Index

Abstract

Health tourism is one of the most important types of alternative tourism that provides sustainable tourism. When examining the coordination among current developments in health tourism in the world, technological innovations, and health tourism providers, it is clear to see that Turkey and Antalya have not yet reached the desired level. This study attempts to evaluate and explain the position of Antalya, which wants to attain a share in health tourism. In this context, a SWOT analysis of Antalya in the development of health tourism was carried out. Antalya is primarily a cheap destination, and this is a very attractive feature for foreign tourists. Health services in Antalya, doctors and other health care personnel, applied treatments, and technological devices are at a very high standard. Tourists who prefer autumn and spring seasons will solve the seasonality problem of Antalya especially during off-peak times. For this purpose, Antalya should additionally be promoted and marketed as a destination for health tourism. In this context, public and private sectors need to cooperate. Within the scope of the responses obtained from the participants, Antalya is required to conduct studies on being easily accessible and reliable for patients. Promotional information in brochures or posters should also be reviewed.

Keywords: Health tourism, Turkey, Antalya.

Received: 12 June 2019 / Revised: 15 July 2019 / Accepted: 19 August 2019/ Published: 8 October 2019

Contribution/ Originality

This study tries to give valuable input to the development of health tourism in Antalya Province of Turkey benefiting from SWOT analysis method. In the written literature there are few researches conducting SWOT analysis of destinations in the development of health tourism. In this context, this study can be evaluated as a starting point at least for Antalya province.


1. INTRODUCTION

Health tourism, in other words, patient mobility has become the fastest growing sector in the world due to globalization, and this has caused serious competition between countries. Centers of attraction are created in order to get a share in this sector. Health tourism plays an important role in the gross national product of many countries, generates employment, creates a variety of occupations, attracts investment and improves the balance of foreign trade. Health tourism develops through the global promotion of doctors, health services, healthcare facilities and the technology of that country. Many promotional techniques about the healthcare services in that country are used to inform, persuade, and guide patients who want to be treated abroad. There are a number of factors affecting the choice of country by international patients participating in health tourism: cultural differences between countries, the political and economic stability of the country, the distance of the country from the patient’s homeland and the accessibility of healthcare services in that country. Visionary and competitive strategies should be implemented in order to compete in health tourism.

With the beginning of the 21st century, the number of people who want to get cheap quality healthcare has increased due to reasons such as the exclusion of many treatments from health insurance coverage in the States, the increase in an elderly population, and thus the increase in medical demands and the need for rehabilitation (Sügür, 2016).

People who leave their homelands for health reasons and travel to other countries to be treated and get cheap, high-quality services are called health tourists, and all these actions are described as health tourism. Health tourism, that is, patient mobility has become the fastest growing sector in the world due to globalization. However, it has also created intense competition between countries. Centers of attraction are created in order to get a share in this sector which has a very high added value, (http://saglik.gov.tr/SaglikTurizmi/belge/1-24202/turkce-uluslararasi-saglik-turizmi-sunumu.html, (access date: 17.09. 2018).

The importance attached to health tourism as an alternative tourism by both the state and the private sector provides many benefits to the public. Investments and service quality increase, health institutions are established, and international health service standards are implemented.

Health tourism, which dates back to ancient times, has two dimensions. The first is that health tourism has been carried out through intercultural communication due to human movements and migrations. Health communication has been established between different cultures through migrations, conquests and discoveries. Health communication can be described as being able to understand people's culture, language and health language. Therefore, health tourism has an important social dimension. The second is the economic dimension. Today, with an increasing population, people’s travel activities which are higher quality, cost less, and involve a lower waiting period comprise the economic dimension of health tourism. Thus, the importance of health tourism has arisen from both the social aspect originating from the intercultural encounter caused by people’s movement for health purposes and the economic aspect resulting from travels for the purpose of treatment (Yüksel, 2017). Referencing UNWTO (2013); Meléndez and Obra (2016) mention that today’s tourists prefer closer destinations and by 2030 visiting relatives and friends, health and religion will comprise 31 per cent of all worldwide travel. Some of the developing countries such as Thailand, India, Singapore, Malaysia, Turkey and Hungary are increasing their health services for international health tourists year by year (Kesar and Rimac, 2011). Among those countries with an interest in health tourism, some are importing and some are exporting health tourists, or both. Most of the importing countries are from North America and Western Europe, whereas exporting countries are from Latin America, Eastern Europe, Africa and Asia (Smith et al., 2011).

In terms of academic studies on health tourism, researchers investigated the main reasons for going abroad for health services, gathering demographical information from health tourists and conducting a swot analysis (Strengths, Weaknesses, Opportunities and Threats) of destinations developing health tourism. Among the main reasons for preferring to go abroad were cost, receiving high-quality service from accredited health institutions, long waiting lists Bies and Zacharia (2007) and decreasing costs of international air travel. Citing Connell (2006); Cuddehe (2009); Gray and Poland (2008); Manaf et al. (2015) it has been mentioned that cost together with quality of health service can be seen as pulling factors for international health tourists. There are some countries like Yemen, Sudan or Libya where the skills of doctors are low; this situation leads people to find alternatives (Lee and Kim, 2015). Referencing Thomas (2011); Marković et al. (2014) it has been stated that since all goods and services are unique to patients, it is not so easy to define and evaluate their quality. Besides, citing Lunt et al. (2010); Ramamonjiarivelo et al. (2015) the importance of sharing knowledge and health-related technologies in orienting people towards better health services has been emphasized. As with general tourism, potential risks also play an important role in deciding whether to travel internationally. Health tourists may experience different issues because of mistakes made by health institutions or problems arising during travel. For these kinds of problems (Gan and Frederick, 2015) cited some researchers that underlined the importance of quality of health services (Demicco and Cetron, 2006) existence of individualized care (Fried and Harris, 2007) and advanced equipment (Demicco and Cetron, 2006). Referencing Han and Hwang (2013) and Snyder et al. (2011); Han and Hyun (2015) added facing language, communication problems and unkind behavior by health staff while receiving health services. Glinos et al. (2010) summarized the main reasons for international travel as; availability, affordability, perception of quality and familiarity (Hanefeld et al., 2015).

Demographical aspects of health tourists also affect the development of health tourism. Components of demographical aspects include: income levels, education levels, age, marital status etc. Referencing Goodrich and Goodrich (1987) and Gan and Frederick (2013); Gan and Frederick (2015) stated that a pioneering study on health tourism defines household income as 41,000 USD per year, and other studies showed that health tourists generally belong to middle income groups. Of course it is possible to see patients (belonging to high level income) travelling abroad. Citing research by Musa et al. (2012); Han et al. (2018) gave demographic details of sample tourists in Kuala Lumpur, Malaysia, saying they were female, belonged to a middle-aged group and traveled with two people with their primary motives for  travel including value for money and receiving the highest quality of health service. There are also other studies showing that health tourists mostly belong to middle-aged groups. In this context (Gan and Frederick, 2015) cited the researches of Lunt and Carrera (2010) and Milstein and Smith (2006).

Citing Scott and Carrington (2011) and Wassermann and Faust (1994); Hanefeld et al. (2015) underlined that the importance of formal or informal relations between health tourists and health institutions should be taken into account and investigated more in terms of understanding future attempts of patients. According to them, all potential networks and relations should be taken into consideration. In addition to relations, geographical and cultural affinity may draw international health tourists. Referencing Connell (2013); Esiyok et al. (2017) it has been stated that these kinds of examples can be seen in Europe, Thailand, India and Singapore. Even religion may affect destination choice. Moghimehfar and Nasr-Esfahani (2011); Kim et al. (2013) give as an example that Muslim couples that need infertility treatment prefer Muslim countries for said treatment.

Heung et al. (2010); Lovelock and Lovelock (2018) stated that in health tourism, the expectation is for travelers to have only health services as  the main and only motivation for travel, but sometimes it may also include leisure activities in addition to health services.

As one of the latest contributions to health tourism literature, a Medical Tourism Index was introduced; citing Fetscherin and Stephano (2016); Aydin and Karamehmet (2017) it was stated that this index includes such major components as: country, tourism, medical cost, medical facility and services as factors that affect the choices of health tourists at a macro level. These factors can be useful in orienting people towards best practices. In addition, at micro level, some companies or agents may affect and organize travel for health tourists. In this context, Medical Retreat Abroad, Malaysian mediTravel, Plant Hospital, Global Choice HealthCare can be given as successful examples (Mohamad et al., 2012).

Visakhi et al. (2017) carried out a scientometric assessment of global health tourism publications between 2007 and 2016. After considering 1422 publications they determined the top 5 countries in terms of publication frequency. These are: USA (Publication share of 24. 12 %), UK (12.59 %), Canada (7.45 %), Australia (7.10 %) and India (3.45 %).

Regarding a SWOT analysis of destinations, Hosseini et al. (2015) carried out research showing strengths, weaknesses, opportunities and threats (SWOT) of Iran in terms of the development of health tourism. According to the results, they suggested taking measures in macro managerial programming for infrastructure, coordinating partners in the health sector, participating in exhibitions, organizing and following measures towards international standards, opening joint offices with other countries, securing visa applications, creating websites showing the potential of the country for health tourism and supervising the price and quality of the health services. Another study on a SWOT analysis of Korean health tourism was conducted by Kim et al. (2013). The results revealed that the strengths and weaknesses of Korea’s health tourism reflect the internal factors and opportunities including support by the government and healthcare industry, whereas threats are mostly related to the existence of new competitors.

2. DEVELOPMENT OF HEALTH TOURISM IN TURKEY AND IN THE WORLD

As of 2016, the share of rapidly growing health tourism in the developed and underdeveloped countries of the world is 62 billion (USD). The countries that have the highest share in this market are India, Singapore, Brazil, Argentina, Mexico, Costa Rica, China, Ukraine, Czech Republic, Hungary, and Poland. The majority of these countries offer high quality check-up and other related services; a minority of them specialize in different areas. For example, Singapore and the Republic of Korea can be given as two of the best examples for cancer treatment (Kılavuz, 2018). The factors determining the distribution of health tourism by country are the reasons for country preference and the reasons that lead to health tourism. Main reasons include getting cheap, high-quality treatment, being treated without waiting too long, getting both health service and a holiday, accessing higher technology and professional services, having specialists in their field, access to treatment in thermal facilities, treatment of chronic diseases related to climate, and anti-ageing, that is, the desire for a long and healthy life (http://www.saturk.gov.tr, accessed 20.09.2018). Liberalization of trade should be taken into consideration in the development of health tourism. With the acceptance of GATS (General Agreement on Trade in Services) health and education services gained momentum across the world (Loh, 2015).

According to a report published by the OECD in 2017, life expectancy of people in the member states has increased by 10 years since 1970 and reached an average of 80.6 years. The life expectancy of people at birth is longest in Japan with 83.9 years and in Switzerland and Spain at 83 years. The lowest life expectancy is in Latvia (74.6 years) and Mexico (75 years). The development of healthier life styles and improvements in health raise people's life expectancy (WHO, 2017). According to figures announced by World Travel Monitor at the ITB Berlin Fair in 2016, the number of cases for international health and medical travel in the world was 11.4 million during that year. This figure corresponds to the 1.4% market share in international travel. In terms of the distribution of types of health tourism, 70% comprises spa holidays with health and wellness tourism, and 30% is made up of medical tourism and rehabilitation tourism. That is, 3.4 million are medical tourists and 8 million are health, wellness and spa tourists. Among these, Germany is the leader of the market by hosting 1 million foreign health and medical tourists. Russia comes in second in Europe, followed by France and Italy. The most important market outside of Europe is USA. Asian markets come in second, third and fourth, as South Korea, China and Japan, respectively.

The gradual growth of the middle class in the world, especially in the Middle East and Asia, has created a demand for more health services. This has resulted in people wanting to access more practical, digital and improved health care. Therefore, this demand is increasing day by day. The percentage of population over 60 years of age in the total population in Europe is given in Table 1 (Republic of Turkey Ministry of Culture and Tourism, 2018).

Table-1. The percentage of population over 60 years of age in the total population in Europe.

Countries
2000
2020
2050
Germany
22.9%
30%
41%
Spain
21.8%
28%
44%
French
20.7%
29%
38%
Belgium
22.1%
30%
38%
Denmark
19.9%
28%
36%

Source: Ministry of Culture and Tourism, 2018.

Due to developments in health tourism, preventive health tourism has emerged in recent years in order to eliminate diseases. People have realized that 70% of early deaths caused by preventable diseases are related to bad habits and quality of life. While the share of the health budget in the USA is 35%, this rate is 8% in densely populated China (Tengilimoğlu, 2017).

Health tourism, as an economic indicator, plays a significant role in the GDP of many countries, that is, it produces employment, creates a variety of occupations, attracts investment and improves the balance of foreign trade. Although health tourism is not a leader in terms of the number of health tourists compared to tourism figures worldwide; it is the sector that consumes the most financing due to high-cost treatment and long periods of stay. The effects of health tourism on the economy are composed of two components. The first one is the tourism input resulting from people's travels, and the second is the contribution of health tourism. In general terms, the main criterion is the increase that health tourism is expected to bring about in the gross national product of the region or country, such as job creation and tax revenue. Part of the effect of expenditure by tourists in different countries for the products and services they receive is direct and part is indirect. The part with a direct impact covers the accommodation facilities in the tourism sector, agencies, transportation, and sports and cultural properties. The economic activities that have an indirect impact consist of those sectors not belonging to tourism and direct consumption by tourists. Therefore, the overall direct and indirect effects create added value for the economy. The most obvious indicator of the impact of health tourism on the economy can be inferred from the improvement to the economy of relevant enterprises. Hospitals, clinics, health centers, spa centers, sanatoriums and health systems are such an example. In addition, health tourism has a positive effect on the development of a country's health system. For this reason, many countries are working on developing health tourism, transferring investments to this sector and thus attracting foreign health tourists. For example, Singapore has a population of 4.4 million and aims to increase the number of health tourists to 1 million per year in a very short period of time. The number of health tourists in Thailand is 1.3 million per year. India welcomes 450,000 international patients annually. South Korea will receive 1 million health tourists in 2020 thanks to special incentives. The figure in 2011 was 500,000 (Dimanche and Andrades, 2016). Another successful health tourism player in the world, Thailand, places the highest importance on health tourism development. According to their 2016-2018 development plan, health and wellness tourism, together with senior tourists were given higher value in terms of their marketing (Pongwat, 2017).

Turkey has made significant progress in health tourism in the last 15 years with successful reforms. Quality, accessibility and technology have developed in health tourism. Health transformation projects are welcomed by other countries in the world. Initiatives serve as an inspiration and a model for these countries. In the last 5 years, the number of patients coming from abroad for treatment has increased, and this has been an important source of income (Ministry of Health Turkey, 2018).

In Turkey, when considering health tourism, the first thing that comes to mind is the health of the people coming to Turkey as tourists. The quality of health services should be increased in tourist areas. Tourists should be able to get better health care than in their own countries. While per capita spending of tourists coming to Turkey for health tourism is 15,000 USD, there are attempts to increase the average expenses of a tourist holidaying in Turkey to 1000 USD. The goal is to make the number of tourists 50 million per year and to gain an income of 50 billion USD. In 2023, 20 billion USD could be earned from health tourism. Turkey is a 1-hour flight from at least 12 countries. In addition, at least 57 countries are a 4-hour flight away. Therefore, 1.5 billion people can be reached. Physical conditions in health services are gradually developing in Turkey, and specialist doctors and high-quality health care are increasing. In this sense, it is not a backward country in the world. A total of 52 health centers in Turkey are accredited worldwide by JCI (Junior Chamber International/International Accreditation Organization) and this number is increasing with studies. At the same time, there is a great need for rehabilitation centers and elderly care. Our country has opportunities in this regard as well. In order to achieve the targets set for 2023, legislation studies are being carried out rapidly (http://www.hurriyetdailynews.com/turkey-aims-to-attract-1-5-million-health-tourism-visitors-per-year-121079, access date: 13.10 .2018).

Turkey's 2023 target in health tourism is to welcome 2 million international patients and make a 20 billion USD income. Despite the advantages of Turkey, it is still not at a level it deserves to be in health tourism. In order to reach the desired level in health tourism it has been recommended to select target countries, and for this purpose a promotion plan for Turkey has been made by the state. Turkey's current and targeted performance indicators for health tourism are shown in Table 2.

Table-2. Performance indicators of health tourism in Turkey.

Performance Indicator
Current situation
Targeted situation
Targeted situation
2011
2017 T
2023T
The number of incoming patients for health tourism (thousand)
156
700
2.000
Health tourism income (annually) (USD)
1 Billion
8 Billion
20 Billion
The number of internationally accredited health centres
2,5
4,5
10
The number of free health zones
─
4
10

Source: http://saglik.gov.tr/SaglikTurizmi/belge/1-24202/turkce-uslararasi-saglik-turizmi-sunumu.html, (access date: 15.09.2018).

Turkey has great potential to become a global leader in health tourism and to get a large market share. The reasons why international patients choose Turkey is evidence for this. The factors which lead people to select Turkey for health tourism include cheap service, short waiting times, the rich cultural heritage of Turkey, a personal service and high-quality standards (http://saglik.gov.tr/saglikturizmi/belge/1- 24202 / turkish-international-health-tourism-presentation.html, (access date: 17.09.2018).

3. METHOD

Istanbul, Antalya and Muğla provinces have the highest share in health tourism in Turkey. Patients who come to Antalya for a holiday and get sick, or come for health tourism, are predominantly citizens of Russia, Germany and England. The most important advantage of Antalya for health tourism is that it is a popular destination in tourism and therefore it can meet all needs. Health institutions and organizations in Antalya work in coordination with agencies, accommodation facilities, and tourism facilities.

As a world-renowned tourism destination, Antalya is a very attractive city to accommodate the sick, elderly and disabled, especially during the low season thanks to its natural beauties, historical and cultural resources, and accessibility. As the city with the highest number of health tourists as well as visitors coming for alternative tourism such as winter tourism, sports, congress and fair tourism, it has had an important place in the context of tourist health and medical tourism since 2006 (Turkish Ministry of Health, 2013).

According to the Health Tourism Sector Report of the West Mediterranean Development Agency (WMDA) in 2013, Antalya gained rapid momentum in health tourism and carried out a series of activities to this end.The same report data indicates that there are a total of 40 hospitals in Antalya, 25 of which are private, 13 are state, 1 is a university hospital, and 1 is a training and research hospital. Besides having JCI accreditation, two of these hospitals have recently made their names in health tourism and have hosted health tourism fairs. Antalya is a health tourism destination that has proven itself in Turkey due to its high-quality technological equipment and treatments, cures, and transplants as well as being an easily accessible city in terms of transport. For example, according to data obtained from the Akdeniz University Organ Transplantation Education, Research and Application Centre, the organ transplants performed at Akdeniz University includean uterus transplant from a cadaver for the first time globally, the first simultaneous heart, kidney and vascular transplant in the world, and the first ever two arms and a leg transplant performed on the same patient. The research was, therefore, carried out in Antalya.

This study attempts to evaluate and explain the position of Antalya, which wants to gain a share in health tourism, the things it requires to achieve this, its strengths and weaknesses, opportunities and threats in regard to health tourism. Antalya can reach the position it deserves in the health tourism market by making optimal use ofits existing potential. The fact that the study may be useful for determining future health tourism strategies by Antalya will increase the importance of the research. At the same time, the study will contribute to determining the needs of Antalya and the development of marketing and promotion strategies for these respective needs.

When the resources related to research methods and techniques are examined, it is noteworthy that the steps and explanations, which are described as scientific method or scientific research steps, are predominantly in line with quantitative research logic (Kıncal, 2013). Quantitative research, which is seen as a result of the dominance of a positivist approach, constitutes the method of the study.

The scope of the research was evaluated in terms of content, geographical region, sector and sampling unit. As the geographical region of the research, the scope of the study covers the province of Antalya, which has recently gained rapid momentum in health tourism and determined the route of health tourism. The study was considered time constraints and financial means. Health and tourism sectors constituted the sectoral scope of the research.

The province of Antalya comprised the universe (the main mass) of this study, which investigated the development and importance of health tourism. After a concrete definition of the universe, the sample must be selected in a suitable way. Sampling is very important, because it is the external validity of the research. In other words, it is necessary to know a concrete universe in which the findings will be applied or generalized (Cresswell, 2005). For these purposes, it was revealed that there were 57 enterprises operating in the field of health tourism in Antalya. The surveys were delivered to enterprises to include each of them in the study. However, only 46 of the 57 enterprises returned and answered the questionnaire. In the study, a questionnaire technique was preferred among the data collection tools used for the quantitative research. The questionnaire consists of 38 questions. The first section includes questions about the demographic features of the participants, followed by questions relating to health tourism. The questions were prepared by the authors to be multiple choice and open-ended questions. The purpose for open-ended questions was to gather clearly the opinions of the participants, not to restrict them and for participants in the research to be uninhibited. The statistical analyses of the data obtained from the research were performed using SPSS (Statistical Package for Social Science) for Windows 22.0 and SAS version 9.4 programs. Descriptive statistics for the quantitative variables of the study are presented as mean and standard deviation, and descriptive statistics for the qualitative variables determined through counting are shown as number and percentage. Research findings are presented in tables and graphs.

4. ANALYSES

According to the research findings, 46 people participated in the study, and the majority of the participants were male (76.09%). When the education level of the participants was examined, it was apparent that 57.78% had a bachelor's degree, 37.78% were postgraduates, 2.22% were high school graduates, and 2.22% had an associate degree. Demographic findings are presented in Table 3.

Table-3. Demographic findings of the participants.

Gender
n
%
Male
35
76.09
Female
11
23.91
Education level
n
%
Graduate
26
57.78
Postgraduate
17
37.78
High school
1
2.22
Associate degree
1
2.22

The examination of findings revealed that there were 21 hospitals, 8 travel agencies, 9 hotels and 6 private clinics as the types of enterprises. In terms of position, 19 managers, 11 chief physicians, 9 health tourism unit managers and 7 sales and marketing managers participated in the study. The details are given in Table 4.

Table-4. Participants of the study.

Enterprise type
n
%
Hospital
21
47.73
Travel agency
8
18.18
Hotel
9
20.45
Private clinic
6
13.64
Your position in the enterprise
n
%
Manager
19
41.30
Chief physician
11
23.91
Health tourism unit manager
9
19.57
Sales and marketing manager
7
15.22

Regarding the participants' health tourism education, although 8 individuals were educated in health tourism (18%), 37 (82%) of them did not receive education in health tourism. The trainings and training periods of the participants who received training in health tourism are presented in Table 5 in detail. Accordingly, the training of participants in health tourism varied. These trainings included Detox - Anti Ageing - Child and Elderly Therapy, Health Tourism Congress and Meetings, Health Tourism Management Certificate Program, Health Management, Health Tourism and International Marketing, and Tourism Medicine Certificate. When the duration of the training was examined, it was apparent that the participants were trained for 6 hours or 2 months.

Table-5. Trainings and training periods regarding health tourism.

Name of the Training
n
%
Antalya chamber of commerce and industry (ATSO)
1
14.29
Detox - Anti aging - Child and elderly therapy
1
14.29
Health tourism congresses and meetings
1
14.29
Health tourism management certificate program
1
14.29
Health management
1
14.29
Health tourism and international marketing
1
14.29
Tourism medicine certificate
1
14.29
Duration of the training
n
%
2 months
1
50.00
6 hours
1
50.00

Table-6. Participants' experiences in the health sector.

Variables
n
%
Experience in health sector
 
 
1 year and below
2
5.00
2-5 years
3
7.50
6-9 years
4
10.00
10 years and more
31
77.50
Your service time in this enterprise
n
%
1 year and below
2
4.44
2-5 years
17
37.78
6-9 years
12
26.67
10 years and more
14
31.11
Years of service
n
%
1 year and below
4
9.30
2-5 years
8
18.60
6-9 years
7
16.28
10 years and more
24
55.81

The experience of the participants in the health sector, their service time in the enterprise, and their years of service in the field of health tourism are shown in Table 6. Accordingly, 77.5% of the participants had 10 years or more experience, 10% had 6-9 years, 7.5% had 2-5 years, and 5% had 1 year or less health sector experience. The findings related to the participants’ service time at the enterprise indicated that31.1% had been working at the enterprise for 10 years or more, 26.6% for 6-9 years, 37.7% for 2-5 years, and 4.4% for 1 year or less. According to the service time at the health tourism enterprises, the majority of them, about 56%, had been serving for 10 years or more. In the health tourism sector in Antalya, the clinics preferred most by foreign health tourists are presented in pie charts. The clinics that foreign health tourists preferred most for health tourism in Antalya included eye care (70.73%), aesthetic (58.54%), dental (31.71%), hair (26.83), and obesity treatment (19.51). According to the percentages, foreign tourists preferred eye care clinics (70.73%) most and obesity treatment clinics (19.51%) least Figure 1.

Figure-1. Pie Charts showing the most preferred clinics by foreign health tourists in health tourism in Antalya.

Figure 2 illustrates the clinics preferred most by domestic health tourists in the health tourism sector in Antalya. The clinics preferred most by domestic health tourists for health tourism comprised aesthetics (41.67%), dental (41.67%), eye care (30.56%), hair (25%), and obesity treatment (19.44%). While foreign tourists preferred eye care clinics most, domestic tourists preferred aesthetic and dental clinics more. The least preferred clinics by both domestic and foreign tourists were obesity treatment clinics.

Figure-2. Pie Charts showing the most preferred clinics by domestic health tourists in health tourism in Antalya.

When we look at the bar graph showing the reasons why foreign health tourists preferred Antalya Figure 3 the fact that the prices were cheap (0.76%) seems to be an important reason. When the other reasons for preference were evaluated using percentages, 0.54% said no and 0.45% said yes for the presence of successful physicians; 0.5% said no and 0.5% said yes for the quality of health institutions; 0.60% of the participants said no for the nature aspect of Antalya and 0.40% said yes; 0.65% said no for short waiting times, 0.34% was yes; and 0.89% said no for easy access to health-related information, and 0.10% said yes. The fact that Antalya was an inexpensive destination was found to be the most important reason for attracting foreign health tourists to the region and the other reasons were concluded not to be very effective.

Figure-3. Bar graph showing the reasons why foreign health tourists preferred Antalya.

Figure 2 presents the reasons why domestic health tourists preferred Antalya. Accordingly, the presence of successful physicians (0.52%) seems to be an important cause. When the other reasons were evaluated using percentages, 0.54% said no and 0.45% said yes for the inexpensive prices; 0.52% said no and 0.47% said yes for the quality of health institutions; 0.60% said no and 0.40% said yes for the nature aspect of Antalya; 0.78% said no and 0.21% said yes for short waiting times; 0.88% said no and 0.11% said yes for easy access to health-related information.

The analysis of both domestic and foreign tourists participating in health tourism indicated that foreign tourists preferred Antalya because it was cheap, while domestic tourists stated the presence of successful physicians in Antalya as the reason for their preference. Other reasons had similar percentages for both domestic and foreign tourists. In addition, easy access to information had the lowest percentage among the reasons for preference by both domestic and foreign tourists. In other words, easy access to information on health tourism is not valid for Antalya; tourists cannot gather information about this subject easily. This situation has a negative impact on the development of health tourism in Antalya.

The strengths, weaknesses, threats and opportunities of Antalya in terms of health tourism were asked via open-ended questions, and the responses were gathered and categorized into themes. The dimensions and sub-dimensions were determined by including basic expressions in accordance with the literature. The swot analysis performed is shown in tables, respectively.

Figure-4. Bar Graph showing the reasons why domestic health tourists preferred Antalya.

According to responses by participants, the dimensions that made up the strengths of health tourism in Antalya consisted of cheap, high-quality and package services, use of technology and accessibility, and strong destination image. By the way, “package service” means that flight, accommodation and health services are offered altogether at a single inclusive price. The responses by participants who expressed that Antalya provided cheap, high-quality and package services (resp: 1, 2, 3, 4,5 ,6,7 ,8,9, 10, 11, 12,13, 14,15, 16,17,18, 19,21,22, 23, 24, 25, 27, 28,29, 31,33, 34,37, 38,39, 40,42,43,45), namely the sub-dimensions, include the following factors: it is cheap for guests coming from abroad, health expenses of foreign guests are covered by their insurance companies, hospitals provide a full service (high hospital quality and high-quality physician services for tourism), accommodation facilities are cheap and easy, abundant, diverse, and high quality, also they are available 365 days a year. Thus its strength in the hospitality industry can be combined with health tourism and marketed as a package. The responses by participants who responded to the use of technology and accessibility (resp: 5,6,9,10,11,14,19,21,22,23,29,30,34,38,41,44) included the facts that “Technology is high, it has an airport, transportation is easy, and there are direct flights from there”. The responses by participants to another aspect, namely the Powerful Destination.

Image(resp:3,5,6,7,8,11,12,13,14,15,16,18,19,20,22,23,24,32,34,38,41,42,44,45),constituted the facts that Antalya has a nice climate, natural and cultural richness and history; Antalya has brand value, it is a well-known tourism destination, there are no language issues, people are hospitable, and it is worldwide famous for face transplant and other organ transplants Table 7.

Table-7. Strengths of health tourism in Antalya for the participants.

Dimension Cheap, high quality and package ** service
Sub-dimensions
  • The fact that it is cheap for the guests coming from abroad
  • The fact that the health expenses of foreign guests are met by their insurance companies
  • Hospitals’ provision of full service in this regard (the high quality of hospital and physician services for tourism)
  • The fact that accommodation facilities are cheap and easy, abundant and diverse, of high quality
  • The fact that accommodation facilities can serve for 12 months, 365 days
  • The fact that  its strength in the hospitality industry can be combined with health tourism and marketed as a package
Respondents 1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,21,22,23,24,25,27,28,29,31,33,34,37,38,39,40,42,43,45
  • Package: The tourism service cannot be stocked; the expression here means that flight + accommodation + health service is offered as an all-inclusive package.
Dimension Technology use and accessibility
Sub-dimensions
  • High technology
  • The fact that  it has an airport, transportation is easy, and there are direct flights from there
Respondents 5,6,9,10,11,14,19,21,22,23,29,30,34,38,41,44
Dimension Powerful destination image
Sub-dimensions
  • Nice climate of Antalya, its natural and cultural richness and history
  • The fact that Antalya has a brand value, it is a well-known tourism destination
  • No language problem
  • People’s hospitality
  • The fact that it is worldwide famous for face transplant and other organ transplants
Respondents 3,5,6,7,8,11,12,13,14,15,16,18,19,20,22,23,24,32,34,38,41,42,44,45,

The weaknesses of Antalya in terms of health tourism were asked via open-ended questions and the responses were gathered and categorized into themes. The dimensions and sub-dimensions were determined by including basic expressions in accordance with the literature and are presented in the following table. The dimensions that made up the weaknesses of health tourism in Antalya and the respondents are as follows: Lack of Information and Resources (resp: 2,5,10,11,12,19,21,22,23,24,25,28,33,34,35,38,44), Regulatory Issues (resp: 19, 21,31), Integration Problems (1,6,7,23,27,30,42), Accessibility and Seasonality Problems (3,4,5,9,16,19,22,24,29,36,38 , 45), Problems in Marketing (Marketing 4P; resp: 7,9,14,15,16,17,19,21,22,23, 30,32,37,38,39,40,43,44) and Weak Brand Image (resp: 8,18,19,20,21,23,34). The answers by participants are expressed as sub-dimensions and shown in Table 8.

The threats to health tourism in Antalya were asked via open-ended questions and the responses were gathered and categorized into themes. The dimensions and sub-dimensions were determined by including basic expressions in accordance with the literature and are presented in Table 9. The dimensions that made up the threats to health tourism in Antalya, prepared according to responses by participants, are as follows: insufficient and poor quality service, diplomatic relations and the global competition environment. The sub-dimensions of insufficient and poor quality service in the table include “Intermediaries, who are called commissioners, only provide marketing on the internet, and guarantee without taking full responsibility; unqualified brokers, and uncertified and uneducated intermediary institutions; inadequacy of some clinics and the increase in unethical institutions, people and institutions offering inadequate and poor quality service; facilities which operate without adequately investing in health tourism and without having adequate physicians and infrastructure;  unsuitable facilities for health tourism, in other words, only focusing on sea, sand, and sun tourism during the summer season; inconsistent price policies of hotels and destabilization of prices, price cutting with a competitive mentality, thus the decrease in quality - on the contrary, quality should be maintained; lack of quality standards; and hair transplantation centers working with a large number of hospitals and not giving confidence.”

Table-8. Weaknesses of health tourism in Antalya for the participants.

Dimension Lack of information and resource
Sub-dimensions
  • The low number of successful physicians dealing with tourism patients
  • Insufficient investors
  • Insufficient knowledge of private hospitals in the region about these issues
  • The low number of high quality health institutions and successful physicians
  • Inadequate superstructure and infrastructures in the field of health / Inadequate investment made in health tourism
  •  The low number of patients
  • People from outside the profession in this job, the increasing number of commissioners in this area, Trained personnel (in terms of mediator / language)
  • The fact that strong organizations and effective communication cannot be done professionally yet
  • The low number of enterprises with JCI certification
  • The low number of accredited hospitals
  • Improvement of certain branches (Physical therapy and rehabilitation)
Respondents
  • 2,5,10,11,12,19,21,22,23,24,25,28,33,34,35,38,44
Dimension
  • Regulatory issues
Sub-dimensions
  • Restrictions on legal regulations for treatment
  • Deficiencies in regulations, Bureaucratic obstacles
  • The fact that Health Tourism Policy has not been established
Respondents 19,21,31
Dimension Integration problems
Sub-dimensions
  • Physical therapy and some SPA services are covered by the insurance of the guests abroad, and many countries, especially the Scandinavian region, support health tourism in this regard. However, in our country, unfortunately, we cannot implement it
  • The fact that organizations operate individually and do not gather under a single roof; health organizations do not work in coordination with each other; they do not cooperate and do not use a common standard price
  • The fact that health tourism and tourism do not work in an integrated way
  • Commission
  • The fact that  health organizations are in a very serious competition and cannot achieve unity
Respondents 1,6,7,23,27,30,42
Dimension Accessibility and seasonality problem
Sub-dimensions
  • Transportation - The number of patients decreases especially when flights are low in number. The number of scheduled flights is low (in winter)
  • The fact that  the city is not very big like Istanbul
  • The fact that  seasonal agglomeration creates a sense of destination visited for sea, sand, sun and holiday in tourists (its seasonality)
Respondents 3,4,5,9,16,19,22,24,29,36,38,45
Dimension Problems in marketing (Marketing 4P)
Sub-dimensions
  • The fact that  publicity is insufficient, the headquarters of hospitals are based in İstanbul and they do not do marketing (except Life Hospital) and they are inadequate in advertising
  • Price uncertainty
Respondents 7,9,14,15,16,17,19,21,22,23,30,32,37,38,39,40,43,44
Dimension Weak brand image
Sub-dimensions
  • Abuse
  • The fact that organizations whose credibility is low and equipment is insufficient try to work in health tourism results in wrong treatments and decreases the trust in our country
  • Its insufficient level of branding
  • The fact that the place of state hospitals in health tourism is low
Respondents 8,18,19,20,21,23,34

The sub-dimensions of the dimension of diplomatic relations consist of "Turkey's political position, terror, the very volatile political agenda; hot war environment in the Middle East; international political conflicts; threats posed due to the political crisis in neighboring countries; the fact that the services offered to patients have to be provided through the prices of the Social Security Institution (SSI) in our country because of the health agreements made with European Union countries in previous years; legally controversial international and national issues; and legal problems arising from the inadequacy of regulation”. The sub-dimensions of the dimension of the global competition environment are “Far Eastern countries that provide high quality and reasonable prices (like India); having countries such as Slovenia, Croatia, Montenegro, Romania and Bulgaria as competitors; the fact that the demand for doctors is met in Western countries with the increase in the elderly population at a national level; and there is little collaboration between foreign insurance companies and Antalya.” The answers by participants, sub-dimensions and respondent numbers are presented in the table.

Table-9. Health tourism threats in Antalya for the participants.

Dimension Insufficient and poor quality service
Sub-dimensions
  • Intermediaries who are called commissioners, only provide marketing on the internet, and guarantee without taking full responsibility, unqualified brokers, and uncertified and uneducated intermediary institutions
  • The inadequacy of some clinics and the increase in unethical institutions, people and institutions offering inadequate and poor quality service
  • Facilities which operate without adequately investing in health tourism and without having adequate physicians and infrastructure
  • Unsuitable facilities for health tourism, in other words, being only focused on sea, sand, and sun tourism in summer season
  • Inconsistent price policies of hotels and destabilization of prices
  • Price cutting with a competitive mentality, thus the decrease in quality - on the contrary, quality should be maintained. Lack of quality standards
  • Hair transplantation centres’ working with a large number of hospitals and not giving confidence
Respondents 1,3,4,6,7,8,9,10,12,14,17,18,19,22,23,24,25,30,31,32,34,35,40,41,43,45
Dimension Diplomatic relations
Sub-dimensions
  • Turkey's political position
  • Terror
  • Very variable political agenda
  • War environment in the Middle East, international political conflicts, the threats posed due to the political crisis in neighbouring countries
  • The fact that the services offered to these patients have to be provided through the prices of Social Security Institution (SSI) in our country because of the health agreements made with the European Union countries in previous years
  • Legally controversial international and national issues, and  legal problems arising from the inadequacy of regulations
Respondents 1,2,5,11,13,16,21,22,44
Dimension Global competition environment
Sub-dimensions
  • Far Eastern countries with high quality and reasonable prices (like India)
  • Having countries such as Slovenia, Croatia, Montenegro, Romania and Bulgaria as competitors
  • The fact that need for doctors is met in western countries with the increase in the elderly population at the national level
  • Little collaboration between foreign insurance companies and Antalya
Respondents 7,10,22,28,30

The opportunities for health tourism in Antalya were asked via open-ended questions and the responses were gathered and categorized into themes. The dimensions and sub-dimensions were determined by including basic expressions in accordance with the literature and are presented in the following table. The dimensions that made up the opportunities for health tourism in Antalya are as follows: accessibility, incentives, capacity in tourism, alternative applications and availability of cheap, high-quality, 12-month service. The answers by participants are presented as sub-dimensions in Table 10.

Table-10. Opportunities for health tourism in Antalya for the participants.

Dimension Accessibility
Sub-dimensions
  • Transportation Facilities (Abroad)
    Easy access to Antalya (2 airports)
Respondents 3,8,12,14,16,19,21,31,33
Dimension Incentives
Sub-dimensions
  • Incentives granted by Ministries
    The fact that  ministries give importance to health tourism, support health institutions and modernize hospitals within the scope of superstructure due to tourism diversification policies
  • If it can be finalized, the work initiated by the chamber of commerce can create new opportunities. 12-14 million tourists that come every year are a very important opportunity.
  • The fact that it has a potential for a business volume with a high added value.    
Respondents 6,19,22,27
Dimension Capacity in tourism
Sub-dimensions
  • Good conditions of the existing hospitals, having good doctors
The structure and adequacy of the health facilities found in Antalya
The presence of quality hospitals and medical teams
No waste of time in the queue
Working of all clinics and health organizations under a roof in unity
  • Surplus bed capacity
    Accommodation facilities in Antalya
    Natural and historical beauty, climate, geopolitical location, modern urbanization
    The brand of Antalya, its natural and historical richness
Respondents 1,3,7,8,10,11,12,14,16,19,20,21,24,25,29,30,31,32,33,34,39,41,43,44,45
Dimension Alternative applications
Sub-dimensions
  • The fact that  it has suitable environments for alternative applications
  • a) Building elderly complexes within the nature intended for the elderly
    b) Organizing hotels for the elderly
    c) Increasing the number of rehabilitation centres
    d) Building blocks – houses for the elderly considering their own culture
    e) The possibility to work with small outpatient clinics or with a hospital complex (Aesthetic-Eye care-> Dental-Rehabilitation -Sightseeing tours -Massage –Physical therapy -usv)
  • Technology
  • Sports tourism
Respondents 1,9,11
Dimensions Availability of cheap, good quality and 12-month service
 
  • Entertainment and sightseeing opportunities for 12 months
  • It’s being a tourism region
  • Quality service provided at affordable prices
  • The fact that all inclusive accommodation is too cheap in the autumn and winter seasons, which are described as off-season by tourism professionals.
  • Possibility of both health and holiday
Respondents 2,4,13,14,17,20,21,22,25,33,35,39,45

The problems relating to health tourism in Antalya were asked via open-ended questions and the responses were gathered and categorized into themes. The dimensions and sub-dimensions were determined by including basic expressions in accordance with the literature and are presented in Table 11. The dimensions that made up the problems of health tourism in Antalya, prepared according to responses by participants, are as follows: marketing (4P) issues(resp:1,3,4,9,10,14,19,21,22,25,29,31,38,40,41,44,45), organization and communication problems (resp: 4,6,9,10,11,12,13,14,16,17,18,22,27,20,34,36,39), lack of support, agreement and regulations (resp: 1,21,22, 32), unconscious behavior (9,30), and hotel and staff problems (resp: 2,11,23,33,35).

Table-11. Problems of health tourism in Antalya for the participants.

Dimension Marketing (4P) problem
Product, Price, Place, Promotion
Sub-dimensions
  • *Inadequate publicity, marketing, and advertising
  • Price differences, poor states in price competition
    Excessive price practices of healthcare facilities, especially for foreign tourists, and the affected guests
    Ethical health organizations
  • Our biggest problem is that the treatments in Istanbul are very cheap. All transactions are carried out at very low cost because all institutions in the health sector want to engage in health tourism
  • The decreasing number of flights to the UK in winter season
Problem of direct flight
Respondents 1,3,4,9,10,14,19,21,22,25,29,31,38,40,41,44,45
Dimension Organization and communication problems
Sub-dimensions
  • Lack of information and welcome office
    Misinformation, Telling lies, Misguiding the patients
    Mutual trust between patients and agencies
    Lack of confidence in patients
  • There are issues of bad image and trust caused by bad experiences in the field of health tourism.
  • The general problem is the distrust towards our country
  • The most important problem is the difficulties in reaching the new patient
  • Foreign language, Shortage of staff who knows a foreign language
    Insufficient number of staff who knows a foreign language other than English in hospitals
  • Professional foreign connections
  • The mismanagement of the process of bringing the patient from overseas. Lack of thorough communication between the patient in the source country and the hospital. Lack of organization, Lack of coordinated work among hotels, agencies and hospitals
  • Tourists’ not spending time in the city
Respondents 4,6,9,10,11,12,13,14,16,17,18,22,27,20,34,36,39
   
Dimension Lack of support, agreement and regulations
Sub-dimensions
  • Lack of state support
  • Lack of regulations, the fact that rehabilitation regulations have not been introduced
  • Limited health care coverage of tourists, Setbacks in wage claims and insurance agreements
Respondents 1,21,22,32
Dimension  
Sub-dimensions
  • The desire to organize a tour every day considering that the elderly is healthy (greed) Unconscious behaviours
  • The biggest problem is the disrespect for the effort and the profession, Not being able to get financial and spiritual return for the service provided
Respondents 9,30
Dimension Hotel and staff problems
Alt Dimension
  • Physical Conditions of hospitalization (hospitality services)
  • Shortage of qualified personnel
    Shortage of auxiliary health personnel, and interested and knowledgeable staff
Respondents 2,11,23,33,35

The sub-dimensions of the problems relating to health tourism in Antalya, namely the participants' answers, are as follows: “Inadequate publicity, marketing, and advertising; price differences, poor environment for price competition, excessive price practices of healthcare facilities, especially for foreign tourists and the affected guests; and ethical health organizations.” The biggest problem is that treatments in Istanbul are very cheap. All transactions are carried out at a very low cost because all institutions in the health sector want to engage in health tourism. In addition to these problems, there are other issues such as the decrease in the number of flights to the UK during the winter season and the problem of direct flights, lack of information and no welcome office, misinformation, telling lies, misguiding the patients, mutual trust between patients and agencies, lack of confidence by patients, issues of bad image and trust caused by bad experiences in the field of health tourism, the general problem of distrust towards our country, the difficulties in reaching the new patient, which is the most important problem, foreign language, shortage of staff that know a foreign language, insufficient number of staff that know a foreign language other than English in hospitals, professional foreign connections, and the mismanagement of the process of bringing the patient from overseas. Furthermore, lack of thorough communication between the patient in the source country and the hospital, lack of organization, lack of coordinated work between hotels, agencies and hospitals, tourists not hanging around in the city, lack of state support, lack of regulations, lack of regulations on rehabilitation, limited health care coverage for tourists, setbacks in wage claims and insurance agreements, the desire to organize a tour every day if the elderly is healthy, unconscious behaviors, disrespect for the efforts made and for the profession, which is an essential problem, not being able to get financial and spiritual return for the service provided, physical conditions of hospitalization (hospitality services), shortage of qualified personnel, and shortage of auxiliary health personnel, as well as interested and knowledgeable staff.

A total of 45.24% of the respondents who answered the question about increasing the market share of health tourism in Antalya through improvements were of the opinion that regulations should be changed while 54.76% disagreed with this opinion. In addition, 35.71% of participants supported the idea that technological advances should be pursued whereas 64.29% did not hold this view. A total of 40.48% of participants believed that health tourism education should be increased while 59.52% did not agree with this idea. Whereas 52.38% of the participants agreed that the number of staff that knows a foreign language should be increased, 47.62% of them disagreed. A total of 57.14% of respondents stated that access to information should be facilitated, but 42.86% of them were not of the same opinion.

5. CONCLUSIONS AND RECOMMENDATIONS

6. LIMITATIONS

There are two main limitations of the study. The first one is that the enterprises included in the sample were reluctant to share information. The second limitation is that the results cannot be generalized due to the small number of enterprises in the sample.

7. RECOMMENDATIONS FOR FUTURE STUDIES

It will be useful to conduct further studies on the subject by employing both quantitative and qualitative methods while including more samples from more than one city or country in order to generalize the results.

Funding: This study received no specific financial support.   
Competing Interests: The authors declare that they have no competing interests. 
Contributors/Acknowledgement: Both authors contributed equally to the conception and design of the study.

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