longevity
Center in the United States of America or Kurotel in Brazil).
3.3 Recommended definitions
Taking into account the above research discussion on descriptions, concepts, terminology and
definitions provided by different bodies (including WHO), academics and countries, around the
concept of health tourism, as well as the discussions and conclusions by the ETC-UNWTO
Roundtable on Health Tourism (Budapest, Hungary, 2016), the following definitions can be
proposed.
Health tourism
Health tourism covers those types of tourism which have as a primary motivation, the
contribution to physical, mental and/or spiritual health through medical and wellness-based
activities which increase the capacity of individuals to satisfy their own needs and function
better as individuals in their environment and society.
Health tourism is the umbrella term for the subtypes: wellness tourism and medical tourism.
51 Deutscher Wellness Verband (2008), Medical Wellness (online), available at: www.dmwv.de/medical_wellness/begriff.html
(24-06-2017).
52 American Medical Tourism Association (2009), Definitions (online), available at:

www.medicaltourismassociation.com/en/index.html (05-07-2017).
Medical tourism
Medical tourism is a type of tourism activity which involves a trip outside the usual
environment, either domestically or internationally, for the use of evidence-based medical
healing resources and services (both invasive and non-invasive). This may include diagnosis,
treatment, cure, prevention and rehabilitation.
Wellness tourism
Wellness tourism is a type of tourism activity which aims to improve and balance all of the
main domains of human life including physical, mental, emotional, occupational, intellectual
and spiritual. The primary motivation for the wellness tourist is to engage in preventive,
proactive, lifestyle-enhancing activities such as fitness, healthy eating, relaxation, pampering
and healing treatments.
Based on the proposed definitions above and the work carried out by the UNWTO Committee
on Tourism and Competitiveness, the 22nd Session of the UNWTO General Assembly held in
Chengdu, China (11–16 September 2017), adopted as Recommendations definitions on health
tourism, medical tourism and wellness tourism.53
3.4 In summary
This section has shown that health tourism can be considered as an umbrella term for both wellness
and medical tourism. Tourism can apply to many aspects of wellbeing, but it is recommended
that the term ‘wellbeing tourism’ is not used, as wellbeing is so broad that it can include almost
any activity. If wellbeing tourism was to be considered as a terminology, then almost any form of
tourism could fall into that category, since the benefits of any trip can contribute to the traveller’s
wellbeing.
It is recommended that the primary motivation of tourists should always be taken into
consideration when defining health tourism. The given definitions are mostly based on motivations
such as improving health, wellness or wellbeing. In some cases, certain resources are needed to
achieve this improvement such as thermal waters. Figure 3.3 summarizes the above suggested
taxonomy of different forms of health tourism. This study suggests a taxonomy of health tourism
in which all major forms of tourism are included and the relationships are indicated.
53 For reference, please see UNWTO Committee on Tourism and Competitiveness at:
http://marketintelligence.unwto.org/content/competitiveness-commitee-ctc.
Figure 3.3 Wellbeing, health and tourism
Wellbeing
Health tourism
Medical tourism Wellness tourism
Medical wellness
Holism
Spirituality
Note: The length of boxes indicate how much of the health tourism spectrum the actual component can cover (e.g. “medical wellness” or “holism”).
Holism is a very broad phenomenon, reflected in the length of the box, whereas medical wellness includes some of medical and some of
wellness.
This taxonomy structure provides the foundation for the analysis, management and development
of any form of health tourism. It is understood that the motivations of tourists to enhance their
health or improve, the facilities and destinations which they go to in order to achieve this, and
the treatments and activities which contribute to this process can be very wide and complex (see
Supply Chapter for more details).
Primary motivation or purpose may be difficult to assess as tourists can have multiple motivations
for a trip or may derive health benefits from an activity just by chance (e.g., being in nature, visiting
an historic thermal bath as one of the attractions of a historic city). However, care must be taken
not to ‘double count’ tourists who come to a destination as cultural or business tourists and then
just happen to use the hotel spa, or tourists who end up hospitalized because of an accident on
holiday (and therefore they become international patients, but not medical tourists). This will lead
to artificially inflated statistics.
All travel in any way or form can potentially contribute to the wellbeing of the traveller. Therefore
it is recommended that the term wellbeing tourism should not be used in the context of health
tourism. It is also important to differentiate between ‘incidental’ health tourists who use a spa or
a medical service just because of its availability in a destination but without pre-planning, and
a tourist who is primarily motivated by health-improvement. For example, a hotel guest on a
business trip visiting the hotel gym and taking a treatment in the hotel spa is not a wellness tourist
by motivation, but a health-conscious traveller who wants to be fit or improve his/her wellbeing.
It is crucial to differentiate between these two alternatives; otherwise every form of tourism could
potentially be labelled as health tourism.
67
T
Chapter 4
The health tourism market
4.1 Preliminary remarks
This chapter provides insights into the latest demand and supply current trends in the health
tourism market, as well as main challenges and opportunities. In terms of content, the chapter
covers the following areas:
Supply side:
–– Main forms of supply (medical, wellness); and
–– Types of facilities (hospitals/clinics, hotels/resorts and spas and baths, retreats).
Demand side:
–– Key motivations of health tourists;
–– Cultural and national differences in demand;
–– Major segments for health and consequently wellness and medical tourism; and
–– International flows in medical and wellness tourism (sending and receiving countries).
In recent years, health tourism seems to have grown exponentially including visits to spas, thermal
baths, hot springs, spa and wellness hotels and resorts, hospitals and clinics for surgery and
medical procedures, as well as spiritual or holistic retreats.
All tourism ideally brings some health benefits or improves wellbeing or happiness, but this is not
enough to qualify as a health tourist in official definitions and the collection of statistics.
Forms of tourists which should not be counted in health tourism definitions and statistics
include the following:1
–– Sun, sea and sand tourists in destinations which have been re-packaged as health tourism
destinations (e.g., seasides or islands being referred to as ‘the world’s greatest outdoor
spa’);
–– Visitors to spa and wellness hotels who do not use the spa facilities at all or where a spa
visit is not a primary motivation (e.g., guests come for business or a conference and may or
may not use the spa);
–– Visitors to the countryside or rural areas where nature is promoted as having health-giving
benefits unless there is (medical) evidence to support it;
–– Doing some fitness or sports activities on holiday because they are available (i.e., the sport
was not a primary motivation for going to that destination);
–– Having medical treatment in a destination due to suffering a sudden illness or an accident;

–– Going to a music or other festival which has a number of holistic, spiritual or wellbeing
activities (e.g., a ‘chill out’ area or yoga classes);
–– Social tourism which is not prescribed by a medical practitioner (e.g., other forms of leisure
and recreation which are not directly related to health);
–– Visiting an historic or heritage spa due to beautiful architecture and not for health reasons;
and
–– Tourists who need dialysis during their stay (called holiday dialysis).
4.2 Market size of health tourism: some estimates
Due to limited, sketchy and dispersed data, it is rather difficult to estimate the size and growth of
health tourism as a market. Estimates in numbers can widely differ depending on the definition
used in the measurement, as well as at country level.
Data compiled by the International Monetary Fund’s balance of payments (BoP) statistics can
provide some insight for a subset of countries reporting trade data on receipts (exports) and
expenditure (imports) from health-related international travel. Spending on healh-related travel
relates to the goods and services acquired by persons going abroad for health-related purposes
(e.g., medical services, other health cares, food, accommodation, local transport, acquired by
those travelling for medical reasons). Health-related travel falls under the ‘personal travel’ item of
the BoP.
Data reported shows the diverse range of countries, from both advanced and emerging economies
from all regions of the world, participating in the health travel services trade.
Available data also reveals wide differences among countries in terms of earnings and expenditure
from health-related travel, though the mixed composition of advanced and emerging economies
suggest flows exchange within and between both categories (advanced to advanced; advanced
to emerging; emerging to emerging; emerging to advanced).
According to trade data reported for 2015 (or for previous year) by a group of countries, the United
States is by far the largest earner (USD 3,600 million) and spender (USD 1,800 million) in terms of
health-related international travel. Turkey generated around USD 900 million in receipts in 2015,
while Kuwait spent some USD 1,600 million and Germany around USD 900 million in international
travel for health-related purposes.
A group of countries generated health-related international travel receipts ranging from

USD 200 million to USD 800 million: Jordan, France, Hungary, Belgium, Thailand, the Republic
of Korea, Costa Rica, Belgium, Mexico, Czech Republic and India. Among the largest spenders,
Belgium, Oman and Canada reported health-related travel expenditure from USD 400 million to
USD 600 million.
The health tourism market 69
Figure 4.1 Receipts generated from health-related international travel, 2015 (USD million)
United States of America 3,598
Turkey 904
Jordan 630
France 604
Hungary 550
Republic of Korea 470
Thailand 427
Costa Rica 365
Belgium 349
Mexico 280
Czech Republic 230
India 226
United Kingdom 156
Canada 143
Poland 119
Tunisia 91
Armenia 79
Lebanon 63
Greece 41
Albania 40
Panama 40
Afghanistan 39
Philippines 36
Slovenia 33
Brazil 32
0 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000
Note: Graph based on countries that report balance of payments data on health-related travel exports (travel item ‘credit’) for 2015 (or previous year if
data missing). The list of countries displayed is a sample of countries reporting data and not a ranking of top earners.
Source: International Monetary Fund.

Figure 4.2 Expenditure made on health-related international travel, 2015 (USD million)
United States of America 1,828
Kuwait 1,569
Germany 938
Nigeria 829
Belgium 481
Canada 434
Oman 382
France 271
Algeria 191
United Kingdom 139
Panama 115
Czech Republic 107
Bermuda 102
Maldives 100
Austria 92
Armenia 82
Republic of Korea 67
Venezuela 65
Mexico 61
Mongolia 47
Albania 46
Philippines 42
Brazil 37
Swaziland 36
Kazakhstan 35
0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000
Note: Graph based on countries that report balance of payments data on health-related travel imports (travel item ‘debit’) for 2015 (or previous year if
data missing). The list of countries displayed is a sample and not a ranking of top earners.
Source: International Monetary Fund.
Net earners (when receipts generated exceed expenditure) include the United States of America
(USD 1,800 million), Republic of Korea (USD 403 million), France (USD 334 million), Mexico
(USD 209 million), Czech Republic (USD 123 million) and United Kingdom (USD 17 million). Health
travel exports contribute to the travel trade balance, though net earnings are comparatively
modest in some countries. For many OECD countries, especially in Europe, figures on health
travel exports are still likely to be significant underestimates.2
Furthermore, a research conducted for the European Parliament’s Committee on Transport and
Tourism (TRAN) estimated health-tourism revenue (medical, wellness, and spa tourism) to total
nearly EUR 47 billion in the EU-28 in 2014, which represents 4.6% of all tourism revenues in the
group of 28 countries of the EU.3
4.3 The supply of health tourism
“From a supply-side perspective it has been shown that health tourism supply is fragmented
and highly diverse”.4 This supply section considers many of the resources and facilities used in
health tourism, such as spas, wellness hotels, hospitals or retreats, as well as the destinations in
which they are located. Although health tourists are motivated by the desire to become healthier,
feel better, relax and recuperate, or to improve lifestyle, they may also be attracted by a certain
resource, destination or facility. The health tourism market is becoming very competitive and there
are numerous places worldwide competing to provide tourists with the optimum health-enhancing
experience.
Health tourism destinations supply two sorts of services: from the supply of medical services,
products and infrastructure, to the supply of tourism services covering travel to and from country,
guides, accommodation, transport and recreation.
The interviewees of this study were asked to characterize the different world regions in terms of
available/possible assets, services and products:
–– Europe is leads based on its traditional bathing history and culture, and the thermal springs;
–– The United States of America was mentioned mainly as a powerhouse in fitness;
–– Asia was associated to the increasing popularity of Eastern medicine, and holistic
experiences; and
–– Africa and the Middle East were mentioned as emerging destinations, due to nature and
wildlife and ancient traditions and leading hospitals, respectively.
The resources and facilities used for health tourism clearly vary according to the type of tourism
and motivations of the tourists. Medical tourists are most likely to use hospitals and clinics,
wellness tourists are more likely to visit spas and wellness hotels, and holistic tourists are most
likely to attend retreats. Wellness tourism destinations have a wellness-specific superstructure
such as health resorts, baths or retreats, which differs from generic tourism superstructure such
as conventional hotels, guesthouses and restaurants.5 Medical tourism has an even more specific
superstructure. However, the boundaries can become somewhat blurred when spas start to
2 Organisation for Economic Co-operation and Development (2014a), Health at a Glance: Europe 2014 (online), available at:
www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-europe-2014_health_glance_eur-2014-en
(19-07-2017).
3 European Parliament TRAN Committee (2017), Health Tourism in the EU: a general investigation, European Parliament,
Directorate General for Internal Policies, Brussels.
4 Voigt, C. (2013).
5 Voigt, C. and Pforr, C. (2013).

offer medical treatments (e.g., cosmetic surgery, dentistry) or hospitals send their patients to
rehabilitate in spas, for example. Private clinics and corporate hospitals are listed as offering ‘pure’
medical tourism, but there is overlap between wellness and medical tourism in therapeutic lifestyle
retreats, traditional European spas (e.g., with thermal, healing waters), ‘medhotels’, medical spas
and ‘wellspitals’ (the latter combining conventional medicine with complementary and alternative
(CAM) therapies).6
The following subsections describe the main locations and facilities for health tourism in more
depth.
4.3.1 Hospitals and clinics
Medical tourism (or travel) typically takes place in a purpose-built health care centre, which
can be a hospital, clinic or even a cruiseship. The number of hospital beds provides a very rough
measure of the resources available for delivering services to in-patients in hospitals. Among OECD
countries, the number of hospital beds per capita is highest in Japan and the Republic of Korea,
with over 11 beds per 1000 population in 2015. Both Japan and the Republic of Korea have ‘social
admissions’, that is, a significant part of hospital beds are devoted to long-term care. The number
of hospital beds is also well above the OECD average in the Russian Federation, Germany and
Austria. On the other hand, large emerging countries in Asia (India and Indonesia) have relatively
few hospital beds compared with the OECD average. This is also the case for OECD and emerging
countries in Latin America such as Mexico, Chile and Brazil.7
The number of hospital beds alone provides little information about the existing or prospective
medical tourism supply. The number of service suppliers can only be estimated based on the
information of accreditation companies and associations/clusters of medical tourism service
suppliers in different countries. There are several certifications provided either by private companies
or professional associations (such as by Accreditation Canada International, Trent, Medical Travel
Quality Alliance or ISO). The following are the ones that define the international medical tourism
market and provide guidelines for prospective patients and facilitators alike (considering the
communication of hospitals and clinics present in the international medical tourism market):
–– The Joint Commission International (JCI) is one of the leading accreditation companies in
the world with headquarters in the United States of America: “JCI identifies, measures, and
shares best practices in quality and patient safety with the world.”8 Over 600 medical centres
and hospitals are accredited by JCI worldwide, mainly in Asia (Thailand, India, Singapore),
but in South America and Europe as well. JCI accreditation is considered to be essential in
international medical tourism; however, it is important to mention that the accreditation is
not tourism specific.
–– Temos International is a German certification company with 17 regional offices worldwide.

It is a neutral and independent certification body and by 2016, some 70 medical centres,
6 Voigt, C. (2013).
8 Joint Commission International (2017), Our Focus (online), available at:

https://jointcommissioninternational.org/about-jci/who-is-jci/ (06-06-2017).
hospitals and clinics worldwide had been certified by Temos, mainly in Southern Europe,
Middle East and Asia. Temos certification is specifically tailored to hospitals and clinics aiming
at medical tourism and international patient management including emergency medicine for
tourists, business travellers, and expatriates. Temos provides certification programmes for
‘Quality in International Patient Care’, ‘Medical Tourism’, ‘Quality in International Dental/Eye/
Reproductive Care/Rehabilitation’, and also offers a certification programme for facilitators
(medical travel coordinators).
–– The Medical Tourism Association offers numerous certification alternatives either for
facilities or for professional such as ‘International Patient Services Training and Certification
for Hospitals and Clinics’ or ‘Certified Medical Tourism Professional’ and ’Certified Medical
Tourism Specialist’, but also for WellHotel certification for medical tourism.
–– The European Spas Association (ESPA) has initiated a quality certification scheme for
(thermal) medical spa establishments. There are two versions of this certification, one for
medical thermal medical spas (baths) (EuropeSpa Med) and other for wellness orientated
wellness hotels, hotel spas and thermal bathes (EuropeSpa Wellness). Altogether, there are
32 EurospaSpa Med and 17 EurospaSpa Wellness certified establishments in Europe.
–– TÜV Hellas launched a Medical Tourism Friendly Hotel certification. As the description
states the certification “[…] gives sensitive individuals, senior people, medical tourists
and international patients, the confidence they need that your business provides safe and
efficient hospitality and accommodation services”.
–– Certification of hospitality services pertaining to Health/ Medical Tourists’ management is

one of Swiss Approval high-end certification programmes. This specific set of criteria for
hotels has integrated quality standards, international best practice and safety principles
for medical and health tourism services. Swiss Approval has integrated international
sustainability standards at its hospitality certification services in accordance with the Global
Sustainable Tourism Council.
Several national level certification systems exist, e.g., in India and also some relatively new
systems such as the MTQUA certification.
The International Medical Tourism Journal (IMTJ) published publically available information
about medical tourism facilities from countries perceived to be important in international medical
travel (table 4.1). Specialist medical centres, such as plastic surgery clinics, IVF centres, dental
clinics, etc. may not be included in the list below. However, these numbers should be read with
caution as they are often inflated.
Table 4.1 Number of medical tourism facilities, 2014

Country Number of medical Source
tourism facilities
(members)
Germany 2,000 German National Tourist Board
Poland 1,100 Polish Association of Medical Tourism
Hungary 600 Institution of Healthcare Strategic Research (ESKI)

Thailand 427 Thailand Med Tourism Portal / Amazing Thailand
India 414 National Accreditation Board for Hospitals and Healthcare Providers (NABH)
Republic of Korea 323 Korea Health Industry Development Institute (KHIDI)
South Africa 240 Medical Tourism Association of South Africa
Turkey 106 Turkish Healthcare Travel Council
Mexico 98 National Tourism Office
Malaysia 71 Malaysia Healthcare Travel Council
Jordan 69 Private Hospitals Association
Israel 60 Israel Medical Tourism Association
Taiwan Province of China 35 Taiwan Medical Tourism Development Association
Costa Rica 30 Association of Medical Tourism in Guanacaste
Singapore 25 Singapore Tourism Board
Lithuania 12 Lithuanian Medical Tourism Cluster
Source: International Medical Tourism Journal database.
Table 4.2 Number of medical tourism providers and facilitators by self-declaration (2017)
Country Providersa Facilitatorsb
India 381 198
United States of America 212 78
Turkey 212 60
Hungary 102 20
United Arab Emirates 101 12
Poland 68 32
Malaysia 66 7
Czech Republic 61 18
Thailand 53 21
Mexico 53 11
Germany 38 29
Belgium 38 3
Philippines 28 6
Country Providersa Facilitatorsb
United Kingdom 25 35
Switzerland 25 9
Israel 22 9
Singapore 21 5
South Africa 21 14
Lithuania 20 25
Republic of Korea 18 3
Brazil 13 6
Costa Rica 12 9
Australia 12 18
Jordan 8 1
Taiwan Province of China 8 1
Iran 7 6
Slovenia 6 3
Colombia 2 4
Cuba 1 0
Total 1,634 643
Notes: a) Hospitals and clinics listed in the directory that are located in the country.
b) Agencies and facilitators listed in the directory that are located in the country. These may handle inbound or outbound medical travellers.
Facilitators or specialized tour operators are those agencies that manage the patient flow and understand the medical, as well as the travel
component of medical tourism
Source: International Medical Tourism Journal database.
The actual size or the relevant revenue of providers listed above is not known or not comparable.
Hospitals and clinics tend to list either the number of interventions, the number of patients, and/
or the revenues from certain procedures. Individual clinics and hospitals, especially those in which
international medical tourism is not the core of the service provision, often find very difficult to
measure the actual costs of revenues from medical tourism. International patients tend to be the
main segment that data can be collected for, but further distribution of data is rarely possible.
There are two important types of treatments in medical tourism: plastic surgery and dentistry. The
latest edition of the ISAPS International Survey on Aesthetic/Cosmetic Procedures Performed
in 2015 counted some 35,000 plastic surgeons worldwide (the top three were the United States
of America (6,500), Brazil (5,500) and China (2,800); there is no reliable data about the number
of surgeons involved in medical tourism.9 ISAPS dedicated a special section on its website to
medical tourism, indicating the current role of this market in plastic surgery. The latest information
9 International Spa Association (2011), Spa Industry Report (online), available at:
www.spalietuva.lt/wp-content/uploads/2011/04/ISPA-US-Spa-Industry-Study-2011-FINAL-260911-online.pdf
(30-06-2017).
about plastic surgery is from 2015. It shows that breast augmentation is the most popular surgical
intervention with approximately 1.5 million interventions worldwide. The most popular non-surgical
intervention is Botox at 4.6 million.
The country with the highest number of procedures is the United States of America with 1.4 million
surgical and 2.6 million non-surgical procedures, whereas Brazil reported 1.2 million surgical and
1.1 million non-surgical procedures.
The prices of certain procedures are often published and even compared to other countries’
prices, still these prices provide very little information for comparing actual revenues or more
importantly, economic performance. It must be noted that procedure prices can be compared
but it is important to mention that every treatment plan can be different depending on the health
status of the patient. The published prices, therefore, are more indicative than final. The treatment
plan and consequently the total price of the treatment can typically be finalised after a personal
consultation on site. In addition, health care providers include a clause in the contract stating
that in the event of certain urgent and/or immediate changes in the treatment during the actual
procedure, especially in the case of invasive treatments, there can be surcharges.
4.3.2 Resorts and hotels
The supply of hotels and resorts is probably the most complex, as well as the simplest in the market.
It is considered simple as it seems that almost no new hotel or resort development including city
hotels would open without an on-site spa or wellness centre. In the hospitality sector, spas or
lately wellness centres have become a necessity. The range of supply is a rather complex one,
since there are huge differences between a spa hotel and a hotel spa, or a destination spa, an
airport spa and a medical spa or a mineral spring spa (bath). Since in many parts of the world the
link between hotels and resorts and spas/wellness centres are inseparable, the discussion below
includes both in the same section.
The growth of hotels and resorts with a spa or more recently, a wellness centre is quite interesting.
The conversion rate of hotel guests to spa/wellness centre guests especially in city hotels is rather
low (a 20% rate is considered to be a very good result, but a single digit number is more realistic).
Nevertheless, developers and hotel brands find it necessary to open and run spa/wellness facilities
as a norm or expectation. It is interesting to note that the rebranding of the TUI Vital brand to TUI
Wellnessurlaub in the German market by the largest travel company in Europe is due to the wide
availability of spas and wellness centres in hotels and resorts (TUI daughter Thomson labels the
product as Spa and Relaxation Holidays, whereas TUI España as Wellness).
In medical tourism, some interesting initiatives should also be mentioned. The hotel sector has
become increasingly involved in the provision of services for medical tourists who would prefer
not to stay in a hospital or clinic while having a treatment. While having certain interventions such
as dental or (minor) plastic surgery, tourists may stay in a hotel or apartment (close to the clinic).
In other cases, tourists may stay in a medical hotel or a so-called ‘Medical Tourism Friendly Hotel’:
–– Medical Hotels: according to the relevant legislation in Hungary an accommodation

establishment can apply to become a medical hotel if the requirements of a hotel are
met, plus some natural healing assets (e.g., hot spring), and either it should have its own
medical centre, or in cooperation with a health care provider under medical supervision
offer therapeutic services. This classification or certification system is not easy to obtain,
considering it is under strict state control and supervision.
–– Medical Tourism Friendly Hotels is a certification module developed together by TEMOS

and TUV RHEINLAND Hellas Certification Organizations. This particular seal of quality
enhances the awareness and specialisation of hotels in order to meet the expectations and
needs of medical tourists, international patients, as well as visitors with no health issues,
tourists with undiagnosed medical problems, elderly people, and visitors and tourists with
chronic diseases. Applicants must meet the demands of ISO 9001 standard.10
–– The Medical Tourism Association’s WellHotel standards intend to promote specific

improvements in the protocols and services impacting the medical traveller’s experience.
The standards are available for hotels, resorts, B&Bs and spas wishing to accommodate
medical tourists.
The new trend in the medical tourism sector is the emergence of the so-called H2H concept
(i.e., Hospital-to-Hotel or Hotel-to-Hospital conversions or medhotels). These new facilities are
blending services and qualities of hospitals, hotels and spas. A medhotel would offer various
medical, as well as wellness and spa services – without the hospital, clinic or sanatoria, or even
a standard hotel feeling and image. This can manifest in either the form of an extended spa,
modified hospital or even a cruise ship.11
The case of Westin represents a shift of focus also taken by many global hotel brands,
e.g., Marriott or IHG towards a more complex health-orientated hospitality offer in which they offer
several options and service alternatives for wellness or health-conscious travellers.
Example 4.1 Maintaining a healthy lifestyle on holiday: Westin
The Westin Difference offers innovative programmes to ensure all guests feel well rested, well nourished and well cared for. Westin
claims that feeling good derives from a relaxing and comfortable environment where careful attention is given to the most important
components of a guest’s stay. Westin recognizes that travel often impacts a guest’s ability to maintain a healthy lifestyle and is
committed to transforming every aspect of a stay into a revitalizing experience. Offering a suite of signature programmes and
experiences (Signature Heavenly® Programs. In-Room Spa Services, SuperFoodsRx® menu, WestinWORKOUT®).
The mission at Westin is to ensure guests leaving the hotel feeling better than when they arrived.
Source: https://westin.marriott.com/wellness/.
The difficulty with the supply side analysis comes down to the role of a spa or wellness centre in a
hotel or resort. A hotel spa is different from a spa hotel, since in the latter, a spa or spa services
and treatments are probably the most important motivation for staying there, whereas a hotel
10 TÜV Rheinland (2013), Medical Tourism Friendly Hotel Certification (online), available at: www.tuv.com/en/corporate/
business_customers/management_system/tourism_leisure/medical_tourism_friendly_hotel_certification/medical_tourism_
friendly_hotel_certification.html (15-09-2017).
11 Xellum (2010).
spa is an additional and complementary service of a hotel. However, there are no international
standards or rules by which a hotel or resort can (or cannot) call itself a spa or wellness hotel.
There are some exceptions:

–– The StayWell initiative by Delos was created from the belief that travellers deserve
environments that positively impact on their wellbeing. The concept’s features and
programmes have been implemented in hotels (MGM Grand Las Vegas) but also in hospitals
(e.g Cleveland Clinic Wellness);
–– Healing Hotels of the World defined three levels for interested hotels. Depending on the
level of specialisation hotels are categorized as standard, advanced or ultimate healing hotel
category; and
–– Wellness Hotels and Resorts International defined a series of quality and service standards
for hotels and resorts, which were interested in gaining wellness hotel status (e.g., regarding
location, service-mix, food and beverage provision, wet areas and treatments).
Providing healthier options for hotel guests is an evident move that can be seen in the market.
This trend now goes beyond improved showers and beds. The so-called ‘healthy hotels’ offer
additional services to their guests to make them healthier.
Example 4.2 IHG EVEN Hotels
Launched in February 2012, the brand was created to meet the large growing demand for a hotel to help wellness-minded
travellers maintain balance on the road and the need for maintaining wellness routines while travelling. Therefore, the brand was
developed to meet a guest’s holistic wellness needs in the areas of exercise, food, work and rest. The new brand has four new
pillars: Keep Active, Rest Easy, Eat Well and Accomplish More. As IHG states global hotel brands build trust when they help guests
make better decisions by offering advice and guidance tailored to their individual needs and preferences. IHG’s EVEN Hotel brand
is developed and positioned as a wellness hotel concept. For concierge services, this means giving personalised recommendations
and supporting guests by providing adequate tools to make their own discoveries. For example, an EVEN branded hotel offers
nutritious menus and amenities, such as guest rooms designed for in-room workouts.
Source: Intercontinental Hotels Group (IHG) (2017), Meet EVEN Hotels. Where wellness built in (online), available at:
www.ihg.com/evenhotels/hotels/us/en/reservation#homepage (13-10-2017).
Hotel brands create their own spa brands (as did Starwood for its brands and Leading Hotels
of the World created Leading Spas of the World) with distinctive brand identities and offers.
These spas are then managed either by the hotel, or by a professional spa operator (e.g., Steiner
Leisure, ESPA) which can take place under the name of the spa brand or a beauty product line
(e.g., Elemis).
It is also interesting to note the concept of wellbeing hospitality suggests the necessity of
introducing and applying an overall approach to improving health, happiness and contentment
within hospitality and destination assets via forms of wellness, leisure, recreation, travel and
health care.
Example 4.3 Healing Hotels of the World
There is a specialized network of hotels and resorts focusing on health and healing. As the credo of Healing Hotels of the World
puts it “Find a variety of ways to help you relax, rejuvenate, learn about and improve your health. Reconnect with yourself, and
experience new dimensions of wellbeing that lead to a life-long transformation into a healthier, happier, more balanced you.
Achieve this through holistic spa treatments, improvement of fitness in ways both ancient and cutting-edge, health consultations,
daily schedules and life style coaching. Find support through the overall healing ambience of the place: the beauty and highest
standard of accommodation, utmost care in service, healthy and healing cuisine, and stunning nature.”
Source: Healing Hotels of the World (HHoW) (2017), Who we are (online), available at: www.who-are-we/: healinghotelsoftheworld.com/who-are-we/
(24-09-2017).
4.3.3 Spas
Spas are defined as “places devoted to overall wellbeing through a variety of professional services
that encourage the renewal of mind, body and spirit”12. So-called ‘spa tourism’ is probably the
best-known form of health tourism. However, it has been argued that spa tourism does not exist
rather that tourists visit spas for reasons of health or wellness.13 Spas are considered to be places
or venues for specific service provision, whereas wellness is known to be a concept (therefore spa
tourism would sound similar to museum tourism, but cultural tourism as an umbrella term does
not include that terminology).
Spa-based tourism means that spa activities are the main or primary focus of the visit, including
water-based activities, body and facial treatments, physical exercise, and/or body-mind-spirit
programmes. Spas are often centred on some form of water treatment (or wet areas), although day
spas sometimes only offer beauty treatments. It should be noted that many wellness hotels and
resorts offer similar facilities and experiences. The difference may be that the word ‘spa’ is often
related to thermal baths or hot springs where the waters have a medical or healing function. This
can create confusion in the minds of consumers, who seem to mainly associate the word ‘spa’
with relaxation, comfort and pampering.
The following categorization of spas tend to play a role in the tourism industry (day spas and club
spas are excluded).14 Airport spas or cruise ship spas could also be added to this list:
12 International Spa Association (2013a).
13 Global Spa Summit (2011).
14 International Spa Association (2013a).

ISPA spa types
Destination spa: a destination spa is a facility with the primary purpose of guiding individual spa-goers to develop healthy habits.
This lifestyle transformation can be accomplished by providing a comprehensive programme that includes spa services, physical
fitness activities, wellness education, healthful cuisine and special interest programming.
Medical spa: a facility that operates under the supervision of a licensed medical doctor whose primary purpose is to provide
medical and wellness care in an environment that integrates spa services.
Mineral springs spa: a spa offering an on-site source of natural mineral, thermal or seawater used in hydrotherapy treatments.
Resort/hotel spa: a spa located within a resort or hotel providing professionally administered spa services, fitness and wellness
components.
Source: International Spa Association (2013a), Types of Spas (online), available at: www.experienceispa.com/resources/spa-goers (25-06-2017).
Destination spas should be given a special mention. These establishments have been rather
special ever since the first one was developed: Rancho la Puerta in Baja California, Mexico, opened
its doors in 1940. These are specialised spas for which guests may travel across continents
and may stay for several weeks (or months, even). At destination spas the accommodation
and the spa element are combined since they offer a complex, integrated and personalised
wellness programme and not only rooms and a spa. Destination spas have a relatively small
number of rooms and offer full board consisting of healthy foods and drinks (prepared typically
from locally produced ingredients). There are not too many destination spas around the world
primarily because of the significant initial capital needed and to the high running costs necessary
to maintain establishments of this type. The global shift and changing interest of the hospitality
industry is evidenced indicated by the purchase of the Miraval Group by Hyatt Hotels in the
beginning of 2017. Miraval has been one of the most acclaimed destination spas (or as it is called
now destination wellness hotel) globally. The take-over suggests Hyatt Hotels’ growing interest in
the more health-oriented hospitality segment.
Interviewees in this research defined spas in detail, especially as many of them are spa practitioners
and have worked in the industry for some years. Most of them mentioned wellness but only a few
mentioned medical care (mainly cosmetic). Improving one’s physical appearance was seen as
important, as were also the restoration of health, healing, wellbeing and escapism from everyday
life. Water is of course a major resource for most spas, but there are also beauty spas which
may not offer water-based treatments. Nature and natural treatments were considered to be
important. Physical fitness activities were also mentioned. Recurrent words included ‘pampering’,
‘relaxation’, ‘renewal’, ‘rejuvenation’, ‘rehabilitation’ and ‘therapeutic’.
Europe, North America, and Asia-Pacific account for over 90% of industry revenues in the spa
industry. The total number of spas, as well as other details can be seen in the table below.15
15 Global Wellness Institute (2014), Global Spa & Wellness Economy Monitor, GWI, New York (online), available at:
www.globalspaandwellnesssummit.org/images/stories/gsws2014/pdf/GWI_Wellness_Economy_Monitor_Report_9.27.14.
pdf.pagespeed.ce.ecLPzZXeYm.pdf (01-07-2017).
Global Wellness Institute (2017).

Table 4.3 Global spa facilities by region, 2015

Regions Estimated total Estimated total Estimated total
number of spas spa revenues spa employment
(USD billion)
Europe 37,420 27.5 745,584
Asia and the Pacific 38,819 21.4 722,588
North America 28,306 20.6 424,174

Middle East and North Africa 4,465 2.1 63,982
Latin America and the Caribbean 10,269 4.9 164,909
Sub-Saharan Africa 2,316 1.1 28,912
Total 121,595 77.6 2,150,147
In terms of revenues and employment, Europe is the largest regional spa market in the world
(and second in terms of number of spas). By 2015 the estimated number of spas reached 37,420
generating USD 27.5 billion revenues and employing around 745,000 employees.16
Figure 4.3 Europe’s top-10 spa markets by number of spas, 2015
Germany 6,488
France 4,011
United Kingdom 3,185
Russian Federation 3,010
Italy 3,023
Spain 2,762
Austria 1,354
Poland 1,209
Switzerland 783
Netherlands 768
0 1,000 2,000 3,000 4,000 5,000 6,000 7,000
16 Global Wellness Institute (2014).

Figure 4.4 Europe’s top-10 spa markets by revenue generated, 2015 (USD million)
Germany 5.95
France 2.96
United Kingdom 2.75
Russian Federation 2.91

Italy 2.46
Spain 1.90
Austria 1.60
Poland 0.60
Switzerland 1.15
Netherlands 0.55
0 1 2 3 4 5 6 7
The most popular activities offered by spas are massage and other body treatments, facial
treatments, manicures, pedicures, exercise facilities and sometimes meditation, yoga or other
body-mind-spirit programmes.
New facilities or concepts have also appeared in several countries in the last few years:
Adventure spas and wellness resorts are cross-over facilities offering spa-like treatments,
healthy gourmet food and plenty of outdoor activities. Adventure-spa goers are looking “for
learning or advancement in outdoor skills [...] and are active vacationers who want a healthy and
active trip”. Guests typically want to combine adventurous, outdoors activities by day (e.g., rock
climbing, kayaking, hiking, biking, yoga) with pampering spa services and luxury treatments by
night.17
Eco spas and wellness resorts are cross-over facilities offering the traveller a design and
philosophy which complements the rhythms of nature. The treatments and food integrate
indigenous plants and rituals.18
Spa-living environments (or spa lifestyle or wellness lifestyle communities) are environments
where people can move permanently, or temporarily (e.g., to a summer home), which may give a
boost to time-share developments. Urban dwellers will also have similar services nearby, since an
increasing number of spas are being developed around urban areas.
17 Pascarella, S. (2008), Enjoy rugged relaxation at adventure spas (online), available at:
www.usatoday.com/travel/deals/inside/2005-10-12-column_x.htm (17-07-2017).

This trend does not stop at hotels or other accommodation establishments (such as the Wellness
Hostel in Saas-Fee (Switzerland). Airlines and airports in particular are also looking for healthier
options and have started to address the health needs of passengers. Air travellers can enjoy of an
increasing number of airport spas (of various kinds), on-board entertainment aimed at wellness
(e.g., Qatar Airways in cooperation with Deepak Chopra) or a Wellness Blanket by British Airways.
Longevity centres (offering medical wellness treatments, lifestyle-based services for seniors) are
spreading mainly in the United States of America, and have become increasingly popular. Similar
concepts exist but under different names such as health spa, wellness clinic or health resort.
4.3.4 Facilities based on natural resources
There are numerous natural resources that have been widely used in health tourism. Probably
the most well-known and most widely available are thermal or hot spings. There are many
other healing or health-enhancing resources which are non-water based but which do not
involve surgical intervention, such as climate, sea and sea climate, mud or peat, natural gases
(e.g., CO2) or healing caves with special and stable microclimate (mud and peat in particular tend
to be applied in hospitals, medical spas or rehabilitation centres).
Balneotherapy (Latin: Balneum, bath) refers to the medical use of water rather than its use for
recreational or leisure activities. Balneology or Balneotherapy tends to be based on bathing in or
drinking medicinal waters, applying mud or peloid packs to the body, as well as the use of some
healing gases (e.g., Mofetta). These are used to treat various conditions, such as musculoskeletal,
gynaecological and dermatological disorders, as well as vascular conditions, amongst others.19
Balneotherapy is widely used by Europeans for muskuloskeletal problems, especially chronic lower
back pain (LBP).20 However, it can be stated that despite some medical evidence, balneology is
not fully recognised as an independent medical speciality at a global level.21
Example 4.4 The Pannonian Lakes in Tuzla, Bosnia and Herzegovina
Millions of years ago, as the great Pannonian Sea receded from the European ground it left millions of tons of salt rock and salt
water underneath the area that today hosts the Pannonian Lakes. The archaeological evidence found in Tuzla positions it as the
area of oldest culture of salt production in Europe, with indications of first salt extraction dating from the Neolithic period more
than 7,000 years ago. As a result of unmitigated excavation process, a substantial portion of the city terrain suffered problematic
infiltrations by underground saltwater which over the years created a number of permanent, unattractive landfills. In 2003 the
problematic salt water landfill in the city centre was transformed into the first Pannonian Lake – a lake filled with natural, mineral-
rich salt groundwater pumped to the surface through salt wells.
At present, the Pannonian Lakes complex consists of three salt lakes, and salt waterfalls, covering an area of about 21,000 m².
The salinity of its water is equal to that of sea, as it contains 30–40g/l of salt. The chemical features of water in the Pannonian
19 Bender, T. et al. (2014), ’Evidence-based hydro- and balneotherapy in Hungary – a systematic review and meta-analysis’,
Int J Biometeorol, 58, pp. 311–323.
20 Karagülle, M. and Karagülle, M.Z. (2014), ’Effectiveness of balneotherapy and spa therapy for the treatment of chronic low
back pain: a review on latest evidence’, Clin Rheumatol, 34, pp. 207–214.
21 Gutenbrunner, C. et al. (2010), ’A proposal for a worldwide definition of health resort medicine, balneology, medical
hydrology and climatology’, Int J Biometeorol, 54, pp. 495–507.
Lakes and waterfalls equals to iodine-bromine-sulfur-sodium-chloride mineral water, a therapeutic type of waters very suitable for
rheumatic diseases, joint inflammation and regenerative rheumatism. It also helps in the case of non-specific gynecological
diseases, sterility, inflammation of the upper respiratory tract, thyroid disease, inflammatory diseases and heart disease. Salty
waterfalls are designed in a way to enable evaporation of iodine vapour, which is especially useful in the treatment of respiratory
disorders. The curative properties of its salt waters constitute a fundamental value of this tourism project, continuing on the long
tradition of natural cures in the region.
Source: Panonika (2017), Pocetna (online), available at: www.panonika.ba (14-11-2017).

Geothermal resources are abundant in many countries and regions around the world. Many
countries have already developed not only significant health industries (medical, wellness or
spa) but also industrial based on these natural resources in agriculture, public heating or power
generation. Several other countries, such as the United States of America are just rediscovering
the ways in which these assets and resources can be used for health purposes. There are an
estimated 25,507 thermal facilities all around the world, two-thirds of which provide spa services
as well. The largest market is Asia-Pacific with 20,146 establishments generating USD 29 billion
revenue in 2015.22
According to the European Spa Association (ESPA), Europe have more than 1,400 spas (mainly
thermal baths) and health resorts, which are medically respected health centres and form
a powerful economic unit generating significant proportions of the gross domestic product of
European Community member countries.23
It is not obvious to establish the number of thermal bath facilities based on natural, hot or thermal
springs. In comparison to ESPA statistics which list 1,400 baths and 12,000 establishments
(baths, hotels, etc.) using natural healing resources in total, the GWI estimates 5,600 thermal
establishments in Europe,24 generating some USD 20 billion revenue in 2015.
The way in which hot springs are used in health tourism in numerous destinations around the
world is examined.25 They include those destinations which have natural thermal waters, whether
they are used for leisure, wellness and/or medical purposes. There is no global understanding
or definition of thermal or hot springs since the temperature and mineral content, as well as the
national level categorization of these springs differ greatly. The International Society of Medical
Hydrology and Climatology (ISMH) provides the platform for predominantly medical professionals,
physicians and balneotherapists to share their experiences and clinical research results. The
European Union Directive 2009/54/EC addresses the exploitation and marketing of natural mineral
waters, but it does not apply to the use of natural mineral waters at source for curative purposes
in thermal or hydromineral establishments.
Often the waters are used for healing, leisure and cultural purposes simultaneously, as many
tourists are curious about the tradition and do not have any specific or diagnosed health problems.
23 European Spas Association (2017), Who we are (online), available at:

www.europeanspas.eu/content/who-we-are/who-we-are (11-10-2017).
25 Erfurt-Cooper, P. and Cooper. M. (2009), Health and Wellness Tourism: Spas and Hot Springs, Channel View, Clevedon.
For example, although New Zealand Maori used hot springs for healing purposes, many tourists
visit them just for leisure and recreation reasons. This is a fairly typical visit pattern for many
historic spas too (e.g., in Budapest, Hungary) where foreign visitors go to the spas t mainly to see
and experience the beautiful heritage buildings. This creates some challenges for the collection
of health tourism data. The Japanese use their hot springs following the Onsen tradition, which is
based on healing and wellness: although often visitors may go just to experience a true Japanese
ritual (i.e., their motivation is more cultural). It can also be difficult to differentiate motivations in
Nordic or Baltic countries where tourists enjoy nature and landscapes as part of their holiday. Even
if they derive in health benefits, this does not make them health tourists as their primary motivation
is rural tourism rather than health improvement. In Iceland, for instance, visiting a thermal facility
is part of an everyday lifestyle and would not constitute a particular motivation for treating specific
or diagnosed health issues.
Example 4.5 Traditional hot springs in New Zealand
New Zealand is a destination where spa services are based on the assets of the natural environment, making bathing in natural
hot springs a key attraction. Maori residents have been bathing in the geothermal muds and sulphurous waters for over 700 years
for healing. In the late nineteenth century, the Government of New Zealand, realized the potential of the country’s mineral watersand
initiated a series of spa developments inspired on the great resorts of Europe. Rotorua in New Zealand has numerous hot springs
in its vicinity because of its volcanic landscape. Maori people were originally attracted to the springs and built whole villages in the
area. The British found the modern town of Rotorua in the 1830s and soon discovered the curative effects of the hot springs. The
first spa facility was initiated with the construction of Te Aroha’s Cadman Baths in 1898 in Waikato. In 2006 the local council made
the decision to restore the historical spa buildings, along with the order of building additional spa facilities with the view of possibly
making Te Aroha a more wellness-focused spa destination. Today the Te Aroha Hot Springs domain is unique in that it is the only
complete Edwardian domain in New Zealand. The mineral spa baths have retained their historic charm resulting in a resurgence
of visitation.
Source: Te Aroha (2012), Visitor Information (online), available at: www.tearohanz.co.nz (22-01-2018).
Hyde-Smith, M. and Hull, J. (2013), ‘Te Aroha wellness tourism: yesterday and today’, in: Smith, M.K. and Puczkó, L. (eds.), Health, Tourism
and Hospitality: Spas, Wellness and Medical Travel, Routledge, London, pp. 361–367.
In South Africa, hot springs have been used mainly for leisure purposes as there was no evidence
to suggest the waters had healing properties. Water could also be used for healing or medical
reasons.26
Example 4.6 South African Thermal Baths
South Africa has some 87 documented thermal springs (Tshibalo, Olivier and Venter, 2010)a, although only about one-third of these
have been developed into resorts of various sizes. Most of South Africa’s thermal springs, particularly those in the Western Cape,
have been used at some time in the past for medicinal purposes, both by European settlers after they arrived in the 17th century
and by indigenous tribes before them. However, the health spa tourism industry in South Africa is dominated by day spas, resort
spas and destination spasb. Medical surgical tourism is also growing quickly. There are currently very few links between South
26 Boekstein, M. (2013), ‘Revitalising the healing tradition: thermal springs in the Western Cape’, in: Smith, M.K. and Puczkó,
L. (eds.), Health, Tourism and Hospitality: Spas, Wellness and Medical Travel, Routledge, London, pp. 369–372.
Africa’s health spa industry and its thermal springs. While there are numerous thermal spring resorts in South Africa, only a few
offer health or wellness treatments. Eight different types of ‘medicinal’ thermal waters are distinguished in South Africa but require
further development for tourism.
a) Tshibalo, A.E.; Olivier, J. and Venter, J. (2010), ‘South Africa Geothermal Country Update (2005–2009)’, in: Proceedings World Geothermal
Congress 2010, Bali.
b) Global Spa Summit (2011).
Source: Boekstein, M. (2013), ‘Revitalising the healing tradition: thermal springs in the Western Cape’, in: Smith, M.K. and Puczkó, L. (eds.), Health,
Tourism and Hospitality: Spas, Wellness and Medical Travel, Routledge, London, pp. 369–372.
Bathing in hot springs has traditionally been connected to ritual bathing as part of religious or
spiritual practices, e.g., the Middle East, North Africa or Israel. Motivations of some visitors
may still be mainly religious, but this would open the door for the recognition of the the spiritual
dimension of health and wellbeing in definitions of health tourism. In countries like Uganda, it is
still believed that ancestors and spirits live in the healing waters.27
In many parts of the world it has become more fashionable to refer to natural spring water and
thermal bath-based tourism as ‘spa tourism’ as it is more marketable. However, this creates
confusion in the minds and experiences of consumers. The word ‘spa’ in most English-speaking
countries denotes a place of relaxation, luxury and pampering. Guests will not expect to find
medical healing waters, doctors and a hospital-like atmosphere. It is therefore better to separate
thermal baths which have medical or healing waters from the spa concept. Note that, for example
in Hungary, the Government introduced a very strict legislative system and medical procedure
to determine when a thermal spring can be called a medical (or healing) spring. Consequently,
thermal baths with certified medical spring(s) can become medical baths.
Tourists who use medical and thermal baths usually have a short-term or long-term medical
condition (often chronic) which is said to be cured or eased through a period of time spent in the
waters (and applying certain balneotherapies). This period of time and the type of water needed is
often prescribed by a doctor and supported by a government-funded social tourism scheme. This
is especially common in Central and Eastern Europe. However, the waters can of course be used
by any tourists without prescription or doctor’s recommendations, yet the time spent in the water
is usually limited, especially in medical or healing waters which contain minerals. Spending time in
thermal waters was shown to contribute to improved relaxation, social cohesion and happiness.28
The relevant legislation regarding how a hot spring can become ‘medical’ may differ from country
to country. A common expected clinical trial is conducted and should be able to provide the
evidence needed to approve the healing properties of the spring based on specific requirements of
the respective national institution or authority administering the certification. This can be essential
in countries where the national health insurance (co-)finances certain treatments provided at the
medical spring-based bathing establishments (e.g., Central and Eastern Europe, Ukraine or the
Russian Federation).
27 Tukamusaba, E. (2013), ‘Hot Springs in Uganda’, in: Smith, M.K. and Puczkó, L. (eds.), Health, Tourism and Hospitality:
Spas, Wellness and Medical Travel, Routledge, London, p. 66.
28 Puczkó, L. (2017), The Impacts of Thermal Spring Visits to Guests’ Wellbeing, unpublished study, Budapest.
Example 4.7 Tourism in thermal baths in the Czech Republic
The Czech Republic is famous for its healing waters and thermal baths. Today the so-called Czech ‘spa industry’ [note: spa in this
contect refers to baths] is considered to be one of the fastest growing industries. Mineral waters have been used for therapeutic
purposes since the beginning of the 12th century, traditionally Czech spa facilities offer balneotherapy, which involves complex
drinking and bathing therapies based on the use of mineral spring waters, peloids and natural gases. Drinking cures have been
used since the 16th and 17th centuries, and since the 18th century mineral waters have been undergoing chemical analysis in
order to prove their healing properties. By the beginning of the 20th century more than two hundred healing mineral water springs
were found in the Czech Republic. During the 19th and beginning of the 20th century most of the well-known spas and spa towns
were built. This includes the spa town of Frantiskovy Lazne in 1793 and the Marianske Lazne spa resort in 1808. Today, 37 spa
towns or health destinations exist in the Czech Republic. However, Karlovy Vary which means the “the baths of King Charles” is
the largest and most famous spa town in the Czech Republic. It was established in the mid-14th century. In this locality, 79 springs
can be found, 12 of which are used for drinking cures. The healing effects of the waters are related to their temperature; for
example, laxative effects are attributed to colder springs, whereas warmer springs have a calming effect, slowing down the
secretion of bile and gastric juices. Karlovy Vary’s spa facilities traditionally specialised in the treatment of digestive disorders,
metabolic diseases and problems of locomotion. Since 2011 the number of tourists has increased, especially from the Russian
Federation and Germany, and the majority stay in spa hotels. As a result, many new spa hotels are being opened.a
However, ethnographic research on health tourism in Marianske Lazne, a major thermal bath or spa resort in the Czech Republic
was undertaken.b In the past, tourists used to visit Czech spas for an average of three weeks and undergo various treatments
prescribed by the spa doctor. In fact, most traditional balneotherapy treatments used to entail four full weeks of specific treatments
and strict diet and exercise programmes. Today, packages are being shortened to two weeks and include wellness and beauty
treatments, as well as medical procedures.
a) Kondrashev, A. (2013), ‘History, Traditions and the Recent Trends in the Spa Industry in the Czech Republic’ in: Smith, M.K. and Puczkó, L. (eds.),
Health, Tourism and Hospitality: Spas, Wellness and Medical Travel, Routledge, London, pp. 329–333.
b) Speier, A.R. (2011), ‘Health tourism in a Czech health spa’, Anthropology & Medicine 18 (1), April, pp. 55–66.
Medical (and sometimes wellness) travellers visit not only thermal springs but healing caves and
microclimates (e.g., mountain areas), have thalassotherapy treatments by the sea, and healing
mud/peat/peloid treatments as well. Climate therapy or ‘climatotherapy’ has been used since
the 20th century for the treatment of various chronic inflammatory dermatoses and pulmonary
diseases. Climate therapy at seaside or mountain resorts has shown improvement in disease
activity and reduced corticosteroid use, for example, high altitude clinics were built specifically
for the rehabilitation of patients with asthma in mountain areas. The World Health Organization
considers thalassotherapy to be traditional medicine and includes it in the same category of
mineral waters.29 The WHO published its Traditional Medicine Strategy 2014–2023 in 2013,30
aiming at supporting Member States in developing proactive policies and implementing action
plans that will strengthen the traditional role medicine plays in keeping populations healthy.
Some recent studies have shown how health tourism using natural resources for healing is
becoming more evidence-based, including forest therapy in Japan or waterfall therapy in Austria,
for example.31
29 Charlier, R.H. and Chaineux, M.C.P. (2009), ‘The Healing Sea: A Sustainable Coastal Ocean Resource: Thalassotherapy’,
Journal of Coastal Research, 25, pp. 838–856.
30 World Health Organization (2013b), Traditional Medicine Strategy 2014–2023 (online), available at:
www.apps.who.int/iris/bitstream/10665/92455/1/9789241506090_eng.pdf (18-07-2017).
31 Steckenbauer, G.C. et al. (2017), ‘Destination and product development rested on evidence-based health tourism‘, in:
Smith, M.K. and Puczkó, L. (eds.), The Routledge Handbook of Health Tourism, Routledge, London, pp. 316–329.
Natural medical resources can provide a solution to diseases that cannot (yet) be completely
healed, e.g., psoriasis. Special treatments based on the Dead Sea or the healing mud of Harkány
(Hungary) can provide patients with long symptomless periods during which they can eliminate or
significantly limit medication. These qualities of natural healing have already become well known
and accepted in many countries, and are also expected to drive domestic and international
medical tourism in the future.
4.3.5 Retreats
There is an increasing number of retreats around the world offering holidays for people who want to
escape from everyday life, stress, and engage in processes of self-development. For example, The
Retreat Company represents more than 500 retreat centres in the United Kingdom and Europe.32
They reported that their most popular requests are for yoga holidays, followed by getaways into
nature, doing nothing at all, as well as detox programmes. Most retreats offer themed packages of
several days which have a specific goal, although many offer a combination of activities designed
to balance different domains. Retreats are mainly catering for wellness and holistic tourists who
are not ill but may feel unbalanced, stressed or in need of some personal time.
Retreat Finder with over 2,500 retreats lists at least twenty categories of retreat, including some
of the following:
–– Art;
–– Meditation;
–– Mens’/womens’ retreats;
–– Movement;
–– Nature/wildlife;
–– Outdoor/adventure;
–– Travel/pilgrimage; and
–– Yoga.
The main motivations for going to retreats are to unwind and de-stress; improve health; to improve
a specific practice (e.g., yoga);33 for social reasons; or spiritual reasons. “Retreats offer the benefit
of physical, emotional and psychological withdrawal from the stresses and strains of everyday life:
a chance to escape from the toxic effects of noise, information overload, unrealistic demands and
the frantic busy-ness of 21st century living; to enjoy a safe haven in which to start to recover from
trauma and to heal on all levels.”34
Retreats provide people the opportunity to resolve some of life’s challenges away from home,
especially at particular moments or stages in life (e.g., crisis, middle age).35 This is particularly
true for women. Retreat holidays can help to replenish areas of peoples’ lives that may become
32 Retreat Company (2017), Retreat Hideaways (online), available at: www.theretreatcompany.com (27-06-2017).
33 Kelly, C. (2012), ‘Wellness Tourism: Retreat Visitor Motivations and Experiences’, Tourism Recreation Research, 37 (3),
pp. 205–213.
34 Zega, K. (2010), ‘Holistic Benefits of a Retreat’, PositiveHealthOnline, 05–2010 (online), available at:
www.positivehealth.com (11-06-2017).
35 Kelly, C. and Smith, M.K. (2017), ’Journeys of the self: the need to retreat’, in: Smith, M.K. and Puczkó, L. (eds.),
The Routledge Handbook of Health Tourism, Routledge, London, pp. 138–151.
neglected due to social and technological forces, and may result in increased stress and decreased
social connection and community support.36
Example 4.8 One of the world’s first holistic tourism retreats: Skyros, Greece
The two Skyros Centres in Greece were set up in 1979 as holistic holiday retreat centres. New centres have been developed since
in other countries such as Thailand. Visitors stay for one or two weeks at a time and undertake a number of self-selected courses
and workshops that are designed to balance body, mind and spirit. Participants can take a range of psychological, therapeutic,
creative, communicative or active courses, usually two per day for five days. Participants are also encouraged to engage in
morning Demos – a community meeting led by a different participant each day, Oekos – an open group discussion / listening
forum, co-listening with one other participant, and work groups based on different collective tasks, and evening and weekend
social activities. The aim of this structure is to create strong bonds between the community members, and to encourage an
atmosphere of support, trust, and openness. Skyros attracts a wide range of people. The majority are professionals (e.g., teachers,
lecturers, doctors, nurses, business and media people). Approximately 70% of participants are in their thirties or forties. Many also
have ‘life issues’ to resolve or may be on the brink of burnout. The ethos behind Skyros is to create more than just a holiday, which
explains why many participants claim to find it so life-changing, and more than 30% visit again. Skyros ‘aftercare’ is excellent. It
includes a letter to all participants, invitations to reunions and social events, and website chat rooms and notice boards.
Source: Skyros (2017), Europe’s Leading Learning Holiday (online), available at: www.skyros.com (16-06-2017).
Sometimes, holistic activities may be categorized as ‘New Age’ because they offer an alternative
perspective on mainstream approaches to health improvement.
Example 4.9 New age centres in Costa Rica
Costa Rica is becoming one of the leaders in sustainable tourism development in the world. It was the leading country in the New
Economic Foundation’s Happy Planet Index which measured wellbeing, longevity and carbon footprint.a Consequently, there are
a number of sustainable wellness resorts and eco-spas in Costa Rica. Organic farms and New Age centres are growing in Costa
Rica.b These are located in rural areas close to nature parks or protected areas. The food is usually home-grown and organic and
gardening may be one of the activities offered to visitors. There is a strong sense of community and alternative lifestyles. Many of
them offer holistic activities. Costa Rican New Age Centres have a high sense of sustainability and eco-friendliness that also
outreaches to local communities. For example the farm VerdEnergia Pacifica produces stoves that burn (used) vegetable oil and
which are distributed among the poorer population in the countryside as a cheap alternative for cooking, as part of their sustainable
development initiatives.c
a) Saamah A. et al. (2012), Happy Planet Index: 2012 Report. A global index of sustainable well-being (online), available at: www.static1.squarespace.
com/static/5735c421e321402778ee0ce9/t/578cb7e8b3db2b247150c93e/1468839917409/happy-planet-index-report-2012.pdf (10-07-2017).
b) Gisolf, M.C. (2013), ‘A new age in tourism: a case study of New Age centres in Costa Rica’, in: Smith, M.K. and Puczkó, L. (eds.), Health, Tourism
b) Gisolf, M.C. (2013).
36 Glouberman, D. and Cloutier, J. (2017), ’Community as holistic healer on health holiday retreats: the case of Skyros’, in:
Smith, M.K. and Puczkó, L. (eds.), The Routledge Handbook of Health Tourism, Routledge, London, pp.152–167.
4.3.6 Conclusions
Figure 4.5 summarizes how the supply of health tourism can be structured. The interrelationships
and overlaps of the various forms of establishments are related to the typology of health tourism.
It is understood that there are several forms of facilities that could provide services in many arenas
of health tourism (e.g., cruises can be as specialised as wellness cruises, but can also host spas,
IVF clinics, dental or plastic surgery clinics). It is recommended to define and clarify the core
market and type of health tourism any facility intends to access and target.
Figure 4.5 Supply of Health Tourism
Health tourism

Concepts
Medical wellness
Holism
Spiritual
MedSpas Thermal medical spas (Baths) Hotel and day spas
Destination spas
Medical hotels and resorts
Wellness hotels and resorts

Supply
Longevity centers Leisure baths
Hospital and clinics
Retreats
Cruises
Healthy hotels and H2H conversions
Note: The length of boxes indicates how much of the health tourism spectrum the actual component can cover (e.g. “medical wellness” or “holism”).
Holism is a very broad phenomenon, reflected in the length of the box, whereas medical wellness includes some of medical and some of wellness.
Figure 4.5 makes an attempt to list and structure the supply of health tourism. Following the logic
of the suggested taxonomy, the facilities and service providers are categorized according to their
most typical or core service offer. The suggested structure of supply highlights the complex nature
of how health tourism services can be offered in various types of establishments. The boundaries
are not always clear and a certain establishment can provide services for more than one form of
health tourism. This does not necessarily make the operation, management and marketing of these
establishments easy. However, the need for sustainable, profitable and successful operations can
sometimes force overlaps and fusions.
Figure 4.6 provides another view of the supply. This approach helps NTOs and DMOs (and their
industry partners) to identify where any facility or supplier may fall. It is essential for any player
in health tourism to understand the key asset or resources they may use. It will be shown in the
Demand section that customers are becoming savvier and look for services, brands and facilities
that represent values they really appreciate, i.e., evidence, personal benefits and local assets,
traditions and rituals.
Figure 4.6 Asset-based categorization of the supply of health tourism
–– Thalasso centres/spas and hotels –– Thermal baths and hotels

–– Longevity centres
–– TCM/TKM centres/hospitals –– Healing nature
–– Destination spas
–– Ayuverdic clinics –– Ashrams and retreats
–– Medical baths/caves –– Eco spas and wellness centres
Evidence and Evidence and

local asset-based local asset-based
medical interventions wellness treatments
(non invasive) and facilities
and facilities
Generic and Generic and

infrastructure-defined infrastructure-defined
(invasive) medical wellness treatments
interventions and and facilities
facilities
–– Hospitals –– Dayspas
–– Clinics –– Hotel spas and spa hotels
–– Medical spas –– H2H conversions –– Wellness hotels and cruises
–– Cosmetic surgery clinics –– Healthy hotels –– Beauty clinics
–– Dental clinics –– Wellness centres
4.4 Demand for health tourism
Several recent studies and reports suggest that health motivation is relatively new, a recent
trend. History proves otherwise. Healing traditions, wellness practices and wellbeing rituals have
marked the history and heritage of several cultures and regions. The Ancient Greeks visited Delphi
searching for spiritual help, the Romans enjoyed thermal (hot) springs and benefited from their
healing characteristics in Caracalla Therme (Rome) and developed purpose built facilities for
soldiers from Bath (United Kingdom) to Aquincum (Hungary). Traditional Chinese Medicine, as
well as Ayurveda has thousands of years of history. Avicenna (or Ibn Sina) compiled the healing
and medical practices of Islam and Persia back in 670 A.D. First the ruling class, and facilitated by
the arrival of trains, the working class travelled to the mountains or to the seaside to enjoy clean
and purifying air (e.g., seaside towns in England or the Mediterranean and Alpine resorts). Former
socialist regimes provided special schemes for the working class, children and the elderly to visit
destinations based on natural healing assets. Travelling for some kind of health motivation is not
new: it is a fundamental motivation for travellers.
Example 4.10 Visa facilitation in Thailand to boost medical visitors
Thailand is an example of a country which successfully offers and promotes the whole range of medical, wellness and spiritual
tourism products. Thailand is known as a centre of ancient healing traditions and techniques which ranges from Thai massage, to
meditation, to herbal medicine, and other holistic practices.
Thailand seeks to promote itself as Asia’s anti-aging centre, boasting 500 medical specialists in this sector.
In 2017, the Government approved 90-day visas for patients and medical visitors from Cambodia, Laos, Myanmar and Viet Nam,
as well as from the People’s Republic of China in a bid to boost Thailand’s medical tourism.
Long-stay 10-year visas are now available for senior nationals of 14 countries including: Japan, Australia, Denmark, Finland,
France, Germany, Italy, Netherlands, Norway, Sweden, Switzerland, the United Kingdom, Canada and the United States of
America.
Source: Tourism Authority of Thailand (TAT).
4.4.1 Motivations for health tourism
Interviewees were asked to comment on what they thought to be the main motivations and
drivers of health tourism. This included both ‘push’ and ‘pull’ factors. It can be seen that price or
affordability was considered the most important aspect (especially for medical tourism), as well as
the quality of products, services and environment. Accessibility of location, as well as the availability
of treatments not available at home or elsewhere was also significant. The reputation and success
of doctors or medical personnel could also influence potential tourists, especially through word-
of-mouth, as well as easily accessible information about places, products and treatments. Some
location-specific factors were mentioned such as climate, atmosphere, traditions and rituals.
Respondents were also asked to identify what they perceived as the main determinants for
attracting tourists to health tourism. Their responses are summarised in the word cloud below.
Interestingly, some of the determinants are

similar to the push and pull factors, but of
course, if the price is too high and location is not
accessible, safe, hospitable or attractive, tourists
will refuse to come. Marketing is seen as the
biggest challenge and communicating properly
what is available.
Health in general is associated with increasing

Main challenges to attract health, tourism according to
value, for example, LOHAS represents that value
interview respondents.
change. LOHAS is an acronym for Lifestyles of
Health and Sustainability, which is a market segment that mainly focuses on health and fitness,
the environment, personal development, sustainable living, and social justice.
Example 4.11 A sustainable spa brand: Six Senses Spa and Resorts
Six Senses Spa and Resorts aim to give a whole new perspective to high-end hospitality. According to the founder and CEO, the
aim is “to create innovative and enlightening experiences in a sustainable environment”. Six Senses is built on the philosophy of
‘SLOW LIFE’; an acronym for sustainable, local, organic, wholesome, learning, inspiring, fun, experiences. The management
philosophy focuses on the rapid evolution of consumer demands and trends: “We are acutely perceptive as to what our market
wants. Not only do we anticipate client demand, we very often go to the next level and actually create demand through innovation.”
Great importance is placed on highly creative concept development which is sensitive to the location and incorporates local
culture and design. Employees are recruited based on shared values, as a means of reinforcing the group’s successful philosophy.
They also aim to create an environment of respect, trust and care through education and training, rewards and career opportunities.
The company works on the basis of providing exceptional experiences customers are looking for. This becomes more challenging
in a competitive industry, but is executed through differentiation of products and by focusing on the harmonisation of the five
senses.
Source: Six Senses (2013), A refreshing reinterpretation of hospitality (online), available at: www.sixsenses.com/about-us/about-us (19-06-2017).
People need to shift from considering health-span and not necessarily lifespan.37 They highlight
that different parts of the body and brain mature at different rates, so it is very difficult to say what
human ‘peak age’ might be. It is widely assumed that the ageing process is a fixed process, once
the peak is reached, an irreversible decline begins. It is quoted that the global market for anti-
ageing products, technologies and services is expected to grow from USD 282 billion in 2015, to
USD 331 billion in 2020. The World Economic Forum anticipates that many people would prefer to
“die young as late as possible”, but while people are living longer, many are living ‘sicker’.
An increasing number of countries have become interested in health tourism (while, however,
defining it mainly as medical tourism). It is anticipated that there can be a significant growth
segment potential. Some interesting cases are cited below:
–– Health tourism in Spain in 2015 accounted for more than EUR 500 million. More than
100.000 foreign patients travel to Spain searching for health treatment. The health tourist
tends to spend 6 to 10 times more than the average. Thus, health tourism has turned being
an important pillar to reinforce and boost the Spain brand. According to estimates, the
health tourism market in Spain has a growth potential of 20% a year. The umbrella body,
SpainCares, intends to provide a platform for cooperation for a wide spectrum of service
providers from hospitals to thermal facilities.38
–– Medical tourism in the Russian Federation is traditionally more related to sanatoria,

generally old renovated sanatoria from the Soviet era. Treatment in such sanatoria, classified
within ‘other spas’, is more associated with rest, recovery and convalescence than particular
treatments. In 2015 medical tourists added RUB 7 billion to RUB 10 billion (USD 108 million
to USD 154 million) to the state budget.39
37 Hewitt, J. (2017), ‘How to grow old like an athete, 2nd February’, World Economic Forum, 02-02-2017 (online), available at:
www.weforum.org/agenda/2017/02/healthspan-vs-lifespan (12-07-2017).
38 SpainCares (2017), Welcome to SpainCares (online), available at: www.spaincares.com/en (28-06-2017).
39 Pontus, Y. (2016), ‘Russia becoming more attractive as medical tourism destination’, Russia Beyond, 19-09-2016 (online),
available at: www.rbth.com/business/2016/09/19/russia-becoming-more-attractive-as-medical-tourism-destination_631159
(18-06-2017).
–– According to the Chinese Tourism Agency primarily traditional Chinese medicine-based

services and centres attract international tourists to China with Hainan, Shanghai and Beijing
being the most popular destinations.40 It is interesting to note that the Chinese are important
medical tourists, too. It is suggested that by 2020 approximately 800,000 Chinese medical
tourists will travel abroad seeking health care services within Asia (e.g., to the Republic of
Korea, Thailand, India or Singapore) but also taking longer distances to the United States
of America, Germany or the United Kingdom.41 The number of Chinese who have received
medical care in the Republic of Korea alone is estimated at 56,000 spending USD 1 billion
in hospital fees in 2016.
–– As a private initiative, Portugal launched a portal dedicated to wellness. The new portal
tripforwellness.com, whcih is licensed by the Portuguese tourism board, enlists a wide
range of services from spa breaks, beach spas, thalassa, medical, as well as holistic and
eco facilities and packages.
Example 4.12 The promotion of health tourism in Argentina
Health, wellness, spa and thermal are among twelve selected niches that Argentina’s tourism organization Inprotur is looking to
highlight as part of its Argentina Authentic campaign. To promote tourism to thermal spas, the country is promoting its 40 thermal
spas with water of volcanic, magmatic or telluric origins to help treat ailments such as illness of the skin, bones, digestive,
breathing and circulatory systems. Meanwhile, for medical tourism, Inprotur is emphasizing the quality, professionalism and high-
tech services of its hospitals and clinics. The country’s tourist organization sees huge potential in luxury travel, with the niche
aimed at those who can afford to stay in a five-star hotel and want tailor-made services as opposed to package travel. In 2017,
Argentina was focusing on medical services, as well as the rich provision of thermal resources in its communication for international
tourists – calling it ‘Life, Beauty and Well-being’.
Source: Instituto Nacional de Promoción Turística (2017), Argentina is Health (online), available at:
http://turismomedico.turismo.gob.ar/en/turismomedico (09-01-2017).
Interestingly, according to Euromonitor International,42 the impact of the global economic crisis,
along with hectic lifestyles and increasing urbanisation are just some of the factors behind the
trend towards increased spa demand and personal wellness lifestyle trends. Consumer price
sensitivity has increased and more than ever consumers are demanding high quality services at
more affordable prices.
Demographic segments are clearly important such as age, gender, income level, life stage,
geography, education, culture or religion. In addition, psychographic segments have become even
more important for wellness tourism analysis such as lifestyle, values, occupation, personality
and hobbies. Life-stage is an important determinant of consumer and tourist behaviour. Younger
people, single and childless people may have very different needs to those in a relationship or
40 Chinese Tourist Agency (2016), Medical Tourism Booming in China (online), available at:
www.chinesetouristagency.com/medical-tourism-a-new-form-of-tourists/ (11-08-2017).
41 China News (2016), Top 8 outbound medical tourism hotspots for China’s affluent (online), available at:
www.list.juwai.com/news/2016/10/top-8-outbound-medical-tourism-hotspots-for-china-s-affluent (17-07-2017).
42 Euromonitor (2016), Global Economies and Consumers in 2017 (online), available at:
www.go.euromonitor.com/rs/805-KOK-719/images/WP_Global_Economies_and_Consumers_in_2017.pdf (20-06-2017).
married, have families or are in the later stages of their life. For example, young people may have
relatively few physical health issues, will be unencumbered by family responsibilities, tend to
have more free time but generally have less spending power. Most likely, they travel with friends
seeking fun (e.g., in aqua parks or fun waters), music festivals perhaps with chill-out zones, or in
some cases to backpack in spiritual destinations (e.g., India) and try out yoga, meditation or other
practices which are associated with a ‘cool’, hippie-like identity. Busy middle-aged executives
tend to have very little spare time because of long working hours and family responsibilities,
but have high spending power and a willingness to pay for short term pampering and luxury
(e.g., day or weekend spas and massage) or work/life balance courses and stress management
(e.g., life-coaching).
Elderly travellers have less spending power but more time, and they may suffer from more
physical health issues. Therefore, medical spas or wellness cruises may provide the best form of
relaxation, although physical mobility problems may hinder their ability to travel. Pregnancy makes
women more aware of their bodies, many tend to eat more healthily, give up smoking, alcohol and
caffeine and tend to begin a programme of specialised exercise (e.g., yoga, Pilates, swimming).
Turning 40 or 50 can make people aware of the need to look after themselves as they reach middle
age, and so-called mid-life crises are not uncommon, often resulting in the desire to retreat for a
while. Many people also have a kind of epiphany if they have a serious illness and start to look
after themselves better and to value every moment of their life. Senior tourists tend to appreciate
the spiritual benefits of travelling more than other groups.43
Although the profiles and characteristics of different segments based on demographics

may seem to be ‘old-school’, there are certain trends that can be relevant to most countries
[note: contemporary segmentation approaches tend to be based on lifestyles, but such market
information are very country or destination specific and leave little room for generalisation, not
even at European level].
Women still are the most important target segment of health services. The ‘women’ segment
however is composed of very distinct sub-segments, based on their needs or life-stage, such as
pregnant women, mothers with children, or so-called PANKs segment (professional aunt, no kids:
women over the age of 18 with no children, but who have a close relationship with children of
friends or relatives.44 Women, and especially middle-aged women, are particularly drawn to spas,
wellness and retreat activities. This includes body dissatisfaction especially after childbirth and in
middle age, the juggling of different roles, especially as carers of children while working, as well
as menopause and the changes this engenders.45
Men are increasingly becoming an important part of the spa guest mix, and the industry continues
to adjust its offerings and marketing efforts accordingly. The global assumption that the spa market
is overwhelmingly female is simply not true, especially in countries which have thermal and hot
spring baths (e.g., Japan, Hungary). In urban hotels and those that cater to business travellers,
the gender split is often closer to 50/50, and in some cases, male spa clients outnumber female
43 Moal-Ulvoas, G. and Taylor, V.A. (2014), ‘The spiritual benefits of travel for senior tourists’, Journal of Consumer Behaviour,
13, pp. 453–462.
44 Euromonitor (2013), World Travel Market, Global Trends Report, WTM.
45 Kelly, C. and Smith, M.K. (2017).

clients. One of the Spa Industry Association’s top-3 trends for 2016 was to focus more on men
and to add some additional ‘male centric’ services such as sports recovery massage.46
Seniors as a particular group of consumers are highly interested in maintaining a healthy lifestyle
and a certain level of vitality long into their retirement. Today’s ageing population is also highly
educated because of the increasing amount of information available to them.47 The key sectors
benefitting from an ageing demographic are:48
–– Nutrition;
–– Health care;
–– Technology;
–– Financial services;
–– Transportation;
–– Household goods;
–– Wellness and fitness;
–– Beauty and personal care; and
–– Leisure and recreation.
Generation X (born: 1966–1976) is savvy when it comes to spa or wellness usage. According to
Hilton’s research data, this generation is up to speed on the latest spa offerings. With this comes
an increasing need for spas to be prepared to answer detailed and pointed questions about
their offerings. Generation X tends to be sceptical and take a ‘prove it to me’ approach to new
treatments and services. As they can also be hyper-critical, it is crucial to both set the expectation
and to deliver on that expectation”49.
Generation Y or Millenials (born: 1977–1994) are those who are most likely to grow up with
better health consciousness than their parents. In Western societies, green or eco-orientation
influenced this segment and so did consumerism. They are confident and experienced travellers
and consumers who tend to know what they want and need. They are comfortable with modern
technology but also appreciate ‘traditional’ approaches and can enjoy the benefits of the slow
movement, too.
Generation Z or post-millennials (born 1995–2012) are the ultimate modern consumer as they
are generally well-informed, mobile, online, love to buy and enjoy life. This group has an awareness
of spas as a day-to-day necessity and is unafraid to try ’the new thing’. More than any other, this
generation is focused on immediate results. As Hilton states they are the youngest spa guests,
the industry needs to keep a close eye on this generation as they will be shaping spa trends for
years to come50.
46 Spa Industry Association (2016), Top 3 trends for the spa and wellness industry in 2016 (online), available at:
www.dayspaassociation.com/top-3-trends (16-06-2017).
47 Agritourism and Agri-Food Canada (2011), Health and Wellness Trends for Canada and the World (online), available at:
www.ats-sea.agr.gc.ca/inter/4367-eng.htm (19-06-2017).
48 Euromonitor (2016).
49 Hilton (2012), Blue paper, Emerging global trends (online), available at:
www.hiltonglobalmediacenter.com/assets/HILT/docs/bluepapers/Spa/SpaBluePaperEnglish.pdf (13-07-2017).
50 Hilton (2012).
Millennials are more likely than any other generation to feel less connected to a local area. Just
under a quarter (24%) of the millennials agree51 that they feel more connected to an online
community than they do to people in their local area, compared to 9% of travellers aged over 65.
While a minority of Millennials say they feel connected to their local area, for a significant majority
this is not the case. Millennials are interested in relationships; they just see them differently. The
“kinship economy” means that relationships are critical. However, in today’s world, relationships
are created differently depending on the person. This is a particularly challenging situation in
several Asian societies that became very tech-savvy and often materialistic as well.
Every wellness element in hotels, spas and retreats, from healthy food to fitness classes to
spiritual healing, ranked as more important for younger travellers 49 and under, Millennials) than
for Baby Boomers (50 and older).52 Whereas the most desirable property types for Baby Boomers
are luxury spa resorts, Millennials and generation X, prefer eco/adventure resorts and authentic
yoga retreats.
Global brands (including hotel brands) should build trust by offering advice and guidance tailored
to individual needs and preferences.53 For the next generation of millennial travellers, this means
giving them the tools to discover for themselves. The “new global explorers”54 of travellers
originating from emerging economies have higher expectations for personalisation than travellers
from developed markets: 78% of Russian Federation and 64% of Chinese expect a hotel to tailor
the experience they have to their personal needs, compared to 43% of the United States of
America and 42% of United Kingdom travellers.
4.4.2 Cultural, regional and national differences
Ideally, more research about guests of different nationalities is needed as their understandings,
perceptions and expectations of health experiences are likely to differ. Individualistic cultures may
prefer to visit the spa alone and in silence. On the other hand, more collective cultures may prefer
to be in groups or with friends. Russian Federation visitors sometimes like to drink and party in
spas. Also, in Asian cultures, it might be expected that employees socialise with their boss or
senior colleagues in the spa. There may also be food preferences depending on religion or culture
(e.g., kosher, halal, vegetarian). Guests from Central and Eastern Europe, Baltic States or former
Soviet Union countries will be familiar with the thermal medical bath tradition, whereas guests
from other countries (e.g., Western Europe or United States of America) may not.55
51 Intercontinental Hotels Group (2012), Creating “moments of trust” The key to building successful brand relationships in the
Kinship Economy (online), available at:
www.ihgplc.com/news-and-media/news-releases/2015/ihg-trends-report-challenges-brands-to-build-trust-capital
(20-07-2017).
52 Spa Finder Wellness 365 (2016), 2015 State of Wellness Travel Report: Part II (online), available at:
http://spaindustry.ca/files/file/Business%20Tools/sfw_wellnesstravelreport091415final.pdf (21-06-2017).
53 Intercontinental Hotels Group (IHG) (2012).
54 Ibid.
55 Tooman, H.; Tomasberg, K. and Smith, M.K. (2013), ‘Cross-Cultural Issues in Health and Wellness Services in Estonia’, in:
Kandampully, J. (ed.), Service Management in Health and Wellness Services, Kendall Hunt Publishers, Dubuque,
pp. 347–361.
Cultural issues can be important in medical tourism, especially for those tourists who decide
to go back to their country of origin because they feel more comfortable, or for those who have
specific religious preferences and needs.56
Nationality can be a very significant element in analyzing tourist needs, but other factors such as
religion and age need to also be taken into account. Health care providers should consider some
of the following expectations when treating Muslim patients:57
–– Special diet;
–– Gender issues;
–– Availability of the information regarding the location;
–– Direction to Mecca; and
–– Hygiene issues for prayer and cleaning.
A more detailed overview of the needs of Muslim guests within the medical, wellness and spa
sectors is provided.58 They emphasise the need to provide female doctors in hospitals, as well as
prayer facilities, halal food and copies of the Koran. Many of the main growth markets for medical
tourism are coming from or to the Middle East, as well as to Muslim countries in Asia such as
Malaysia, so therefore it is critical to consider many of these issues. It could even mean branding
and certifying hospitals and health care facilities as Halal (e.g., like the Halal Certified Medical
Hospital facility in Chennai, India). Halal spas are also becoming increasingly popular and offer
unique services.
Islamic spas should follow certain principles of ISP (Islamic spa practice):59
–– Designing the space so that it is closed and hidden from the view of non-Muslims;
–– Segregation of men and women;
–– Employees and therapists in a womens’ spa should be women;
–– Women can beautify themselves but it should be moderate and not exceed Islamic limits;
and
–– Beauty products should be from halal sources.
Cultural and national differences might also be typical of different regions of the world. It is
possible to consider some parts of the world in terms of their regional assets, as well as their
traditions. For example, there are some resources and assets that are specific to certain regions
(e.g., Europe, the Baltic States, the Balkans, the Nordic region). Europe has rich traditions and a
very wide range of services and products already available for health tourism. As an indication of
how important regional differences are, a short overview of all these differences is presented from
Northern, Western, Eastern and Southern Europe.
56 Ormond, M. (2013), ‘Claiming ‘cultural competence’: the promotion of multi-ethnic Malaysia as a medical tourism
destination’, in: Hall, C.M. (ed.), Medical Tourism: The Ethics, Regulation, and Marketing of Health Mobility, Routledge,
London, pp. 187–200.
57 Younis, M.Z. (2011), ‘Muslim Patients’, EMTC2011, 28-04-2011, Barcelona.
58 Smith, M.K. and Hindley, C. (2017), ‘Halal Tourism’, in: Al-Riyami, H.; Al Muhrzi, H. and Scott, N. (eds.), Tourism in the Arab
World: An industry perspective, Channel View, Bristol.
59 Yaman, R.; Ishak, N. and Alias, Z. (2012), ‘Beauty treatment & spa design from Islamic perspective’, Procedia – Social and
Behavioral Sciences, volume 50, p. 492.
Table 4.4 Regional differences in European health tourism

Northern Europe Southern Europe
–– Landscape-based tourism (e.g., fjords, lakes, forests) –– Traditional and contemporary approaches in parallel
contributing to lifestyle and wellbeing (e.g., thermal baths and holistic retreats)
–– Active outdoor recreation (e.g., Nordic walking) –– Primary emphasis still on treatments and therapies for the
–– Healthy gastronomy based on fresh fish, berries, rye physical body
and oats –– Thermal facilities usually offer medical treatments
supervised by health care practitioners
–– Home of saunas
–– Cold water treatments (e.g., Lake Wellness) –– Revival of thalassotherapy
–– Development of healing landscapes –– Home of the ’Slow’ movement
–– Abundant geothermal resources (with hydrotherapy –– Mediterranean diet contributing to wellbeing

and recreation focus) –– Destination of intra-European holistic travel
–– Protestant simplicity influencing lifestyle and healing –– Luxury hotel and resort spas
practices
Western Europe Central and Eastern Europe
–– Preventative focus based on lifestyle –– Medical (curative) focus with evidence-based approaches
–– Emphasis on mental, as well as physical health –– Emphasis on treatments and therapies for the physical
–– Lifestyle-based approach to health and wellness body
–– Complementary and alternative (drug-free) treatments –– Limited application of lifestyle-based wellness

growing in popularity –– Mainly conventional medicines administered by doctors or
–– Thermal baths or spas tend to offer relaxation and through pharmacies
beauty treatments –– (Public) Baths offer medical treatments supervised by
–– Medical destinations and thermal bath towns practitioners
–– Maturing hotel spa and spa hotel, pleasure bath –– Medical bath destinations
market (with signs of saturation)
Source: adapted from Smith, M.K. and Puczkó, L. (2009), Health and Wellness Tourism, Butterworth Heinemann: Elsevier, London.
The table summarizes the key factors and influential trends that shape the offer and development
of health tourism in Europe. It should be noted that this summary indicates how complex and
different the approach to health tourism can be even within one region.
The same is true for other regions, for example, the Baltic States (Estonia, Latvia and Lithuania),
which focuses mainly on their thermal baths and spas, sauna traditions and mud therapy, but with
future potential for more thalassotherapy or forest therapy.60 Some research-based generalisations
can also be made about the Balkan region too, where many of the countries have an abundance
of thermal waters, but many of which have not been fully developed for tourism purposes. The
Balkan region overall is rich in other natural resources, as well as thermal waters, such as sea
coasts, mountains, forests and an abundance of herbs and plants which can be used for both
cuisine and healing.61 The same can be said from the Black Sea and the Caucasus Mountains,
e.g., more than 2000 springs were discovered in Georgia, with healing mineral waters and suplhur
baths.
60 Smith, M.K. (2015), ‘Baltic Health Tourism: Uniqueness and Commonalities’, Scandinavian Journal of Tourism and
Hospitality, 15 (4), pp. 357–379.
61 Smith, M.K. et al. (2015), Balkan Wellbeing and Health Tourism: Final Report, Budapest Metropolitan University, Budapest.
Country-by-country and destination-to-destination analysis can identify further differences. These

differences are great assets both for international and domestic tourism since destinations (and
facilities) can create their own unique offers and specializations (e.g., signature treatments). Market
developments nevertheless show a great deal of generalization and standardization, e.g., widely
available wellness centres and spas in most hotels, which tend to be almost identical. NTOs and
DMOs need to consider local assets and benchmark intelligence when advising service providers
or creating marketing or branding messages.
4.5 Demand for wellness tourism
One of the Top 10 Global Consumer Trends identified by Euromonitor is ‘Wellness as a Status
Symbol’.62 Healthy living is becoming a status symbol, as more consumers opt to flaunt their
passion for wellness through paying for boutique fitness sessions, ‘athleisure’ clothing, food with
health-giving properties and upscale health and wellness holidays. Wellness holidays promote the
idea that consumers can take some time off, transform themselves and return as a better, happier
person – as ‘wellness leisure’.
Global wellness economy enables consumers to incorporate wellness into their lives – how they
live, work, play, and travel.63 A number of wellness services are listed that tend to be incorporated
to wellness tourism products. Although this list is not exhaustive, it covers most of the main
activities.64
–– Body and facial beauty treatments;
–– Water-based and sweat-bathing treatments and facilities;
–– Manual pressure based and manipulative body-based therapies;
–– Herbal medicine and natural remedies;
–– Healthy nutrition and diet;
–– Exercise and fitness;
–– Mind/body interventions;
–– Meditation and relaxation techniques;
–– Expressive therapies and creative arts;
–– Energy therapies; and
–– New age educational activities such as counselling and workshops.
However, couples became the number one segment for wellness and spa services followed by
groups of friends, and families.65 Some sources also suggest that the number of men who are
interested in spas is increasing, especially in Germany and Spain.66
According to the Global Wellness Institute, the global wellness economy was estimated at
USD 3,400 billion in 2013 and USD 3,700 billion in 2015 while wellness tourism reached
62 Euromonitor (2017), Top 10 Global Consumer Trends for 2017, Euromonitor, London.
64 Voigt, C. (2013).
65 The Tourism Observatory for Health, Wellness and Spa (2017).
66 Mintel (2011), ‘Spa Life UK’, UK Spa Life Conference, 8 November, Elveden.
Euromonitor (2011), Global Medical Tourism Briefing: A Fast Growing Niche Market, Euromonitor International, London.
USD 494 billion in 2014 and USD 563 billion in 2015.67 The number of international wellness trips
is estimated at 116 million and domestic trips at 575 million resulting in USD 187 million and
USD 376 million expenditure, respectively.
It should be noted that these assumptions include so-called secondary wellness tourism,
i.e., guests with other motivations opting for a spa or wellness treatment during their stay. The
total data includes the spa or wellness demand of those who are on a business, cultural or any
other type of trip, too.
If only the primary motivation was considered, the relevant share of wellness tourism would be
13% of the suggested total figures of the total number of wellness trips. Primary demand is
estimated at 7% (691 million trips) and 16% (USD 563 billion) of total expenditure.68 The United
States of America is by far, the largest wellness tourism market today, generating USD 167 billion
in 2012 and 202 billion expenditure in 2015 combining international and domestic expenditures
annually.69 It is suggested that international wellness tourists spend 61% more than other forms
of tourists (spending approximately 1,900 USD per trip). There are significant differences in
terms of spending capacity by nationalities. In German-speaking countries foreign tourists spent
USD 140 per day, in Spanish-speaking countries it can reach as high as USD 195, whereas in
Russian-speaking countries USD 160. Wellness tourism expenditure is expected to generate as
much as USD 1.6 trillion combined direct, indirect and induced impact70 (i.e., including direct
spending on services and products, as well as further spending by service providers and
employees on other services and products).
4.5.1 Motivations, segments and profiles
Travelling with the motivation of wellness is not independent from the motivation of visiting spas
(e.g., hotels, resorts, etc.). The difference is that wellness is a concept while spas are venues
or facilities. The industry is not altogether in agreement about the connection between spas
and wellness, but it is generally accepted that wellness services and treatments take place in
various forms of facilities, most of which are spas. Therefore, the market overview of wellness will
incorporate spa-related information, too. Models and benchmarking information for motivation
of wellness tourism is not widely available and the related data are not always very up-to-date
and the categorization differs from country-to-country or research-to-research (partly a result of
different understandings and definitions).
Countries, destinations and companies create their very own segments and profiles. Since the
market is very much differentiated by culture, location and traditions, this is understandable.
68 Global Wellness Institute (2013), The Global Wellness Tourism Economy, GWI, New York (online), available at:
www.globalwellnesssummit.com/images/stories/pdf/wellness_tourism_economy_exec_sum_final_10022013.pdf
(02-07-2017)

Nevertheless, due to the wide range of segmentation practices, approaches and typologies, it
is very difficult to identify clear target segments, especially for a foreign market. Below, some
relevant segmentation and motivation approaches from the wellness, spa and retreat market are
introduced.
Three different types of wellness tourists in Australia are identified:71

–– Beauty spa;
–– Lifestyle resort; and
–– Spiritual retreat visitors.
Although all participants in the study were seeking transformation of the self, each group of tourists
placed different emphasis on physical, psychological or spiritual transformations. Each group also
differed significantly in terms of their demographic and travel behaviour characteristics.
Although much of the research on spa consumers is not directly related to tourism, it can be
assumed that the profiles and motivations are broadly similar. Spa data demonstrates that the
majority of spa goers still tend to be women, e.g., in spas in the United States of America around
78% are women.72 However, women tend to travel in groups or with a man when they travel for
wellness.73 The number one reason that people go to a spa is to reduce or relieve stress and
relax.74 Spas offer a precious refuge and safe space in which to disconnect from the world and
technology, to be touched and cared by another person, and to bring the mind, body and spirit
back into alignment.75 Spa goers are segmented and identified by four motivation factors:76
1. Social;
2. Relaxing;
3. Healthy; and
4. Rejuvenating.
The share of core wellness and spa visitors (travelling with a real motivation of health), constituted
only 12% of domestic travellers. This raises the question: how the general trends for a healthier
lifestyle can actually be translated into healthier trips? The classification of ISP77A categories is
applied where core customers are those who believe that spa/wellness is an important part of their
lifestyle, mid-level customers are interested in learning about spa and wellness but have limited
commitment and peripheral customers enjoy spa and wellness services, but altogether show
little interest.78 The data show that international visitors possess a strong dedication to spa and
wellness, whereas domestic visitors are only moderately dedicated.
72 International Spa Association (2011).
73 Spa Finder Wellness 365 (2016).
74 International Spa Association (2013c), Why Spa? (online), available at: experienceispa.com/resources/spa-goers
(27-06-2017).
75 McCarthy, J. (2013), ‘The Psychology of Spas & Wellbeing’, Psychology of wellbeing (online), available at:
www.psychologyofwellbeing.com/psychology-of-spa (23-06-2017).
76 Koh, S.; Yoo, J.J.-E. and Boger, C.A. (2010), ‘Importance performance analysis with benefit segmentation of spa goers’,
International Journal of Contemporary Hospitality Management, 22 (5), pp. 718–735.
77 American Spa (2004), ISPA Study on consumer trends sheds light on the “world” of spas (online), available at:
www.americanspa.com/spa-news/ispa-study-on-consumer-trends-sheds-light-on-world-spas (19-06-2017).
78 The Tourism Observatory for Health, Wellness and Spa (2013a).

Figure 4.7 Market distribution of spa customers by origin and segment, 2016 (%)
Russian-speaking countries 33
67
17
Spanish-speaking countries
43
German-speaking countries 64
36
■ Budget
10 ■ Mid-level market
Market total 35 ■ Upmarket/luxury
55
0 10 20 30 40 50 60 70 80
Note: Segments (budget, mid-level or upmarket/luxury) not shown on the graph for some origin markets are due to lack of data.
Source: Tourism Observatory for Health, Wellness and Spa (2017).
The importance of so-called mid-level market in German-speaking markets confirms the mature
state of industry in these countries.
There have been a few studies on sub-segments, where spa goers are grouped into three clusters:79
1. Escapists: interested in improving their health;
2. Neutralists: interested in rejuvenating themselves; and
3. Hedonists: interested in relaxing and rejuvenating.
The profile and motivations of thermal bath visitors, for example, in Central and Eastern Europe
is usually quite different from leisure or beauty spas. Here, guests tend to be older (over 55) and
there are likely to be more equal numbers of men and women. Although Hungarians use their
thermal waters mainly for healing, many foreign visitors go for cultural reasons (e.g., to visit the
beautiful buildings). Japanese use their hot springs in the Onsen tradition, which is based on
healing and wellness, but foreign visitors may go just to experience a true Japanese ritual. In
South Africa, hot springs have been used mainly by domestic tourists for leisure purposes as there
was no evidence to suggest the waters had healing properties.
Australians do not visit spas because they do not know what spas offer (29%), they think that
spas are not for people like them or that spas are too self-indulgent (both 19%), they do not
79 Koh, S.; Yoo, J.J.-E. and Boger, C.A. (2010).

have time for the spa (29%), and there is no spa in a convenient location (18%).80 The rest were
uncomfortable in spas because of the ’hard sell’ approach or about having treatments such as
a massage by a man (both 13%). Positive and trustworthy experiences need to be created for
first-timers, in order for them to become repeat consumers, and non-goers should be offered
incentives such as discounts or free samples of products. Budget spas (or similar establishments)
should also be created (for example the Barking Bathhouse in London, which aimed to become a
community facility and not a luxury establishment).
Baby Boomers over 45 generally dominate the lifestyle resort and spiritual retreat experience.
Spiritual retreats in Australia tend to attract the highest proportion of visitors over the age of
55 (38%) and the highest percentage of males (26%) of all wellness facilities in Australia.81 The
motivation for going on a holiday retreat can be to detach from everyday life, to connect to one’s
spirituality, go on a journey of self-discovery, or simply to rest and relax.82
Yoga is currently the most popular activity in retreats. The research on yoga practice and yoga-
based tourism suggests that tourists are most likely to be women (at least 70% of them) and aged
between 30 and 50, although there are variations according to countries.83 Although more women
than men tend to practice yoga, there are large numbers of male yoga teachers and spiritual
gurus. Men are perhaps more likely to get involved in martial arts and practices perceived to
be more ‘masculine’ such as Tai Chi and Chi Kung. True yoga enthusiasts do not see yoga as a
fitness or exercise programme, rather as a spiritual path which aims to balance body, mind and
soul. Yoga tourists are a distinctive segment who are motivated primarily (sometimes only) by their
interest in yoga.84 The kind of visitors who choose yoga holidays are those who already tend to
practise yoga at home, although some beginners are also attracted to yoga holidays because of
positive press and promotions. The experiences of yoga tourists in Rishikesh, which is known to
be the yoga capital of India, were examined.85 It was shown that yoga tourists were motivated by
the spiritual nature of the destination. They were not looking for luxury but to make life simpler and
to meet spiritual goals and gain peace of mind.
A retreat visitor typology was developed as follows:86

–– Refuge seekers (seeking peace, rest, quietness and respite from everyday pressures);
–– Learners (those wishing to learn a new practice like yoga or to be part of a programme led
by a well-known teacher);
–– Exporatory dabblers (visitors who have never tried retreat activities but who have always
wanted to);
80 Voigt, C.; Howat, G. and Brown, G. (2010).
81 Voigt, C.; Howat, G. and Brown, G. (2010).
82 Black, S. (2011), ‘Holistic Retreats: Holidays for an Inner Journey’, Positive Health Online (online), available at:
www.positivehealth.com/article/retreats-and-travel/holistic-retreats-holidays-for-an-inner-journey (07-07-2017).
83 Sziva, I.; Kulcsár, N. and Smith, M.K. (2013).
Smith, M.K. and Sziva, I. (2017).
84 Ali-Knight, J. (2009), ‘Yoga Tourism’, in: Bushell, R. and Sheldon, P.J. (eds.), Wellness and tourism: Mind, body, spirit,
place, Cognizant Communication, New York, pp. 84–98.
85 Aggarwal, A.K.; Guglani, M. and Goel, R.K. (2008), ‘Spiritual and Yoga Tourism: A case study on experience of Foreign
Tourists visiting Rishikesh India’, in: Conference on Tourism in India – Challenges Ahead, IIMK, 15th – 17th May.
86 Kelly, C. (2012).
–– Reinforcers (often repeat visitors who want to deepen their practice and have a clear idea
of their goals); and
–– Spiritualists (visitors looking for personal development of a spiritual nature who may be more
likely to choose ashrams or pilgrimage centres).
There is one further segment that also needs to be mentioned, the so-called LGBTQ (Lesbian-
Gay-Bisexual-Transgender-Queer) market. There is limited factual data for the size of LGBTQ
market in wellness (especially in the spa market) but the market assumes that since the LGBTQ
community considers physical appearance to be very important, it is speculated that health-

related trips are on the rise, which translates tolarge sums of spending, especially on gay-friendly
spas or spa hotels and resorts.
A roadmap and segmentation approach is provided on how to travel would take place in 2030.87 It
is suggested that wellness and luxury will become the number one type of experience for the so-
called ‘reward hunters’ (i.e., focusing on self-indulgent travel with a mix of luxury, self-improvement
and health). Such travellers will look for a high degree of personalisation, memorable experiences
and can be easily inspired for another booking. They will look for more than just pampering and
will want to be taken care of emotionally or spiritually, as well as physically.
Figure 4.8 Wheel of wellness – translated to travel motivations
–– Appearance
–– Relaxation
Physical –– Rejuvenation
–– Indulgence
–– Establish self-esteem
–– Appearance
–– Learning Intellectual Emotional
–– Refuge
–– Improving self
–– Pamper
Wheel of tourism
motivations
–– Occupational Wellness
–– De-stress
–– Important others Social Occupational
–– Escapism/Refuge
–– Reward oneself
–– Indulgence Spiritual
–– Appearance
–– Refuge
–– Pamper
87 Lundy, L. (2015), ‘Future Traveller Tribes 2030, Building a more rewarding journey’, Frost & Sullivan – Amadeus (online),
available at: www.amadeus.com/documents/future-traveller-tribes-2030/amadeus-traveller-tribes-2030-airline-it.pdf
(28-06-2017).
4.5.2 Flows of wellness tourism
In terms of wellness tourism, the flows are rather difficult to establish. There is very limited
comparable and actual consumption-based information available.
The current study advocates that only the primary motivation of tourists should be considered
when identifying true wellness tourism. This approach would make international data collection
and comparison relatively straightforward.
Following this logic, the table below shows the number of trips with primary motivation only,
based on the results of the Global Wellness Institute.88 Note that individual country figures and
percentages can differ greatly. In 2011, Austria was considered to be the European leader in
health-orientated (which in this case refers to wellness) holidays but still only about 12% of all
tourists were taking health-oriented holidays in Austria at that time.89 This includes both medical
and wellness tourism. By 2015, reports suggested that wellness tourism in Austria was facing
increasing competition, therefore this percentage may be lower now.90 In other countries, the
figure can be significantly lower, for example, it was estimated in Hungary that health tourism
represents around 4.7% of all tourism even though it is a major Government priority. Central
statistical offices (or even industry organizations) either do not (yet) collect data about the forms
of health tourism or, due to the varying terminology of health tourism, the data is not comparable
or has only limited comparability.
According to findings of the World Travel Monitor conducted by IPK International, the world
population undertook some 11.4 million international health-oriented and medical trips in 2016,
resulting in a market share of 1.4% on all outbound trips worldwide. IPK points out that nearly
70% of all international health and medical outbound trips have been made mainly for health-
oriented reasons such as wellness an spa holidays.91
The estimates in the table below give only rough estimates about the number of wellness trips with
primary motivation and they may be slightly or even considerably inflated.
89 ABA (2011), Invest in Austria (online), available at: www.aba.gv.at/EN/Sectors/WellnessTourism/Health+Tourism.aspx

(15-06-2017).
90 International Medical Travel Journal (2015b), Wellness tourism struggling in Austria (online), available at:
www.imtj.com/news/wellness-tourism-struggling-austria (17-07-2017).
91 ITB-Berlin (2017), Health-oriented and medical tourism: Germany leading globally (online), available at:
www.itb-berlin.de/Presse/Pressemitteilungen/News_48322.html?referrer=/de/Presse/Pressemitteilungen/ (13-12-2017).
Table 4.5 Number of wellness trips by region, 2013 and 2015 (million)
Region Number of wellness trips with both Number of estimated wellness trips
primary and secondary motivation with primary motivation
secondary and primary (million)b
(million)a
2013 2015 2013 2015
North America 172 186 19 21
Latin America 35 47 4 6
Europe 216 250 24 28
Africa 44 5 1 1
Middle East and North Africa 7 8 1 1
Asia and the Pacific 152 194 17 22
Total 586 691 77 78

Note: Number of wellness trips with primary motivation, based on individual region data.
Sources: a) Global Wellness Institute.
b) Estimates for primary motivation based on Global Wellness Institute data assuming that the typical share of primary wellness trips is around
11% of total trips, based on individual countries’ data.
According to the GWI studies mentioned above, Europe receives the highest number of wellness
trips; the major inbound source markets are the European countries, followed by North America,
the Gulf countries, and high-income Asian countries.
Similarly, the table below shows the number of trips with primary motivation in individual European
countries by the Global Wellness Institute (same studies as above). Note that individual country
figures and percentages can differ greatly. The estimates in the table below therefore give only
rough estimates.
Table 4.6 Number of wellness trips by country in Europe, 2013 and 2015 (million)
Countries Number of wellness trips with both Number of estimated wellness trips with
secondary and primary motivation primary motivation
(million)a (million)b
2013 2015 2013 2015
Germany 49.3 50.2 6.5 6.4
France 27.3 25.8 3.3 3.3
United Kingdom 17.8 18.9 2.4 2.2
Austria 11.3 12.1 1.5 1.6
Switzerland 10.2 11.6 1.5 1.0
Spain 10.0 11.3 1.4 1.5
Russian Federation 10.0 10.3 1.3 1.4
Italy 8.1 6.6 0.8 0.7

Note: Number of wellness trips with primary motivation, based on individual region and country data.
Sources: a) Global Wellness Institute.
b) Estimates for primary motivation based on Global Wellness Institute published country-specific data.
4.6 Demand for medical tourism
Medical tourism is a very popular and seemingly attractive form of tourism for an increasing
number of countries. Differences in prices and waiting times, the availability of certain procedures
in another country make travelling for medical, i.e., most typically surgical interventions a realistic
alternative. Undertaking a long-haul trip for serious surgeries (e.g., heart surgeries) can be risky at
any age. To facilitate this special matter several airlines (e.g., Lufthansa or Turkish Airlines) have
invested in specific patient-carrying accommodation on board.
IMTJ’s Medical Tourism Climate Survey 2016 reviews medical tourism provision in 27 countries
with the following main results:92
–– 64% of clinics, hospitals and medical tourism agencies reported growth in international
patient numbers in 2015. 20% recorded no increase and 15% experienced a decline;
–– 82% expect their international patient numbers to grow in the short-term;
–– When asked to name the most popular destinations, in terms of patient numbers, the
respondents selected India, Thailand and the United States of America;
–– Over 48% expect annual growth of more than 10% in the medical tourism market over the
next five years;
–– The largest increase in international patient numbers over the next five years is expected to
come from cancer treatment, cosmetic surgery and stem cell treatments; and
–– Respondents named the leading destinations in terms of quality and range of services
provided to international patients, ranking the United States of America, India and Germany.
These are followed by Singapore, Thailand, Turkey and Malaysia.
It is difficult to determine exact numbers of medical tourists. The main issue lies around the
definition of ’medical tourist’. “The usual problem is that many countries and organizations have
an incentive to over claim numbers. Many country figures are nothing more than an estimate […],
based on no actual figures at all”93.
Furthermore, it is questioned whether medical tourists and medical travellers should be counted
separately (as discussed in the definitions section, it was concluded that they should not).94 There
are several kinds of international patients,95 but it could be debated whether or not many of them
can be called medical tourists (e.g., the first three categories):
–– Temporary visitors abroad (representing incidental demand);
–– Long-term residents (this can include ex-patriates, foreign students, soldiers or people who
retired to another country);
92 International Medical Travel Journal (2016b), Medical Tourism Climate Survey 2016 (online), available at:
www.imtj.com/resources/medical-tourism-climate-survey-2016 (18-07-2017).
93 Youngman, I. (2012), ‘Ian Youngman revisits the figures of medical tourism’, International Medical Travel Journal,
20-03-2014 (online), available at: www.imtj.com/articles/2012/medical-tourism-statistics-30151 (19-06-2017).
94 Munro, J.W. (2012), ‘What is Medical Tourism?’, Medical Travel Quality Alliance (online), available at:
www.mtqua.org (28-06-2017).
95 Connell, J. (2012).
Glinos, I. (2012), ‘Worrying about the wrong thing: patient mobility versus mobility of health care professionals’, Journal of
Health Services Research and Policy, 17 (4), pp. 254–256.
Lunt, N. et al. (2012).
Munro, J.W. (2012).

–– Tourists who decide to have medical treatment (e.g., cosmetic surgery or dentistry) once in
a country even though they may not have planned it;
–– Border-crossing patients (e.g., those within the EU or those who go to a neighbouring
country);
–– Diasporic patients (e.g., emigrants or migrant workers who go back to their own countries
for treatment);
–– Outsourced patients (those who opt to be sent abroad by their national or local health
agencies for special treatments or because their governments have bilateral agreements
with another country); and

–– Patients with rare diseases or who travel for treatment not available in their own countries.
There should be a separation between international patients and medical tourists, where the latter
refers only to those whose primary motivation for travel was medically driven.
Figures tend to be overestimated when resident expatriates, accidental medical tourists

(holidaymakers, business travellers), spa and wellness visitors and multiple counting of unique
patients, are considered.
The latest estimate from Patients Beyond Borders is that market size is USD 45.5 billion to
USD 72 billion, based on approximately 14 million cross-border patients worldwide spending
an average of USD 3,600 – USD 7,600 per visit, including medically-related costs, cross-border
and local transport, inpatient stay and accommodations. It was estimated that some 1.4 million
Americans would travel outside the United States of America for medical care in 2016.96
It can be stated that depending on the source estimates of the value of the medical tourism market
differ greatly:
–– IMTJ: USD 11 billion
–– Patients Beyond Borders: USD 45.5 to USD 72 billion
–– Deloitte: USD 60 billion (2008)
–– Medical Tourism Association: USD 100 billion
4.6.1 Motivations, segments and profiles
The main motivational drivers of medical tourism can listed as below:

–– Lack of insurance and services (in one’s home country);
–– Lower cost;
–– Better quality care;
–– More up-to-date technology;
–– Procedure unavailable at home; and
–– Shorter waiting periods.
Cost seems to be the main motivating factors for many international tourists, as the following
case study of tourists from the United States of America shows. However, price differences may
not be the only or ultimate role for travelling abroad for medical care. Quality and the provision of
advanced techniques are key drivers as well.
96 Patients beyond Borders (2016), Medical Tourism Statistics and Facts (online), available at:
www.patientsbeyondborders.com/medical-tourism-statistics-facts (25-09-2017).
Example 4.13 Motivations of travellers from the United States of America for going for medical tourism
For Americans, this new willingness to go abroad for care is driven primarily by cost. By one set of estimates, the out-of-pocket
price of a hip replacement in the United States of America is USD 75,000, compared with USD 9,000 in India; while a heart bypass
surgery costs USD 210,000 here versus USD 12,000 in Thailand. Those tenfold or more savings costs may be impossible to resist.
Insurance companies are looking at foreign health care as a way to save money, with self-insured employers, and even state and
local governments, also exploring this option. A knee replacement that costs an insurance company USD 35,000 in the United
States of America runs for just USD 13,000 in Singapore, with the airfare and hotel expenses included in the cost for the patient
and a travelling companion. But money is not the only factor. Other nations may offer treatments or procedures illegal or unavailable
in the United States of America, such as euthanasia experimental procedures or new drugs not have FDA approved. Stem cell
therapy – unavailable in the United States of America but offered elsewhere – is a prime example of what Cohen calls “circumvention
tourism”, or people travelling to other countries for treatments banned here. More than 200 hospitals in China offer stem cell
therapies to foreign patients, with the largest provider, Beike Biotechnology, charging USD 30,000 per treatment.
Source: McArdle, E. (2013), ‘As Americans travel to other countries for medical care, I. Glenn Cohen looks at the implications at home and abroad’,
Harvard Law Bulletin, 1 July 2013 (online), available at:
https://today.law.harvard.edu/feature/patients-without-borders-i-glenn-cohen-on-the-rise-of-medical-tourism/ (19-10-2018).
Depending on the speciality and the health condition of the tourist, several other drivers can
become influential, such as reputation of the physician, evidence information of treatments,
or governmental agreements. The motivation for an international (or domestic) medical trip is
influenced by the above listed factors. Destinations and providers use a mix of these drivers.
The role of each driver can very much depend on the state of health (or medical indication),
the home country (or city), the economic and/or social status, the cultural background or the
health insurance policy of the traveller. Other motivations might include going back home for
medical treatments because of culture or linguistic comfort in the country or origin; recovering in
a more beautiful or tranquil setting than at home and enjoying the tourism attractions; or having a
cosmetic surgery away from home with the purpose of being kept a secret.
Example 4.14 Medical tourism in the Czech Republic
According to the Czech Tourist Authority, the Czech Republic has emerged as a favorite European destination for medical tourism.
Over the years, the country has not only been recognized for the affordable price of care, but also for the historically excellent level
of medicine and the quality education of Czech specialists and medical staff alike. In addition, the country’s beauty, the inhabitants’
hospitality, the unique cultural heritage, local cuisine and indulgent Czech spas all together provide harmony, which is sought after
by people from all over the world.
The Czech Republic highlights ‘safety’ in its promotion as medical tourism destination: a “Safe Place Where You Will Receive the
Best Care”.
The Czech Tourist Authority indicates eight reasons to travel to Czech Republic for medical care:
–– Competitive prices;
–– A high standard of care;
–– Suitable treatment/surgery dates;
–– The availability of the latest technologies and medical procedures;
–– Strict hygienic standards;
–– The highest patient safety standards during hospitalization;

–– Associated spa care and natural healing sources; and
–– A broad spectrum of leisure activities (cultural and natural sights, rich history) for both the patient and their escort.
Source: CzechTourism (2018), Medical tourism in the Czech Republic (online), available at: www.czechtourism.com/p/us-medical-tourism/
(22-01-2018).
The interviewed NTO representatives

summarised their views and experiences on key
motivation factors as follows:
The destinations and health care providers are

less interchangeable in medical tourism than in
wellness tourism, since the medical condition of
the prospective traveller is crucial. If someone
Main push and pull factors according to interview was interested in dental care in a foreign
respondents. country, the person would not be interested in
orthopaedic treatments in the same country.
Chronic problems can be one of the most important reasons why employers may cover the
medical treatments of their employees.97
Example 4.15 Employer support for medical tourism in the United States of America
Wal-Mart Stores Inc., the largest employer in the United States of America, has entered domestic medical tourism by offering
insured employees no-cost heart and spine surgeries at Temple’s Scott and White Memorial and seven other hospitals across the
United States of America. Health care cost pressures are pushing companies toward narrowing the number of physicians and
hospitals covered by their insurance policies. Since 1996, for example, Wal-Mart has urged employees and their dependents to
use the Mayo Clinic’s three hospitals for organ transplants. From January 2013, if Wal-Mart’s 1.1 million insured ‘associates’ and
their dependents choose Mayo, Scott and White or another of the preferred hospitals, they can save thousands of dollars in out-
of-pocket costs for heart and spinal surgeries.
Source: Dallasnews (2012), Wal-Mart turning to medical tourism to lower employee health costs (online), available at:
www.dallasnews.com/business/health-care/article745164.ece (17-07-2017).
There are no reliable international figures on popularity of services. In addition, certain treatments
can be popular in certain countries. Whereas spas can become a motivation for a wellness
trip, in medical tourism, hospitals do not have the same roles. Accordingly, hospital or clinical
tourism cannot be discussed; moreover, it is not advisable to profile medical tourism by medical
specialities either.
97 Corporate Wellness Magazine (2016), Employers Can Help to Prevent the High Costs of Chronic Diseases (online), available
at: www.corporatewellnessmagazine.com (23-10-2017).
Therefore, the list of popular treatments can be based on secondary information and suggestions
from the interviews. The top specialities for medical travellers are:98
–– Cosmetic surgery;
–– Dentistry (general, restorative, cosmetic);
–– Cardiovascular (angioplasty, CABG, transplants);
–– Orthopedics (joint and spine; sports medicine);
–– Cancer (often high-acuity or last resort);
–– Reproductive (fertility, IVF, women’s health);
–– Weight loss (LAP-BAND, gastric bypass); and

–– Scans, tests, health screenings and second opinions.
4.6.2 Flows of medical tourism
Flows of health tourism often seem to be from relatively wealthy, western developed countries. This
is especially true when many medical tourists choose countries where treatments are significantly
cheaper than home. However, there are exceptions to this, for example Nigerians travelling to
India or South-Americans travelling to the United States of America for medical treatments. Two-
way flows are seen from advanced economies to emerging ones, and vice-versa, in addition to
internal flows within advanced economies or within emerging ones.
Example 4.16 Nigerian medical tourists in India
About 40,000 Nigerians visited India in 2015, half of them for medical reasons, such as transplant surgery, joint replacement and
dental surgery, among other procedures. Nigerians spent USD 1.3 billion on medical tourism in India in 2014.
India is increasingly becoming popular with Africans seeking medical treatment overseas, because of its more affordable, state-
of-the-art equipment, its highly skilled doctors and the treatments are approved by the World Health Organization (WHO) and the
US Food and Drug Administration. In addition to quality medical services provided by its hospitals and doctors, patients go to
India because medical costs are a lot cheaper compared with the United States of America and the United Kingdom.
For example, a kidney transplant in India costs about USD 13,000, while the same procedure will cost up to USD 300,000 in the
United States. The transplant package includes preoperative medical checkups, consultations and follow-up, surgery and
surgeon’s fees, anesthetist’s fees and drugs.
The package also includes the patient’s stay in the hospital (in an air-conditioned deluxe room with TV, cable, and phone); food for
the entire duration of the patient’s stay in hospital; airport pickup and drop-off; and board for one accompanying attendant.
Source: The Guardian (2016), Nigerians spent USD 1.3 billion on medical tourism in India in 2014 (online), available at:
https://guardian.ng/news/nigerians-spent-1-3-billion-on-medical-tourism-in-india-in-2014/ (12-07-2017).
Rao, P. (2016), ‘India’s medical tourism gets Africans’ attention’, in: Africa Renewal (online), available at:
www.un.org/africarenewal/magazine/december-2016-march-2017/india%E2%80%99s-medical-tourism-gets-africans%E2%80%99-attention
(23-06-2017).
Bilateral agreements provide a special framework for international medical tourism (i.e., they
can affect which countries tourists go to). Several countries (from North or Central Africa, or the
Middle East) have already signed agreements with health care providers in the United Kingdom,
98 Woodman, J. (2014), ‘International Medical Tourism Facts’, Patients Beyond Borders (online), available at:
www.patientsbeyondborders.com/medical-tourism-statistics-facts (12-06-2017).
Germany, in Dubai or Malaysia. These agreements specify the beneficiaries (e.g., government
officials, military personnel) who can take part in the schemes and the health care services that
are to be provided in the receiving country.
There are also relatively large flows of domestic tourists in less wealthy countries to state-
supported or social health tourism destinations, for example those that have thermal baths
and healing waters. More research and data are needed to comment in detail on the flows of
medical tourists to and from different countries and continents and give the examples of Western
Europeans taking advantage of the growing familiarity with countries as a result of the opening of
Eastern Europe and the former USSR (for example, between the United Kingdom and Poland).99
As an example of East-West demand it is estimated that more than 70,000 Russians travel abroad
for medical treatments each year (to Republic of Korea, Thailand, Dubai, Switzerland and the
United Kingdom). In recent years, the flows of Russian and Russian-speaking medical tourists
are returning to regions and countries where there was once a significant Russian presence or
large Russian-speaking minorities, for example, Central and Eastern Europe and the Baltic States.
Héviz in Hungary, Karlovy Vary in the Czech Republic or Jurmala in Latvia are just some examples.
The Russian-speaking market has become important in several Western European countries, such
as in the United Kingdom (especially in London) or in Germany (e.g., in Berlin or in Bavaria).
Diasporic tourists (i.e., immigrants living and working in another country) often go back to
their country of origin for health treatments, as they feel more comfortable with the system and
language (e.g., Koreans living in Australia, New Zealand or the United States of America). Previous
colonial links such as those between the United Kingdom and India have led to the establishment
of a medical tourism market.
Proximity is also a factor that contributes to medical-related movements, e.g., between the
United States of America and Mexico.
99 Lunt, N. (2012).
Figure 4.9 Flows of international medical tourism
Central
Asia and
Russia
North
Africa GCC
Central
Central Africa
and South
America
Legend: The darker shades indicate the role of the destination country – the darker the shade, the more important the country is as destination country
(in the case of the United States of America the sender and destination country status combined).
Arrows indicate the flow from sender to destination country.
Example 4.17 The growth of tourists from Russian Federation to Hévíz, Hungary
Lake Hévíz in Hungary is a unique attraction worldwide since it is the largest biologically-active natural thermal lake on the planet.
Although Lake Echo of New Zealand is larger and its water is warmer, it simply cannot be compared to Lake Hévíz as it is not
suitable for bathing and cannot be used for medical purposes. It is scientifically proven that its waters have curative effects and
they are completely replenished each day. Water temperature may reach 23–25°C in winter and 33–36°C in summer. The normal
duration of a medical treatment in Hévíz is approximately two weeks and includes mechanotherapy, balneotherapy, physiotherapy
treatments, drinking therapy or a combination of the above. Despite this, Héviz is still relatively unknown internationally. Until
recently, approximately 90% of the total tourist arrivals, guest nights and receipts were generated by domestic, German, Austrian,
Russian and Ukrainian visitors. However, there is a new marketing slogan “Hévíz, the fountain of life!” and many more Russian
visitors are starting to come to Heviz for health tourism since the nearby airport started new routes and targeted promotion in the
Russian Federation began. Between 2009 and 2011 Russian arrivals and guest nights increased by more than 200%.a However,
2015 saw a drop of 10%–15% in terms of Russian tourists, although this was apparently compensated by the growing number of
Hungarian, Slovak and Czech visitors.b By 2016, it was thought that a direct flight from Moscow might help to boost the number
of Russian tourists again.c
a) The Tourism Observatory for Health, Wellness and Spa (2013b), The Economic Impacts of Health Tourism in Hévíz, Hévíz-Balaton Airport, Corp., Hévíz.
b) Budapest Business Journal (2015), Mayor: Hévíz sees less Russian visitors, more Hungarian, Slovak, Czech (online) available at:
www.bbj.hu/economy/mayor-heviz-sees-less-russian-visitors-more-hungarian-slovak-czech_102249 (05-07-2017).
c) Daily News Hungary (2016), More Russian tourists might visit Héviz thanks to a direct flight (online), available at:
www.dailynewshungary.com/more-russian-tourists-might-visit-heviz-thanks-to-a-direct-flight (13-07-2017).
4.6.3 Conclusions
The typology of the demand suggests that customers can be categorized by their health
consciousness first. This gives an idea to any destination about its options and possibilities.
Customers with very limited or very low health consciousness or motivation are not likely to
become either a medical or a wellness tourist. Only in rare and unfortunate circumstances,
e.g., suffering from a terminal illness, they might consider travelling for health purposes (and this
can be either a surgical intervention, a non-invasive therapy or a holistic treatment).
Customers who are health conscious at least occasionally could be more drawn to a destination
that offers health-related services or would book health-orientated hotel. Destinations would need
to run serious market assessments and would need benchmark, as well as lifestyle-based market
intelligence in order to identify the most relevant segments and target markets. Otherwise they
may only attract visitors who come because of ‘cheap deals’ or an aquapark, but would not
use the sophisticated and expensive health services, equipment and personnel. Such destination
development mistakes are relatively common.
Figure 4.10 Consumer health services – health tourism conversion
Spectrum of health tourists
Accidental health tourists Health-aware tourist Core health tourist

(e.g., having a medical check-up (e.g., business tourists using a hotel (e.g., medical tourists having an
while on holiday; tourists using gym; leisure tourists visiting a day operation; tourists staying in a
emergency services without spa while on another type of holiday) destination spa)
pre-planning)
Recreational leisure time consumer Occasional health consumer Health-conscious consumer

(e.g., using spas for fun or recreation (e.g., goes to the spa or gym (e.g., healthy diet, regular exercise)
only) irregularly)
Spectrum of health services consumers
Low Health motivation High
Legend: Natural conversion: this conversion can happen based only on the health interest of the consumer.
Organic conversion opportunity: this conversion requires more involvement and direction from the operators, facilitators or marketers
since the health interest and/or awareness can be relativel low or limited.
It is suggested that the conversion rate of leisure consumers to health tourists will be higher where
the level of health consciousness or motivation for health-enhancement is consequently higher in
everyday life, e.g., ‘health conscious consumers’ are more likely to become ‘Core health tourists’
with a primary motivation for health-enhancement when on holiday. On the other hand, those
people who like to use the gym or a spa regularly in their everyday life may seek similar services
abroad and are more likely to become ‘health-aware travellers’. Even those who enjoy spas or
water-based (thermal) facilities for fun, rest and recreation may be persuaded to visit a spa resort
for a longer holiday. Even if their motivation is not primarily a health-enhancing one, they may
discover additional health services while on holiday, and later become a ‘health-aware traveller’ or
even a ‘core health tourist’. Those who decide to use health services while on a different kind of
holiday (e.g., visiting a dentist or a day spa) may also be convinced to using other health services
abroad in future but with some pre-planning. This may not be applicable to those who have an
accident or have to use emergency services while on holiday, however, NTOs and DMOs therefore
need to have proper demand profiling available, otherwise they may target segments not ready
or interested in taking part in health tourism. The impact and volume of health-related services
(especially with mobile or wired wellness and health solutions) will grow regardless of the primary
motivation for travel.
There is a special consideration for accompanying persons, more regarding medical but also
relevant wellness tourism. There are several medical procedures (especially invasive treatments)
which mean that the patient would need to stay in hospital (or in a rehabilitation centre) for several
days or even weeks. Patients undergoing complicated and/or risky treatments tend to arrive with
either a close family member or a friend (in certain cases, for example from Gulf Cooperation Council
countries it can mean the extended family, too). Hospitals now provide suites or apartments which
can accommodate not only the patient, but his or her family, too. Accompanying persons behave
like ‘normal’ tourists, i.e., they generate demand for excursions, shopping or other activities. In
wellness tourism, the accompanying person (here, there is less likely to be more than one, except
in wellness hotels or thermal baths where children are also permitted) can demand similar services
to the wellness tourist.
One-day visitors also make use of medical and wellness tourism facilities, such as cross-border
or same-day visitors in addition to local customers. Same-day medical tourists in Europe are those
who visit a medical bath or have minimal invasive on non-invasive treatments (e.g., Germans to
Poland, Romanians to Hungary). The market is way larger in terms of recreation and fun-orientated
tourism (which in some statistics would be considered as wellness motivations). Thermal baths and
spas are in abundant supply and visitors organize same-day visits to Austria, Germany, Slovenia
or Hungary visiting these establishments (many of which now cater especially for families with
small kids). Same-day health tourists can be therefore either domestic, cross-border or incidental
(i.e., those who decide on their treatment only when they are in the destination).
In summary, in many cases the destination itself, facilities, brands, natural resources, health
care practitioners or health care technology play the most important role in the decision-making.
However, the destination country itself may not be the most decisive factor for international health
tourists.
4.7 Managing and marketing health tourism
Health tourism can be organized, managed, developed and marketed at many different levels.
This can include global (e.g., networks and associations), regional (e.g., clusters), national
(e.g., DMOs, NTOs, clusters), sub-national and local (e.g., DMOs, associations, medical destination
management bodies/Kurdirektion), and at operator or facility level. This study focuses on national
and destination level activities.
Health tourism at global and at national level is often fragmented. There is no single representative
body (neither industrial nor governmental) at global level. There are national associations and
some international initiatives such as the Medical Tourism Association (providing services at every
level from individual member to national organizations) and the Global Healthcare Tourism Council
(focusing on destinations at national level), but with no global representation. The Global Wellness
Institute (GWI) is a non-profit organization with a mission to empower wellness worldwide by
educating the public and private sectors about preventative health and wellness. The GWI carries
out research on the wellness economy and promotes roundtables discussions. The Global
Wellness Summit is hold annually and gathers industry leaders.
Other multi-country industry associations and cooperations (or initiatives) include the Asia-Pacific
Spa and Wellness Coalition (APSWC) in South-East Asia, the European Spa Association (ESPA-
EHV), Termatalia (primarily in South America) and the International Spa Association (ISPA).
4.7.1 Policy making and regulation
In terms of general health policy “Health 2020” is the new European health policy framework.
It aims to support actions across governments and societies to: “significantly improve the health
and well-being of populations, reduce health inequalities, strengthen public health and ensure
people-centred health systems that are universal, equitable, sustainable and of high quality”100.
It has two strategic objectives:
1. Improving health for all and reducing health inequalities; and
2. Improving leadership and participatory governance for health.
The WHO Resolution WHA59.26 urges member states to:101

–– Promote multi-stakeholder dialogue at national level;
–– Adopt policies, laws and regulations that deal with issues identified in dialogue;
–– Apply/establish coordination mechanisms to address public-health related aspects;
–– Create constructive and interactive relationships across public and private sectors; and
–– Continue to develop capacity at national level for potential opportunities/challenges.
The European Union defines policies and initiatives to improve and protect human health, and to
support the modernisation of Europe’s health system. It urges member states to aim for efficient
spending on health that can promote economic growth. It is understood that Europe needs smart
investments in health:
–– Spending smarter – but not necessarily more – in sustainable health systems;
–– Investing in peoples’ health, particularly through health promotion programmes; and
–– Investing in health coverage as a way of reducing inequalities and tackling social exclusion.
The current (2016–2020) actions focus on the following challenges:

–– Achieving greater cost-effectiveness;
–– Competitiveness together with safety;
100 World Health Organization (2012), The evidence base of Health 2020 (online), available at:
www.euro.who.int/__data/assets/pdf_file/0015/170502/RC62-id02-Eng.pdf?ua=1 (20-07-2017).
101 World Health Organization (2006), Resolutions (online), available at:

www.apps.who.int/gb/ebwha/pdf_files/WHA59-REC1/e/Resolutions-en.pdf?ua=1 (22-06-2017).
–– Tackling emerging global threats;

–– Evidence-based policy making; and
–– Addressing the risk factors of chronic disease.
Most of these objectives and observations are not directly linked to health tourism. These
objectives, however, can provide grounds for better harmonization and policy making for health
tourism.
However, the interviewees in this research suggested that international legislation for health
tourism would be important but that it is unlikely to happen anytime soon. The role of governments
in creating legislation, strict standards and ensuring safety was seen as crucial. There are national
regulations and legislation in France, Denmark, Germany or Israel (amongst others) pertaining who
can practice and where treatments can take place. Tunisia is one the countries that implements
a specific legislation on thalassotherapy that sets strict criteria for the conception and running of
centres, under the quality label ISO17680. Of the many types of health tourism, medical tourism
requires the most preparation and management. This is due to the significantly higher risks (some
of which are anticipated, some are real). The travelling patients can put in in risk their life or
physical health undergoing an invasive treatment in another country. As seen earlier, the European
Union introduced the Cross-border Healthcare Directive (Directive 2011/24/EU on patients’ rights
in cross-border health care) in order to provide cross-border regulation for a fast-growing business.
Example 4.18 The Medical Tourism Law in Israel
On the way to regularizing the medical tourism industry in Israel, the Medical Tourism Law was approved in the Knesset Plenum,
the unicameral national legislature of Israel. The bill was promoted by both Ministry of Health and Ministry of Tourism.
The bill is based on a few principles:
1. Protection of the Israeli patient: one of the purposes of the bill is to prevent the impairment of the care that is given to the
Israeli patient, and even to improve it when possible;
2. Increasing the income of the Israeli economy from medical tourism; and
3. Ensuring the professional and ethical care of the medical tourist: rules were established which will ensure that the medical
tourist will receive professional, ethical, and fair care, which will aid the development of the branch over time.
According to the data of the Ministry of Tourism, in the past few years around 30,000 medical tourists arrive each year, with most
of them coming from the Russian Federation, Ukraine, Eastern Europe, Cyprus and other neighbouring countries.
Source: Ministry of Health, State of Israel (2017), The Medical Tourism Law was approved in its First Reading in the Knesset Plenum (online), available
at: www.health.gov.il/English/News_and_Events/Spokespersons_Messages/Pages/22032017_4.aspx.
NTOs and DMOs may not get directly involved with patient flows but it is necessary to bear in
mind that international medical care has several liability and data security issues. Since personal
medical/health information can be very sensitive data protection and data management during
medical tourism is an essential quality element of the service.
Any organization dealing with or processing personal data of EU citizens has to comply with the
European Union Regulation 2016/679 which will come to effect on 25 May, 2018. The regulation,
which is often referred to as GDPR (General Data Protection Regulation), defines rights, as well
as duties. Both medical and wellness tourism deal with a potentially large amount of personally
identifiable information. GDPR requires both the intermediaries, such as medical tourism
facilitators, and the final service providers, such as hospitals, doctors or hotels, to apply and
comply with the regulation, otherwise they can face significant fees and charges from the data
protection authorities. It is advised to any health tourism provider either within or outside of the
European Union to familiarize themselves with GDPR regulation in detail.102
Insufficient services or medical malpractice can actually ruin the brand of the destination, therefore
destination management organizations or clusters can influence and regulate the ways in which
patient flow and the actual medical care is provided.
Example 4.19 Free Healthcare Zones in Turkey
In Turkey, medical tourism investments are supported within the frame of related legislation. Accordingly, health care organizations
and medical tourism companies are supported with the financial incentives for market penetration, patient transfer, promotion
abroad and other advertising activities. Moreover, due to a legal reform in Corporate Tax Law, the health care tourism companies
are subject to corporate tax reduction under certain conditions. In order to make Turkey an attractive area regarding medical
tourism and to increase foreign investments in the medical sector, the establishment of free health care zones has come to the fore
since 2011. Free Healthcare Zones are based on the Free Trade Zones Law. Free zones may be defined as zones that are located
in country borders and regarded as outside of customs areas and that are not or partly subject to commercial and financial laws
of the related country. Free zones provide numerous advantages to investors such as tax reductions, tax exemptions, social
security prime exemptions, infrastructure facilities and minimized bureaucracy. These zones are accessible to the foreign investors.
Source: Herdem (2014), Medical Tourism and Free Healthcare Zones In Turkey (online), available at:
www.herdem.av.tr/medical-tourism-and-free-healthcare-zones-in-turkey (11-07-2017).
Example 4.20 Managing and regulating hot springs in Japan
Health tourism in Japan is mainly based on the use of natural hot springs throughout the country and resorts known as Onsen.
There are more than 3000 Onsen in Japan, mainly used by domestic tourists and local residents; as foreign tourists are not familiar
with the bathing rituals and the Onsen, these are not always promoted extensively to foreigners in other languages. Some of them
are set up in a hospital or sanatorium and treatment can be given under medical supervision. The Japanese health care is one of
the leading systems in the world, and hot springs have remained an important component of its curative and rehabilitation
treatments recommended by doctors. It may be covered by health insurance, if prescribed by a doctor. However, the majority of
Onsen are simple bathing establishments used for personal wellness. A large percentage of visitors come for short weekend
packages. The quality of the waters is strictly controlled and it is not expected that they are artificially heated or cooled with other
water which is not naturally and locally sourced. Many Onsen have been owned and managed by the same family for centuries
which ensures quality and authenticity. The hot springs are also protected by the Japanese Government since the Hot Spring Law
of 1948. The hot springs in Onsen must reach certain standards regarding temperature and mineral composition and clinical trials
are being undertaken to test their effectiveness in balneological treatments.
Source: Erfurt-Cooper, P. (2013), ‘Wellness Tourism: a perspective from Japan’, in: Voigt, C. and C. Pforr, C. (eds.), Wellness Tourism: A Destination
Perspective, Routledge, London, pp. 235–254.
102 European Parliament (2016), Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016 on
the protection of natural persons with regard to the processing of personal data and on the free movement of such data,
and repealing Directive 95/46/EC (General Data Protection Regulation), European Parliament (online), available at:
https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=uriserv:OJ.L_.2016.119.01.0001.01.ENG (12-04-2018).
There are many examples of medical tourism collaboration at national level all around the world.
Examples of public-private sector partnership include the Turkish Healthcare Tourism Development
Council (THTDC), the Korea Health Industry Development Institute (KHIDI), the Malaysia Healthcare
Travel Council (MHTC) or the China International Health and Medical Tourism Association.
An increasing number of governments (either national, regional or local) identify one or more
forms of health tourism as one of the key priority areas for development. This prioritization can
materialize in development strategies, marketing initiatives, financial incentives or certain policy
measures as the following examples indicate:
–– The Dubai Health Authority (DHA) provides a quality health care system in Dubai by setting
and ensuring policies and strategies for health care in public and private hospitals and clinics
in Dubai. DHA facilitates health regulation about Dubai medical tourism and launched at the
end of 2016 The Dubai Health Experience service for medical tourists.
–– To organize Iran’s medical tourism, a strategic council was set up with representatives of
the health and foreign ministries, the Medical Council of the Islamic Republic of Iran and
Iran’s Cultural Heritage, Handicrafts and Tourism Organization (ICHHTO). The Iran’s Health
Tourism Strategic Council stated that any hospital or clinic offering medical services to
foreigners, as well as travel agencies that attract and organize tours for health tourists must
have official permits from ICHHTO, the Health Ministry and the Foreign Ministry. 98 hospitals
and clinics and 14 travel companies have so far been issued health tourism permits across
the country103.
–– The Korea Health Industry Development Institute which also runs Medical Korea is focusing
on cancer treatments and started a special medical tourism course for the nation’s experts
The First Global Health care CEO Course back in 2012. The course programmes included
topics such as “The Needs and Prospects for International Cooperation in Medical Tourism
Industry”, “Trends of Global Health Care”, “Strategy for Overseas Medical Market”, ”Success
Cases of Medical Tourism”, and ”Medical Tourism Policy of Overseas Institutions”.104
–– Azerbaijan, rich with natural resources, found its niche in the sphere of medical tourism.
The Ministry of Culture and Tourism has developed a draft “Action Plan for the Development
of Health Tourism for 2018–2020.” New infrastructure has been created in Naftalan,
Galaalti, Gabala, Nakhchivan and Lankaran. The health tourism in Azerbaijan has been
noticeably improved after the adoption of the state programme on development of resorts in
2009–2018. The Association to support the health and thermal tourism in Azerbaijan
was established in order to boost the health tourism, , as well as modern medical and health
centers were opened in Baku, Naftalan, Nakhchivan and other regions of the country.105
103 International Medical Travel Journal (2017a), Iran Shifts Gears in Promoting Medical Tourism (online), available at:
www.imtj.com/news/iran-shifts-gears-promoting-medical-tourism (23-07-2017).
104 Hancinema (2012), KHIDI President Ko Kyung-Hwa Opens Medical Tourism CEO Course (online), available at:
www.hancinema.net/khidi-president-ko-kyung-hwa-opens-medical-tourism-ceo-course-47064.html (04-07-2017).
105 AITF (2018), Azerbaijan prepares action plan for development of health tourism (online), available at:
http://aitf.az/en-opennews/6535.41.html (3-05-2018).
–– Within Poland’s economic strategy for 2012–2015, medical tourism was selected as one
of the fifteen priority areas of the Polish industry to receive funding from both the national
Government and the European Union. Poland is already a popular medical tourism destination
for patients seeking dental treatment, cosmetic surgery and aesthetic treatment. Polish
orthopaedic and rehabilitation services are highly regarded too. Most patients come from
Germany, and the United Kingdom, some from France, the United States of America and
the Scandinavian countries. The promotional programme focuses on the following markets:
Denmark, Sweden, Norway, Germany, the Russian Federation, the United Kingdom and the
United States of America. Polish dental treatment and dental cosmetics are more popular in
Germany, United Kingdom and Scandinavian countries, as well as the Russian Federation.
Moreover, Polish cardiosurgery and neurosurgery services are also known in Europe and in
the United States of America. There is an opportunity to attract patients from Denmark to
treat cancer in Poland. Polish health resorts and spas are popular in the Russian Federation
and it is believed that they can attract Polish community in the United States of America
back to their health resorts and spas.106
–– Many of China’s new wealthy segments are luxury travellers who head overseas for high-
end health care in affluent locations. They are going to places like Western Europe for
indulgent hotel stays, shopping sprees, and expensive procedures like stem cell treatments,
spa therapy, and detoxification programmes. With regard to the precise locations, big cities
like Shanghai and Beijing – with their high quality facilities and often Western-trained doctors
– have taken serious steps towards becoming legitimate destinations in the competitive
medical tourism marketplace. The former established the Shanghai Medical Tourism
Products and Promotion Platform (SHMTPPP) in 2010, an official government-supported
medical tourism portal. The platform was soon able to bring together over 20 participating
hospitals into the metropolis, handling patient inquiries online, helping contact hospitals
offering the right treatment, and even arranging the entire trip. The goal is to promote China
as a leading destination for advanced health care, hence its website provides a wealth of
information pertaining to China’s top hospitals, the most popular procedures with overseas
patients, and costs.107
–– Balneology, spa and wellness tourism have been established as a special interest tourism
cooperation area and a key priority by the Organization of the Black Sea Cooperation
(BSEC) members.
On the other side of the spectrum, some country authorities are financing less medical travel and
putting more restrictions into it. The reasons given for this were:108
–– Lower oil prices mean there is less revenues in the oil-producing countries that have been
traditionally sources of outbound medical tourists;
–– There are increasingly more good hospitals in alternative destinations as opposed to
traditional and consolidated ones;
106 International Medical Travel Journal (2012), Poland invests in a medical tourism initiative for 2012-2015 (online), available at:
www.imtj.com/articles/2012/polish-medical-tourism-40179/#sthash.6SYI7LPr.dpuf (28-06-2017).
107 Mymedholiday (2013), China’s Seeking its Share of the Growing Medical Tourism, Market (online), available at:
www.mymedholiday.com/blog/2013/11/1074/chinas-seeking-its-share-of-the-growing-medical-tourism-market
(18-07-2017).
108 Medical Travel Quality Alliance (2016), 7 Medical Tourism Trends to Watch in 2016 (online), available at:
www.mtqua.org/2016/02/24/7-medical-tourism-trends-2016 (27-06-2017).
–– Uncertainty is growing about the quality of care, with regards to the availability of critical
drugs in areas affected by war and terrorism;
–– Clinical outcomes and other troubles of returning medical tourists are being more closely
tracked; and
–– Some governments want to encourage more use of their own newly developed local health
care infrastructure.
Example 4.21 Thermal spa tourism in Slovenia
Slovenia has 20 thermal sources that are commercially used by thermal spas. Until 1990, 80% of guests were coming as direct
referrals using doctor’s prescriptions or insurance company contacts. After that period, thermal spas had to find most of their
business on the free market. This meant a complete re-thinking and re-designing of their businesses adding wellness to their
existing orientation. Between 1995 and 2010 all Slovenian spas renewed their swimming pools, upgraded and sometimes enlarged
their accommodation facilities, and added wellness programmes to their classical health spa (i.e., medicine based) offer.
Consequently new segments of guests joined the traditional convalescent ones. Unfortunately, these guests were not very
compatible as the latter wanted to use the medical services, recover and relax and the former wanted to enjoy the wellness
facilities for leisure purposes. Hotel managers recognised that the two segments needed to be spatially separated, so today all
Slovenian thermal spas have a segmented offer. The vast majority of guests are wellness guests staying in quality hotels (4-stars,
4-stars superior and 5-stars) and medical insurance guests are accommodated in lower grade hotels (3-stars). A new national
Health Tourism Strategy was adopted in 2013.
Health and well-being has been identified as one of the most important products in terms of their impact on revenues and image.
Framed in the Strategy for the Sustainable Growth of Slovenian Tourism for 2017–2021, health and wellbeing will receive
promotional support, active product development and management at the national level.
Source: Lebe, S.S. (2013), ‘Wellness tourism development in Slovenia in the last two decades’, in: M.K. Smith and L. Puczkó (eds.), Health, Tourism
Ministry of Economic Development and Technology, Republic of Slovenia (2017), Strategy for the Sustainable Growth of Slovenian Tourism for
2017–2021 (online), available at:
www.slovenia.info/uploads/publikacije/the_2017-2021_strategy_for_the_sustainable_growth_of_slovenian_tourism_eng_web.pdf.
Some countries are positioning themselves in certain forms of health tourism, for example, dental
tourism.
According to Patients Beyond Borders the top dental tourism destinations are as follows:109
1. For United States of America citizens it is Mexico and Costa Rica;
2. For Europeans it is Hungary; and
3. For Asians it is Thailand.
In terms of policy, education, capacity development and training alternatives should be

considered. As seen previously, the health tourism spectrum is very wide and often rather
specialized, which would necessitate specialist skills and knowledge. There are numerous spa
schools and training centres, but so far health, wellness or medical tourism education (either formal
or vocational) has been limited. Especially in medical tourism, collaboration between medical and
business schools would be necessary (e.g., as was launched between Semmelweis University and
METU Budapest Metropolitan University in Hungary). “Wellness tourism is labour intensive and
demands the management of a wide range of employees with skills which draw on traditions that
109 Patients beyond Borders (2017), Dentistry (online), available at: www.patientsbeyondborders.com/procedure/dentistry
(26-11-2017).
cross tourism, hospitality, health, healing, fitness, sport and spirituality”110. This is also the case
for medical tourism. Education and training therefore should be in the forefront of any national
and destination level body, if they want to ensure international competitiveness. “Aesthetic and
emotional dimensions lie at the heart of work in wellness tourism and pose organizational and
management challenges” and “employees in spas, for example, need to have a certain degree of
emotional and spiritual engagement with their work and clients”111.
Interestingly, some situations can arise with regard to limit or even ban medical tourism, e.g., to
stop the outflow of limited available foreign exchange in the case of outgoing medical tourism.112
4.7.2 Networks in health tourism
In some regions or countries of the world, health tourism clusters have been developed. Such
clusters can help to establish quality criteria and build brands. “Stronger local and regional
collaboration amongst various health tourism providers will become a crucial prerequisite for
the future development of health tourism destinations”.113 The wellness tourism sector is highly
fragmented and diverse, however quality tourism experiences need to be delivered through
destination management organizations or networks of organizations.114 A resource-based
approach is not enough without a strategic approach to destination management. A health tourism
cluster should aim for “relational strategic destination management”. Future wellness destination
management should try to find the key factors for successful collaboration and leadership
e.g., relating structures and relationships to their effects on wellness destination coordination,
collaboration and competitiveness.115 Horizontal collaboration across administrative borders, as
well as vertical collaboration of actors on local, regional, national and international levels is also
highly suggested. Several recommendations for health tourism collaboration are made:116
–– Ensure that there is a strong leader who is willing to guide the project for at least two or more
years;
–– Secure funding not only for establishment and research, but also for implementation and
monitoring;
–– Identify what resources, products and services are common to a region or destination. Are
they strong enough to build a definite health tourism brand?;
–– Make sure consumer research is robust. Is there definitely a market for health tourism and at
which levels (transnational, national, sub-national, local)?; and
–– Are national agendas stronger than the desire for wider collaboration? If so, a strategy based
on complementarity should be considered.
110 Patients beyond Borders (2017).
111 Ibid.
112 Youngman, I. (2015), ‘Medical tourism under attack and “on the back foot’, International Medical Travel Journal,
08-01-2015 (online), available at: www.imtj.com/articles/2015/medical-tourism-under-attack-40191 (14-06-2017).
113 Pforr, C. and Locher, C. (2013), ‘Health tourism in the context of demography and psychographic change: a German
perspective’, in: Voigt, C. and Pforr, C. (eds.), Wellness Tourism, Routledge, London, pp. 255–268.
114 Prideaux, B.; Berbigier, D. and Thompson, M. (2013), ‘Wellness tourism and destination competitiveness’, in: Voigt, C. and
Pforr, C. (eds.), Wellness Tourism, Routledge, London, pp. 45–60.
115 Tuominen, T. et al. (2014), Developing a Competitive Health and Well-being Destination (online), available at:
www.julkaisut.turkuamk.fi/isbn9789522165404.pdf (23-06-2017).
116 Konu, H. and Smith, M.K. (2017), ’Cross-border health tourism collaborations: opportunities and challenges’, in: Smith,
M.K. and Puczkó, L. (eds.), The Routledge Handbook of Health Tourism, Routledge, London, pp. 298–314.
The establishment of a health care cluster or medical cluster is perhaps the most important step
in establishing a medical tourism destination, as it can enhance the location’s chances of success
as a destination for medical tourists and increasing patient flow, as well as developing a brand
name for the location.117 A health care cluster can be described as an independent organization of
hospitals, clinics, medical professionals and the government of a specific city, state, or region.118
A health care cluster is funded by all the participants in the health care cluster and represents the
interests of all the members. Clusters join together several partners both from private and public
sector: service providers, local, regional or national government representatives, education and
research institutions. There are numerous clusters all around the world, e.g., in Mexico, Colombia,
Croatia, Thailand, Lithuania, Greece or the United States of America (e.g., in Arizona or Florida).
–– Kvarner Health Tourism Cluster gathers members from the medical, tourism and university
sectors, as well as accompanying services with the goal of creating a recognizable and
competitive health tourism product at local and international level. The organization
focuses on preparations and placements of recognizable and competitive health tourism
products which follow world trends, traditions, the resource base and specific features of
the destination. The cluster is directed towards strengthening and development of health
tourism in Kvarner, in accordance with the strategic documents which define the destination
as “the destination of health”.
–– Spaincares is a strategic alliance of tourism and health in Spain offering the best services
for health while enjoying excellent tourist facilities. Spaincares is the brand which represents
the Spanish Cluster of Health Tourism, formed by the most representative tourist and health
institutions in the country. Spaincares is the brand which represents the Spanish Cluster of
Health Tourism, formed by the most representative tourist and health institutions in the country
such as Spanish Private Health Alliance (ASPE), Medical Spa Spanish Association (ANBAL),
Spanish Confederation of Hotels and Touristic Stays (CEHAT), Spanish Confederation of
Travel Agencies (CEAV), and regional health tourism Spanish projects are also present in
Spaincares. The alliance between these industries ensures a global and competitive service
at the best possible price and quality. Spaincares offers more than 50 hospitals, medical
spas and nursing homes to undergo a medical treatment or intervention, and many hotels
to stay in.
–– Berlin-Brandenburg’s ‘Health Capital’ initiative which is run by the Cluster Healthcare

Industries has established health tourism and prevention as one the key focal points.
Working closely together with VisitBerlin in the areas of health promotion, prevention and
health tourism – in high-end medicine and within a broad spectrum of certified health resorts
and wellness programmes – branded as Health Excellence.
Clusterisation is not limited to medical tourism. Wellness tourism providers also often choose this
form of cooperation. A Wellness Cluster is described as a “natural resources of a geographical
location, its services and infrastructure, the integrated activity of wellness and health service
117 Medical Tourism Association (2013).
118 Medical Tourism Association (2014), Medical Tourism Index (online), available at: www.medicaltourismindex.com
(21-06-2017).
providers and administrative institutions in creating wellness products and services meeting the
needs of customers”119.
However, forming an association or cluster is not enough to become a successful destination in

health tourism. Although there are several benefits of clusterisation, the cooperation works only if
members (partners) share the same vision and they understand that every member (partner) has to
participate and often financially contribute as well. The definition of key performance indicators
at a very early stage is essential. Should that not happen, the measurement of the effectiveness
and efficiency of the cooperation can become random and dissatisfying. Many medical tourism
clusters are failing to be fully successful because of the lack of consideration of certain key
elements. These elements are some of the most important:120
–– How to address environmental sustainability and potential medical waste ‘balloon effect’;
–– Ideas for membership fees as they relate to sustainability of the cluster entity;
–– Cluster leadership training and professional development;
–– Public and private or PPP funding of the cluster;
–– Customer satisfaction, dispute resolution activities offered by the cluster;
–– Marketing, advertising, promotion, and public relations of the health tourism product and
the region;
–– Regulatory compliance of health care, privacy, security, Internet communications, medical
records construction, and practitioner licensure and accreditation;
–– International trade and exportation regulation, and the potential to establish free trade zones;
–– The establishment of qualifications to participate in health tourism;
–– The potential effect of informal economies currently in place;
–– Educational capacity building;
–– Cultural sensitivities;
–– Potential private sector physician brain drain and its effect on local health care access of
citizens; and
–– Inviting and managing relationships of foreign direct investors.
Cooperation that aims at cross-country territories face even larger challenges. There are some
initiatives that incorporate several countries or regions:
A Baltic Health Tourism Cluster was established in 2013, aiming at increasing collaboration
between the Baltic countries Estonia, Latvia and Lithuania in the field of health tourism. The
Cluster is a partnership of existing national clusters and associations with signatories from all
three Baltic countries. A Memorandum of Understanding was signed in October 2013 representing
collaboration between The Lithuanian Medical Tourism Cluster, The Latvian Health Tourism
Cluster and the Estonian Health Tourism Cluster. The main purpose is to increase the global
competitiveness of the region in health tourism. Secondary aims include the following:
–– Enhancing Trust and Co-opetition among the Partners and their Members;
–– Improving Quality (accessibility, safety, effectiveness, efficiency, etc.) of the services provided
to clients/patients; and
–– Joint Marketing resources and efforts to effectively promote the Cluster’s services to the
potential and new target markets (e.g., the Russian Federation, Belarus and Ukraine).
119 Hopeniene, R. and Bagdoniene, L. (2010), ‘Lithuanian wellness cluster: pros and cons’, RESER (online), available at:
www.reser.net/materiali/priloge/slo/bagdoniene_l_hopeniene_r.pdf (04-07-2017).
120 Todd, M. (2012), ‘Is there any point of clusters beyond the hype?’, International Medical Travel Journal, 10-08-2012 (online),
available at: www.imtj.com/articles/2012/medical-tourism-clusters-30138 (22-01-2018).
Alpine Wellness was a trademark which originated in Austria as part of destination development
more than ten years ago and was a cross-border regional initiative between Germany (Bavaria),
Austria (Salzburg), Switzerland and Italy (South-Tirol). One of the main objectives was to redefine
‘superior tourism’ and promote the Alps worldwide as one of the most attractive and effective
regions for wellness. Alpine Wellness Philosophy meant rediscovering the knowledge associated
with the nature, culture and quality of life in the region. The specialist areas or sub-brands of
Alpine Wellness were:
–– Alpine Relaxing (e.g., whey baths, hay baths, saunas with views, natural sources for treatment
and food);
–– Alpine Fitness (outdoor activities in nature);
–– Alpine Health (tailor-made medical wellness packages for preventative health and alleviation
of symptoms such as asthma or allergies); and
–– Alpine Character (hotel architecture, room furnishings, locations).
The cooperation did not prove to be sustainable long-term although successful for more than ten
years, now the concept is only operating in Austria. The Bayern part is now called WellVital (the
regional brand), in Switzerland the links goes directly to mySwitzerland, and in Italy it is BellaVita.
Lessons from the Alpine Wellness Initiative are to be learned, especially vis-avis other mountain
initiatives such as the health tourism development objectives reflected in the ‘Strategy for the
Future Sustainable Tourism Development of the Carpathians’, which defined how health tourism
could be implemented in the region, e.g., considering climate therapy (healing lung, and allergic
illnesses).121
Nordic Wellbeing is a customer-driven concept based on unique values of the Nordic countries
anchored in nature, outdoor life, cleanliness and healthy image. The initiative begun in Sweden
by Julie Lindahl based on Nordic values of Design, Food, Gardens and Herbs, Outdoor Life and
Relaxation. Further initiatives were based on nature, culture, traditions and lifestyle. A Nordic
Wellbeing Tourism network was established involving Finland, Denmark, Sweden, Norway, Iceland:
their academic research is based on product development, innovation, image and branding. The
main aim is to enhance the competitiveness of Nordic Tourism enterprises and destinations.122
Figure 4.11 introduces an idealized network cooperation aiming at developing, managing and
marketing health tourism. Such a cluster can be considered sustainable and successful (but the
measures of success are to be determined as step one), as it can represent the complexity of the
industry. A wide range of governmental, as well as industry representation is essential if a cluster
has a national focus. Regional or destination-based clusters should also involve regional or local
governments and other bodies, since tourism is an interdependent industry, especially health
tourism.
121 Carpathian Convention (2016), Strategy for the Future Sustainable Tourism Development of the Carpathians (online),
available at: www.carpathianconvention.org/tl_files/carpathiancon/Downloads/03%20Meetings%20and%20Events/
Working%20Groups/Sustainable%20Tourism/Carpathian_SusTourStrat_2409_ConsultationDraft.pdf (24-09-2017).
122 Nordic Innovation (2011), Innovating and re-branding Nordic wellbeing tourism (online), available at:
www. nordicinnovation.org/Global/_Publications/Reports/2011/2011_NordicWellbeingTourism_report.pdf (19-07-2017).
Figure 4.11 A typical national cooperation network structure
National government level (ministries, departments)
Commerce/ Foreign
Tourism Education Labour Health …
trade affairs
Wellness tourism cluster Medical tourism cluster
National industry
Regional industry association(s)
association(s)
Private sector
Legend: Direct link (planning, regulation, development).
Consultative link (initiatives, promotion).
4.7.3 Health tourism regions and destinations
Tourism destination management has been widely discussed and analysed in recent years. The
management of destinations specialized in health tourism is not significantly different from the
management of other forms of destinations. It has to be noted that the members of the cooperation
can be rather different from that of ‘standard’ destinations, especially considering health care
industries, therefore specialised industry knowledge and experience would be necessary for such
destinations.
Most thermal/hot spring based destinations are well-established since they date back 100 years
or more. Examples include Bath (United Kingdom), Baden-Baden (Germany), Vichy (France) or
Hévíz (Hungary). In German-speaking countries health destinations (or Kurort) tend to establish
a Kurdirektion (i.e., cure directorate) as a form of destination management organization that is
responsible for the management of the destination.
In terms of destinations, “wellness destinations can range from multinational or multiregional

developments, entire countries, regions, islands, cities or communities to single, self-contained
resort complexes, often referred to in the literature as destination spas”.123 It is not always clear
why health tourists choose one destination over another. “A destination that lacks a comparative
advantage in key wellness resources such as mineralised water may not be competitive in all
areas of wellness but may be able to develop product offerings in areas of the wellness market
that lie in the lifestyle and beauty spa resorts end of the wellness product spectrum”.124 However,
123 Voigt, C. and Pforr, C. (2013).
124 Prideaux, B.; Berbigier, D. and Thompson, M. (2013).

there is also considerable competition to offer uniqueness in lifestyle and beauty products. One of
the key ways of doing this may be to focus on what is local and culturally authentic.
The development of health regions especially in Germany where there are currently around
60 health regions in the country is discussed.125 Health regions develop around primary health
care providers, as well as institutions, or companies that specialise in products and services
related to the health economy. One of the aims of creating such regions is to improve the quality of
life for those living in the region, attracting complementary industries and specialised employees
to the region, creating competitive destinations. Indeed, some health region developments have
been primarily based on tourism, e.g., Kneippland Unterallgau which includes three traditional
Kur resorts. Other examples include Bournemouth and Poole in the United Kingdom, where a
project called “Destination Feel Good” was aimed at the promotion of wellbeing as a destination
resource.126 The Dutch province of Zeeland is being developed as a ‘health region’ which is both
attractive for residents and tourists,127 with a programme being developed based on the ideas of
the Blue Zones projects, as developed in the United States of America.
Example 4.22 The ‘king’ of thermal baths: Baden-Baden, Germany
Baden-Baden is considered as the ‘king of spa [bath] towns’ in Europe because of its heritage and traditions. 800,000 litres of
healing thermal waters flow from 23 springs each day. For centuries, Baden-Baden was the meeting place for the noble, important
and rich. Facilities and services were all developed to meet the expectations of this population segment (e.g., a casino, promenade,
exclusive hotels, festival hall, theatre, Kurhaus). Product developments was to be kept closely focussing on preserving what made
the town unique and including the diversification expected by the market (e.g., programmes such as ‘Fitness for Executives’ or
’Golf and Health’). The town centre is pedestrianised and full of cafés, restaurants, shops selling branded products (e.g., jewellery,
watches) and luxury hotels. Besides the health facilities of the individual hotels and clinics, there are two baths. Friedrichsbad or
the Römerbad (Roman Bath) represents history and tradition, while Caracalla Therme is for the new demand, with pleasure and
wellness services (e.g., sauna world). The two facilities are located separately and not linked with each other. The town management
and planning has proved to be successful, since it was possible to keep the historic charm, while developing new facilities
targeted for new markets.
Source: adapted from Smith, M.K. and Puczkó, L. (2009), Health and Wellness Tourism, Butterworth Heinemann: Elsevier, London.
There are several new technological developments in health tourism destinations, which can
become direct competitors to traditional destinations.
125 Pforr, C. et al. (2013), ‘Health regions: building tourism destinations through networked regional core competencies’, in:
Voigt, C.and Pforr, C. (eds.), Wellness Tourism, Routledge, London, pp. 99–111.
126 Bournemouth University (2015), Destination Feel Good (online), available at:
www.microsites.bournemouth.ac.uk/destinationfeelgood (08-07-2017).
127 Kruizinga, P. (2017), ‘Health tourism and health promotion at the coast’, in: Smith, M.K. and Puczkó, L. (eds.) Routledge
Handbook of Health Tourism, Routledge, London, pp. 386–398.
Example 4.23 High tech healthcare cities
Specialized health care cities or destinations are being developed all over the Gulf. The Dubai Healthcare City (DHCC) is currently
branded as a ‘Health and Wellness Destination’ pays special attention to quality health care through:
–– Physicians’ credentials;
–– CPQ accreditation (ISQua, the global organization that accredits the accreditors, has awarded four-year accreditation to
the regulator of Dubai Healthcare City’s Centre for Healthcare Planning and Quality for patient safety and service quality
standards);
–– International affiliations;
–– Medical malpractice insurance;
–– 9090 specialties;
–– More than 505 spoken languages;
–– Clinically master planned and commercialized land; and
–– Anchor projects and strategic partnerships.
Health City Cayman Islands, which accepted its first patients in early 2014, is a 140-bed tertiary-care hospital in Grand Cayman
and a center of excellence in cardiac surgery, cardiology and orthopedics. Over the next decade, the hospital will expand to a
2,000-bed facility, and expects to be a JCI (Joint Commission International, United States of America). It is an accredited facility
providing care in major specialties including neurology, oncology and other cutting edge tertiary care disciplines. The complex is
also projected to have a medical university and an assisted-care living community.a
Dilmunia Health Island in Bahrain is a 1.25 million m2 mixed-use project with 17% of the total area dedicated to wellness
services, a resort-style health island, where balance is restored and life is enhanced. Positioned off the northeast coast of Bahrain,
it includes world-class health facilities, luxury hotels and spas, lifestyle attractions, environmental interaction and residential
luxury.b
a) Health City Cayman Islands (2016), Introduction (online), available at: www.healthcitycaymanislands.com (18-11-2017).
b) Dilmunia (2017), Masterplan (online), available at: www.dilmunia.com/masterplan (26-09-2017).
Example 4.24 Managing the Dead Sea as a destination
The Dead Sea is both a resource and a destination for three countries. It is the world’s largest, lowest, saltiest natural spa known
for its healing powers for thousands of years. The sea is located between Jordan, Israel and Palestine around 462 m below sea
level. It has year-round hot weather, enriched oxygen atmosphere, therapeutic UVB solar radiation, mineral-rich mud, thermo-
mineral hot springs and luxurious spas. Research has shown that the combined climatic factors have a long lasting positive
therapeutic effect on dermatological diseases such as psoriasis, eczema and rheumatic or degenerative joint diseases.
Thalassotherapy and Balneotherapy are carried out by bathing in the Dead Sea region’s special mineral spring waters, providing
temporary relief of arthritic pain. The pollen-free atmosphere and unpolluted air, higher oxygen content, high barometric pressure
and low humidity soothe the symptoms of asthma, cystic fibrosis and certain lung diseases. Coronary function, depression and
hypertension are treated by Climatotherapy and by Heliotherapy. However, the water levels in the Dead Sea are being significantly
diminished as sinkholes are appearing because of the diversion of water, high evaporation rates and mining industries. The Red
Sea – Dead Sea Conveyance, sometimes called the Two Seas Canal, is a planned pipeline that will provide potable water to
Jordan, Israel and the Palestinian territories, bring sea water to stabilise the Dead Sea water level and generate electricity to
support the energy needs of the project.
Source: Gasul, D. (2013), ‘Opportunities and barriers to sustainable health tourism development in the Israeli Dead Sea Region’, in: Smith, M.K. and
Puczkó, L. (eds.), Health, Tourism and Hospitality: Spas, Wellness and Medical Travel, Routledge, London, pp. 373–378.
Harasheh, S. (2013), ‘Therapeutic tourism on the Dead Sea of Jordan is in danger’, in: Smith, M.K. and Puczkó, L. (eds.), Health, Tourism and
Hospitality: Spas, Wellness and Medical Travel, Routledge, London, p. 174.
So-called ‘wellness communities’ represent a fusion approach between hospitality and the wellness
industries. Predominantly built as living quarters and residences there are now developments with
hospitality components (e.g., the Octave Living Destination Retreat by GOCO near Shanghai,
China).
Figure 4.12 summarizes the relationship between health tourism concepts, supply and destinations.
The figure combines the categorization of health tourism proposed in this report, the various
supply elements and destination level management approaches. Health tourism facilities and
related organizations need to have a clear focus in terms of activities, targets and prospective
members, and partners. Several clusters have been initiated or established but many of them have
a short lifespan.
Figure 4.12 The role of health tourism destinations in the health tourism system
Health tourism

Concepts
Medical wellness
Holism
Spiritual
MedSpas Thermal medical spas (Baths) Hotel and day spas
Destination spas
Medical hotels and resorts
Wellness hotels and resorts

Supply
Longevity centers Leisure baths
Hospital and clinics
Retreats
Cruises
Healthy hotels and H2H conversions
Traditional healing (thearmal) destinations

Destination
Health/healthcare cities/villages
Medical tourism cluster Wellness tourism cluster
Wellness communities
Note: The length of boxes indicates how much of the health tourism spectrum the actual component can cover (e.g. “medical wellness” or “holism”).
Holism is a very broad phenomenon, reflected in the length of the box, whereas medical wellness includes some of medical and some of wellness.
Probably, there are few countries in the world not considering the development of some sort of
health tourism. The Caribbean islands, for example, have been negotiating for many years the
likely alternatives and directions for organizing health tourism conferences and developing position
papers. Literally every European country has become active in health tourism, somewhat fuelled
by the cross-border health care initiative. However, it seems that even successful developments
such as the Alpine Wellness initiative may have their own life cycle, but local assets (either natural
or cultural) in health tourism can really become the foundations for long-term development128.
4.7.4 Marketing and branding

It is absolutely essential for any NTO and DMO to understand their ability to make a major
difference in the market. The health tourism market is becoming very savvy, and the various
and often-experienced segments do not tolerate false promises and mis-communicated branded
products and services.
Not only countries, but regions or destinations (re)brand themselves as either health, medical
or wellness destinations. Related strategies and marketing plans and activities are developed,
special publications and market specific portals have been created. There are numerous national
strategies and plans in Germany (Innovative Gesundheitstourismus – a very complex and innovative
strategy), as well as in Spain (Turismo de Salud en España – where health mainly means medical)
and Hungary (Health Tourism Development Concept and Dental Tourism Development Strategy).
Example 4.25 Marketing wellness tourism in Australia
The role of wellness tourism stakeholders in Australia is examined where the wellness tourism sector is relatively new (most
wellness service providers are less than ten years old). The main emphasis is on spas and retreats. Operators seem to think that
consumers (including tourists) are not well informed about wellness services offered in Australia except perhaps in the state of
Victoria, which has been actively promoting wellness tourism. There have been few efforts at national or regional level to make
wellness tourism a priority in promotion. Many wellness operators and providers did not seem interested in whether their business
was promoted through a DMO or not, however in some destinations marketing alliances had been formed to promote wellness
tourism (e.g., in the south-west of western Australia).a The Internet plays an extremely important role in promotion and distribution,
as most Australian wellness providers rely on the direct-to-customer business model. Unfortunately, the images used to portray
wellness tourism in the media, especially in magazines, tend to be very stereotyped and mainly based on young women enjoying
beauty treatments. This does not reflect the diversity of the wellness tourism products available in Australia. There is currently only
one Australian destination with a core positioning based on wellness tourism, Daylesford/Hepburn Springs. Unlike most other
wellness facilities in Australia, this one makes use of natural mineral springs, but generally these waters have been under-used and
under-promoted. It is recommended that Australia should market better its pristine and beautiful scenery, its indigenous cultural
traditions in health and spirituality, its relaxed and laid-back atmosphere, and its focus on sustainability. A unique Australian
wellness product could be developed and marketed based on the concept of ’barefoot luxury’.
a) Voigt, C. and Laing, J. (2013), ’An examination of the extent of collaboration between major wellness tourism stakeholders in Australia’, in: Voigt, C.
and Pforr, C. (eds.), Wellness Tourism, Routledge, London, pp. 63–77.
The marketing and branding of any health tourism form in principle does not differ greatly from
other typical niche tourism forms. There are a few major differences, though.
128 Tourism Observatory for Health, Wellness and Spa (2017).

In medical tourism, especially in evidence-based medical tourism, the role of a doctor or a

specialist at the permanent place of residence of the prospective international medical tourist
could play a decisive role. Although anyone can search on the Internet and learn a lot about a
medical tourism destination from health care providers’ or facilitators’ websites or from specialised
portals the recommendation from a doctor (or another patient with similar health issues) is still
very important. Medical professionals may have very little knowledge of treatments widely used
in other destinations (e.g., balneotherapy). This lack of information can influence the professional
opinion of this physician, should a patient refer to him for special advice. The question is not
easy, since NTOs or DMOs may not be seen as a trustworthy source of information for medical
professionals. The role of a specialist from the destination country, therefore, is paramount. Their
work, academic and professional achievements, awards and publications can pave the way for
a destination, treatment or approach to become a magnet for medical tourists. Destinations
cannot bridge this gap and they need to seek collaboration with the medical profession (and
health care administration). This collaboration should pay particular attention to evidence
creation, i.e., clinical trial of such a kind that would be accepted in the sender country’s health
care administration or drug authority). The dissemination of clinical evidence should take place in
international medical circles and in the tourism industry. The organization or at least the initiation
of training for physicians (collecting CME points) is certainly one way to go for DMOs and NTOs.
Such training would widen the knowledge base and experience of doctors who treat or consult
prospective patients in sending regions.
Example 4.26 Balneotherapy evidence
In 2013, the International Journal of Biometerology published a systematic review and meta-analysis of clinical trials conducted
with Hungarian thermal mineral waters. The analysis identified 122 studies in different databases including 18 clinical trials. The
trials had a very different focus such as the effect of hydro- and balneotherapy on chronic low back pain (five studies), osteoarthritis
of the knee (four studies), and osteoarthritis of the hand (two studies). Other trials evaluated balneotherapy in chronic inflammatory
pelvic diseases, and the effect on various laboratory parameters. The results confirmed the beneficial effect of balneotherapy on
pain with weight bearing and at rest in patients with degenerative joint and spinal diseases. A similar effect has been found in
chronic pelvic inflammatory disease. Based on trial evidence balneotherapy has some beneficial effects on antioxidant status, and
on metabolic and inflammatory parameters.
Source: Bender, T. et al. (2014), ’Evidence-based hydro- and balneotherapy in Hungary – a systematic review and meta-analysis’, in: International
Journey of Biometerology, 58, pp. 311–323.
The Global Wellness Institute (then Global Spa Summit) initiated the development of a global
database for spa-evidence related data and information. The web-based database was launched
in 2012. By 2014 the database was rebranded as Wellness Evidence (Discover the Medical
Evidence of Wellness Approaches). As a national example, in Finland there are several initiatives to
prove the benefits of using a sauna. Since sauna culture is strongly associated with Finland, these
initiatives also attempt to define and to disseminate the ‘true’ way of using a sauna. In Germany
or in Austria, saunas (and steam rooms) have become sources of more than just health, leisure or
relaxation. The so-called ‘sauna rituals’ (or Aufguss in German) refer to the themed and most often
entertainment-oriented use of saunas. Sauna masters create their very own sauna rituals including
being dressed up as a special character, using e.g., salt, ice, gels or chocolate between rounds
of pouring water on the stones. This goes beyond the health benefits of guests and tourists, and
provides a certain degree of entertainment too.
In order to attract tourists, research has been done on how spa experiences can be linked to
aspirational and fantasy elements in addition to authenticity.129 This might include designing spas
in exotically beautiful landscapes, connecting the history of spas to royalty, drawing on ancient
and indigenous traditions and myths, or promoting the use of contemporary spas by famous
celebrities. The most decisive factors for international wellness tourism are the treatments, brand
and reputation, and the location, the last being the most important for international trips.130
Example 4.27 An example of a unique spa
Botanique Hotel and Spa opened in Brazil in 2012. The aim of the spa is to set a new benchmark in luxury hospitality by focusing
on all that is local and indigenous to Brazil. It was built by regional architects and designers using local slate, stone and wood. It
has a ‘farm-to-fork’ philosophy with national cuisines and wines, and a library with over 400 titles by Brazilian authors. The spa is
referred to as ‘the world’s first 100% Brazilian spa’. The spa includes a rainforest sauna, an indigenous-inspired treatment menu,
including Afro-Brazilian massage techniques and native American movements, a bath filled with fresh milk and ground brazil nuts,
and Brazilian martial arts like capoeira. A geologist from a nearby University recommended a water menu of 15 sparkling and still
waters from around the country. Another professor specialising in aromatherapy helped to create 28 essential spa oils from
ingredients in the surrounding mountains. Extensive research has also been carried out by 19 professors and scientists to prove
the benefits of the treatments.
Source: Botanique (2013), Botanique: Spa and Wellness (online), available at: www.botanique.com.br/english/index.html (22-06-2017).
National level branding messages were selected from all around the world which can introduce how
a certain country presents its health, medical or wellness tourism offer. These are countries that
have been branding their services for many years and the changes and development of the brand
messages can also be observed in several cases. The Government of India, for example prepared
guidelines for the promotion of wellness and medical tourism as niche tourism products.131
129 Laing, J.; Voigt, C. and Frost, W. (2013), ‘Fantasy, authenticity and the spa tourism experience’, in: Voigt, C. and Pforr, C.
(eds.), Wellness Tourism, Routledge, London, pp. 220–234.
130 The Tourism Observatory for Health, Wellness and Spa (2017),
131 Government of India (2015), Revised guidelines for the promotion of wellness and medical tourism as niche tourism
products (online), available at: www.tourism.gov.in/sites/default/files/REVISED%20GUIDELINES%20FOR%20
WELLNESS%20%26%20MEDICAL%20TOURISM%20AS%20ON%2020.03.2015.pdf (02-07-2017).
Table 4.7 Country branding messages, 2008–2017

Country Messages Year
Argentina Wellness tourism: “The pleasure of absolute relax” 2013
Health Argentina. World Friendly 2017
Armenia “Nature’s healing power” 2013
Austria “Europe’s No. 1 Spa Destination” 2008

“Feel good in Austria” (or Schlank und Schön) (for non-German speakers)
“Wohfühlen. Lebenselixier” (“Well-feeling. The Elixir of life”) and “Kuren. Entspannungen”

(“Cures. Relaxation”) (for German-speaking countries)
Ayurveda: “Wir berühren Sie. Ayurveda berührt Körper, Geist und Seele.” 2011
(We touch you-Ayurveda touch the body, mind and soul) (Ayurveda Rhyner)
“Arrive and revive” 2013
Bulgaria “Waters of Wellness-Refreshing. Bulgarian Spas” 2007
“Open doors open hearts. Balneology and Spa Tourism” 2008
“A discovery to Share” 2013
Canada “All aboard! Take a seat on the Route to well-being” 2013

(Central Canada, Canadian Tourism Commission)
Croatia “To Croatia for Strength and Health” 2000
“The Way of Life” 2008
“Croatia, the strength of a new morning” (welllness) 2013
Your smile, the most positive energy 2017

Full of well-being
Egypt Spirituality: Soul Searching in Egypt 2013
France “Harmony and Well-being. Are you looking for de-stress or feel revitalised?” 2008, 2013
France: a detox destination 2017
Germany “Everything but Stress” 2000
“Germany has everything your heart and soul could desire. Here you’ll discover new meanings 2008
of happiness. Welcome to a world of well-being”
“Germany does you good: health and wellness” 2013
Health and wellness in Germany: welcome to the land of the natural remedy 2017
Greece Spa: ”The energy of the mind is the essence of life” (Aristotle) 2013
Lithuania Refreshment for Everyone (Catalogue of Health Resorts and Spa Centres) 2016
India Wellness: 2008

§ Ayurveda: “A gateway to Indian Medical Heritage”
§ Yoga: “Communion of soul with the universal soul or God”
§ Well-being: “Nature’s gift for well-being” 2011
Morocco “A paradise of well-being” 2013

Country Messages Year
Serbia “Spas and Health Resorts in Serbia” 1999
“Legendary Mineral Springs and Mountain Air. Since the Roman Empire travelers have sought the 2008
rejuvenating effects of the region’s forests and waters.” (wellness)
“Springs of Life and Vitality” (health resorts) 2013

Oases of greenery and tranquillity” (Spas and Health Resorts)
Slovenia “With Nature to Health” 1999

“Wellness – tailor-made for you.” “Wellness is not a remedy, but a healthy way of life”. 2008
“Healthy: The country of well-being” 2013
Slovenia is a land of water and spas 2017
South “Spiritual: The Sacred South” 2008

Africa
“Leave ordinary behind” 2012
Switzerland “Health Destination” 2008
“Oases of relaxation” 2013
Source: Smith and Puczkó (2013, 2017a).
It is worth noting that destinations seem to be facing very fierce competition especially at national
level (see the list GWI collected about the number of countries actively promoting wellness tourism
or IMTJ’s list on medical tourism). Several brands have been transformed within a very short time.
In spite of such branding efforts, the destination per se does not necessarily play the decisive
role in destination choice (as seen earlier). There are several other drivers that influence health
travel decisions. It is therefore interesting to see what the real meaning of the Medical Tourism
Index (MTI) is. The MTI was created to measure the attractiveness of a country as a medical
tourism destination (in terms of overall country image and environment; health care and tourism
attractiveness and infrastructure; and availability and quality of medical facilities and services;
see: www.medicaltourismindex.com). This new initiative ranked Canada in first place in 2015.
NTOs and DMOs might like to know that there are unlimited awards all around the world aiming
at a certain aspect of health tourism. Being associated with an award can be attractive, especially
in a very competitive market. The award winning status can provide a unique selling proposition
for a health tourism provider. Customers and tourists can value these awards and may base their
location selection on the assumption tof being treated by the best in the industry. The awareness of
this wide selection of awards, however, can be limited. Customers may have limited understanding
and knowledge about the nature of the awards, therefore both the awarding bodies, as well as the
applicants would need to do more about the education of the target markets.
Although most of the international industry awards are targeting individual service providers such
as the Chrystal Awards (Asia and the Pacific), IMTJ Medical Tourism Awards, World Spa and
Wellness Awards, the European Health and Spa Awards, Wellness Travel Awards have introduced
awards for destinations since 2014.
4.7.5 Health tourism distribution
The role of traditional tour operators is limited in health tourism. Apart from wellness and spa hotels
which are packaged and distributed by large tour operators, most market players are significantly
smaller and more specialised. Some established players such as Fit Reisen (Germany), Skyros
Holidays (United Kingdom), Wellbeing Escapes (United Kingdom), Wellbeing Travel (United
States of America), Mutsch Reisen (Germany) operate in selected destinations and for specially
targeted segments. This is not surprising since medical tourism requires wider services than an
average tour operator could deliver (as discussed earlier). On the other hand, due to the special
product concepts and related demand of holistic and spiritual services, mass distribution of such
destinations would not be appropriate. Interestingly, even large tour operators tried to enter the
health tourism market a couple of years ago. Neckermann/Thomas Cook used to have the ‘CARE’
whereas the TUI Group used to run the ‘VITAL’ brand. These brands, however, were discontinued.
In North America, wellness tourism has become a key focus area for many travel agents (even
special tranings are offered for the interested agents about how to market and sell wellness
tourism). There are several specialist (distribution and tour operation) companies that focus on
all or certain types of wellness and/or medical tourism services (Wellness Hotels and Resorts
International, Crysal Theme Cruises, Healing Holidays, Eat.Ray.Move, Spabreaks, The Healthy
Holiday Company, Essential Escapes, Wellbeing Escapes, beauty24.de, Healing Hotels of the
World, etc.).
The so-called ‘Package Travel Directive’ (90/314/EEC) protects European consumers going
on holiday and covers pre-arranged package holidays. The new Directive entered into force on
31 December 2015. Member States must transpose it by 1 January 2018 and it will be applicable
from 1 July 2018. Medical travel is not excluded from the new rules and as far as regulators
are concerned there is no difference between package holiday and medical tourism. The new
Directive applies to three different sorts of travel combinations:132
–– Pre-arranged packages: ready-made travel from a tour operator made up of at least two
elements: transport, accommodation or other services, e.g., medical services;
–– Customised packages: selection of components for the same trip by the traveller and bought
from a single business online or offline; and
–– Linked travel arrangements: looser combinations of travel services, for instance if the
traveller, after having booked one travel service on one website, is invited to book another
service through a targeted link or similar and the second booking is made within 24 hours.
In such cases the traveller must be informed that he/she is not being offered a package, but
that, under certain conditions, pre-payments will be protected.
Such strict regulation may cause medical tourism facilitators to reconsider their operations and
licensing.
Distribution is often supported by special packaging tactiques. The TOHWS 2013 report identified
the most likely complementary services wellness and spa operators tend to package, in order to
make their core services more attractive.
132 International Medical Travel Journal (2018), Medical Travel Agencies Active in the EU Must Comply from 1 July (online),
available at: www.imtj.com/news/medical-travel-agencies-active-eu-must-comply-1-july/ (02-06-2018).
Figure 4.13 Wellness and spa services in a package (% of total accompanying services)
Conferences, congresses,
60
business meetings
Wedding/honeymoon 51
Events and festivals 41
Culture and heritage

34
Golf 28
Sea 22
Adventure activities 19
Mountain activities 17
Eco activities 14
Religion/spiritual sites
11
and events
River/lake activities 8
Skiing 8
Horse riding 7
Air travel 3
Safari 3
0 10 20 30 40 50 60 70
Source: The Tourism Observatory for Health, Wellness and Spa (2013a), International Wellness & Spa Tourism Monitor 2012–2013, TOHWS, Budapest.
There is a wide range of services from business meeting and conferences to safaris that can be
combined with wellness and spa services, especially in non-invasive treatments with medical
services.
Table 4.8 Wellness and Spa Services in a Package – Regional differences

Elements of Africa The Americas Asia Australia Europe
packages
Number 1 Wedding/ Wedding/ Wedding/ Conferences, Conferences,

honeymoon honeymoon honeymoon congresses, congresses,
business meetings business meetings
Number 2 Golf Conferences, Conferences, Wedding/ Events and

congresses, congresses, honeymoon festivals
business meetings business meetings
Number 3 Conferences, Adventure activities Events and Culture and Culture and
congresses, festivals heritage heritage
business meetings
Number 4 Sea Events Culture and Sea Golf

heritage
Number 5 Adventure activities Events and Religion and spiritual Eco activities Sea
festivals sites and events
Source: The Tourism Observatory for Health, Wellness and Spa (2013a), International Wellness & Spa Tourism Monitor 2012-2013, TOHWS, Budapest.
Medical tourism facilitators are typically responsible for the patient flow and experience. The
medical tourism facilitator is a specialized agent who has the knowledge of both tourism and
the health care industry, and can link the patient health care providers. The facilitator organizes
and books the travel component, takes care of the patient during his or her stay and helps with
the medical service providers, too. The case manager assigned to the patient and to the case
specifically, is the key reference point for the patient during the whole process including the
bookings, accepting the treatment plan to the financial arrangements (note that medical tourism
faciliators are not just tour operators).
The market of insurance companies providing international health care insurance policies is
rather small. There are only a couple of players (such as Seven Corners, Medical Travel Shield,
Novacorpus, Techniker Krankenkasse or Global Protective Solutions), and even those provide
limited services that can be applicable for international medical tourists. Travel medicine insurance
(i.e., covering incidental medical care during travel) or health care plans for expats are available for
international tourists, but do not qualify as medical tourism insurance policies.
NTOs’ and DMOs’ practices are not exempt from the general trend, i.e., they are moving towards
the Internet and social media based communication and promotion for health tourism services.
Many organizations have already prepared and published specialised magazines, brochures,
portals, video channels, applications introducing and promoting health, wellness, spa or fitness
services, and relevant destinations (and service providers). The cultural differences and traditions
are defining factors in these instances. How a certain product or service is translated into the
sender countries’ language is not necessarily an easy task, and tourism organizations must avoid
mirror translations at any cost. As discussed earlier, cultures and languages may have their own
understanding of a term or concept, hence a simple (and not contextual) translation may change
the meaning completely.
Individual operators have also started to explore how they can get involved in the introduction
and promotion of health, wellbeing, spiritual traditions or rituals of the local community or culture.
In such cases, these programmes, services or treatments would not necessarily become primary
motivations but most certainly help the accommodation provider, as well as the destination to
build a stronger and more unique brand.
Online platforms and social media channels were given special attention in this study and sites
from the medical and wellness tourism arena, and from various markets representing Europe and
North America in particular were analysed:

–– treatwell.com (used to be as wahanda.com),
–– spafinder.com;
–– placidway.com;
–– treatmentabroad.com;
–– mymedholiday.com;
–– patientsbeyondborders.com;
–– tripadvisor.com;
–– lonelyplanet.com; and
–– beauty24.de.
Table 4.9 Online platform and social media in health tourism

Overall Attempt to provide an extensive but not necessarily The analysed sites in wellness tourism offer
experience and global view on the medical and wellness tourism wide-spread services, with possibility for booking
coverage market, bringing together the supply and the demand appointments as well, which is a key service of the
side. sites.
There are key areas, on which the sites focus e.g., Many have a special focus on the United States’
Asian countries (Thailand, India), and key customer market, but provide search engines for finding
segments (e.g., British, American). facilities all over the world.
The sites’ search engines are very sophisticated
and every country or destination can be searched
for the best offers, and new destinations can be
reached as well (e.g., Eastern-Europe, or Africa).
Support for The sites share information for the patients with The sites provide inspirations for healthy lifestyle in
travel decision specific tips: highlighting risks, disadvantages of various forms: tips, articles, mottos, experiences.
making destinations, processes, and focusing on values They provide very useful information about the
and advantages. service suppliers.
Accreditation is a critical issue and is often
highlighted. Price of the treatments is also a key
issue, detailed price information, and price
comparison, however, can be found only at some
of the sites (e.g., Treatment Abroad). On the rest of
the sites prices are rare, or missing.
Sharing Several sites provide moderated patients’ stories, Permit sharing ‘free’ reviews, and rankings, which
experiences, testimonials, and give possibility for ratings. are much more popular than in the case of medical
reviews Sharing ‘real’ reviews without moderation, which tourism.
are much more valuable, are rare due to liability This can be explained by the fact, that wellness
issues. The Treatment Abroad community is open tourism is a more open, much less private
for ‘free’ reviews: mainly in orthopaedic surgery experience than that of medical tourism (and
(mainly about facilities in Thailand), cosmetic liabilities are much less pricey). The wellness
surgery (Spain, Belgium), dental treatments
community is much more active.

(Cyprus, Hungary, Poland) and infertility treatments
Sharing experiences, photos; results seems to be
(Turkey). The comments are about experiences
important on the sites, as well as on the social
gained at the given facility, e.g., about quality,
media channels of the sites. Although travelling for
know-how, staff, hospitality, results of treatments.
wellness is an important first motivation, it can be
Mainly those with great or almost great
seen that a large segment of the travellers consider
experiences write the reviews so this can lead to a
wellness as part of their everyday lifestyle rather
bias of information. Comments tend to be
than what they would like to practise when they are
pre-moderated, i.e., the site informs the health care
on a business trip or vacation (with another
provider about a negative story or comment before
motivation than wellness).
it publishes such an entry. This is due to the high
risk of ethical and/or legal responsibilities for which
the sites do not want to be liable.
They provide Medical travel topics are popular on the travel There is a great interest in wellness facilities and
very useful sites. services (spa, wellness hotels, massage, sauna).
information Topics of dental treatments, heart and eye The analysis of the forum topics showed the same
about the surgeries are the most popular themes in the trend as the forums on the sites, that people
service analyzed travel forums. The new, popular hubs (or travelling with another motivation than wellness, are
suppliers destinations) of medical tourism also appear in the particularly interested in finding wellness services at
listings. Most searches focus on Asian, mainly Thai the given destination (from Mexico to Uzbekistan).
destinations and service suppliers. Beside the
medical services, people are interested in extra
vacation tips in the chosen destination, as well as
for rehabilitation, relaxation.
Information for Online sites offer very useful and detailed The sites share useful information for professionals,
professionals information for professionals, in the forms of by providing forums, blogs, and articles about the
articles, news about the latest trends, innovation latest trends.
and know-how, too. The blogs, forums are active, These platforms are very active, though the
though the comments are rare. The professional comments are rare.
community do not tend to be using these peer-to-
The wellness sites place great efforts on using the
peer tools. Among the social media channels,
social media channels (e.g., Instagram, Pinterest),
Facebook and Twitter are used the most, though it
much more than medical service suppliers, which
should be noted again, that the ‘fans’ are not really
can be again explained by the different nature of the
active, comments are very rare. Only in closed
experience.
Facebook, which are specialized in a certain
indication or illness one can find active users.
Source: Based on wahanda.com/trawell.com; spafinder.com; placidway.com; treatmentabroad.com; mymedholiday.com; patientsbeyondborders.com and

tripadvisor.com; lonelyplanet.com and beauty24.de.
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Chapter 5
Conclusions and recommendations
Health tourism is certainly one of the fastest growing forms of tourism. This study has highlighted
the complexity of health tourism and its various related sectors. The discussions about definitions,
supply and demand, management and marketing were based on literature and research available
at the time. Several sources of primary data were collected especially for this study. Topics
debated are by no means final, but still offer an understanding of the industry.
The study recommends structure, taxonomy and definitions for health tourism. Considering global
trends, as well as the local specifics of the most important forms of health tourism, the following
structure is recommended:
–– Wellbeing as an overarching concept but not as a type of tourism;
–– Health tourism as an umbrella term for every form of tourism under the structure, including
wellness and medical tourism; and
–– Sub-categories may also be recognized such as medical wellness or spiritual tourism.
The analysis of the supply and demand of health tourism identified several relevant issues such as
typologies of services providers and the lack of trustworthy and comparable data and information
(neither at country nor at destination level). The industry overview summarized the most relevant
organizational, destination management and marketing issues related to health tourism.
Several concluding remarks are offered below with related recommendations for professionals
working within health tourism and its related sectors, including NTOs, DMOs, and industry
professionals.
5.1 Expectations
There is still some confusion over definitions of health tourism and its related subsectors.
Several points are important to remember. First, improving one’s health in the long-term (not only
whilst on holiday) should be a primary motivation of a particular trip. Health tourism trips usually
take place in regions or destinations which have the specific infrastructure and supervision (e.g.,
medical or wellness professionals) to support it. Grey areas include holidays which are based on
sports, located in nature (e.g., rural tourism), gastronomy based tourism (e.g., slow food), business
tourism when guests stay in a hotel with a spa or a ’healthy hotel’, and some beach holidays which
are being re-packaged as wellness holidays. It is recommended for operators to avoid ‘wellness-
washing’, where possible. Over-use of the term will soon dilute or distort the concept, leading to
consumer confusion and disappointment. Also, defining it too broadly can lead to over-inflation of
statistics which then become meaningless.
Many countries are now focusing on promoting health tourism, however it should be beared in
mind that it often represents only a comparatevely minor share of a country’s tourism product as a
whole. Data reflecting the size need to be honest about producing and releasing data that genuily
represents the popularity of health tourism resources and assets in their country. More effort
should be oriented in the production of consistent and harmonized data, in order to measure the
size and value of the health tourism market in a reliable and standardized way.
5.2 Management and planning
Sustainability or responsibility has become an extremely important phenomenon in all industries

of the world, but equally or even more so in health tourism, which often relies on natural resources
and assets. It is within the interest of health facilities (spas and wellness hotels in particular)
to investigate associations and networks which can help in becoming greener, environmental-
friendly and socially responsible. This can also result in financial savings for the company and
can enhance their reputation amongst consumers. It can even lead to the winning of awards or
the attribution of labels which in return raises their profile further. Still, when wellness is de-facto
considered as a sustainable-oriented practice the likely contradiction between the intended image
and the actual luxury operations may prevail.
When managing health tourism it is certainly important to have a fundamentally sustainable

approach in terms of development, planning and impact management. It is also critical to observe
regulations and ethics, especially in medical tourism which is highly sensitive and litigious. In
many cases, it may be beneficial to join an exisiting association, network, cluster or specialist, or
general DMO. If not available, establishing one could be advantageous to share good practice,
improve quality and to develop complementary rather than competitive facilities. However, the
success of a destination and/or provider does not necessarily depend on the presence of a
wellness or medical tourism-oriented body.
Destinations need to look at the impacts of health tourism. The wellbeing or quality life of local
citizens is equally important as the health improvement of tourists. Monitoring economic, social
and environmental impacts need dedicated attention and resources.
In many countries (especially in Central and Eastern Europe) there is a high demand of domestic
tourism for thermal (medical) baths, but only because visitation is still pubilicly funded. If this
funding is withdrawn or becomes unavailable, operators cannot rely only on international tourist
flows as repleacement for the demand. It is important to imagine a future scenario where no public
funding is available, in order to develop facilities and services accordingly.
Hospitality and good service are fundamental pillars of any form of tourism, but it can be even
more important in health tourism to develop employees’ soft skills and emotional empathy. A good
bedside manner in medical tourism, for example, or sensitivity when dealing with body treatments
in spas is essential. Retreat operators also need to be aware of the mental and psychological
impacts of their work.
As part of a health tourism strategy, destinations should look into travel facilitation issues (visa
policy, enhanced connectivity), the diversification of source markets and segments, the attraction
of investment, the establishment of a regulatory framework, including legislation, incentives and
Conclusions and recommendations 143
standards, the quality of service and infrastructure, the accreditation and certification of health
tourism facilities and practices, as well as product development involving e.g., the meetings
industry or gastronomy. Health tourism can help tackling seasonality as it does not necessarily
follow a seasonal pattern compared to other tourism segments, and can be integrated into
365-day destination strategies as seen in Croatia, Greece or Slovenia.
Collaboration and partnerships are key among the different stakeholders involved in the health
tourism value chain: destinations, authorities, accommodation and transport, providers, facilitators.
The tourism and health care industries can learn from each other to optimize the delivery of
services and ensure a quality tourism experience. The successful public-private initiatives to
promote health tourism put in place in some of the leading health tourism destinations, and which
can be considered best practices, could be replicated in other countries. Finally, the cooperation
with international organizations concerned becomes essential.
5.3 Marketing and research
Destinations should analyse their product-segment matrices properly. There are new product
concepts emerging, as a result NTOs and DMOs should provide industry with relevant trend
information, as a way to address new market segments (e.g., men, LGBT or generation Z) and
focus on the benefits the guests could gain (e.g., refuges or hideaways).
In medical interventions and wellness treatments guests are increasingly looking for evidence-
based and natural treatments.1 These can be thermal/hot springs, ethnobotany elements
(e.g., herbal or homeopathic remedies), thalassotherapy, or local wellbeing concepts building on
a wide array of natural and cultural assets and resources. NTOs and DMOs need to extend their
understanding and network in order to incorporate these unique and authentic resources into
tourism products.
Marketing health tourism is seen by the interviewees in this research to be an essential factor
but also one of the most challenging aspects. It is not enough to have wonderful resources,
products and services if no one knows about them. However, marketing budgets may be limited
and knowledge of the right media could be lacking. Good knowledge is needed of competing
destinations and facilities, clichés and stereotypes should be avoided, instead innovative and
creative approaches are recommended.
5.4 Segments and motivations
There are several lifestyle and leisure trends affecting health tourism. One of the more critical
ones is the ageing population and managing the rise of chronic diseases relating to stress,
inappropriate diet and lack of exercise.
In terms of demand and marketing, it is important to understand the different segments that may
be attracted to health tourism products and services. As shown in this study, the medical tourism
1 The Tourism Observatory for Health, Wellness and Spa (2014), International Wellness & Spa Tourism Monitor 2014
(preliminary data), TOHWS, Budapest.
sector operates somewhat differently from the wellness one, with motivations being closely linked
to price or affordability, access, government policies, insurance provision, and perceptions of
quality and safety. On the other hand, wellness is starting to become segmented according to age,
gender and even cultural preferences. It is recommended for health tourism facilities, especially
spas and wellness hotels not to try to attracting all segments simultaneously, but instead to focus
on one or two appropriate segments who are ideally compatible with each other.
New forms of technology such as eHealth and mHealth (or Artificial Intelligence and robotics in
the near future) can bring new solutions and opportunities to health care, as well as how tourism
service providers communicate and relate to their guests, and not only to those whose primary
motivation is health, medical or wellness orientated.
Health tourism or more appropriately almost every form of health tourism has become an attractive
‘new’ product for destinations, individual developers and operators. This is true in some countries
and destinations, but not all. Travelling for health reasons has been one of the most fundamental
motivations of humankind for centuries. However, this is a form of tourism that still lacks reliable
data and information, making it hard to compare performance at country, destination or individual
facility level.
Pilot data collections, e.g., regarding motivational and performance information at destination level,
as well as more evidence-based analysis and exchange of case studies and best practice, could
further enhance the understanding of the phenomenon. The industry should also take advantage
of the growing academic research in health tourism, as can positevely influence management,
operation or legislation.
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Chapter 6
Development of health tourism – toolkit for
implementing a Health Tourism Development
Strategy
In order to help NTOs and DMOs develop and manage health tourism, a health tourism toolkit
was developed. This toolkit explains the necessary steps of every stage with detailed description
of the related activities, lists the results and outcomes of every stage and discusses the most
important critical points of the process.
The toolkit intends to provide guidelines for especially those NTOs and DMOs about to enter
and develop any or several forms of health tourism. The toolkit represents a flow of thinking and
interlinked steps of activities. The application of the Toolkit can take up to three years whereas the
actual steps may take less time depending on the resources available for the implementation. The
status and form of health tourism relevant to the destination can also influence the time period
necessary.
Toolkit for implementing a Health Tourism Development Strategy

146
Setting up Development Team Inventory analysis International benchmark and Consumer data and segmentation
(1–2 months) (4–8 months) competitor analysis (13–18 months)
(9–12 months)
Team composition: Inventory of existing assets and –– National and destination level –– Health data
–– Tourism representatives: resources: (brand, communication, flows, –– Domestic and international
NTO, DMO, professional –– Cultural, natural, spiritual and etc.) visitors
association(s) holistic –– Clusters and associations –– Motivations (core/medium/
–– Healthcare representative(s) –– Infra- and superstructure: (members, activities) peripheral) local, domestic and
–– Hospitality representative(s) technical/technological, –– Scientific support (evidence, international
specialized infrastructure research data, education, etc.) –– Image
–– CAM representative(s)
–– Organizations –– Industry (health, spa, wellness, –– Satisfaction (key factors)
–– Financials medical activities, events)
–– Lifestyle-based segments
–– PESTLE analysis
Responsibility: Responsibility: Responsibility: Responsibility:

NTO / DMOs + relevant Ministries Development Team + NTO + DMOs Development Team Development Team + research agency
Implementation and monitoring Positioning and branding Planning, development and

(continuous) (26–35 months) incubation
(19–25 months)
–– Implementing the communication –– Identification of unique elements, –– Selecting key development

campaign signatures, key development destinations
–– Monitoring of impacts areas, and unique value –– Development of products,
propositions signature treatments, local
–– Market information system
–– Identification of relevant services characters
–– Monitoring satisfaction and and destinations for development
quality –– Responsible Planning and impact
(by health tourism forms) analysis
Health Tourism Development
–– International benchmark –– Definition of action plan for the
Strategy –– Networking with local suppliers
branding campaign(s) and groups
–– Supporting the branding of the –– Identification of expected quality
key destinations criteria, creating manuals,
training for the service suppliers
–– Setting up health tourism
NTO = National tourism organization management team within the
DMO = Destination management organizations
organization
Responsibility: Responsibility: Responsibility:
CAM = Complementary and alternative Development Team + NTO+DMOs Development Team + NTO+DMOs Development Team + NTO+DMOs
medicine

Setting up Development Team Content
(1–2 months) The members of the development team should represent a wide spectrum of knowledge. The identification of likely assets and
resources for health tourism development require the involvement of experts with relevant competencies. This does not necessarily
Team composition: mean that the team becomes too large, but more like defines the pool of experts who can be brought in for consultation:
–– Tourism representatives: –– Geographer: search, identification and evaluation of geographical resources;
NTO, DMO, professional
–– Historian (ethnographer, anthropologist, etc.): search, identification and evaluation of historical, cultural and heritage resources;
association(s)
–– Environmentalist: estimation of likely impacts of proposed developments;
–– Healthcare representative(s)
–– Healthcare specialist: evaluation of resources and development possibilities in health care (infrastructure, human resources,
–– Hospitality representative(s)
capacities, ethics and transparency);
–– CAM representative(s)
–– Tourism specialist: understanding the link between tourism/travel and healthcare and related industries;
Responsibility: –– Destination planner: complex understanding of destination development and networking;
NTO / DMOs + relevant Ministries
–– Complementary and alternative medicine (CAM) specialist(s): expertise in alternative therapies relevant to the country/
destination;
–– Quality assurance specialist: responsibility for generating quality assurance system and/or accreditation /certification guidelines
for health tourism; and
Inventory analysis
–– International legal advisor: evaluation legal risks, contracting issues.
The planning team either together with the existing dedicated team/person or on their own should agree on the working definition of
health related services, tourism and the anticipated relationship between travel and tourism.
International benchmark and
competitor analysis Results
–– The development team is set up.
–– The relevant competences, knowledge and experience are available.
Consumer data and segmentation –– Working relationship between involved parties is agreed.
–– Common understanding of initial status of and challenges in health and tourism is defined and agreed (Inception Report).
Decision points
Planning, development and
–– Team composition: should the initial team have limited understanding and representation of the wide spectrum of health
incubation
tourism, development and marketing alternatives and options become limited and they risk missing key development options
and resources.
–– Role of team members: the relationship between travel and health has several areas that are sensitive or even represent a high
Development of health tourism – a toolkit
level of risk. Team members should agree that this is not only a tourism led area of tourism. Health professionals should also
Positioning and branding develop an understanding of tourism as a business activity which heavily relies on focused marketing activities that may follow
the logic of tourism and not that of healthcare.
–– Mandate of planning team: many countries/destinations may not have experience in or history of health tourism (development
or management). The mandate of the team can be of many forms and length. If there is an existing team then the planning team
can serve as groups of advisors on a permanent basis for the first years of the project. If there is no existing team or person,
Implementation and monitoring
then the planning team can become the initial team which then passes its mandate to a permanent one.
147
Content
148
Setting up Development Team

The inventory analysis provides the baseline for future development. The development team is to get to know the most important
unique resources and assets, on which genuine, unique experiences and value propositions can be built.
The inventory analysis should focus on the following dimensions:
Inventory analysis 1. Evaluation of existing resources including: healthcare infrastructure (primary, secondary and tertiary), speciality medical
(4–8 months) infrastructure and treatments (dental, plastic surgery, IVF, stemcell, etc.), hospitality infrastructure (including specialized services,
e.g., wellness hotels, resorts and spas), natural healing assets (springs, climate, peat/mud), cultural healing traditions and rituals,
Inventory of existing assets and
facilities built on local healing assets, holistic and spiritual resources (e.g., chakras, first nation sites);
resources:
2. Evidence-based medicine and CAM practices (existing studies, clinical trials and test, clinical staff);
–– Cultural, natural, spiritual and
holistic 3. Medical/wellness/spa/holistic/spiritual opinion leaders and celebrities (e.g., famous physicians, new inventions by clinical staff,
therapists);
–– Infra- and superstructure:
technical/technological, 4. Key domestic destinations specialized in or incorporating health tourism assets (e.g., local organizations such as Kurdirektion,
specialized infrastructure statistical data, experiences);
–– Organizations 5. Organizations including industry associations (e.g., physicians, spa professionals, destinations, hotels), specialized clusters
(e.g., medical, wellness or spa tourism or healthcare clusters);
–– Financials
6. PESTLE analysis (relevant international and domestic political, economic, social, technological, legal end environmental trends);
–– PESTLE analysis
and
Responsibility: 7. Financials including financing schemes (both public and private sector sources) such as state-funded healthcare and/or medical
Development Team + NTO + DMOs tourism services and facilities (e.g., speciality hospitals, thermal baths), private and state health insurance policies, cross-border/
international patient flow related financial arrangements and policies.
International benchmark and Results

competitor analysis
–– A clear, honest picture ‘map’ of the country/destination regarding the unique and general resources/assets. Assets – to find out
those unique resources (e.g., traditions, rituals, natural assets such as mineral water), which can determine the unique selling
point of the country, and to map the most interesting destinations in the country.
Consumer data and segmentation –– Identifying the key (domestic) destinations of wellness and/or medical tourism and the key market players.
Decision points
–– Width of the supply to be tested and analyzed. Several destinations/countries may not support or understand the holistic end of
the spectrum; therefore, the assessment of those resources would not qualify.
incubation
–– The involvement of industry representatives in the analysis and discussions. Since the industry can be very fragmented,
certain industry representatives may find other players less ‘serious’ or less relevant (this is a typical point of discussion between
medical and wellness or spa professionals).
Positioning and branding –– The role and understanding of evidence-based medicine and practices. Evidence-based medicine is not (yet) widely
accepted or understood therefore there should be an initial decision about the position of such medical interventions in the
analytical process.
–– The involvement and role of (national and/or private) healthcare providers and insurance companies. In certain countries the
Implementation and monitoring national health insurance plays a dominant role in medical travel (e.g., social tourism). The relevant policies and practices of third
country insurers can also have a significant impact on health, medical and wellness providers.

Content
The benchmark analysis gives the baseline for the positioning strategy, so as to see what are the unique or special qualities and
resources the country/destination should build on. Steps include:
–– Key industry data and information about the domestic market (including travel and healthcare data, education and training
Inventory analysis potential);
–– Identification and analysis of international/national key players (e.g., companies, brands, operators);
–– International health tourism trends including (depending on the decisions earlier) medical, wellness, spa and holistic information
International benchmark and and data;
competitor analysis –– Identification and analysis of the key international competitors for the country/destination (first-line competitors are those that
(9–12 months) provide similar assets/services, while second-line competitors are those that are more successful based on similar resources;
–– National and destination level –– Identification and analysis of relevant industry organizations (e.g., NTO/DMO departments, industry associations/clusters) and
(brand, communication, flows, events (e.g., awards, congresses, expos); and
etc.) –– Identification and analysis of relevant marketing activities by international players (marketing, branding, promotion, segmentation
–– Clusters and associations and targeting activity).
(members, activities)
Results
–– Scientific support (evidence,
research data, education, etc.) –– Clear picture about the market (both domestic and international).
–– Industry (health, spa, wellness, –– Best practices (domestic and international).

medical activities, events) –– Inventory of industry players.
Responsibility: –– Inventory of industry events.

Development Team
Decision points
–– The type and source of data/information to be considered sound and trustworthy. The health tourism market seriously lacks
sound and comparable information and data. Available data can be dubious, inflated or could refer to only one or more sub-
Consumer data and segmentation segments of the industry although it might use similar terminologies and definitions (i.e., always look for data collection methods
and approaches and never use data/sources that have no such information available).
–– The data/indicator the team considers as a measure of success. Success can be measured in many ways, e.g., length of
Planning, development and stay or average spend. However, at national or destination level the measure of success (or performance) should be not be
incubation limited to such standard measures given the often very specific characteristics of the market. Local economic impact
measurement, quality of life assessment can and also should be considered as measures of success.
–– Criteria for competitor selection. This is not only a health tourism specific challenge but it is particularly interesting in this case
since base data can be confusing, e.g., the average length of stay cannot be compared between two destinations one of which
Positioning and branding
may focus on evidence-based medical approaches, whereas the other is specialized on plastic surgery. In the first case the
relevant data can be up to 3 to 4 weeks, whereas in the second case it is approximately one week. If a destination has a natural
resource it should not select a destination with highly specialized clinics as a likely competitor.
–– Scope of analysis in terms of marketing activity, i.e., is it limited to competitors or does it include best practices from wider
coverage. Interesting examples can come from destinations or companies that are not considered as competitors…
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Content
150

Consumer surveys give an overview about the actual and potential customers. This market in terms of global market intelligence is
relatively underdeveloped, therefore market information can be very limited. Especially as if there were any targeted information at
all, it could well could be limited to only one or a few segments (e.g., only dental or spa). NTOs/DMOs cannot really avoid the initial
Inventory analysis data collection(s) preferably regarding both existing and potential markets. The survey(s) should focus both on domestic and
international markets (based on the initial selection of relevant segments) and should collection information about:
–– Health status and understanding of health (and wellness, wellbeing, etc.) of the relevant markets);
International benchmark and –– Experiences and satisfaction levels (existing health travellers);
competitor analysis –– Activities during stay (existing health travellers);
–– Motivation for travelling for health reasons;
Consumer data and segmentation –– Key barriers of not travelling for health reasons;
(13–18 months) –– The image of the country/destination as a health/medical/wellness/etc. destination; and
–– Health data –– The image of the competitors, travel activity and attitude to travel to the competing countries.
–– Domestic and international

Results
visitors
–– A better understanding of existing guests (characteristics, motivations, experiences, etc.).
–– Motivations (core/medium/
peripheral) local, domestic and –– A better understanding of potential guests (characteristics, motivations, barriers, etc.).
international –– Lifestyle-based segmentation factors (including demography, etc.).
–– Image –– Product/segment matrices (at national and destination level).
–– Satisfaction (key factors) –– Product/segment matrices (by health tourism segments).
–– Lifestyle-based segments
Decision points
Responsibility:
–– Applicable research methods. Any amount of money can be spent on market studies; therefore, it is essential for the team to
Development Team + research agency
decide what outcome/result(s) they are looking for. Qualitative and quantitative methods can provide information that is
complementary and helps to understand the results from other research. Since the concept of health (and wellbeing and
happiness, etc.) is not completely exact and can mean different things in different countries and to different segments,
qualitative methods seem to be the most appropriate.
incubation
–– What to research. Most people never travelled for any health reason (or at least they would not categorize their trips as such).
This leaves the researchers with the challenge of how to formulate the questions in order to collect the relevant information.
Most customers would not use certain healthcare, wellbeing or happiness related words or expressions. The formulation of
Positioning and branding questions, especially in other languages may need special attention.
–– How to understand data. One of the key results of such data collection is the definition of relevant segments. Contemporary
segmentation prefers lifestyle-based segments. However, based on economic, cultural or political factors, lifestyles are not as
standardized as demographics in terms of segmentation information. Lifestyle-based segments can differ greatly by not only
continents and countries, but also by cities or neighbourhoods.

Content
Based on the country-specific experience and service propositions and assets, national and/or destination level planning can take
place. In line with the defined position (or positions for various products), the relevant strategies and impact assessment measures
Inventory analysis can be defined. The objective is the development/initiation of a destination and/or segment specific product portfolio:
–– Expected offers and qualities of facilities involved in any form of health tourism (e.g., quality criteria, etc. in hospitals, spas,
International benchmark and hotels);
competitor analysis –– Development plan for relevant evidence-based modalities (e.g., clinical trial, international communication, etc.);
–– Development plan of human resources (e.g., vocational, regular education and on the job-training);
Consumer data and segmentation –– Application of relevant measures set by responsible tourism (e.g., involvement the local suppliers, CSR programmes);
–– Definition of the likely roles and responsibilities of governmental/public organizations (e.g., public health insurance, public
health); and
incubation –– Initiation of health tourism management organizations (based on the relevant form(s) of health tourism), e.g., association, clusters
(19–25 months) and support for pilot initiative(s).
–– Selecting key development Results

destinations
–– Destination(s) and products for pilot as well as for long-term development are defined.
–– Development of products,
–– Plan for providing evidence for any form of health (care) service to be used in health tourism is accepted.
signature treatments, local
characters –– Plans for human resources development and training are defined.
–– Responsible Planning and impact –– Initial organizational structure accepted.
analysis
Decision points
–– Networking with local suppliers
and groups –– Form(s) of health tourism to be developed. It seems to be an easy decision but it can cause disagreement if a sub-sector of
health tourism is selected for development. Healthcare representatives may oppose and would require evidence(s) from a very
–– Identification of expected quality
early stage. This can delay the planning process and would require extra efforts for creating a common language.
criteria, creating manuals,
training for the service suppliers –– Locations to be developed. The selection of destination(s) where any form of health tourism could be developed would need
very special attention, since the requirements of the actual form may necessitate additional, not necessarily tourism related
–– Setting up health tourism
development(s) too (e.g., orthopedic patients cannot rely on standard public transport infrastructure, or most airlines are not
management team within the
equipped to cater for patients pre- or post-operation).
organizations
–– Form(s) of cooperation. There are several forms of networks and cooperation available (e.g., for-profit or non-profit,
Responsibility: membership-based or informal). The form of health tourism, the type of industry players and participating organizations can
Development Team + NTO+DMOs influence the decision and selection. The same form (e.g., cluster) can work for one kind of service and in a certain region/
country but would not work in another. Tradition and culture of cooperation development need to be considered.
Positioning and branding –– Education and training. In most countries and destinations health tourism may not be the most obvious choice or it may not
have a history. Education and training of specialist skills and competencies would need to be provided for a wide spectrum of
players or partners. These can be delivered at many different levels and forms (post-secondary, vocational, BA, MA, post-
graduate, on-the-job, train-the-trainer programmes). A complex and coherent training and education plan would be necessary
including medical, business and social sciences schools.
151
Content
152

Positioning means the definition of the intended unique market position. It can be a bottom-up and/or a top-down process even
running parallel. First, the key health tourism destinations and representatives of selected health tourism forms should provide input
for the country/destination position. Also, the positioning activity can be top-down (especially if the development is new) by
selecting maximum 5 USPs. The market position should reflect the response to the international (and for DMOs the domestic)
Inventory analysis benchmark information. Based on international experience it is advised to position the wellness and the medical market separately.
However, because of the blurring market situation, especially if the destination wants to be strong both in medical and wellness, it
can be considered to create an umbrella position for health tourism. This umbrella position (and brand) can be supported and further
refined with sub-brands for medical or wellness services.
International benchmark and The process should use:
competitor analysis –– Data and information from a consumer survey about the image of the country, the key destinations and relevant products; and
–– Data from service suppliers (and citizens) to understand the existing inner image.
The brand(s) developed should help the customer understand what the destination is and what it can offer customers.
Consumer data and segmentation Results
–– Value propositions for the relevant health tourism forms and the relevant health tourism destination.
–– Umbrella and/or sub-brands brand(s) (NTO or DMO level) that can be different by target segments.
Planning, development and –– Brand development plan for the next 5–10 years defining what the brand is and what the brand is not. The branding plan
incubation should include:
–– Most profitable target market segments;
–– Overall positioning statement;
Positioning and branding –– Brand platforms and promises;
(26–35 months)
–– External marketing plan, timeline, budget; and
–– Identification of unique elements, –– Internal communication plan.
signatures, key development
areas, and unique value Decision points
propositions –– Definition of differentiating elements. Note that differentiation can come in numerous ways and forms including:
–– Identification of relevant services –– By the product (e.g., features, performance, durability, reliability, style, design);
and destinations for development
–– By the corresponding services (e.g., service delivery, customer training);
(by health tourism forms)
–– By relevant personnel (e.g., competence, courtesy, trust, credibility, reliability, responsiveness, communication);
–– Definition of action plan for the
branding campaign(s) –– By the image elements (e.g., symbols, atmosphere, events); and
–– Supporting the branding of the –– The physical qualities of the health services are often overridden by the soft or psychological factors (e.g., personnel).
key destinations –– Translation of benchmark information. It can be very tempting to position against a certain and assumedly successful
destination (following the so called Red Ocean strategy) just based on some numerical factors (e.g., patient or bath visitor
Responsibility:
numbers). As stated earlier, industry data can be dubious and inflated or it may just mean something else. The selected position
Development Team + NTO+DMOs
and brand(s) should not risk creating false promises (e.g., translating a bath/hot spring as ‘spa’ for North-American markets or
using the term ‘spas’ for German speaking markets).
–– Brand definition. The identity, personality and promise of the brand are delicate measures, which can evolve and develop. New
destinations in particular (either national, regional or local level) should consider the long term life of the selected brand(s), since
the industry develops very fast and brands should be able to follow these changes.

Content
It can differ greatly what an NTO or DMO can actually implement. In certain countries NTOs can initiate and support product
development. In other countries NTOs and DMOs tend to focus on communication related activities. The implementation of the
actions decided in the previous steps therefore may fall under the authority of several different stakeholders (public, private and
non-profit alike). However, without close cooperation between the tourism and healthcare industries, the implementation of any
Inventory analysis action can bring limited success. The action plan (either at national or at destination level, or by product forms) for implementation
should consider:
–– The identified key values and how those can be translated to industry and product levels (e.g., specifications or branding);
–– The identified quality requirements (e.g., quality assurance schemes either national/local level or applying for an international
International benchmark and scheme) and considering awards schemes (existing or new, domestic and international);
competitor analysis –– Organizational issues including international organizational development (e.g., designated persons or departments) or initiation
of new cooperation (e.g., cluster, association);
–– Implementation of the branding plan; and
–– Monitoring activities including the identification of Key Performance Indicators and benchmark information.
Consumer data and segmentation
Results
–– Quality assurance systems and processes.
Planning, development and –– Recommended organizational structure(s) with clear responsibilities and tasks.
incubation –– Monitoring a benchmarking system.
Decision points
–– Responsibilities. The success of any cooperation depends on the definition and distribution of responsibilities and tasks at the
Positioning and branding time of the inception. Expectations that are not justified or supported will result in nothing but disappointment. NTOs’ or DMOs’
promotional activities on sender markets without the help and support from healthcare/wellness/spa sector and professionals
can only have limited impacts. This is especially true for evidence-based medicine which is not understood let alone accepted in
several countries.
Implementation and monitoring –– Quality assurance. There are several quality seals (international and national) available. However, it is not often clear why and
(continuous) for whom an assurance/certification programme was initiated (i.e., for internal quality assurance/process reasons or for
market(ing) reasons). The governmental and/or industry leaders must have clear answers for the why and for whom!
–– Implementing the communication
campaign –– Organization(s). Organizations (old or new) per se cannot solve challenges, e.g., the establishment of a medical tourism cluster
itself would not ensure success. The financial challenges can be paramount since cluster activities (e.g., research,
–– Monitoring of impacts
representation, etc.) can and do cost large sums. The involvement of state bodies (as we can see in several Asian countries) can
–– Market information system ensure some degree of financial stability and indication of governmental support.
–– Monitoring satisfaction and –– Monitoring. The monitoring and benchmarking of any form of health tourism can be difficult and complicated. This is due to the
quality limited data and information available and the often different understandings in various countries and cultures. It is anticipated
–– International benchmark that only such data should be considered that are based on primary motivation of any traveller, therefore primary data collection
is not something NTOs or DMO can or should avoid. Impact assessment and monitoring, including local impact assessment and
Responsibility: quality of life measurements is something also to be considered. Comprehensive monitoring should be a primary task since the
Development Team + NTO+DMOs fragmented and complex market needs trusted information and data.
153
155
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Annex 1
List of interviewees
–– Ada Kostrz-Kostecka (Project Manager, European Centre for Enterprise, Poland)

–– Adriane Kinzel (Kurotel Longevity Medical Center and Spa, Brazil)
–– Alceste Santuari (Researcher, Italy)
–– Anne Marie Moebes (Wellbeing Travel, CEO, United States of America)
–– Carola Kempe-Ketola Finavia (Finavia of Helsinki Airport, Finland)
–– Dr Toad Nahai (International Society of Aesthetic Plastic Surgery/ISAPS, United States
of America)
–– Christoff Pforr (Researcher, Australia)
–– David Boucher (Companion Healthcare, United States of America)
–– Dina Glouberman (Founder, Skyros Holidays, United Kingdom)
–– Dr Mary Wong (former manager, Malaysia Health Travel Council/MHTC, Malaysia)
–– Elena Bogatcheva (Founder, Spa and Wellness Council International, Russian Federation)
–– Ella Stimpson (President, International Spa Asssociation/ISPA, United States of America)
–– Franz Linser (Advisor to Cluster Wellness Tirol, Austria)
–– Jeremy McCarthy (Former Director of Spa, Starwood Hospitality Group)
–– Joachim Lieber (Secretary, European Spa Association/ESPA)
–– Kim Soo Woong (Korea Healthcare Industry Development Institute/KHIDI, Republic of Korea)
–– Laila al Jasmi (Former head of Dubai Healthcare City, Dubai, United Arab Emirates)
–– Laimutis Packevicius (Founder and manager, Medical Tourism Cluster Lithuania)
–– Lori Robertson (Executive Director, Leading Spas of Canada, Canada)
–– Mala Marua (Founder, Mystic Asia, India)
–– Maria K Todd (CEO, Mercury Health Care, United States of America)
–– Mia Ahn (Founder, Arizona Wellness Association, United States of America)
–– Mike Wallace (Director of Spa, Danubius Hotels, Inc., Hungary)
–– Roger Allen (Development manager, Thermarium, Austria)
–– Susie Ellis (Founder and CEO, Global Spa and Wellness Summit, United States of America)
–– Uwe Klein (Founder of European Medical Tourism Conference Health and CEO Care Strategy,
Germany)
–– Vladan Veskovic (Secretary, Serbian Spa Association, Serbia)
–– Zeki Karagulle (President, International Society of Medical Hydrology and Climatology,
Turkey)
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Annex 2
Word cloud health tourism scenarios
for categorization
Word cloud respondents were given a number of

different scenarios on cards to consider involving
tourists who visited various countries or
destinations for specific activities and
treatments. They were asked to define each of
the tourists or forms of tourism in question. The
respondents after reading the scenario were
requested to categorize them from the list
provided (i.e., medical tourism, medical travel,
wellness tourism, wellbeing tourism. The
respondents could add their comments and
Screenshot of the opening page from the word cloud survey suggestions to every scenario.
round 1.
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Annex 3
Grouping of the scenarios from the word cloud
exercise
The following list shows which cards were sorted into each of the standardised categories. We
have standardised similar category names into a total of 16 standardised categories. In addition,
with screenshots we introduce the workflow based on which respondents could decide their
preferences.
Round 2 of the exercise was a card sorting exercise, where respondents (28 experts) were asked
to group scenarios they considered to be similar together and then to name the type of tourists in
each of the groups they created (for example “medical tourist”, “wellness traveller” or any other
term they thought clearly defines the type of tourist or traveller they are). Card sorting as a method
is considered to be a good way of developing structure and hierarchy, and helped to further
agree definitions. A total of 68 unique category/group names were created by the participants.
Similar category names were divided into a total of 16 standardised categories. This annex shows
which cards were sorted into each of the standardised categories. The following categories were
developed following the sorting process:
–– Accident and emergency (e.g., breaking a leg on holiday)
–– Activity tourist (e.g., skier having a massage)
–– Corporate wellness (e.g., prevention trip)
–– Cosmetic treatment (e.g., breast augmentation)
–– Health and beauty (e.g., teeth whitening)
–– Health and spiritual (e.g., yoga weekend)
–– Health and wellness (e.g., detox trip)

–– Holistic tourist (e.g., silent meditation trip)
–– Medical traveller (e.g., hair implant)
–– Non-health/medical/wellness tourist (e.g., regular cancer check-up)
–– Non-tourist (e.g., respite travel)
–– Relaxation (e.g., staying in ayurveda hotel)
–– Tourist/traveller (e.g., social tourism trip)
–– Wellness and spa tourist (e.g., rejuvenation package)
–– Wellness/wellbeing tourist (e.g., visiting public bath)
Table below shows how many cards in total were assigned to each category, and of these, how
many cards were unique (i.e., assigned to the given category only).
Annex 3: Grouping of the scenarios from the word cloud exercise 161
Table A3.1 Word cloud categorization of health tourism scenario cards

Standardised categories Participants who Total scenario cards Unique scenario Agreement
used this category in this category cards
Medical traveller 15 140 19 0.49
Wellness/wellbeing tourist 13 111 20 0.43
Accident and emergency 4 10 6 0.42
Activity tourist 3 5 2 0.83

Health and wellness tourist 8 69 28 0.31
Tourist/traveller 9 36 11 0.36
Health and beauty 2 14 9 0.78
Holistic tourist 3 17 9 0.63
Corporate wellness 5 9 3 0.60
Non tourist 3 9 4 0.75
Wellness and spa tourist 4 30 15 0.50
Relaxation 1 8 8 1.00
Not enough information 1 1 1 1.00
Non health/medical/wellness 1 5 5 1.00
Cosmetic treatment 1 5 5 1.00
Note: The Total Scenario Cards in each category refers to the number of scenarios respondents linked to that category (everybody had 28 scenario cards
The number of Unique Scenario Cards indicates how many scenarios were under this category only.
The level of Agreement indicates how much correlation was detected among scenarios in each category (i.e., the scenarios under the Medical
Traveller category achieved medium agreement, i.e., half of the scenarios listed here were listed under another category, too, whereas the
scenarios under Activity Tourist were listed mainly under this category).
The table shows that several categories were created and respondents could identify most of
the scenarios under the terms medical and wellness (see total scenario cards under these two
categories), but the level of agreement was not very strong.
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List of examples, figures and tables

List of examples
Example 2.1 State support of health tourism in Malaysia 29
Example 2.2 The Growth of preventative wellness in the Netherlands 35
Example 2.3 Combining traditions and new technology in the Republic of Korea 37
Example 2.4 The m-health market 39
Example 2.5 A sustainable spa: the Blue Lagoon, Iceland 42
Example 2.6 The therapeutic benefits of nature 42
Example 3.1 Wellbeing tourism in Australia 50
Example 3.2 Health tourism in Jordan 53
Example 3.3 Byron Bay, Australia – A holistic health and wellness destination 57
Example 4.1 Maintaining a healthy lifestyle on holiday: Westin 77
Example 4.2 IHG EVEN Hotels 78
Example 4.3 Healing Hotels of the World 79
Example 4.4 The Pannonian Lakes in Tuzla, Bosnia and Herzegovina 83
Example 4.5 Traditional hot springs in New Zealand 85
Example 4.6 South African Thermal Baths 85
Example 4.7 Tourism in thermal baths in the Czech Republic 87
Example 4.8 One of the world’s first holistic tourism retreats: Skyros, Greece 89
Example 4.9 New age centres in Costa Rica 89
Example 4.10 Visa facilitation in Thailand to boost medical visitors 92
Example 4.11 A sustainable spa brand: Six Senses Spa and Resorts 93
Example 4.12 The promotion of health tourism in Argentina 94
Example 4.13 Motivations of travellers from the United States of America for going for medical tourism 110
Example 4.14 Medical tourism in the Czech Republic 110
Example 4.15 Employer support for medical tourism in the United States of America 111
Example 4.16 Nigerian medical tourists in India 112
Example 4.17 The growth of tourists from Russian Federation to Hévíz, Hungary 114
Example 4.18 The Medical Tourism Law in Israel 118
Example 4.19 Free Healthcare Zones in Turkey 119
Example 4.20 Managing and regulating hot springs in Japan 119
Example 4.21 Thermal spa tourism in Slovenia 122
Example 4.22 The ‘king’ of thermal baths: Baden-Baden, Germany 128
Example 4.23 High tech healthcare cities 129
Example 4.24 Managing the Dead Sea as a destination 129
Example 4.25 Marketing wellness tourism in Australia 131
Example 4.26 Balneotherapy evidence 132
Example 4.27 An example of a unique spa 133
List of figures
Figure 2.1 PESTLE analysis 24
Figure 2.2 Key factors in the political environment 25
Figure 2.3 Health spending changes (real terms), 2001–2013 28

Figure 2.4 Key factors in the economic environment 31
Figure 2.5 Key factors in the socio-cultural environment 33
Figure 2.6 Key factors in the technological environment 37
Figure 2.7 Key Factors in the natural environment 40
Figure 2.8 Key Factors in the Legal Environment 43
Figure 3.1 Wheel of wellness 55
Figure 3.2 Global wellness economy, 2015 56
Figure 3.3 Wellbeing, health and tourism 65
Figure 4.1 Receipts generated from health-related international travel, 2015 (USD million) 69
Figure 4.2 Expenditure made on health-related international travel, 2015 (USD million) 70
Figure 4.3 Europe’s top-10 spa markets by number of spas, 2015 81
Figure 4.4 Europe’s top-10 spa markets by revenue generated, 2015 (USD million) 82
Figure 4.5 Supply of Health Tourism 90
Figure 4.6 Asset-based categorization of the supply of health tourism 91
Figure 4.7 Market distribution of spa customers by origin and segment, 2016 (%) 103
Figure 4.8 Wheel of wellness – translated to travel motivations 105
Figure 4.9 Flows of international medical tourism 114
Figure 4.10 Consumer health services – health tourism conversion 115
Figure 4.11 A typical national cooperation network structure 127
Figure 4.12 The role of health tourism destinations in the health tourism system 130
Figure 4.13 Wellness and spa services in a package (% of total accompanying services) 137
List of tables
Table 4.1 Number of medical tourism facilities, 2014 74
Table 4.2 Number of medical tourism providers and facilitators by self-declaration (2017) 74
Table 4.3 Global spa facilities by region, 2015 81
Table 4.4 Regional differences in European health tourism 99
Table 4.5 Number of wellness trips by region, 2013 and 2015 (million) 107
Table 4.6 Number of wellness trips by country in Europe, 2013 and 2015 (million) 107
Table 4.7 Country branding messages, 2008–2017 134
Table 4.8 Wellness and Spa Services in a Package – Regional differences 138
Table 4.9 Online platform and social media in health tourism 139
Table A3.1 Word cloud categorization of health tourism scenario cards 161
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List of abbreviations and acronyms

AAC Agritourism and Agri-Food Canada

ABA ABA – Invest in Austria
A.D. anno Domini
AHHA American Holistic Health Association
ANBAL Spanish Medical Spa Spanish Association
APSWC Asia-Pacific Spa and Wellness Coalition
ASPE Spanish Private Health Alliance
ASPS American Society of Plastic Surgeons
BFY ‘better-for-you’
BRIC Brazil, the Russian Federation, India and China
BoP balance of payments
CABG coronary artery bypass grafting
CAGR compound annual growth rate
CAM complementary and alternative medicine
CEAV Spanish Confederation of Travel Agencies
CEHAT Spanish Confederation of Hotels and Touristic Stays
CEO Chief Executive Officer
CIS Commonwealth of Independent States
CME continuing medical education
CPQ Center for Health care Planning and Quality
DHA Dubai Health Authority
DHCC Dubai Health care City
DMO destination management organization
DPM destination programme manager
EC European Commission
EIU Economic Intelligence Unit
EPF European Patients’ Forum
ESKI Health care Strategy Research Center (Egészségügyi Stratégiai Kutatóintézet)
ESPA EHV European Spa Association
ETC European Travel Commission
EU European Union
EUR euro
FDA Food and Drug Administration (United States of America)
FDI foreign direct investments (newspaper)
FMT Free Malaysia Today

FOMO fear of missing out
GATS General Agreement of Trade in Services
GCC Gulf Cooperation Council
GDP gross domestic product
GRC Geothermal Resources Council
GSS Global Spa Summit
GSTC Global Sustainable Tourism Council

GSWS Global Spa and Wellness Summit
GWI Global Wellness Institute
HRI Health care Research Institute (PriceWaterhouseCoopers)
ICHHTO Cultural Heritage, Handicrafts and Tourism Organization (Iran)
ICT information and communications technology
IHG EVEN Intercontinental Hotels Group (EVEN Hotels)
IHMT International Hospitals and Medical Tourism (magazine)
IMTJ International Medical Tourism Journal
IoT Internet of things
ISAPS International Society of Aesthetic Plastic Surgery
ISMH International Society of Medical Hydrology and Climatology
ISO International Organization for Standardization
ISP Islamic Spa Practice
ISPA International Spa Association
IT information technology
IUTO International Union of Tourism Offices
IVF in-vitro fertilization
JCI Joint Commission International
JOMO joy of missing out
JTB Jordan Tourist Board
KHIDI Korea Health Industry Development Institute
LAP-BAND laparoscopic adjustable gastric band
LBP lower back pain
LGBT lesbian, gay, bi-sexual, trans-gender
LOHAS lifestyles of health and sustainability
LTC long-term care
METU Budapest Metropolitan University
MHTC Malaysia Health care Travel Council
MIS minimally invasive surgery
MTA Medical Tourism Association
MTI Hungarian News Agency (Magyar Távirati Iroda)
MTQUA Medical Travel Quality Alliance
MYR Malaysia ringgit
NABH National Accreditation Board for Hospitals and Health care Providers (India)
List of abbreviations and acronyms 167
NAV Hungarian Tax Office

NDD nature deficit disorder
NHS National Health Service (United Kingdom)
NIS New Israeli Sheqel
NTO national tourism office
OECD Organisation for Economic Co-operation and Development
ONS Office for National Statistics
OTA online travel agency or Organic Trade Association (United States of America)
PESTLE political, economic, social, technological, environmental
PPACA Patient Protection and Affordable Care Act (United States of America)
PPP public-private partnership
SHMTPPP Shanghai Medical Tourism Products and Promotion Platform
SIAT Applied Research and Innovation Services (United States of America)
SLOW LIFE sustainable, local, organic, wholesome, learning, inspiring, fun, experiences (six senses)
SME small and medium-sized enterprises
SOWELL social tourism opportunities in wellness and leisure activities
spa sanum per aqua
THTDC Turkish Health care Tourism Development Council
TK Turkish Airlines
TOHWS Tourism Observatory for Health, Wellness and Spa
TRAN European Parliament Transport and Tourism Committee
UN United Nations
UNSTAT United Nations Statistics Division
UNWTO World Tourism Organization
USAID United States Agency for International Development
USCIPP US Cooperative for International Patient Programs
USD United States of America dollar
USITC United States International Trade Commission
USSR Union of Soviet Socialist Republics
UVB ultraviolet B
WEF World Economic Forum
WHO World Health Organization
WTO World Trade Organization
WTTC World Travel and Tourism Council
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This 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.
The World Tourism Organization (UNWTO), a Founded in 1948, the European Travel Commission
United Nations specialized agency, is the leading (ETC) is a non-profit organization whose role is to
international organization with the decisive and market and promote Europe as a tourism destination
central role in promoting the development of in overseas markets. ETC’s members are the
responsible, sustainable and universally accessible national tourism organizations of 33 European
tourism. It serves as a global forum for tourism countries. Its mission is to provide added value to
policy issues and a practical source of tourism members by encouraging exchange of information
know-how. Its membership includes 158 countries, and management expertise and promoting
6 territories, 2 permanent observers and over awareness about the role played by the national
500 Affiliate Members. tourism organizations.
World Tourism Organization: www.unwto.org European Travel Commission: www.etc-corporate.org

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${protocol}://www.e-unwto.org/doi/book/10.18111/9789284420209 - Saturday, February 02, 2019 5:38:54 PM - IP Address:186.83.134.

Exploring Health Tourism

Exploring Health Tourism

World Tourism Organization (UNWTO) European Travel Commission (ETC)

Tel.: (+34) 915 678 100 Tel.: (+32) 2 - 548 90 00

Permission to photocopy this material in Spain must be obtained through:

CEDRO, Centro Español de Derechos Reprográficos Tel.: (+34) 913 08 63 30

1.1 Purpose of the study 17

1.2 Methodological approach 19

1.3 Study overview 20

Chapter 2 Analysis of macro-environmental factors 23

2.1 Political factors 24

2.2 Economic factors 30

2.3 Socio-cultural factors 33

2.4 Technological factors 36

2.5 Natural factors 40

2.6 Legal factors 43

Chapter 3 Development of a taxonomy for health tourism 47

3.1 Preliminary remarks 47

3.2 Discussing definitions around heath tourism 49

3.3 Recommended definitions 63

4.1 Preliminary remarks 67

4.2 Market size of health tourism: some estimates 68

4.3 The supply of health tourism 71

4.3.4 Facilities based on natural resources 83

4.4 Demand for health tourism 91

4.5 Demand for wellness tourism 100

4.6 Demand for medical tourism 108

4.7 Managing and marketing health tourism 116

Chapter 5 Conclusions and recommendations 141

5.1 Expectations 141

5.2 Management and planning 142

5.3 Marketing and research 143

5.4 Segments and motivations 143

Chapter 6 Development of health tourism – toolkit for implementing

Annex 1 List of interviewees 155

Annex 2 Word cloud health tourism scenarios for categorization 157

List of examples, figures and tables 163

List of abbreviations and acronyms 165

References and bibliography 169

Zurab Pololikashvili Peter de Wilde

The growing segment of health tourism

Defining health tourism: recommended taxonomy and definitions

Factors shaping health tourism

The market of health tourism

Supply of health tourism

Demand of health tourism

Management and marketing

Conclusion and recommendations

The new phase in human evolution represents a culmination of thousands of years

1.1 Purpose of the study

4 UNWTO Committee on Tourism Competitiveness, http://cf.cdn.unwto.org/sites/all/files/pdf/ctc_definitions_en_web.pdf and

1.2 Methodological approach

1.3 Study overview

Figure 2.1 PESTLE analysis

2.1 Political factors

Figure 2.2 Key factors in the political environment

2.1.1 Working and leisure time

2.1.2 Supported holidays